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World Of Tanks Best Destroyer
TOP 10 World Of Tanks Best Destroyer Results at 10Bestify.com
WW2 Tank Destroyer Division Panther Patch Distressed Tee
ASIN: B07BJ778TS
Brand: The Salty Veteran Novelty Shirts & Apparel
COBI Small Army Sd. Kfz. 184 Panzerjäger Tiger
The Sd. Kfz. 184 Panzerjäger Tiger was a German heavy tank destroyer used during World War II. The Ferdinand was designed on the chassis of Tiger (P) prototype. The bullets shot from this cannon could destroy frontal armor of every allied tank. The cannon was placed in the quarterdeck instead of the rotating turret. The advantage was also the height of the vehicle. This unique tank destroyer replica has operable trap doors in the quarterdeck and at the front of the vehicle. It has also a cannon that moves up and down and an operable back bonnet....
ASIN: B071LNLPRP
Brand: COBI
The Ghost Army of World War II: How One Top-Secret Unit Deceived the Enemy with Inflatable Tanks, Sound Effects, and Other Audacious Fakery
The Ghost Army of World War II describes a perfect example of a little-known, highly imaginative, and daring maneuver that helped open the way for the final drive to Germany. It is a riveting tale told through personal accounts and sketches along the way—ultimately, a story of success against great odds. I enjoyed it enormously. – Tom BrokawIn the summer of 1944, a handpicked group of young GIs—including such future luminaries as Bill Blass, Ellsworth Kelly, Arthur Singer, Victor Dowd, Art Kane, and Jack Masey—landed in France to conduct a secret mission. Armed with truckloads of inflatable tanks, a massive collection of sound-effects...
ASIN: B00WYJL0O0
American Knights: The Untold Story of the Men of the Legendary 601st Tank Destroyer Battalion (General Military)
An unmissable white-knuckle ride from the Kasserine pass to Anzio, Operation Dragoon to the final attacks on the Third Reich, this is the gripping story of the men and machines that took on Nazi Germany's best. This book not only reveals the technical details and origins of the 601st Tank Destroyer Battalion, it places the reader on the front lines of the European war. As the war swung in the favor of the Allies, it became clear that no final defeat of the Third Reich would be possible until the armored monsters of the Panzerwaffe were defeated. But who would, or even could, take on the mighty Tigers and Panthers, just a handful of whom could...
Brand: Osprey Publishing Publishing
EagleEmblems PM0086 Patch-Army,Tank Destroyer (3'')
This gorgeous PATCH-ARMY,TANK DESTROYER (3'') has the finest details and highest quality you will find anywhere! PATCH-ARMY,TANK DESTROYER (3'') is truly remarkable. Product Details: •Condition: Brand New •Item SKU: SS-EAG-PM0086
ASIN: B007037QSY
Brand: EagleEmblems
Italeri Ferdinand Tank Destroyer Model, 510036501, World of Tanks, 1:35
Ferdinand tank destroyer model, World of Tanks, art. no. 510036501, in 1:35 scale has a length of approx. 24.2 cm. Model kits and finished models from Italeri, an Italian traditional manufacturer of fine miniatures, who inspires the model buyers for more than 50 years worldwide. Over the years, they have built their reputation and a huge fan community. Since 1962, Italeri has been producing kits and finished models in 1:16 to 1:720 scales without compromising on values of quality and perfect fit. Italeri tools, paints and other accessories are used throughout the brand and enjoy great popularity. Model assembly requires paints, glue and a s...
ASIN: B00O4BK8QW
Brand: Italeri
ASIN: B00JGUI66A
Brand: 505 Games
World War 2 Japanese Tank Destroyer World War 2 UnPainted Tin Metal 54mm Action Figures Toy Soldiers Size 1/32 Scale for Home Décor Accents Collectible Figurines ITEM #ww-13
The Soviet Union signed a non-aggression pact with Nazi Germany on 23 August 1939. In addition to stipulations of non-aggression, the treaty included a secret protocol that divided territories of Romania, Poland, Lithuania, Latvia, Estonia and Finland into German and Soviet "spheres of influence", anticipating potential "territorial and political rearrangements" of these countries. Stalin and Hitler later traded proposals after a Soviet entry into the Axis Pact.Germany invaded Poland on 1 September 1939. Joseph Stalin waited until 17 September before launching his own invasion of Poland. Part of southeastern (Karelia) and Salla region in Finl...
ASIN: B01MRICN4R
Color: UnPainted
Brand: Ronin Miniatures
Liili Mouse Wrist Rest and Small Mousepad Set, 2pc Wrist Support IMAGE ID: 2033538 achilles tank destroyer mk10 from second world war photo taken at night
Manufacture: Designed, Printed and Shipped out of our California Facility.Features:Our mouse wrist rest is made of satin fabric, filed with premium foam. High quality satin cloth provides a nice, silky comfortable feel under your hand, Minimizing Fatigue over extended periods of time. The Mouse Wrist Rest is a must for anyone who uses the computer on a daily basis. The weave also Modern style pattern design, suitable for office, restaurant, home, or bars.Warm Tip:All merchandise is Hand Crafted and Designed by Natural Body Comfort. There will be slight variances to the actual purchased item, as all are made with a repeating fabric pattern. Co...
ASIN: B07DD5MXD6
Color: 2042
Brand: Liili
API ALGAEFIX Algae Control Solution 4-Ounce Bottle
Treat and control algae growth and reduce your freshwater aquarium maintenance with API ALGAEFIX Algae Control. This revolutionary product is specially developed to control many types of algae, including "green water" algal blooms and string or hair algae, and it will not harm fish or plants when used as directed. Weekly doses of API ALGAEFIX Algae Control will control algae growth and reduce aquarium maintenance. Do not overdose. To treat algae, add 1 ml per 10 gallons of water and repeat every three days until algae is controlled. Siphon or scrape any dead algae from aquarium. Use this aquarium treatment weekly to control algae growth and r...
ASIN: B00025YVHG
Color: -
Brand: API
American Knights : The Untold Story of the Men of the Legendary 601st Tank Destroyer Battalion
"Describes the Tank Destroyer Battalion, the 601st, a new military unit that took on the Third Reich's armored tanks of the fierce and seemingly indestructible Panzerwaffe in the final battles of World War
An unmissable white-knuckle ride from the Kasserine pass to Anzio, Operation Dragoon to the final attacks on the Third Reich, this is the gripping story of the men and machines that took on Nazi Germany's best. This book not only reveals the technical details and origins of the 601st Tank Destroyer Battalion, it places the reader on the front lines of the European war.As the war swung in the favor of the Allies, it became clear that no final defeat of the Third Reich would be possible until the armored monsters of the Panzerwaffe were defeated. But who would, or
Color: MulticolorMulti
US Tank and Tank Destroyer Battalions in the ETO 1944–45
Overshadowed by the United States Army's armored divisions, the separate tank and tank destroyer battalions had the difficult mission of providing armored support for US infantry divisions in the 1944-45 campaigns. This book details the organizational structures and deployment of these units: the standard tank battalions, tank battalions (light), tank battalions (mine exploder) and tank battalions (special), self-propelled and towed tank destroyer battalions. It also covers the tactics used by these units in their attempts to assist the infantry, as well as providing a listing of all the battalions that took part in the Northwest Europe
Overshadowed by the United States Army's armored divisions, the separate tank and tank destroyer battalions had the difficult mission of providing armored support for US infantry divisions in the 1944–45 campaigns. This book details the organizational structures and deployment of these units: the standard tank battalions, tank battalions (light), tank battalions (mine exploder) and tank battalions (special), self-propelled and towed tank destroyer battalions. It also covers the tactics used by these units in their attempts to assist the infantry, as well as providing a listing of all the battalions that took part in the Northwest Europe
UPC: 3355196
Jagdpanther Tank Destroyer : German Army and Waffen-Ss, Western Europe 1944-1945
Combining the destructive firepower of the 88mm gun with the outstanding mobility of the Panther series, the Jagdpanther is quite probably the best-known tank destroyer of the Second World War. In the vehicle's first action on 30 July 1944, three Jagdpanthers managed to destroy eleven British tanks in a vicious two minute fire fight near the village of Les Loges in Normandy, cementing the Jagdpanther's reputation as a potent tank killer. In his fifth book in the TankCraft series, Dennis Oliver uses contemporary photographs and meticulously researched, superbly presented color and monochrome illustrations to tell the story of these heavy
M36/M36b1 Tank Destroyer
Going into WWII, the prevailing strategy of the US command was that takns were not to be used to engage enemy tanks in combat. Rather, tanks were to be the armored spearhead to breach enemy positions. Enemy tanks were to be dealt with by specialized weapons, aptly named tank
Going into WWII, the prevailing strategy of the US command was that tanks were not to be used to engage enemy tanks in combat. Rather, tanks were to be the armored spearhead to breach enemy positions. Enemy tanks were to be dealt with by specialized weapons, aptly named tank destroyers.While the 3-inch weapon of the M10 was superior to that found on earlier US tank destroyers, it was still found to be inadequate against the ever-increasing weight of German armor. An even larger gun, the 90mm M3, was placed in a new, bigger open-topped turret on 100 new hulls purpose
M18 Hellcat Tank Destroyer 1943–97
The M18 76mm Gun Motor Carriage was developed for the US Army's Tank Destroyer Command. It was the only tank destroyer deployed during World War II actually based on their requirements for speed and firepower. This book examines the development of this vehicle, the controversies over the need for high-speed tank destroyers, and its actual performance during World War II. Special emphasis is placed on examining its performance in its intended mission. Coverage also includes derivative vehicles of the M18 such as the M39 armored utility
World of Tanks - Best Tank Destroyer Line! - (World of Tanks X1 Gameplay)
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RedVsBlue,Tanks,TDs,Tank,Destroyer,Tank Destroyer,WoT,World
Wotb: TOP 5 | Favourite Tank destroyers
Wotb, top 5 favourite tank destroyers. Videos like this is very hard to do, as you think you have your favourites, then you play another tank, that you just love. It was hard picking a top 5 as th...
Wotb,Wot blitz,WoT,Blitz,World of tanks blitz,World of tanks,Wotb top 5,Wotb meadsy69,Meadsy69,TO...
► World of Tanks: USA vs USSR Tank Destroyer Lines - Face Off #19
World of Tanks USA Tank Destroyers vs Soviet/USSR Tank Destroyers. World of Tanks Tank Face Off Series. World of Tanks 15 vs 15 Tank Battle Series. World of Tanks USA vs USSR. ►Streaming: http://ww...
World of Tanks Epic,Epic Win,Epic Fail,WOT EPIC BATTLE,world of tanks new tank,World of Tanks Epi...
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There is continued and exciting research that proves education in an outdoor environment is beneficial for children. An outdoor classroom provides a permanent space where outdoor lessons can take place on a regular basis without leaving the school grounds. While new curriculum that aligns to nature and the outdoors is beneficial, there is no need to create new lessons for this environment to be meaningful. Just being outside provides children with opportunities to experience fresh air and open space, while improving performance. Research has documented increases standardized test scores, enhanced attitude about school, improved in-school behavior, improved attendance, and overall enhanced student achievement when students learn in nature.
A dedicated outdoor classroom provides an area for unique hands-on lessons. This could include art projects, experiments, or loud musical lessons that can't be conducted inside. It could also extend learning in meaningful ways. According to the National School Board Association, Barnard Elementary School in Washington, D.C., is an example of a school that has successfully integrated outdoor activities into its curriculum, When Principal Grace Reid realized that students lacked knowledge about where their food came from, she helped build an herb and vegetable garden, providing experiences for authentic learning. As a result, students are more willing to try new foods and choose healthier options, and Principal Reid has applied for grants to help teachers make outdoor education a part of their lesson plans.
Outdoor classrooms are also an ideal solution for schools that need to expand their current classroom space and maximize the use of their school grounds. As class sizes increase, outdoor classrooms provide the extra space needed without having to extend the school and cause a significant amount of disruption. The opportunity to learn outdoors can also potentially give children who find it difficult to concentrate or engage inside an alternative option. Installing an outdoor classroom area is something that all schools should seriously consider, given all the notable benefits that it could bring to the education of their students.
Placemaking. More than the latest buzzword.
Make your next placemaking project one that provides community comfort, pride, and engagement.


