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Use of this content is subject to the Terms and Conditions AN EVIDENCE-BASED APPROACH TO TREATING OTITIS MEDIA
Pediatric Clinics of North America - Volume 43, Issue 6 (December 1996) - Copyright 1996 W. B. Saunders Company
AN EVIDENCE-BASED APPROACH TO TREATING OTITIS MEDIA Richard M. Rosenfeld MD, MPH
From the Department of Otolaryngology, State University of New York Health Science Center at Brooklyn; and the Division of Pediatric Otolaryngology, Department of Otolaryngology, University Hospital of Brooklyn and The Long Island College Hospital, Brooklyn, New York Patient care is ideally based on evidence derived from the best available studies. The practitioner who treats children with otitis media is
fortunate in this regard, because a wealth of high quality clinical trials and epidemiologic studies have been published. Further, much of
this evidence has been synthesized into bottom-line efficacy estimates and treatment guidelines that deal specifically with the medical
management of otitis media. [70] [71] [72] [79] [84]
Otitis media implies the presence of a middle ear effusion (MEE), or fluid in the middle ear space (Table 1) . MEE accompanied by acute
symptoms is called acute otitis media (AOM). AOM is caused by ascent of viral or bacterial pathogens from the nasopharynx into the
middle ear during an upper respiratory infection. MEE without associated symptoms is called otitis media with effusion (OME). OME
may arise as a sequelae to AOM or spontaneously; the latter is also called silent otitis media when it occurs as an incidental finding during
physical examination or screening tests. The nonspecific term ear infection applies to AOM and OME, because pathogenic bacteria
generally are present in the middle ear with both conditions. [63]
This article presents an evidence-based approach to managing otitis media. Rational management begins by understanding the natural
history of untreated otitis media and knowing what to expect from medical therapy. [74] Next, a stepwise treatment plan is presented,
based on epidemiologic studies, systematic reviews of clinical trials, and personal experience as a pediatric otolaryngologist who has
successfully treated thousands of children with otitis media.
TABLE 1 -- OTITIS MEDIA DEFINITIONS AND EPIDEMIOLOGY
Otitis Type
Fluid in the middle ear space,
Diagnosis requires assessment
regardless of cause; hearing loss
of middle ear function by
may be present depending on the
pneumatic otoscopy or
volume of fluid
Myringitis
Erythema of the tympanic membrane,
Most often viral but may be
without MEE; similar appearance
seen in early stages of AOM
occurs from dilation of tympanic
or during resolution; does
membrane vessels when crying
not require antibiotic
during otoscopy
MEE with rapid onset of one or more
Most frequent diagnosis made
of the following: otalgia, ear pulling,
by pediatricians; affects
otorrhea, fever, irritability, anorexia,
about 50% of children by
vomiting, or diarrhea
age 1 year, 65% by age 2
years, and 70% by age 3
MEE without signs or symptoms of
Occurs in both healthy children
acute infection; chronic OME
and following an episode of
implies duration longer than 2 to 3
AOM; 15% prevalence with
Recurrent AOM
At least three episodes of AOM in the
Affects about 15-30% of
past 6 months, or four episodes in
children; MEE may persist to
12 months; also called the otitis-prone condition
varying degrees between
AOM = acute otitis media, OME = otitis media with effusion.
Address reprint requests to Richard M. Rosenfeld, MD, MPH Department of Otolaryngology Long Island College Hospital 340 Henry Street Brooklyn, NY 11201 Otitis media has a favorable natural history. Data from observational studies [80] [86] and from control groups in randomized control trials [71] [72] [79] [84] show that most cases of AOM and OME resolve without treatment (Table 2) . For example, in two recent well-designed clinical trials, 86% and 92% of placebo-treated children with AOM were clinical cures. [15] [38] To appreciate the impact of natural history on perceptions of treatment efficacy, consider the following: If 100 children with AOM caused by amoxicillin-resistant bacteria are nonetheless treated with amoxicillin, how many will have complete clinical resolution in 7 to 14 days? About 70% to 90% will be "cured" as shown in Table 2 . The child's immune system cares little if the bacteria are resistant to the drug; it mounts an effective inflammatory response regardless. If 100 children with persistent OME after AOM have chiropractic manipulation for 1 month, how many will resolve? About 60%, assuming that chiropractic is no better than placebo. If "treatment" is continued for an additional 2 months, the "cure" rate will rise to 90%. If 100 children with silent OME detected in a school screening program receive homeopathic treatment for 3 months, how many will resolve? About 65%, assuming that homeopathy is no better than placebo. If "treatment" is continued for an additional 3 months, 85% will be "cured" of effusion. If 100 children with recurrent AOM take garlic concentrate for 12 months, how much will the frequency of AOM diminish? About 1.5 to 3.0 annual episodes will be "prevented," assuming that garlic is no better than placebo. TABLE 2 -- NATURAL HISTORY OF UNTREATED OTITIS MEDIA
Approximate Rate
of Spontaneous
Population Studied
antibiotic trials of initial empiric therapy antibiotic trials, most with OME duration 4-8 weeks * Resolution of asymptomatic middle ear effusion not required for cure. The examples above are provided to illustrate the favorable natural history of otitis media, not to demean alternative medicine. Alternative medicine, however, is used by 11% of children, [76] most often for chronic disease (e.g., otitis media) and without the knowledge of the child's physician. [23] Because most cases of otitis media are self-limited, the efficacy of alternative medicine--or any intervention--can be judged only by prospective clinical trials with a parallel control group. Without a thorough appreciation of the spontaneous course of untreated otitis media, practitioners and caregivers can easily mistake natural history for treatment effects. Short-term spontaneous resolution of AOM most likely reflects the host immune response and local inflammatory reaction. This phenomenon is appreciated in Denmark, Norway, Sweden, and the Netherlands, where most children 2 years of age and older with nonsevere AOM are not treated initially with antibiotics. [28] [36] Unfortunately, the middle ear inflammation that accompanies AOM can result in lingering OME after symptom relief. Spontaneous clearance of residual OME, however, occurs in 90% of children within 3 months (Table 2) as inflammation subsides and the eustachian tube reopens. Because OME is so common following antibiotic treatment for AOM, clearance of the fluid is unnecessary for a successful outcome in efficacy trials. [72] Long-term spontaneous resolution of recurrent AOM and chronic OME most likely reflects a gradual maturation in the child's immune system and eustachian tube function. Further, because most patients seek medical care when at their worst, the next event is often a change for the better, irrespective of treatment given (regression to the mean). [21] Children enter clinical trials for recurrent AOM with three to five annual episodes but average only one to two episodes during the next 12 months when treated with placebo. [84] A similar pattern has been reported for children with recurrent sore throat after entering a tonsillectomy trial. [59] More than 250 clinical trials have sought to define the impact of medical treatment on otitis media. Systematic literature reviews (meta-analysis) of published randomized control trials yield the mean estimates of treatment efficacy listed in Table 3 . These data have been summarized as follows [74] : Antibiotics have a modest but statistically significant impact on the treatment of otitis media. About seven children with AOM or OME must be treated to improve a single child, beyond what would occur from natural history alone. Despite this modest effect, some studies show faster symptom relief with antibiotics than with placebo. [15] [38] [51] Antibiotics have a modest but statistically significant impact on the prevention of otitis media. Preventing a single episode of AOM requires that prophylaxis be given to one child for 9 months, or to nine children for 1 month. Subgroup analyses have not demonstrated a significant increase in clinical efficacy for newer, more expensive drugs over established standards, such as amoxicillin, when treating AOM or OME. Combining an antibiotic with an oral steroid seems promising, but the evidence is sparse, inconsistent, and just misses statistical Antihistamine and decongestant preparations, alone or in combination, have comparable efficacy to placebo. Consequently, there is no justification for their use when treating OME, unless they are consciously administered to achieve a placebo effect. TABLE 3 -- WHAT TO EXPECT FROM MEDICAL TREATMENT FOR OTITIS MEDIA
Treatment Group
Statistically
Impact of Therapy
Significant?