Its summer, the perfect time to put your feet up a read a good book! Thank goodness there is plenty of new reading material out there on our very favorite topic, wedding planning. Here are four of the latest and greatest editions to inspire you and help you plan the wedding youre dreaming of.
Legendary wedding planner Mindy Weiss shares her latest labor of love, The Wedding Book- The Big Book for your Big Day. This must read, stylish, comprehensive tome is chocked full of great advice and common sense tips to take the stress out of wedding planning. Mindys devotion to helping brides just leaps off the pages, and even though she is a sought after celebrity wedding planner, her guidance is given with every bride in mind. Learn how to get organized, stay on budget, and wow your guests from the get-go, from a pro that knows.
Anne Chertoff, author of the popular blog From I Will to I Do, has partnered with Russell and Hazel to create a super cute and ultra useful workbook, The Wedding Organizer. Choose your exterior design from their fantastic options and then print out over 30 different wedding planning worksheets (for free, and as many times as you need) to add to their basic system and totally customize your wedding planning process.
Style expert Susie Coelho has written Style Your Dream Wedding, a book absolutely packed full of incredible images, including many by our Junebug member photographers and dear friends John and Joey Hong of John and Joseph Photography. (Including the lovely one on the stairs above from Junebug's Luly Yang at the Seattle Art Museum Fashion Report! Fun!) Susie breaks wedding planning down according to 8 different styles and provides advice and ideas for creating a perfectly personal and stylish event.
Mindy book was great! I just added the others to my must read list!
Great list! I gotta get that last one, iDo. Hopefully Christa will do a series and keep the book updated with all the newest in wedding planning online.


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LAUSITZRING (Germany), 28 July 2013 – The EuroSpeedway of Lausitzring, located not far from Berlin, hosted the thirteenth Grand Prix of the FIM Motocross World Championship and despite the high temperatures, 16000 people attended the first ever Grand Prix at the Circus Maximus. Antonio Cairoli and Jeffrey Herlings handed another overall victory to KTM, while Clement Desalle and Ken De Dycker were second and third in MX1 and Jordi Tixier and Glenn Coldenhoff completed the MX2 podium.
Rotorua's John Phillips, with 23rd and 20th placings, was 24th overall in the MX2 class.
Gautier Paulin crashed in the beginning of the first race when he was in the lead and he had to be taken to the hospital as he sustained a hefty concussion. The French rider is ok, but he will spend the night over in a local hospital near the track. Tomorrow Paulin will travel to France to have further exams and he might not be able to take part in the upcoming Grand Prix next weekend.
The final race of the fourth round of the EMX125 European Championship took place this morning at Lausitzring and Pauls Jonass obtained a comfortable victory ahead of Calvin Vlaanderen and Anton Lundgren. During the German Grand Prix also took place the opening round of the Honda EMX150 series and British Mitchell Lewis became the first leader of the championship after winning with great authority today. Italians Alberto Forato and Filippo Grigoletto completed the top three.
Red Bull KTM Factory Racing's Antonio Cairoli felt really good during the whole weekend and he admitted that it was thanks to the fact that he was finally able to do some physical training before the weekend. The Italian found the track quite demanding and whereas in the first race he could not catch Clement Desalle and had to settle down with the second position, in the second race Cairoli took the holeshot and dominated the heat until the chequered flag. At the end of the event Cairoli explained that he really likes racing in places with outstanding facilities like the ones at Lausitzring and he believes that the FIM Motocross World Championship needs to go towards this direction.
Rockstar Energy Suzuki World's Clement Desalle finished tight in points with Cairoli but his 1-2 result made him finish on the second step of the podium. The Belgian rider explained that his start was not that good in the first moto, but he quickly found the good rhythm to take the lead and open a big gap with the rest of the riders. Desalle made several mistakes during the rest of the heat, but he succeeded to stay on two wheels and won the first race. In the second one he battled with Tommy Searle for the second position during a couple of laps, but in the end Desalle managed to open a gap with the British rider and started giving chase to Cairoli. However, Desalle could not catch the Italian and crossed the finish line second. Desalle is now second in the MX1 championship, but he is 108 points away from Cairoli.
The third overall position went for Red Bull KTM Factory Racing's Ken De Dycker after finishing fourth and third in today's races. The Belgian admitted that he struggled a lot with the heat, but in the end he was able to obtain two solid results and made it to the podium. De Dycker enjoyed riding the German track but he explained that if it had not been so hot, he would have been able to do it much better. The Belgian is now third in the point standings.
CLS Kawasaki Monster Energy Pro Circuit's Tommy Searle was a bit disappointed today as he missed the podium being tight in 38 points with De Dycker. In the first race Searle obtained a strong third place but in the second one he was only able to finish fourth. The British rider was second in the first lap of the second race, but Desalle was coming really fast from behind and after exchanging the second position several times, Searle could not follow the rhythm and dropped down to the fourth place.
Rockstar Energy Suzuki World's Kevin Strijbos struggled once again with his starts but as usual he was able to make two incredible recoveries. The Belgian finished fifth in both races, but while in the first one he started from the seventh place, in the second one Strijbos had to move up from an initial thirteenth position. Kevin Strijbos is still fifth in the championship and Tommy Searle is now 22 points away from the Belgian.
David Philippaerts obtained the best result of the season this weekend by finishing sixth overall. In the first race Philippaerts got stuck behind Karro and Guarneri when his compatriot crashed, and the Honda rider was down in the nineteenth position. However, Philippaerts managed to recover his rhythm and crossed the finish line in the eighth place. In the second heat Philippaerts was fifth after the start and he did his best to hold such position, but in the end he finished sixth.
Joel Roelants did also really good today and finished seventh overall thanks to his 6-9 result, whereas his compatriot Jeremy Van Horebeek was only able to finish eighth this weekend. Milko Potisek fulfil his goal for the weekend as he finished ninth overall and Matiss Karro completed the top ten.
Home rider Max Nagl is still struggling with some problems in his stomach and the high temperature today did not help the German rider to do well in front of his home crowd. Nagl finished twelfth in both races and finished fourteenth in the Grand Prix.
Rui Gonçalves obtained the Get Athena Holeshot Award in the first race, but unfortunately he crashed when he was racing a strong moto in fifth. The Portuguese rider was forced to retire after hitting his head heavily in the crash and he did not take part in the second moto as he was being examined carefully.
Red Bull KTM Factory Racing's Jeffrey Herlings had a perfect weekend at Lausitzring after dominating the qualifying race yesterday and wining both heats today. The red plate holder could not take the holeshot in any of the races, but he quickly moved to the lead and crossed the finish line of both motos with a comfortable advantage over the second classified. Next weekend Herlings will have the first opportunity to be proclaimed World Champion, so he is already looking forward to racing in Loket, Czech Republic.
It was not an easy weekend for his teammate Jordi Tixier who always suffers from stomach ache when it is so hot, but in the end he was very satisfied because he was able to finish second overall. In the first race he started fifth and after the first five laps he managed to overtake José Butrón and he was able to keep a consistent rhythm until the end of the race. With three laps to go Dean Ferris crashed while he was riding ahead of the French rider, so Tixier crossed the finish line third. In the second race Tixier took the holeshot and kept the lead during four laps, but he had to slow down because he was making a lot of mistakes and he was risking too much. Tixier crossed the finish line second, so he ended second in the Grand Prix.
Standing Construct KTM's Glenn Coldenhoff was visibly emotional when he crossed the finish line and realized he was third overall and had just obtained his maiden podium in the FIM MX2 World Championship. The Dutch rider gave it all in both races and at the end of the second one he was hardly able to stand up. Coldenhoff obtained a consistent third position in the first race, but in the second one he had to fight hard with Max Anstie to keep the third position until the chequered flag.
KTM Silver Action's José Butrón admitted that it has been a very tough weekend for him, but he was satisfied with his fourth overall position. In the first race the Spanish rider started third, but he struggled a lot to keep the rhythm and he was only able to cross the finish line in sixth. In the second race Butrón was determined to give it all and after a poor start in the twelfth position, he did an incredible recovery to finish fourth.
Rockstar Energy Suzuki Europe's Max Anstie had one of the best weekends of the season by finishing fifth overall. The British rider did not have a good start in the first race, but he managed to move from his initial thirteenth position to a final fourth place. Anstie was fifth after the start of the second race and in the second half of the moto he exchanged the third position with Glenn Coldenhoff who was riding third. In the end Anstie made a mistake when he was third and he had to settle down with a ninth place. This weekend's fourth overall position gives Anstie some extra motivation to face the upcoming weekends where he will give it all again to finish on the podium.
Dean Ferris was not really lucky this weekend even if he rode really well in both races. In the first one the Australian rider started second and at the end of the race Christophe Charlier overtook him and after four laps Ferris crashed and was only able to cross the finish line in ninth. In the second race Ferris started down in the tenth place, but he managed to find a good rhythm and crossed the finish line in fifth, which gave him an overall sixth place.
Jake Nicholls finished eighth in both races and ended seventh overall in the Grand Prix, followed by Christophe Charlier, who made an incredible first race finishing second, but he crashed in the first stages of the second race and a problem on his Yamaha forced him to retire.
Mel Pocock obtained the Get Athena Holeshot Award in the first race, but he crashed in the first lap and was only able to finish sixteenth. In the second race the British rider was sixth and finished ninth overall ahead of Harri Kullas.
The Grand Prix of Germany was broadcasted LIVE in Germany on Sport 1+, in the USA on Be In Sport, in France on Be In Sport 2 and Motors TV France, in Italy on SportItalia, in Slovenia on Sport TV, in Portugal on Sport TV3, in the UK on Motors TV UK, in Brazil on Bandsports, in Thailand on True Vision, in Africa on Al Jazeera Sport and Sport TV, in the Middle East on Al Jazeera Sport, in Europe on Motors TV Europe and worldwide onMX-LIFE.TV .
By clicking here you will be able to download the complete TV coverage of the MXGP of Germany.
After this outstanding event in a brand new track, the FIM Motocross World Championship is travelling to the old school track of Loket in the Czech Republic to celebrate the fourteenth Grand Prix of the season. The sixth round of the EMX250 European Championship and the fifth round of the EMX125 European series will also take place in Loket during the same weekend as the Czech Grand Prix.