Qualification of these comments is required. First, the results apply only to clinical efficacy; the ability of antibiotics to destroy middle ear pathogens-- bacterial efficacy--may exceed that suggested by clinical outcomes. [45] Second, bacterial resistance patterns are changing, with an increasing prevalence of multidrug-resistant Streptococcus pneumoniae [49] and beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis. [11] Older studies may have included children with bacteriology different than those encountered today, but the high rate of spontaneous otitis media resolution makes it unlikely that this would substantially alter results. Finally, because the results reflect mean treatment effects, individual patients may vary in their response to antibiotics. The modest impact of antibiotics on otitis media argues for judicious treatment, not therapeutic nihilism. Although natural history--not antibiotics-- accounts for most clinical resolution of AOM, delayed suppurative complications (e.g., mastoiditis) are exceedingly rare compared with the preantibiotic era. For OME the modest short-term benefit of antibiotics makes it unlikely that prolonged or repetitive therapy will offer any advantage; therefore, treatment should be limited to one or two drugs spaced at least several weeks apart. For recurrent AOM, the modest benefits of antibiotic prophylaxis probably are exceeded by the risk of accelerated bacterial resistance, particularly in group day care, where horizontal transmission of resistant organisms is common. [13] Prophylaxis might be reserved for selected children not enrolled in day care, with frequent or severe infections. SELECTING AN ANTIBIOTIC FOR OTITIS MEDIA Recommended drugs for managing otitis media are listed in Table 4 . The most important decision concerns which class of antibiotic to use--prophylactic, first-line, second-line, or third-line--not which agent to administer within a class. Prophylactic antibiotics are indicated only for recurrent AOM as defined in Table 1 ; there is no benefit to long-term prophylaxis for OME. [66] [83] First-line antibiotics are used for initial empiric therapy of uncomplicated AOM or OME. Second-line drugs are indicated for initial treatment failures, complicated infections, and children with ipsilateral conjunctivitis suggesting H. influenzae infection. [12] Because no comparative differences in clinical outcomes have been reported among second-line antibiotics, drug choice should be based on cost, convenience, and tolerance. If the prevalence of beta-lactamase-producing pathogens is rising, [11] [25] how can amoxicillin still be the drug of choice for initial treatment of otitis media? It is because of a favorable natural history, which occurs independently of bacterial resistance patterns. [64] AOM treatment failures occur despite susceptible bacteria, and successes occur despite bacterial resistance. [61] [72] For example, if 20% of children with uncomplicated AOM have beta-lactamase-producing bacteria, resistance will account for failure in only 4% of cases because spontaneous resolution is 80%. This theory assumes that 35% of AOM is caused by S. pneumoniae, 30% by H. influenzae, and 10% by M. catarrhalis, of which approximately 0%, 35%, and 90% produce beta-lactamase. [10] Penicillin-resistant S. pneumoniae are rising in prevalence, particularly among children in group day care. [81] Recent use of a beta-lactam antibiotic is TABLE 4 -- RECOMMENDED DRUGS FOR MEDICAL MANAGEMENT OF OTITIS MEDIA
Frequency,
Pediatric Daily
Category; Generic (Trade) Names
Still the drug of choice for initial therapy 1 tsp each 10 lb body When child is penicillin-allergic ac = before meals, pc = after meals.
also a risk factor. Amoxicillin achieves MEE levels effective against 90% of pneumococci with intermediate penicillin resistance, contrasted with the inadequate levels achieved by most second-line drugs. [39] [53] This helps explain reports of pneumococcal bacteremia and meningitis during initial treatment of AOM with cefixime [57] and clarithromycin. [68] For highly penicillin-resistant pneumococci, the only orally administered antibiotic with adequate MEE levels is clindamycin, [39] [53] hence its listing as a third-line agent in Table 4 . Note that Clostridium difficile colitis can occur with any broad-spectrum antibiotic and is no more common with clindamycin than with amoxicillin or the cephalosporins. [26] A pediatric suspension of clindamycin is available.