text:
Label: DILTIAZEM HYDROCHLORIDE injection
Packager: Akorn, Inc.
Diltiazem hydrochloride injection is a calcium ion influx inhibitor (slow channel blocker or calcium channel antagonist). Chemically diltiazem hydrochloride is 1,5-benzothiazepin-4(5H)one,3-(acetyloxy)-5-[2-(dimethylamino)ethyl]-2, 3-dihydro-2-(4-methoxyphenyl)-, monohydrochloride, (+)-cis-. The structural formula is:
The molecular formula is C22H26N2O4S•HCl
Diltiazem hydrochloride is a white to off-white crystalline powder with a bitter taste. It is soluble in water, methanol, and chloroform. It has a molecular weight of 450.99.
Diltiazem hydrochloride injection is a clear, colorless, sterile, nonpyrogenic solution. It has a pH range of 3.7 to 4.1. Diltiazem hydrochloride injection is for direct intravenous bolus injection and continuous intravenous infusion.
Each mL contains: Active: 5 mg Diltiazem Hydrochloride. Inactives: 0.75 mg Citric Acid USP, 0.65 mg Sodium Citrate Dihydrate USP, 71.4 mg Sorbitol Solution USP, and Water for Injection USP up to 1 mL, Sodium Hydroxide and/or Hydrochloric Acid are used for pH adjustment.
Diltiazem inhibits the influx of calcium (Ca2+) ions during membrane depolarization of cardiac and vascular smooth muscle. The therapeutic benefits of diltiazem in supraventricular tachycardias are related to its ability to slow AV nodal conduction time and prolong AV nodal refractoriness. Diltiazem exhibits frequency (use) dependent effects on AV nodal conduction such that it may selectively reduce the heart rate during tachycardias involving the AV node with little or no effect on normal AV nodal conduction at normal heart rates.
Diltiazem slows the ventricular rate in patients with a rapid ventricular response during atrial fibrillation or atrial flutter. Diltiazem converts paroxysmal supraventricular tachycardia (PSVT) to normal sinus rhythm by interrupting the reentry circuit in AV nodal reentrant tachycardias and reciprocating tachycardias, eg, Wolff-Parkinson-White syndrome (WPW).
Diltiazem prolongs the sinus cycle length. It has no effect on the sinus node recovery time or on the sinoatrial conduction time in patients without SA nodal dysfunction. Diltiazem has no significant electrophysiologic effects on tissues in the heart that are fast sodium channel dependent, eg, His-Purkinje tissue, atrial and ventricular muscle, and extranodal accessory pathways.
Like other calcium antagonists, because of its effect on vascular smooth muscle, diltiazem decreases total peripheral resistance resulting in a decrease in both systolic and diastolic blood pressure.
In patients with cardiovascular disease, diltiazem hydrochloride administered intravenously in single bolus doses, followed in some cases by a continuous infusion, reduced blood pressure, systemic vascular resistance, the rate-pressure product, and coronary vascular resistance and increased coronary blood flow. In a limited number of studies of patients with compromised myocardium (severe congestive heart failure, acute myocardial infarction, hypertrophic cardiomyopathy), administration of intravenous diltiazem produced no significant effect on contractility, left ventricular end diastolic pressure, or pulmonary capillary wedge pressure.The mean ejection fraction and cardiac output/index remained unchanged or increased. Maximal hemodynamic effects usually occurred within 2 to 5 minutes of an injection. However, in rare instances, worsening of congestive heart failure has been reported in patients with pre-existing impaired ventricular function.
The prolongation of PR interval correlated significantly with plasma diltiazem concentration in normal volunteers using the Sigmoidal Emax model. Changes in heart rate, systolic blood pressure, and diastolic blood pressure did not correlate with diltiazem plasma concentration in normal volunteers. Reduction in mean arterial pressure correlated linearly with diltiazem plasma concentration in a group of hypertensive patients.
In patients with atrial fibrillation and atrial flutter, a significant correlation was observed between the percent reduction in HR and plasma diltiazem concentration using the Signmoidal Emax model. Based on this relationship, the mean plasma diltiazem concentration required to produce a 20% decrease in heart rate was determined to be 80 ng/mL. Mean plasma diltiazem concentrations of 130 ng/mL and 300 ng/mL were determined to produce reductions in heart rate of 30% to 40%.
Pharmacokinetics and Metabolism
Following a single intravenous injection in healthy male volunteers, diltiazem hydrochloride appears to obey linear pharmacokinetics over a dose range of 10.5 to 21 mg. The plasma elimination half-life is approximately 3.4 hours. The apparent volume of distribution of diltiazem hydrochloride is approximately 305 L. Diltiazem is extensively metabolized in the liver with a systemic clearance of approximately 65 L/h.
After constant rate intravenous infusion to healthy male volunteers, diltiazem exhibits nonlinear pharmacokinetics over an infusion range of 4.8 to 13.2 mg/h for 24 hours. Over this infusion range, as the dose is increased, systemic clearance decreases from 64 to 48 L/h while the plasma elimination half-life increases from 4.1 to 4.9 hours. The apparent volume of distribution remains unchanged (360 to 391 L). In patients with atrial fibrillation or atrial flutter, diltiazem systemic clearance has been found to be decreased compared to healthy volunteers. In patients administered bolus doses ranging from 2.5 mg to 38.5 mg, systemic clearance averaged 36 L/h. In patients administered continuous infusions at 10 mg/h or 15 mg/h for 24 hours, diltiazem systemic clearance averaged 42 L/h and 31 L/h, respectively.
Based on the results of pharmacokinetic studies in healthy volunteers administered different oral diltiazem hydrochloride formulations, constant rate intravenous infusions of diltiazem hydrochloride at 3, 5, 7, and 11 mg/h are predicted to produce steady-state plasma diltiazem concentrations equivalent to 120-, 180-, 240-, and 360-mg total daily oral doses of diltiazem hydrochloride tablets or capsules.
After oral administration, diltiazem hydrochloride undergoes extensive metabolism in man by deacetylation, N-demethylation, and O-demethylation via cytochrome P-450 (oxidative metabolism) in addition to conjugation. Metabolites N-monodesmethyldiltiazem, desacetyldiltiazem, desacetyl-N-monodesmethyldiltiazem, desacetyl-O-desmethyldiltiazem, and desacetyl-N, O-desmethyldiltiazem have been identified in human urine. Following oral administration, 2% to 4% of the unchanged diltiazem appears in the urine. Drugs which induce or inhibit hepatic microsomal enzymes may alter diltiazem disposition.
Following single intravenous injection of diltiazem hydrochloride, however, plasma concentrations of N-monodesmethyldiltiazem and desacetyldiltiazem, two principal metabolites found in plasma after oral administration, are typically not detected. These metabolites are observed, however, following 24 hour constant rate intravenous infusion. Total radioactivity measurement following short IV administration in healthy volunteers suggests the presence of other unidentified metabolites which attain higher concentrations than those of diltiazem and are more slowly eliminated; half-life of total radioactivity is about 20 hours compared to 2 to 5 hours for diltiazem.
Diltiazem hydrochloride is 70% to 80% bound to plasma proteins. In vitro studies suggest alpha1-acid glycoprotein binds approximately 40% of the drug at clinically significant concentrations. Albumin appears to bind approximately 30% of the drug, while other constituents bind the remaining bound fraction. Competitive in vitro ligand binding studies have shown that diltiazem binding is not altered by therapeutic concentrations of digoxin, phenytoin, hydrochlorothiazide, indomethacin, phenylbutazone, propranolol, salicylic acid, tolbutamide, or warfarin.
Renal insufficiency, or even end-stage renal disease, does not appear to influence diltiazem disposition following oral administration. Liver cirrhosis was shown to reduce diltiazem's apparent oral clearance and prolong its half-life.
Diltiazem hydrochloride injection is indicated for the following:
Atrial Fibrillation or Atrial Flutter. Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter. It should not be used in patients with atrial fibrillation or atrial flutter associated with an accessory bypass tract such as in Wolff-Parkinson-White (WPW) syndrome or short PR syndrome.
Paroxysmal Supraventricular Tachycardia. Rapid conversion of paroxysmal supraventricular tachycardias (PSVT) to sinus rhythm. This includes AV nodal reentrant tachycardias and reciprocating tachycardias associated with an extranodal accessory pathway such as the WPW syndrome or short PR syndrome. Unless otherwise contraindicated, appropriate vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection.
The use of diltiazem hydrochloride injection for control of ventricular response in patients with atrial fibrillation or atrial flutter or conversion to sinus rhythm in patients with PSVT should be undertaken with caution when the patient is compromised hemodynamically or is taking other drugs that decrease any or all of the following: peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium.
For either indication and particularly when employing continuous intravenous infusion, the setting should include continuous monitoring of the ECG and frequent measurement of blood pressure. A defibrillator and emergency equipment should be readily available.
In domestic controlled trials in patients with atrial fibrillation or atrial flutter, bolus administration of diltiazem hydrochloride injection was effective in reducing heart rate by at least 20% in 95% of patients. Diltiazem hydrochloride injection rarely converts atrial fibrillation or atrial flutter to normal sinus rhythm. Following administration of one or two intravenous bolus doses of diltiazem hydrochloride injection, response usually occurs within 3 minutes and maximal heart rate reduction generally occurs in 2 to 7 minutes. Heart rate reduction may last from 1 to 3 hours. If hypotension occurs, it is generally short-lived, but may last from 1 to 3 hours.
A 24-hour continuous infusion of diltiazem hydrochloride injection in the treatment of atrial fibrillation or atrial flutter maintained at least a 20% heart rate reduction during the infusion in 83% of patients. Upon discontinuation of infusion, heart rate reduction may last from 0.5 hours to more than 10 hours (median duration 7 hours). Hypotension, if it occurs, may be similarly persistent.