Single-dose intramuscular ceftriaxone is no "magic bullet" for AOM, and its impact on OME has not been studied. Recent trials show a mean 79% clinical improvement with single-dose ceftriaxone versus 84% improvement with 10 days of amoxicillin, [33] cefaclor, [17] or trimethoprim-sulfamethoxazole. [4] [58] Although the difference is not statistically significant, we cannot conclude with certainty that 79% resolution offers any benefit beyond natural history. Further, liberal use of a potent, broad-spectrum antibiotic, such as ceftriaxone, may accelerate bacterial resistance. [81] Consequently, the author suggests reserving ceftriaxone for third-line therapy (e.g., second-line treatment failures) and for AOM with intracranial or intratemporal complications (e.g., meningitis). The optimal duration and dosing of antibiotic therapy is uncertain. Amoxicillin-treated children with AOM had similar outcomes with 3-day versus 7-day, [37] 3-day versus 10-day, [18] 5-day versus 10-day, [35] and 10-day versus 20-day regimens. [43] Furthermore, clinical resolution is unaltered when amoxicillin is given once, twice, or thrice daily. [50] [65] These negative findings are not surprising given that the majority of AOM clinical resolution occurs by natural history and that there is no worldwide consensus on whether antibiotics are necessary for most cases. Limited data are available for OME, but the findings for AOM most likely apply. Because efficacy estimates (see Table 3) are derived mostly from clinical trials using 10-day therapy and dosing schedules approved by the manufacturer, the author recommends that practitioners do the same. Individualized variations in duration and dosing, however, are unlikely to significantly alter results. AOM remains the most common childhood disorder seen in physicians' offices and in hospital emergency departments. Annual visitation rates for AOM have more than doubled from 1975 to 1990, with a corresponding rise in antibiotic drug prescription rates. Although amoxicillin is currently prescribed twice as often as other drugs, a disturbing trend has occurred toward increased use of more expensive, broad-spectrum agents, such as cephalosporins. This trend may contribute to rising health care costs and the emergence of antibiotic resistance. [48] Aggressive treatment for AOM with expensive, broad-spectrum antibiotics reflects unrealistic expectations on the part of practitioners and caregivers (Table 5) . [74] There is no benefit to initial empiric therapy with second-line drugs (see Table 4) over first-line agents, because 70% to 90% of AOM improves clinically without treatment. For the 90% to 95% of children who respond favorably to antibiotics, about 80% of cures are from spontaneous resolution and only 10% to 15% from drug therapy. [72] The primary benefit of antibiotic treatment on AOM is most likely to reduce the incidence of delayed suppurative complications, TABLE 5 -- STEPWISE APPROACH TO MANAGING ACUTE OTITIS MEDIA
Base decisions on cost, convenience, and tolerance, not bacterial spectrum; use a second-line antibiotic (see Table 4) if otitis-conjunctivitis syndrome or early relapse of prior AOM About 90-95% symptom relief, excluding asymptomatic MEE, within 10-14 days (80% from spontaneous resolution, 10-15% from antibiotic); main purpose of antibiotic is to reduce chance of suppurative complications Use a second-line antibiotic (see Table 4) if symptoms persist; retreatment with first-line drugs is less effective Reserve for retreatment failures with severe symptoms, or those refractory to third-line antibiotics (see Table 4) ; no role for tympanocentesis earlier in therapy Residual OME after AOM is the rule, not the exception, and may last for several months; consider reating with a second-line antibiotic (see Table 4) after 6-8 weeks similar to the impact of antibiotics on group A streptococcal pharyngitis. For example, acute mastoiditis complicated more than 20% of cases of AOM in the preantibiotic era [75] but now has an incidence of less than 0.1%. [52] Persistent AOM following treatment is most often secondary to middle ear inflammation after bacteria are killed, either by antibiotics or by the host immune response. Other causes of persistent AOM include bacterial resistance to the initial antibiotic [61] and viral pathogens or copathogens in the middle ear. [19] Because the cause of failure generally is not apparent, continued antibiotic therapy is indicated to cover any persistent bacteria that may predispose the child to suppurative complications. Retreatment with a second-line antibiotic is more effective (60-90% clinical resolution) than retreatment with amoxicillin or trimethoprim-sulfamethoxazole (25-40% clinical resolution). [62] Penicillin-resistant S. pneumoniae may cause persistent AOM, particularly in otitis-prone children fewer than 2 years of age who attend group day care. [8] [85] Clindamycin is the most effective orally administered antibiotic for resistant pneumococcus; about two thirds of highly resistant strains also may be susceptible to intramuscular ceftriaxone (not single-dose therapy). [8] High-dose amoxicillin (60-80 mg/kg/d) also has been proposed and may be appropriate first-line therapy for high-risk children in communities with endemic penicillin resistance. [14] Myringotomy should be reserved for cases refractory to second-line and third-line antibiotics and for children with immune dysfunction or multiple drug allergies. When used as initial therapy for severe AOM, however, myringotomy is no more effective than antibiotics alone. [38] Residual OME after resolution of acute symptoms is a consequence--not a complication--of AOM. About 50% of children in clinical trials have anasymptomatic effusion following treatment for AOM, unrelated to the duration or bacterial spectrum of the initial antibiotic. [43] [72] Fortunately, about 90% of episodes resolve spontaneously within 3 months unless acute reinfection occurs (see Table 2) . Treatment of residual OME with additional antibiotics has a modest impact on short-term cures (see Table 3) , but the impact on long-term cure is uncertain. [84] Therefore, at most, one first-line antibiotic and one second-line antibiotic should be used for stubborn effusions following AOM.
The first step in managing OME is diagnosing its presence. Many children with OME have a normal-appearing tympanic membrane, making it easy to miss an effusion unless middle ear function is assessed. Tympanometry is used most often in this regard, although pneumatic otoscopy has comparable accuracy. [82] The positive predictive value for OME of a flat (type B) tympanogram (i.e., the likelihood that an effusion is present if the tympanogram is abnormal) is between 49% and 99%. A false-positive tympanometry result can be caused by impacted cerumen, a foreign body, tympanic membrane perforation, or improper placement of the instrument tip on the ear canal wall. Because of these limitations, pneumatic otoscopy is recommended for primary diagnosis of OME with tympanometry as a confirmatory test. [79] Detecting OME does not imply a need for active treatment (Table 6) . About 90% of effusions less than 2 to 3 months' duration resolve without treatment within a few months (see Table 2) . OME of longer duration has cure rates of only 15% to 30% from watchful waiting (see Table 2) , even when observation is extended to 30 months. [41] Regardless of OME duration, the impact of antibiotic therapy is marginal (see Table 3) and short-lived; antibiotic-treated and placebo-treated children have comparable outcomes several weeks after completing therapy. [44] Aggressive antibiotic treatment of OME is therefore difficult to justify, especially because the incidence of delayed suppurative complications is near TABLE 6 -- STEPWISE APPROACH TO MANAGING OTITIS MEDIA WITH EFFUSION
Most cases resolve without treatment (see Table 1) , particularly when following a recent episode of AOM Antibiotics boost short-term resolution by about 15% and therefore benefit only one child of every seven treated; do not use repetitive, prolonged, or prophylactic antibiotics Limit passive smoke exposure; treat sinusitis; control food and inhalant allergies Any child can be tested, regardless of age; tube insertion is recommended for bilateral effusions lasting 4 months or longer with an associated hearing loss Most effective when hearing is normal and child is not otitis-prone; observe varicella precautions (see text) Chronic effusions without hearing loss can be managed expectantly; consider surgery if accompanied by otalgia, recurrent AOM, retraction pockets, speech problems, or antibiotic intolerance zero. Autoinflation of the eustachian tube, by means of a plastic nasal cannula and attached balloon, is a harmless adjunct to watchful waiting that may be tried in older children. [7] [77] Prophylactic antibiotics and antihistamine-decongestant preparations offer no benefits beyond placebo therapy.