In the controlled clinical trials, 3.2% of patients required some form of intervention (typically, use of intravenous fluids or the Trendelenburg position) for blood pressure support following diltiazem hydrochloride injection.
In domestic controlled trials, bolus administration of diltiazem hydrochloride injection was effective in converting PSVT to normal sinus rhythm in 88% of patients within 3 minutes of the first or second bolus dose.
Symptoms associated with the arrhythmia were improved in conjunction with decreased heart rate or conversion to normal sinus rhythm following administration of diltiazem hydrochloride injection.
Diltiazem hydrochloride injection is contraindicated in:
Patients with sick sinus syndrome except in the presence of a functioning ventricular pacemaker.
Patients with second- or third-degree AV block except in the presence of functioning ventricular pacemaker.
Patients with severe hypotension or cardiogenic shock.
Patients who have demonstrated hypersensitivity to the drug.
Intravenous diltiazem and intravenous beta-blockers should not be administered together or in close proximity (within a few hours).
Patients with atrial fibrillation or atrial flutter associated with an accessory bypass tract such as in WPW syndrome or short PR syndrome.
As with other agents which slow AV nodal conduction and do not prolong the refractoriness of the accessory pathway (eg, verapamil, digoxin), in rare instances patients in atrial fibrillation or atrial flutter associated with an accessory bypass tract may experience a potentially life-threatening increase in heart rate accompanied by hypotension when treated with diltiazem hydrochloride injection. As such, the initial use of diltiazem hydrochloride injection should be, if possible, in a setting where monitoring and resuscitation capabilities, including DC cardioversion/defibrillation, are present (see OVERDOSAGE). Once familiarity of the patient's response is established, use in an office setting may be acceptable.
Patients with ventricular tachycardia. Administration of other calcium channel blockers to patients with wide complex tachycardia (QRS = 0.12 seconds) has resulted in hemodynamic deterioration and ventricular fibrillation. It is important that an accurate pretreatment diagnosis distinguish wide complex QRS tachycardia of supraventricular origin from that of ventricular origin prior to administration of diltiazem hydrochloride injection.
Cardiac Conduction. Diltiazem prolongs AV nodal conduction and refractoriness that may rarely result in second- or third-degree AV block or sinus rhythm. Concomitant use of diltiazem with agents known to affect cardiac conduction may result in additive effects (see PRECAUTIONS, Drug Interactions). If high-degree AV block occurs in sinus rhythm, intravenous diltiazem should be discontinued and appropriate supportive measures instituted (see OVERDOSAGE).
Congestive Heart Failure. Although diltiazem has a negative inotropic effect in isolated animal tissue preparations, hemodynamic studies in humans with normal ventricular function and in patients with a compromised myocardium, such as severe CHF, acute MI, and hypertrophic cardiomyopathy, have not shown a reduction in cardiac index nor consistent negative effects on contractility (dp/dt). Administration of oral diltiazem in patients with acute myocardial infarction and pulmonary congestion documented by x-ray on admission is contraindicated. Experience with the use of diltiazem hydrochloride injection in patients with impaired ventricular function is limited. Caution should be exercised when using the drug in such patients.
Hypotension. Decreases in blood pressure associated with diltiazem hydrochloride injection therapy may occasionally result in symptomatic hypotension (3.2%). The use of intravenous diltiazem for control of ventricular response in patients with supraventricular arrhythmias should be undertaken with caution when the patient is compromised hemodynamically. In addition, caution should be used in patients taking other drugs that decrease peripheral resistance, intravascular volume, myocardial contractility or conduction.
Acute Hepatic Injury. In rare instances, significant elevations in enzymes such as alkaline phosphatase, LDH, SGOT, SGPT, and other phenomena consistent with acute hepatic injury have been noted following oral diltiazem. Therefore, the potential for acute hepatic injury exists following administration of intravenous diltiazem.
Ventricular Premature Beats (VPBs). VPBs may be present on conversion of PSVT to sinus rhythm with diltiazem hydrochloride injection. These VPBs are transient, are typically considered to be benign, and appear to have no clinical significance. Similar ventricular complexes have been noted during cardioversion, other pharmacologic therapy, and during spontaneous conversion of PSVT to sinus rhythm.
Diltiazem hydrochloride is extensively metabolized by the liver and excreted by the kidneys and in bile. The drug should be used with caution in patients with impaired renal or hepatic function (see WARNINGS). High intravenous dosages (4.5 mg/kg tid) administered to dogs resulted in significant bradycardia and alterations in AV conduction. In subacute and chronic dog and rat studies designed to produce toxicity, high oral doses of diltiazem were associated with hepatic damage. In special subacute hepatic studies, oral doses of 125 mg/kg and higher in rats were associated with histological changes in the liver, which were reversible when the drug was discontinued. In dogs, oral doses of 20 mg/kg were also associated with hepatic changes; however, these changes were reversible with continued dosing.
Dermatologic events progressing to erythema multiforme and/or exfoliative dermatitis have been infrequently reported following oral diltiazem. Therefore, the potential for these dermatologic reactions exists following exposure to intravenous diltiazem. Should a dermatologic reaction persist, the drug should be discontinued.
Due to potential for additive effects, caution is warranted in patients receiving diltiazem hydrochloride injection concomitantly with other agent(s) known to affect cardiac contractility and/or SA or AV node conduction (see WARNINGS).
As with all drugs, care should be exercised when treating patients with multiple medications. Diltiazem hydrochloride undergoes extensive metabolism by the cytochrome P-450 mixed function oxidase system. Although specific pharmacokinetic drug-drug interaction studies have not been conducted with single intravenous injection or constant rate intravenous infusion, coadministration of diltiazem hydrochloride injection with other agents which primarily undergo the same route of biotransformation may result in competitive inhibition of metabolism.
Digitalis. Intravenous diltiazem has been administered to patients receiving either intravenous or oral digitalis therapy. The combination of the two drugs was well tolerated without serious adverse effects. However, since both drugs affect AV nodal conduction, patients should be monitored for excessive slowing of the heart rate and/or AV block.
Beta-blockers. Intravenous diltiazem has been administered to patients on chronic oral beta-blocker therapy. The combination of the two drugs was generally well tolerated without serious adverse effects. If intravenous diltiazem is administered to patients receiving chronic oral beta-blocker therapy, the possibility for bradycardia, AV block, and/or depression of contractility should be considered (see CONTRAINDICATIONS). Oral administration of diltiazem with propranolol in five normal volunteers resulted in increased propranolol levels in all subjects and bioavailability of propranolol was increased approximately 50%. In vitro, propranolol appears to be displaced from its binding sites by diltiazem.
Anesthetics. The depression of cardiac contractility, conductivity, and automaticity as well as the vascular dilation associated with anesthetics may be potentiated by calcium channel blockers. When used concomitantly, anesthetics and calcium blockers should be titrated carefully.
Cyclosporine. A pharmacokinetic interaction between diltiazem and cyclosporine has been observed during studies involving renal and cardiac transplant patients. In renal and cardiac transplant recipients, a reduction of cyclosporine dose ranging from 15% to 48% was necessary to maintain cyclosporine trough concentrations similar to those seen prior to the addition of diltiazem. If these agents are to be administered concurrently, cyclosporine concentrations should be monitored, especially when diltiazem therapy is initiated, adjusted or discontinued.
The effect of cyclosporine on diltiazem plasma concentrations has not been evaluated.
Carbamazepine. Concomitant administration of oral diltiazem with carbamazepine has been reported to result in elevated plasma levels of carbamazepine (by 40 to 72%), resulting in toxicity in some cases. Patients receiving these drugs concurrently should be monitored for a potential drug interaction.
A 24-month study in rats at oral dosage levels of up to 100 mg/kg/day, and a 21-month study in mice at oral dosage levels of up to 30 mg/kg/day showed no evidence of carcinogenicity. There was also no mutagenic response in vitro or in vivo in mammalian cell assays or in vitro in bacteria. No evidence of impaired fertility was observed in a study performed in male and female rats at oral dosages of up to 100 mg/kg/day.
Category C. Reproduction studies have been conducted in mice, rats, and rabbits. Administration of oral doses ranging from five to ten times greater (on a mg/kg basis) than the daily recommended oral antianginal therapeutic dose has resulted in embryo and fetal lethality. These doses, in some studies, have been reported to cause skeletal abnormalities. In the perinatal/postnatal studies there was some reduction in early individual pup weights and survival rates. There was an increased incidence of stillbirths at doses of 20 times the human oral antianginal dose or greater.
There are no well-controlled studies in pregnant women; therefore, use diltiazem hydrochloride injection in pregnant women only if the potential benefit justifies the potential risk to the fetus.
Diltiazem is excreted in human milk. One report with oral diltiazem suggests that concentrations in breast milk may approximate serum levels. If use of diltiazem is deemed essential, an alternative method of infant feeding should be instituted.
The following adverse reaction rates are based on the use of diltiazem hydrochloride injection in over 400 domestic clinical trial patients with atrial fibrillation/flutter or PSVT under double-blind or open-label conditions. Worldwide experience in over 1300 patients was similar.