Clinicians can improve the odds of OME resolution by modifying risk factors and controlling concurrent illness. The risk of getting AOM or OMEis increased with passive smoke exposure, group day-care attendance, and bottle-feeding rather than breast-feeding infants. [79] The associations, however, are modest (relative risk about 2.0), and many breast-fed children cared for at home by nonsmokers still obtain otitis media. Nonetheless, efforts to limit smoke exposure seem prudent, particularly for children in group day care, in which 18% of cases of OME may be attributable to parental smoking. [24] Because allergy to milk proteins may cause middle ear inflammation, [6] the author recommends a milk-free diet for several weeks as a diagnostic trial in children fewer than 2 years of age. In older children with OME, concurrent illnesses, such as sinusitis and allergic rhinitis, should be brought under optimal control. A child with bilateral OME for 3 months or longer should undergo hearing evaluation. [79] No child is too young to test, including infants fewer than 6 months of age. OME generally causes a mild conductive hearing loss (27 dB hearing level [HL]), but 20% of ears have a pure-tone average of more than 35 dB HL. [27] Although the relationship between early OME and language development is controversial, the literature supports a direct connection between hearing and language with middle ear effusion as an intermediate variable. [28] Placement of tympanostomy tubes is recommended for children with 4 to 6 months of bilateral OME and hearing loss, defined as 20 dB HL or higher for the better ear. [79] Hearing levels obtained in a soundproof booth, however, may underestimate the auditory impact of OME on children in real-world listening environments. For example, the ability of children to recognize words presented at soft levels or with background noise deteriorates when OME is present, even when hearing levels are normal. [69] Difficulties in word recognition may cause behavioral problems, poor attention span, or poor school performance. Therefore, affected children with bilateral OME and normal hearing may still benefit from tympanostomy tubes on a selective basis. Finally, hearing levels fluctuate relative to the volume of middle ear fluid and should be periodically retested when deferring surgery because of normal hearing. Steroid therapy is not recommended for children 3 years of age or younger with OME [79] but may be used selectively in older children as a last-resort medical alternative to surgery. [73] Oral prednisone or prednisilone (see Table 4) is given concurrently with a second-line antibiotic, provided that there has been no varicella exposure for 3 weeks and there is no coexisting AOM or sinusitis. Children who get varicella while taking steroids should discontinue the drug and be considered for oral acyclovir therapy to minimize the likelihood of severe disease. [1] Relapse of OME occurs in 40% of initial responders following steroid-antibiotic therapy, yielding a 6-month cure rate of about 25%. Children without hearing loss or recurrent AOM seem to have the most favorable outcomes. [73] Decisions concerning the relative merits of ongoing medical therapy for OME versus surgical intervention (i.e., tympanostomy tubes) must be individualized (Table 7) . Children with asymptomatic OME who also have normal hearing, speech, school performance, and tympanic membrane appearance may be monitored with extended periods of watchful waiting. The key word in the preceding sentence is monitored; implicit in a wait-and-see approach is interval otoscopy and audiometry every 3 to 4 months to detect changes in hearing status or the structural integrity of the tympanic membrane. In contrast, a hearing-impaired TABLE 7 -- FACTORS INFLUENCING DECISIONS FOR OR AGAINST SURGERY FOR OME
Favors Alternatives to
Favors Surgery
*Cleft palate, immunodeficiency, Down syndrome, craniofacial anomalies, Eskimos, Native Americans. child with unilateral or bilateral OME and a baseline sensorineural loss would benefit from early tympanostomy tube insertion, not prolonged medical therapy. Adenoidectomy is effective for OME in older children [30] [47] [60] but is not recommended for those age 3 years or younger. [79] A network of primary care doctors representing nine countries was asked to rate how certain they were when diagnosing AOM in young children. Survey results indicated a disconcerting 58% level of diagnostic certainty in patients aged 0 to 12 months, rising to 66% at 13 to 30 months, and 73% for children more than 30 months of age. [29] These results illustrate the difficulty of diagnosing AOM in young children, not the incompetence of the physicians surveyed. With recurrent AOM, the issue of diagnostic certainty is paramount because of a geometric increase in the potential consequences. Even a skilled otoscopist can struggle to glimpse the tympanic membrane in an uncooperative child with small ear canals or obstructing cerumen. If obstructing cerumen cannot be removed easily, the child should be referred to an otolaryngologist for microscopic cleaning of the ear canal. When the tympanic membrane is visualized, a test of middle ear function is performed to verify that a MEE is present (tympanometry or pneumatic otoscopy). Unfortunately the severity of tympanic membrane inflammation predicts neither the presence of MEE nor the clinical course of recurrent AOM. [3] A red eardrum commonly occurs during brisk crying and viral myringitis, which are self-limited conditions distinct from AOM.