Adverse events reported in controlled and uncontrolled clinical trials were generally mild and transient. Hypotension was the most commonly reported adverse event during clinical trials. Asymptomatic hypotension occurred in 4.3% of patients. Symptomatic hypotension occurred in 3.2% of patients. When treatment for hypotension was required, it generally consisted of administration of saline or placing the patient in the Trendelenburg position. Other events reported in at least 1% of the diltiazem-treated patients were injection site reactions (eg, itching, burning) - 3.9%, vasodilation (flushing) -1.7%, and arrhythmia (junctional rhythm or isorhythmic dissociation) - 1.0%.
In addition, the following events were reported infrequently (less than 1%):
Cardiovascular: Asystole, atrial flutter, AV block first degree, AV block second degree, bradycardia, chest pain, congestive heart failure, sinus pause, sinus node dysfunction, syncope, ventricular arrhythmia, ventricular fibrillation, ventricular tachycardia.
Dermatologic: Pruritus, sweating
Gastrointestinal: Constipation, elevated SGOT or alkaline phosphatase, nausea, vomiting
Nervous System: Dizziness, paresthesia
Other: Amblyopia, asthenia, dry mouth, dyspnea, edema, headache, hyperuricemia.
Although not observed in clinical trials with diltiazem hydrochloride injection, the following events associated with oral diltiazem may occur:
Cardiovascular: AV block (third degree), bundle branch block, ECG abnormality, palpitations, syncope, tachycardia, ventricular extrasystoles
Dermatologic: Alopecia, erythema multiforme (including Stevens-Johnson syndrome, toxic epidermal necrolysis) exfoliative dermatitis, leukocytoclastic vasculitis, petechiae, photosensitivity, purpura, rash, urticaria
Gastrointestinal: Anorexia, diarrhea, dysgeusia, dyspepsia, mild elevations of SGPT and LDH, thirst, weight increase
Nervous System: Abnormal dreams, amnesia, depression, extrapyramidal symptoms, gait abnormality, hallucinations, insomnia, nervousness, personality change, somnolence, tremor
Other: Allergic reactions, angioedema (including facial or periorbital edema), CPK elevation, epistaxis, eye irritation, gingival hyperplasia, hemolytic anemia, hyperglycemia, impotence, increased bleeding time, leukopenia, muscle cramps, nasal congestion, nocturia, osteoarticular pain, polyuria, retinopathy, sexual difficulties, thrombocytopenia, tinnitus Events such as myocardial infarction have been observed which are not readily distinguishable from the natural history of the disease for the patient.
Overdosage experience is limited. In the event of overdosage or an exaggerated response, appropriate supportive measures should be employed. The following measures may be considered:
Bradycardia: Administer atropine (0.6 to 1.0 mg). If there is no response to vagal blockade administer isoproterenol cautiously.
High-degree AV Block: Treat as for bradycardia above. Fixed high-degree AV block should be treated with cardiac pacing.
Cardiac Failure: Administer inotropic agents (isoproterenol, dopamine, or dobutamine) and diuretics.
Hypotension: Vasopressors (eg, dopamine or levarterenol bitartrate).
Actual treatment and dosage should depend on the severity of the clinical situation and the judgment and experience of the treating physician.
Diltiazem does not appear to be removed by peritoneal or hemodialysis. Limited data suggest that plasmapheresis or charcoal hemoperfusion may hasten diltiazem elimination following overdose.
The intravenous LD50's in mice and rats were 60 to 38 mg/kg, respectively. The toxic dose in man is not known.
Direct Intravenous Single Injections (Bolus)
The initial dose of diltiazem hydrochloride injection should be 0.25 mg/kg actual body weight as a bolus administered over 2 minutes (20 mg is a reasonable dose for the average patient). If response is inadequate, a second dose may be administered after 15 minutes. The second bolus dose of diltiazem hydrochloride injection should be 0.35 mg/kg actual body weight administered over 2 minutes (25 mg is a reasonable dose for the average patient). Subsequent intravenous bolus doses should be individualized for each patient. Patients with low body weights should be dosed on a mg/kg basis. Some patients may respond to an initial dose of 0.15 mg/kg, although duration of action may be shorter. Experience with this dose is limited.
Continuous Intravenous Infusion
For continued reduction of the heart rate (up to 24 hours) in patients with atrial fibrillation or atrial flutter, an intravenous infusion of diltiazem hydrochloride injection may be administered. Immediately following bolus administration of 20 mg (0.25 mg/kg) or 25 mg (0.35 mg/kg) diltiazem hydrochloride injection and reduction of heart rate, begin an intravenous infusion of diltiazem hydrochloride injection. The recommended initial infusion rate of diltiazem hydrochloride injection is 10 mg/h. Some patients may maintain response to an initial rate of 5 mg/h. The infusion rate may be increased in 5 mg/h increments up to 15 mg/h as needed, if further reduction in heart rate is required, the infusion may be maintained for up to 24 hours.
Diltiazem shows dose-dependent, non-linear pharmacokinetics. Duration of infusion longer than 24 hours and infusion rates greater than 15 mg/h have not been studied. Therefore, infusion duration exceeding 24 hours and infusion rates exceeding 15 mg/h are not recommended.
Dilution: To prepare diltiazem hydrochloride injection for continuous intravenous infusion aseptically transfer the appropriate quantity (see chart) of diltiazem hydrochloride injection to the desired volume of either Normal Saline, D5W, or D5W/0.45% NaCl. Mix thoroughly. Use within 24 hours. Keep refrigerated until use.
* 5 mg/h may be appropriate for some patients.
Diluent
Volume Quantity of
Diltiazem Hydrochloride
Injection to Add Final
Concentration Administration
Dose* Infusion Rate
100 mL 125 mg (25 mL) 1 mg/mL 10 mg/h
15 mg/h 10 mL/h
15 mL/h
250 mL 250 mg (50 mL) 0.83 mg/mL 10 mg/h
Diltiazem hydrochloride injection was tested for compatibility with three commonly used intravenous fluids at a maximal concentration of 1 mg diltiazem hydrochloride per milliliter. Diltiazem hydrochloride injection was found to be physically compatible and chemically stable in the following parenteral solutions for at least 24 hours when stored in glass or polyvinylchloride (PVC) bags at controlled room temperature 15° to 30°C (59° to 86°F) or under refrigeration 2° to 8°C (36° to 46°F).
dextrose (5%) injection USP
sodium chloride (0.9%) injection USP
dextrose (5%) and sodium chloride (0.45%) injection USP
Because of potential physical incompatibilities, it is recommended that diltiazem hydrochloride injection not be mixed with any other drugs in the same container.
If possible, it is recommended that diltiazem hydrochloride injection not be co-infused in the same intravenous line. Physical incompatibilities (precipitate formation or cloudiness) were observed when diltiazem hydrochloride injection was infused in the same intravenous line with the following drugs: acetazolamide, acyclovir, aminophylline, ampicillin, ampicillin sodium/sulbactam sodium, cefamandole, cefoperazone, diazepam, furosemide, hydrocortisone, sodium succinate, insulin (regular: 100 units/mL), methylprednisolone sodium succinate, mezlocillin, nafcillin, phenytoin, rifampin, and sodium bicarbonate.
Parental drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.
Transition to Further Antiarrhythmic Therapy
Transition to other antiarrhythmic agents following administration of diltiazem hydrochloride injection is generally safe. However, reference should be made to the respective agent manufacturer's package insert for information relative to dosage and administration.
In controlled clinical trials, therapy with antiarrhythmic agents to maintain reduced heart rate in atrial fibrillation or atrial flutter or for prophylaxis of PSVT was generally started within 3 hours after bolus administration of diltiazem hydrochloride injection. These antiarrhythmic agents were intravenous or oral digoxin, Class I antiarrhythmics (eg, quinidine, procainamide), calcium channel blockers, and oral beta-blockers.
Experience in the use of antiarrhythmic agents following maintenance infusion of diltiazem hydrochloride injection is limited. Patients should be dosed on an individual basis and reference should be made to respective manufacturer's package insert for information relative to dosage and administration.
How Supplied:
Diltiazem Hydrochloride Injection, 0.5% (5 mg/mL) is supplied:
NDC 17478-937-05 5 mL single-dose vial in packages of 10
NDC 17478-937-10 10 mL single-dose vial in packages of 10
NDC 17478-937-25 25 mL single-dose vial in package of one
NDC 17478-937-26 25 mL single-dose vial in packages of 10 contains 25 mL vial (NDC 17478-937-25)
SINGLE-DOSE CONTAINERS. DISCARD UNUSED PORTION.
Storage: Store under refrigeration 2° to 8°C (36° to 46°F). DO NOT FREEZE. May be stored at room temperature for up to 1 month. Destroy after 1 month at room temperature.
Manufactured by: Akorn, Inc.
DH00N
Rev. 05/18
Principal Display Panel Text for Container Label:
Hydrochloride Injection
25 mg/5 mL (5 mg/mL)
5 mL Single-dose Vial
For Direct I.V. Bolus Injection and Continuous I.V. Infusion.
Principal Display Panel Text for Carton Label:
Diltiazem Hydrochloride Injection
For Direct Intravenous Bolus Injection and Continuous Intravenous Infusion
Warning: SINGLE-DOSE CONTAINERS. DISCARD UNUSED PORTION.
10 Sterile Vials (5 mL each)
Rx only Akorn Logo
Route of Administration INTRAVENOUS
Diltiazem Hydrochloride (UNII: OLH94387TE) (Diltiazem - UNII:EE92BBP03H) Diltiazem Hydrochloride 5 mg in 1 mL
citric acid monohydrate (UNII: 2968PHW8QP)
sorbitol (UNII: 506T60A25R)
sodium hydroxide (UNII: 55X04QC32I)
NDC:17478-937-05 10 in 1 CARTON 12/21/2006
5 mL in 1 VIAL; Type 0: Not a Combination Product
10 mL in 1 VIAL; Type 0: Not a Combination Product
Labeler - Akorn, Inc. (117696770)
Registrant - Akorn Operating Company LLC (117693100)
Akorn, Inc. 117696832 MANUFACTURE(17478-937) , ANALYSIS(17478-937) , STERILIZE(17478-937)
Akorn, Inc 117696790 PACK(17478-937) , LABEL(17478-937)
1 1791229 dilTIAZem hydrochloride 25 MG in 5 mL Injection PSN
2 1791229 5 ML diltiazem hydrochloride 5 MG/ML Injection SCD
3 1791229 diltiazem hydrochloride 25 MG per 5 ML Injection SY
4 1791232 dilTIAZem hydrochloride 50 MG in 10 mL Injection PSN
5 1791232 10 ML diltiazem hydrochloride 5 MG/ML Injection SCD
6 1791232 diltiazem hydrochloride 50 MG per 10 ML Injection SY
7 1791233 dilTIAZem hydrochloride 125 MG in 25 mL Injection PSN
9 1791233 diltiazem hydrochloride 125 MG per 25 ML Injection SY
https://dailymed.nlm.nih.gov/dailymed/labelrss.cfm?setid=5e36488b-8f2d-4dc9-b803-af1829e6fdd0

redpajama_set_name: RedPajamaCommonCrawl


The Crystal Devotion Biodegradable Cremation Ashes Urn is made from a biodegradable thermoplastic material called Arboform. This urn will remain intact and will not start degrading until it is buried in soil and so can be used as an ornamental urn. If ground burial is chosen, this urn will take 5-8 years to degrade. The urn features a push on lid, which can be further sealed using an appropriate sealant.
The urn consists of Crystals in a flower design to signify the dedication and love for your close one. It comes in two different finishes.


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redpajama_set_name: RedPajamaGithub


Investment firms face ongoing pressures on their client reporting functions and are having to look for ways to do more with less. We believe the client reporting industry is entering a third phase in its evolution and one that can help firms to meet these challenges head on.
Reporting as a Service is a registered trade mark of Opus Nebula Limited.
Company Number 9270336. Registered in England and Wales.


text:
Britney Spears Brings Colton Haynes Onstage During "Freakshow" & Her Reaction Is Everything — VIDEO
By Kristie Rohwedder
Astrid Stawiarz/Getty Images Entertainment/Getty Images
The Piece of Me residency's summer 2016 hiatus is over, so you know what that means (ya know, other than the obvious "the Queen of Las Vegas has returned to her throne on the Strip" answer)— Brit Brit's back to putting lucky audience members in harnesses and parading them across the stage. On Wednesday evening, the show took a turn for the Roy-mazing when the "Make Me..." singer unknowingly invited a certain small screen star to join her while she performed her hit 2007 song "Freakshow." As Entertainment Weekly points out, Britney Spears brought Colton Haynes onstage, walked the Arrow star on a leash, and gave the audience somethin' so outside the norm.
Shortly after the presumably life-altering moment happened, Hayes shared a clip of the presumably life-altering moment on Instagram. Though Spears did not recognize the Teen Wolf actor, she sure did tip her fedora to his good looks and good dance moves. Oh, and she autographed a T-shirt for him. Such a lucky duck, that Colton Haynes!
Here are all of the things that happen in the Instagram video that I love/envy from the bottom of my broken heart, ranked (because why not?).
6. Britney Spears Told Him To Call Her Anytime
Reason for rank: Augh, what a dream. This would've been no. 2 if the pair actually exchanged digits onstage and became buddies; I would've been all about a friendship that has "Freakshow" to thank.
5. Britney Spears Called Him Beautiful
RFR: Ahwooga! (Yeah, it's an obvious observation, but that doesn't make it any less excellent.)
4. Britney Spears Complimented His Rear End
RFR: AHWOOGA! (And yeah, this also happens to be an obvious observation. Again, that doesn't make it any less excellent.)
3. Britney Spears Signed A T-shirt For Him While He Held Said T-shirt Against His Own Torso
RFR: Welp, "Hold It Against Me" is stuck in my head (and I'm not mad at it).
2. Britney Spears Complimented His Dancing
RFR: His dance moves were praised by Danceney. That'd be like Oz from Buffy the Vampire Slayer complimenting your werewolfness, i.e., a phenomenal compliment.
1. He Was Onstage With Britney Spears
RFR: To share the stage with The Legendary Ms. Britney Spears is an unparalleled honor.
Truly a moment for the ages.
He's so lucky, he's a star!
Images: britneyspearsgifs/tumblr (6)


From delivery costs to workforce challenges, reliable timely data on the early years and childcare sector is hard to come by. The About Early Years research programme was launched by independent EY research experts Ceeda, to fill this gap.
We carry out research across the year with a representative panel of registered day nurseries, pre-schools and childminders. Working with a sector-led advisory group, the programme delivers timely, relevant analysis you can use with confidence. Get involved and join the panel, you will enjoy tailored analysis to support your planning and inform policy direction too.
A brilliant and wide-ranging discussion was had at the recent About Early Years Workforce Roundtable, with thought provoking presentations from June O'Sullivan MBE, Chief Executive of LEYF, Julie Hyde, Director at CACHE and Guy Browning, Sunday Times cartoonist and Guardian columnist. Download all the insights, including speaker presentations and thoughts and ideas shared in discussions HERE. We look forward to sharing news on any future developments occurring as a result of the event - register for our newsletter to make sure we keep you posted.
All the latest figures on costs, funding shortfalls, capacity, quality, business confidence and operating conditions are rounded up in our annual report, a must read for every decision-maker in early years.
Download free from our reports page, or order our enhanced report package with supporting spreadsheets.


text:
Il Principe del Deserto
By James Southall Monday January 14, 2013
Composed by Ennio Morricone
GDM / 2012 / 77:14
A 1989 miniseries with a decent cast (Rutger Hauer, Omar Sharif, Elliot Gould), Il Principe del Deserto was an action/adventure in which a group of mercenaries tries to rescue a boy kidnapped from his mother by his father. It was written by Sergio Donati amongst others and directed by Duccio Tessari.
Ennio Morricone's score is highlighted by two outstanding romantic themes, "Il figlio e la nostalgia" and "Il principe del deserto". They both employ Edda dell'Orso-style wordless vocals (performed in this case by Pina Magri); the former is a kind of instrumental song form (for orchestra), the latter a grander affair with added choir that sounds a little like certain parts of the more melodic moments of the composer's magnificent Secret of the Sahara. Its solo violin arrangement in "Attimi d'amore" is spectacularly beautiful. "Dissolvenze desertiche" presents another fine variation on the theme, Morricone adding in a loneliness and longing with a pan flute solo. Less immediately striking but on closer examination also very beautiful is the standalone "Morte di Mulay", a reflective piece highlighting a lovely oboe solo.
Another standalone piece which is really wonderful is the fantastically-named "Ninna nanna per un'insonnia", which is like a more pleasant variation on the theme from Desert of the Tartars. There's some fine action material too – "Il Nonno" features some dynamic brass material and is a really thrilling piece. "Arrivano" features a wonderfully triumphant brassy fanfare which appears out of nowhere but is a little gem of a track in the middle of the album. "Insolita rincorsa" is a really vibrant piece of action, more of that trademark layered Morricone brass proving as effective as ever. Slightly less impressive (on CD at least) are some of the suspense cues, which make rather difficult listening, but there are some fine ones too – "Preparazione alla corsa" opens with a plaintive melody before some strident string and brass work make an uncomfortably – impressively – tense closing half to the cue. A 46-minute album was released at the time the show was first aired (1991); more recently, there have been two expanded editions from GDM, most recently this album which features the 77-minute complete score, remastered. To tell the truth, most of the extra half-hour of music is made up of variations on what was already there, but it's easily reprogrammed to give the original album sequence (which is a much stronger listen). Morricone visited very similar musical territory a few years later in I Guardiani del Cielo, which is a bit better, but this still has an awful lot to offer.
Rating: ****
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Tags: Ennio Morricone, GDM, Il Principe del Deserto soundtrack review
Gorbadoc (Reply) on Tuesday 15 January, 2013 at 09:15
I really like the huge amount of Morricone reviews you're providing (I also consider him the best film composer of all time), it makes me discover scores I hadn't heard of before (like this one, I'm excited to get to know it!). Keep up the excellent work!
Maarten (Reply) on Tuesday 15 January, 2013 at 21:43
Gorbadoc: That's the same for me! I have about 20+ Morricone CD's, in my collection, so there remains a lot waiting to be discovered for me. I never heard of this series or music. After reading this great review, I immediately bought the CD on i-Tunes. I'm sure I won't regret it!


Antonio was born ca. 1635 in Rimini (Italy). He died in 1700 in Vienna, where he lived the major part of his working life. He entered the dowager Empress (widow of the Austrian Emperor Ferdinand III) Eleonora's service in Vienna in 1658. From 1682 until his death in 1700 he was imperial court Kapellmeister in Vienna. Besides chamber music he composed more than 170 operas and more than 40 oratorios. He also composed religious music: two masses, three hymns and a Stabat Mater are preserved.
The text is according to "Analecta", but only stanzas 1 - 6 and 19 and 20 are used.
This cd is a live registration of the annual concert organized by the Dutch Stabat Mater Foundation and performed on April 6, 2014 in the St. Petrus church at Oirschot.
The CD is a recording of the annual concert of the Stabat Mater Foundation in Oirschot in the first weekend of April 2017.


The workout arrangement with the reps of 21-15-9 is always fun, never too long.
One of my favorite combination for this type of workout I did recently.
The box jumps are the rest. Handstand pushups are the fun part and the deadlift the heavy one. The time cap we got was 15 minutes.
Before we started I thought I wouldn´t be able to finish on time. But I finished with a big smile with at least 2 minutes to spare, as I´ve said, I often fail to look at the clock.
For some exercises 21 is a high number of reps. If the weight is heavy I go for fewer reps at a time and shorter brakes instead. For the first 21 I either use 11-10 or 8-7-6. Or even use the multiplication table and do 7-7-7, then 5-5-5 with the 15 or the better version 8-7 and end with 3-3-3 or 5-4.
But often I do the last round of 9 unbroken. Cause after you´ve already done 36 reps, 9 more aren´t that bad.
Even though I have theses numbers prepared in my head before I start, they don´t control how I break. That is just if the weight is too heavy to proceed. But I still think of the number in my head and use it to count, like I start with one box jump, then count up to 8, then the next jump I don't say 9, but 7. So after I´ve counted the half way up, I start counting down.
Even though I am fond of the handstand push up, I do not excel at it, I keep falling down. I go in with my number plan but then fall down in the middle of my counting. So movements like that don't fit very well in with exercises that you often have a no rep in, but can use as a guideline of how far you have come.
I really like the more complex movements as the handstand push ups and muscle ups, that are body weight but still harder than the usual air squat or sit ups.