Recognizing that problems with diagnostic certainty can never be completely avoided, the author recommends tailoring the treatment of recurrent AOM episodes accordingly. When certainty is high, treatment of the episode should proceed as outlined earlier (see Table 5) . Examples include purulent otorrhea, a bulging tympanic membrane, or acute symptoms with a documented MEE. When certainty is low, the caregiver may be given a prescription for a first-line antibiotic and told to treat the child only if acute symptoms do not subside after 24 to 48 hours of expectant therapy. This approach avoids unnecessarily treating viral myringitis and false-positive diagnoses of AOM. When certainty is moderate, judgment is required. Infants and young children with severe symptoms should probably be treated, but older children with nonsevere symptoms may be managed expectantly. Primary prevention of recurrent AOM involves modifying risk factors and using vaccines (Table 8) . Children in group day care are at increased risk for recurrent AOM, but the size of the group--not day care per se--is responsible. [42] [46] When the group size is six children or fewer, risk is not increased. Pacifiers should be discouraged in day care settings, because their use accounts for 25% of recurrent AOM in children less than 3 years of age. [56] Children in day care also benefit from an influenza A vaccine, which reduces the incidence of AOM by about 40% during the influenza season (January to February). [20] [34] In contrast, the pneumococcal vaccine (children 2 years or more) does not decrease overall incidence of AOM but reduces vaccine-type pneumococcal AOM. [9] This may be beneficial given a rising prevalence of multidrug-resistant pneumococcus. Finally, breast-feeding (4 months or longer) has been shown to reduce AOM frequency in longitudinal studies. [2] [22] Enthusiasm for antibiotic prophylaxis of recurrent AOM must be tempered by reality: a child must be treated for 9 months, on average, to prevent one AOM episode beyond what would occur from natural history alone. [74] Although TABLE 8 -- STEPWISE APPROACH TO MANAGING RECURRENT ACUTE OTITIS MEDIA
Distinguish myringitis from true otitis media; confirm MEE by tympanometry or pneumatic otoscopy Limit passive smoke exposure; consider group day- care alternatives; discourage pacifier use in day care Encourage breast feeding; control allergies; consider pneumococcal vaccine (age 2 years or more) or influenza vaccine (day care) Risk of acclerated bacterial resistance often outweighs minimal benefit of prolonged antibiotic prophylaxis Antihistamine/decongestant combinations are of no benefit; chiropractic, homeopathy, and naturopathy are unproven Recurrent AOM with minimal symptoms can be managed expectantly; consider surgery if accompanied by febrile seizures, antibiotic intolerance, hearing loss, speech problems, or chronic OME statistically significant, the clinical significance is questionable when balanced against risks of accelerated bacterial resistance. Particular caution applies to children in group day care, where bacterial resistance is already more common. [67] Intermittent prophylaxis during respiratory illness is appealing but may be less effective than continuous treatment. [5] Furthermore, when OME persists between episodes of recurrent AOM, prophylaxis does not increase resolution of the baseline effusion. [66] [83] These findings argue for judicious use of antibiotic prophylaxis on a restrictive and individualized basis.
When medical options have been exhausted, surgery must be considered. Tympanostomy tubes are effective in controlling recurrent AOM, with or without intercurrent OME, because they effectively bypass the child's immature and poorly functioning eustachian tube. [16] [31] [32] Breakthrough episodes of AOM while on antibiotic prophylaxis are not a mandatory prerequisite to tube insertion because of the concerns about prophylaxis expressed earlier. What is important, however, is the frequency and severity of AOM episodes and the presence or absence of associated sequelae, such as hearing loss, speech problems, or multiple drug allergies. Adenoidectomy is effective for recurrent AOM in children who have had tympanostomy tube insertion at least once previously. [60] More than 20 years ago, a shrewd clinician remarked, "There is little evidence that those antimicrobial agents which hypothetically or in vitro are more effective . . . are superior in the treatment of otitis when compared to penicillin alone." [78] Several hundred clinical trials later, the advantages of broad spectrum drugs remain unproved, and questions remain as to whether antibiotics are required for most episodes of AOM. Further, antibiotics have been demoted to the status of optional therapy for OME. [79] This situation is unlikely to change as new studies with new antibiotics proliferate. What is clear, however, is that accelerated patterns of bacterial resistance mandate an evidence-based approach to managing otitis media. Bacteria have an uncanny ability to learn new mechanisms of antibiotic resistance. [55] A large part of bacterial "education" has undoubtedly been fueled by antibiotic prescriptions from well-intentioned physicians, with unrealistic expectations of drug efficacy. A judicious approach to antibiotic treatment of otitis media can result only from knowing the spontaneous course of the disorder and incremental effect of antibiotics on clinical outcomes. In this article, a series of unifying concepts are developed to help practicing clinicians with an evidence-based approach to managing otitis media. Critical review of the published evidence suggests that the most favorable outcomes from medical treatment will occur if practitioners: appreciate the favorable natural history of untreated otitis media realize that OME may take months to resolve following a single AOM episode modify risk factors to improve the odds of spontaneous resolution use pneumatic otoscopy and confirmatory tympanometry to diagnose OME recognize the limited impact of antibiotic therapy on treatment and prevention balance the benefits of antibiotics against the risk of accelerated bacterial resistance avoid repetitive, prolonged, or prophylactic antibiotic treatment of chronic OME avoid ineffective therapy, such as antihistamine/decongestant preparations An important aspect of management is helping caregivers understand the natural history of otitis media and the impact of medical treatment on short-term and long-term outcomes. Realistic expectations on the part of all involved parties should facilitate rational decisions about watchful waiting, medical therapy, and the need for surgical intervention. Special thanks to the countless investigators who conduct and publish clinical trials and epidemiologic studies on otitis media, without whom an evidence-based approach to treatment would be impossible. I am also indebted to Dr. Charles Bluestone for his insights and inspirations, which underlie many of the concepts explored herein. References
1. AAP Committee on Infectious Diseases: The use of acyclovir in otherwise healthy children with varicella. Pediatrics 91:674, 1993 2. Aniansson G, Alm B, Andersson B, et al: A prospective cohort study on breast-feeding and otitis media in Swedish infants. Pediatr Infect Dis J 13:183, 1994 3. Appelman CLM, Claessen JQPJ, Touw-Otten FWMM, et al: Severity of tympanic membrane inflammation as a predictor of clinical course of recurrent acute otitis media. Br Med J 306:895, 1993 4. Barnett ED, Klein JO, Teele DW, et al: Short course therapy for acute otitis media: Single dose ceftriaxone. In Abstracts of the Sixth International Symposium on Recent Advances in Otitis 5. Berman S, Nuss R, Roark R, et al: Effectiveness of continuous versus intermittent amoxicillin to prevent episodes of otitis media. Pediatr Infect Dis J 11:63, 1992 6. Bernstein JM: The role of IgE-mediated hypersensitivity in the development of otitis media with effusion. Otolaryngol Clin North Am 25:197, 1992 7. Blanshard JD, Maw AR, Bawden R: Conservative treatment of otitis media with effusion by autoinflation of the middle ear. Clin Otolaryngol 18:188, 1993 8. Block SL, Harrison CJ, Hedrick JA, et al: Penicillin-resistant Streptococcus pneumoniae in acute otitis media: Risk factors, susceptibility patterns and antimicrobial management. Pediatr Infect 9. Bluestone CD, Klein JO: Management. In Otitis Media in Infants and Children, ed 2. Philadelphia, WB Saunders, 1995, pp 145-240 10. Bluestone CD, Klein JO: Microbiology. In Otitis Media in Infants and Children, ed 2. Philadelphia: WB Saunders, 1995, pp 55-72 11. Bluestone CD, Stephenson JS, Martin LM: Ten-year review of otitis media pathogens. Pediatr Infect Dis J 11(Suppl):7, 1992 12. Bodor FF: Systemic antibiotics for the treatment of the conjunctivitis-otitis media syndrome. Pediatr Infect Dis J 8:289, 1989 13. Boken DJ, Chartrand SA, Goering RV, et al: Colonization with penicillin-resistant Streptococcus pneumoniae in a child-care center. Pediatr Infect Dis J 14:879, 1995 14. Bradley JS, Kaplan SL, Klugman KP, et al: Consensus: Management of infections in children caused by Streptococcus pneumoniae with decreased susceptibility to penicillin. Pediatr Infect 15. Burke P, Bain J, Robinson D, et al: Acute red ear in children: Controlled trial of non-antibiotic treatment in general practice. Br Med J 303:558, 1991 16. Casselbrant ML, Kaleida PH, Rockette HE, et al: Efficacy of antimicrobial prophylaxis and of tympanostomy tube insertion for prevention of recurrent acute otitis media: Results of a randomized clinical trial. Pediatr Infect Dis J 11:278, 1992 17. Chamberlain JM, Boenning DA, Waisman Y, et al: Single-dose ceftriaxone versus 10 days of cefaclor for otitis media. Clin Pediatr 33:642, 1994 18. Chaput de Saintonge DM, Levine DF, et al: Trial of three-day and ten-day courses of amoxycillin in otitis media. Br Med J 284:1078, 1982 19. Chonmaitree T, Owen MJ, Patel JA, et al: Effect of viral respiratory tract infection on outcome of acute otitis media. J Pediatr 120:856, 1992 20. Clements DA, Langdon L, Bland C, et al: Influenza A vaccine decreases the incidence of otitis media in 6- to 30-month-old children in day care. Arch Pediatr Adolesc Med 149:1113, 1995 21. Dawson-Saunders B, Trapp RG: Association and prediction. In Basic and Clinical Biostatistics, ed 2. Norwalk, Appleton & Lange, 1994, pp 161-185 22. Duncan B, Ey J, Holberg CJ, Wright AL, et al: Exclusive breast-feeding for at least four months protects against otitis media. Pediatrics 91:867, 1993 23. Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United States: Prevalence, costs, and patterns of use. N Engl J Med 328:246, 1993 24. Etzel RA, Pattishall EN, Haley NJ, et al: Passive smoking and middle ear effusion among children in day care. Pediatrics 90:228, 1992 25. Faden H, Doern G, Wolf J, et al: Antimicrobial susceptibility of nasopharyngeal isolates of potential pathogens recovered from infants before antibiotic therapy: Implications for the management of otitis media. Pediatr Infect Dis J 13:609, 1994 26. Fekety R, Shah AB: Diagnosis and treatment of Clostridium difficile colitis. JAMA 269:71, 1993 27. Fria TJ, Cantekin EI, Eichler JA: Hearing acuity of children with otitis media with effusion. Arch Otolaryngol 111:10, 1985 28. Friel-Patti S, Finitzo T: Language learning in a prospective study of otitis media with effusion in the first two years of life. J Speech Hear Res 33:188, 1990 29. Froom J, Culpepper L, Grob P, et al: Diagnosis and antibiotic treatment of acute otitis media: Report from International Primary Care Network. Br Med J 300:582, 1990 30. Gates GA, Avery CA, Prihoda TJ, et al: Effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion. N Engl J Med 317:1444, 1987 31. Gebhart DE: Tympanostomy tubes in the otitis media-prone child. Laryngoscope 91:849, 1981 32. Gonzalez C, Arnold JE, Woody EA, et al: Prevention of recurrent acute otitis media: Chemoprophylaxis versus tympanostomy tubes. Laryngoscope 96:330, 1986 33. Green SM, Rothrock SG: Single-dose intramuscular ceftriaxone for acute otitis media in children. Pediatrics 91:23, 1993 34. Heikkinen T, Ruuskanen O, Waris M, et al: Influenza vaccination in the prevention of acute otitis media in children. Am J Dis Child 145:445, 1991 35. Hendrickse WA, Kusmiesz H, Shelton S, et al: Five vs. ten days of therapy for acute otitis media. Pediatr Infect Dis J 7:14, 1988 36. Jensen PM, Lous J: Treatment of acute otitis media in Danish general practice. In Abstracts of the Sixth International Symposium on Recent Advances in Otitis Media, Fort Lauderdale, FL, 37. Jones R, Bain J: Three-day and seven-day treatment in acute otitis media: A double-blind antibiotic trial. J Royal Coll Gen Pract 36:356, 1986 38. Kaleida PH, Casselbrant ML, Rockette HE, et al: Amoxicillin or myringotomy or both for acute otitis media: Results of a randomized clinical trial. Pediatrics 87:466, 1991 39. Kaplan SL, Mason EO Jr: Antimicrobial agents: Resistance patterns of common pathogens. Pediatr Infect Dis J 13:1050, 1994 41. Lieberman A, Bartal N: Untreated persistent middle ear effusion. J Laryngol Otolaryngol 100:875, 1986 42. Louhiala Pekka J, Jaakkola N, Ruotsalainen R, et al: Form of day care and respiratory infections in children. Am J Public Health 85:1109, 1995 43. Mandel EM, Casselbrant ML, Rockette HE, et al: Efficacy of 20- versus 10-day antimicrobial treatment for acute otitis media. Pediatrics 96:5, 1995 44. Mandel EM, Rockette HE, Paradise JL, et al: Comparative efficacy of erythromycin-sulfisoxazole, cefaclor, amoxicillin, or placebo for otitis media with effusion in children. Pediatr Infect 45. Marchant CD, Carlin SA, Johnson CE, et al: Measuring the comparative efficacy of antibacterial agents for acute otitis media: The "Pollyana" phenomenon. J Pediatr 120:72, 1992 46. Marx J, Osguthorpe D, Parsons G: Day care and the incidence of otitis media in young children. Otolaryngol Head Neck Surg 112:695, 1995 47. Maw AR: Chronic otitis media with effusion (glue ear) and adenotonsillectomy: Prospective randomised controlled study. Br Med J 287:1586, 1983 48. McCaig LF, Hughes JM: Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA 273:214, 1995 49. McCracken GH Jr: Emergence of resistant Streptococcus pneumoniae: A problem in pediatrics. Pediatr Infect Dis J 14:424, 1995 50. Murph JR, Dusdieker LB, Booth B, et al: Is treatment of acute otitis media with once-a-day amoxicillin feasible? Clin Pediatr 32:528, 1993 51. Mygind N, Meistrup-Larsen KI, Thomsen J, et al: Penicillin in acute otitis media: A double-blind placebo-controlled trial. Clin Otolaryngol 6:5, 1981 52. Nadal D, Herrmann P, Bauman A, et al: Acute mastoiditis: Clinical, microbiological, and therapeutic aspects. Eur J Pediatr 149:560, 1990 53. Nelson CT, Mason EO Jr, Kaplan SL: Activity of oral antimicrobials in middle ear and sinus infections caused by penicillin-resistant Streptococcus pneumoniae: Implications for treatment. 