If you enjoy playing bridge, bring your players.
$10.00 per person tickets on sale next weekend.
Please join us in praying the Rosary on Sunday, October 7th at 4 p.m.
at St. Ignatius Parish on Sunday October 7, at 4:00 p.m.
We have registered for this COAST to COAST Event.
St. Ignatius the Martyr Parish Fundraiser For Special 60th Anniversary Project May 2019.
Pilgrimage to Camino de Compostela Final Stage with Spiritual Leader Father Jeremiah Budau, OFM Conv.
for light refreshments and a friendly get-together.
NEXT MEETING Tuesday, September 4, 2018 7:00 p.m. Parish Hall Our meetings are open to parishioners.
The Parish Financial Statement was available with the bulletin No. 652, the week of March 18, 2018.
Everyone is invited to the meeting, on Monday, March 19, at 7 p.m. in the church hall.
Members of the Finance Council were be on hand to review the statement and address questions and concerns.
WILL BE HELD AFER THE MASSES ON MAY 5 AND 6, 2018 in the church hall. Everyone is invited to the meeting.
Christmas Luncheon - members will be contacted by phone or email to confirm attendance.
NEXT MEETING Tuesday, JANUARY 15 10 A.M. IN THE PARISH HALL.
making sleeping mats for disaster victims.
Our Autumn collection - Socks and Undergarments for the homeless of Ottawa.
Also collecting Jars of Peanut butter and Crackers for organizations helping those in need in the city of Ottawa. Details in the weekly bulletins.
March 5, 2019 Shrove Tuesday Fundraiser.
Coats for Kids Project Autumn 2018..
on Tuesday, March 27, 2018 in the Church Hall at 7p.m.
FUNDRAISING COMMITTEE meeting April 8 after the 10:00 a.m. Mass.
Saturday, December 8, 12:00 noon - 5:00 pm - Parish Hall. and Sunday December 9 after the 10 a.m. mass.
This fundraiser will help with the repairs for the church.
It was an evening of music, dancing, singing, listening, and enjoying.


text:
Methodist Women's Hospital Visiting Hours and Policy
Visitor hours at Methodist Women's Hospital are 5 a.m. to 9 p.m.
EFFECTIVE MONDAY, OCTOBER 17, 2022:
Masking is optional at some Methodist Health System clinics.
When visiting a Methodist Clinic – please be mindful of the posted signage indicating if a mask is required.
Our staff are also happy to assist and provide clarification.
Hospitals and Clinics within Acute Care Hospitals:
All adult and child visitors/support persons will continue to be screened and must be capable of wearing well-fitted, hospital-grade, multilayer procedural masks.
Fabric masks, gaiters, vented masks, face shields and bandanas are not allowed.
Fabric masks over surgical masks and nonvented N95/KN95 masks may be allowed.
Appropriate masks will be provided at entrances.
Visitors and Support Persons
There are no restrictions on the number of support persons allowed to accompany a patient at Methodist Physicians Clinics, Hospital-Owned Clinics and Outpatient Diagnostics.
There are no restrictions on the number of visitors who may visit non-COVID patients during regular visiting hours. Visitors may access all public areas and do not need to leave the hospital immediately after visiting patients.
Lab-confirmed COVID-positive patients will be permitted to have up to two visitors at a time during regular visiting hours. Visitors should not access public areas during or after their visit and should leave the hospital after visiting the patient.
In Surgical Care Settings, two support persons are permitted in the waiting areas during regular visiting hours at hospital locations.
Emergency Departments:
The Emergency Department (ED) allows up to two visitors/support persons to stay with an ED patient.
Critical Care, NICU and Other Specialty Units:
Critical care, NICU (see below) and other specialty units may have additional visitor-specific guidelines.
Patients receiving end-of-life care as determined by the care team are an exception to the policies above.
Additional exceptions may be discussed with the facility's administrative personnel or infection prevention experts.
Methodist Women's Hospital NICU Visitor Guidelines
Revised June 2022
Outside of Flu Season*:
A maximum of four individuals may visit at a time, including parents.
All visitors, including parents, must be well and wear a well-fitted, multilayer procedural mask appropriately at all times.
Visitors under age 14 must:
Be sibling of a patient
Be toilet-trained (no diapers/pull-ups)
Provide written documentation of up-to-date immunizations
During Flu Season*:
All visitors must be 14 or older.
Visitors (with the exception of parents) must provide written documentation of a current flu vaccination and be seven days removed from the date of vaccination.
*Flu season is typically from late winter through early spring, as designated by the Centers for Disease Control and Prevention (CDC).
Cafeteria and Gift Shop
Visitors are encouraged to stay in the patients' rooms and waiting areas, but may access the cafeteria and gift shop spaces.
Learn about additional patient and visitor services, such as interpreters, spiritual care and service animals,


The Edmonton Oilers announced today they have acquired centre Derek Roy from the Nashville Predators, in exchange for centre Mark Arcobello.
Roy, 31, has appeared in 26 games for the Predators this season, posting 10 points (1G, 9A) and two penalty minutes.
The native of Ottawa, Ontario, has spent time with the Buffalo Sabres, Dallas Stars, Vancouver Canucks, St. Louis Blues and Nashville Predators through 11 NHL seasons, accumulating 502 points (178G, 324A) and 369 penalty minutes in 692 career NHL games.
The 5'9", 184-pound centre has also appeared in 49 career playoff games, recording 27 points (7G, 20A) and 36 penalty minutes.
Roy also represented Canada internationally at the 2008 and 2009 World Hockey Championships, registering 18 points (9G, 9A) and 10 penalty minutes in 18 games.


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electrical production plant
Electricity generation - Wikipedia
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May 13, 2019· A typical hydroelectric plant is a system with three parts: a power plant where the electricity is produced, a dam that can be opened or closed to control water flow, and a …
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The effect of a Power Plant Electrifying a City in Anno 1800. Utility poles carry power cables across the streets, lantern posts illuminate sidewalks, and newfangled auto-mobiles make the streets unsafe at 16 km/h. A Power Plant consumes either gas or oil, but unlike every other Production Building in the game, does not produce electricity as a ...
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Coal plays a vital role in electricity generation worldwide. Coal-fuelled power plants currently fuel 38% of global electricity and, in some countries, coal fuels a higher percentage of electricity. Highcharts Cloud. Pie chart with 5 slices. View as data table. Chart. Created with Highcharts 8.0.0. Coal Oil Natural gas Nuclear Renewables.
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Aug 30, 2018· Much of the electricity used in the United States and worldwide comes from thermoelectric power plants. This type of production includes fuels such as coal, oil, gas-fired, nuclear, and other lesser-used methods, such as geothermal and burning waste material. Production of electrical power results in one of the largest uses of water in the ...
Egypt List of Operating Power Plants|EGYPTROL
West Delta Electricity Production Company; Plant Type No. of Units Installed Capacity(MW) Fuel Commissioning Year Turbine Manufacturer; Kafr El-Dawar (St) 4 x 110 : 440: N.G-H.F.O : 1980-1984-1986: SCODA: Damanhour Ext300 (St) 1 x 300 ...
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Tesla's factory in Fremont, California is one of the world's most advanced automotive plants, with 5.3 million square feet of manufacturing and office space on 370 acres of land. Following the City of Fremont's approval of Tesla's expansion plans in 2016, the company will nearly double the size of the facility to almost 10 million ...
Sigma Electric Manufacturing Corporation
Sigma Electric is proud to be the trusted supply chain partner of global leaders in market segments such as electrical, lighting, industrial, power tools, process instrumentation, appliances, and telecom. We work closely with each customer to help them meet the challenges of a highly competitive business environment forging long-term ...
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This is a list of electrical generating stations in Newfoundland and Labrador, Canada.. Newfoundland and Labrador has forty-eight power stations, and mainly rely on hydropower for its generation needs. The province's main power station, the 5,428-megawatt Churchill Falls Generating Station, mainly supplies Quebec, under a 65-year contract, due to expire in 2041.
Electric Generating Costs: A Primer - IER
Aug 22, 2012· The cost of generating electricity includes the capital cost, the financing charges, and the production or operating costs (including fuel and maintenance of the technology) at the point of connection to an electrical load or the electricity grid. When determining what new plant to build, a utility company will compare all these costs across the slate of available generating units.
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Like nuclear, our estimates of daily electrical output from coal-fired power stations have been calculated based on reported maximum capacity figures, found here, and an average capacity factor of 64%. 4 The largest operating coal plant in the world is the Tiachung Power Plant in Taiwan; with a maximum capacity of 5500 MW, average daily output ...
Building a world that works. Welcome to GE.COM. Your browser is out of date and some functionality on this site may be not be supported.
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