55. Neu HC: The crisis in antibiotic resistance. Science 257:1064, 1992 56. Niemela M, Uhari M, Mottonen M: A pacifier increases the risk of recurrent acute otitis media in children in day care centers. Pediatrics 96:884, 1995 57. Ottolini MG, Ascher DP, Cieslak TJ, et al: Pneumococcal bacteremia during oral treatment with cefixime for otitis media. Pediatr Infect Dis J 10:467, 1991 58. Owen MJ, Chonmaitree T, Hornberger B, et al: Bacteriologic and clinical efficacy of ceftriaxone in treatment of acute otitis media. In Abstracts of the Sixth International Symposium on Recent Advances in Otitis Media, Fort Lauderdale, FL, 1995, p 131 59. Paradise JL, Bluestone CD, Bachman RZ, et al: History of recurrent sore throat as an indication for tonsillectomy. N Engl J Med 298:409, 1978 60. Paradise JL, Bluestone CD, Rogers KD, et al: Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement: Results of parallel randomized and nonrandomized trials. JAMA 263:2066, 1990 61. Pichichero ME, Pichichero CL: Persistent acute otitis media: I. Causative pathogens. Pediatr Infect Dis J 14:178, 1995 62. Pichichero ME, Pichichero CL: Persistent acute otitis media: II. Antimicrobial treatment. Pediatr Infect Dis J 14:183, 1995 63. Post JC, Preston RA, Aul JJ, et al: Molecular analysis of bacterial pathogens in otitis media with effusion. JAMA 273:1598, 1995 64. Prellner K: Is beta-lactamase producing bacteria of major importance for unfavourable development of acute otitis media? Acta Otolaryngol (Stockh) 493:109, 1992 65. Principi N, Marchisio P, Bigalli, et al: Amoxicillin twice daily in the treatment of acute otitis media in infants and children. Eur J Pediatr 145:522, 1986 66. Principi N, Marchisio P, Massironi E, et al: Prophylaxis of recurrent acute otitis media and middle-ear effusion: comparison of amoxicillin with sulfamethoxazole and trimethoprim. Am J Dis 67. Reichler MR, Allphin AA, Breiman RF, et al: The spread of multiply resistant Streptococcus pneumoniae at a day care center in Ohio. J Infect Dis 166:1346, 1992 68. Reid R, Bradley JS, Hindler J: Pneumococcal meningitis during therapy of otitis media with clarithromycin. Pediatr Infect Dis J 14:1104, 1995 69. Rosenfeld RM, Madell JR, Green J: Auditory function in normal-hearing children with middle ear effusion. In Abstracts of the Sixth International Symposium on Recent Advances in Otitis 70. Rosenfeld RM, Mandel EM, Bluestone CD: Systemic steroids for otitis media with effusion in children. Arch Otolaryngol Head Neck Surg 117:984, 1991 71. Rosenfeld RM, Post JC: Meta-analysis of antibiotics for the treatment of otitis media with effusion. Otolaryngol Head Neck Surg 106:378, 1992 72. Rosenfeld RM, Vertrees JE, Carr J, et al: Clinical efficacy of antimicrobial drugs for acute otitis media: Meta-analysis of 5400 children from thirty-three randomized trials. J Pediatr 124:355, 73. Rosenfeld RM: Nonsurgical management of surgical otitis media with effusion. J Laryngol Otolaryngol 109:811, 1995 74. Rosenfeld RM: What to expect from medical treatment of otitis media. Pediatr Infect Dis J 14:731, 1995 75. Rudberg RD: Acute otitis media: comparative therapeutic results of sulphonamide and penicillin administered in various forms. Acta Otolaryngol 113(Suppl):1, 1954 76. Spigelblatt L, Laine-Ammara G, Pless IB, et al: The use of alternative medicine by children. Pediatrics 96:811, 1994 77. Stangerup SE, Sederberg-Olsen J, Balle V: Autoinflation as a treatment of secretory otitis media: A randomized controlled study. Arch Otolaryngol Head Neck Surg 118:149, 1992 78. Stickler GB: How many more treatment trials in otitis media? Am J Dis Child 125:403, 1973 79. Stool SE, Berg AO, Berman S, et al: Otitis Media with Effusion in Young Children. Clinical Practice Guideline, Number 12. AHCPR Publication No. 94-0622. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, July 1994 80. Teele DW, Klein JO, Rosner B: Epidemiology of otitis media in children. Ann Otol Rhinol Laryngol 89:5, 1980 81. Tenover FC, Hughes JM: The challenges of emerging infectious diseases: Development and spread of multiply-resistant bacterial pathogens. JAMA 275:300, 1996 82. Toner JG, Mains B: Pneumatic otoscopy and tympanometry in the detection of middle ear effusion. Clin Otolaryngol 15:121, 1990 83. Varsano I, Volovitz B, Mimouni F: Sulfisoxazole prophylaxis of middle ear effusion and recurrent acute otitis media. Am J Dis Child 139:632, 1985 84. Williams RL, Chalmers TC, Stange KC, et al: Use of antibiotics in preventing recurrent acute otitis media and in treating otitis media with effusion: A meta-analytic attempt to resolve the 85. Zenni MK, Cheatham SH, Thompson JM, et al: Streptococcus pneumoniae colonization in the young child: Association with otitis media and resistance to penicillin. J Pediatr 127:533, 1995 86. Zielhuis GA, Straatman H, Rach GH, et al: Analysis and presentation of data on the natural course of OME in children. Int J Epidemiol 19:1037, 1990 Copyright 2011 Elsevier Inc. 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This statement was developed by a workgroup at the meeting of the International Work Group on Death, Dying and Bereavement in Victoria, British Columbia on April 28 – May 3, 2013. You have full permission to translate the document into other languages, and to distribute it via websites, blogs, the media, and other venues. It is our intention that the message be shared widely. When does a b
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Security Sector Reform in Guatemala For 26 years, from 1960 until 1996 and the signing of the Accord for a "Firm andLasting Peace", Guatemala was the setting of one of the bloodiest of LatinAmerica's Cold War armed conflicts. During this period, a national security doctrinemilitarized the state. The last provision of the Peace Accord in Guatemala, the'Agreement on the Strengthening of


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If you haven't heard already, storytelling is a pretty big online marketing strategy. Marketing is no longer only about what your brand is doing, but people now also wish to know why. You may be questioning the powere of storytelling in marketing. What makes storytelling a worthy marketing tactic? How much time is needed to do it right and how should the story be told? It is important to understand why storytelling is important if you want it to be done right.
The main reason why businesses are turning to storytelling as a powerful marketing tool has a lot to do with the audience. It's all about the minds of those who hear the story. People cannot resist a good story as it is more memorable when told in a captivating way.
Stories have been around since the beginning of human civilisation. Even in the stone age, stories were used as a way to send messages and educate one another. Cave paintings, for example, were a way of telling newcomers to that cave what they should do and where they should go. Learning from stories is naturally drilled into our minds.
The moment we hear the words "once upon a time", we tune in. From that point, we are hooked. We must know what happens! It comes naturally to us. We are trained to listen and interpret stories. Everything we heard as children made us crave more.
Not only do people love stories, but it is something that has helped shape our minds. That is why most fairy tales come with lessons to learn from. This is why they are the best method for sending messages to children.
A good story requires imagination. When listening to a story, we can imagine visuals of what is being said. That is how a good story is crafted. What we hear, we see. Stories come to life in our minds as we create the environment as it is told to us. This is why when it comes to marketing, it is important to make the consumer "see" what it is that you have to offer.
The best way to do this is by creating compelling content that allows them to envision what life would be like if they went to you for your goods or services! When it feels real, it will have more impact on whether your website visitor will choose you over your competitors. The aim is to make yourself stand out from the rest with memorable and informative content that will leave people wanting to know more. When a person feels like they are part of a story, they become closer to the brand.
You can use storytelling on almost every page of your website and digital presence. Whether you are writing blog posts for weekly content, email newsletters or simply your homepage. You can see the power of storytelling everywhere you look online, even on social media. To create a connection between you and the reader, personality is key. Don't get too personal but be sure that you are sending out a clear message. Stories that show a struggle and are authentic tend to get the best responses.
A good story requires a lot of creativity, and if you wish to send out regular content such as blogs or newsletters, that creativity must refresh itself each week. Having a creative digital marketing agency to do the hard work for you can make everything much easier. Search and More can provide your website with captivating copy, insightful blog content and eye-grabbing emails to bring more people to your website and generate conversions. Get in touch for more information.


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'Dead' Again: Is This the End of Holly Sutton on General Hospital?
Soap Hub 2022-12-01
The show had several options…and chose wisely.
Photo bySoap Hub
Holly Sutton is "presumably" dead again on General Hospital. Of course, no one on soaps is ever truly dead, and thankfully this time, Robert Scorpio and Felicia Scorpio know the truth. Even if they didn't, and the show had gone that route, there were still ways it could be undone.
Holly Sutton: I've Looked At Life From Both Sides Now
There are some obvious scenarios at play here, with the most obvious one being the one they chose — that Robert Scorpio (Tristan Rogers) and Holly (Emma Samms) are working together to get her out from under Victor Cassadine's (Charles Shaughnessy) thumb.
After all, that nasty Victor can't make a dead woman do his dirty work, can he? By faking her death, Robert would be able to let Holly steal away to someplace safe — and search for her son. Thankfully, this was the route they took.
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GH: Tell Me, Who Are You?
If they hadn't, we would have been wondering who that was who went up in flames. They could have been a professional Robert hired. An ex-WSB agent who knows how to pull off these kinds of cons. Or maybe they could have said it was Paloma!
Sure, Holly said she saw Victor shoot her sister in front of her eyes. But if Victor faked Holly's death, he could certainly fake Paloma's, too. They could have said Paloma was the one who stole the jewels, held Laura Collins (Genie Francis) at gunpoint, and then got careless with a stove. And the real Holly was still out there, hiding, waiting for the right time to resurface. But that's not the way GH ended up going.
General Hospital: If All Else Fails
The worst, most unforgivable option for fans would have been if Holly really was truly, and most sincerely, dead this time. But then we would have to ask ourselves what story point this served. Robert had already thought his ex-wife was dead, so it wasn't keeping him from getting involved with anyone else.
Not only that, he's already mourned her once — well, twice, really — so what was the point of watching him do it again, especially since he's on so rarely, it's likely he'll be doing most of it off-camera. Luckily, General Hospital wisely chose to do the first option, leaving the story open for Emma Samms to one day return — and that is winning as far as Robert and Holly's fans are concerned.
General Hospital (GH) airs weekdays on ABC. Check your local listings for airtimes. For more about what's coming up in Port Charles, check out all the latest that's been posted on GH spoilers, and for an in-depth look at the show's history, click here.
For more about what's happening on your favorite soaps, join the conversation over on our Facebook Page, check out our Twitter feed, or look for an update on our Instagram stories. See you over there!
# General Hospital# Soap Operas# Holly Sutton# Felicia Scorpio# Robert Scorpio
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Blithe Spirit Certainly Spirited, but not as "Blithe" as Expected
jennamarynowskion February 8, 2014 /0 comments
Francie Goodwin-Davies in Blithe Spirit. Photo credit: Rad Grandpa Photography.
Written by famous playwright/actor/composer/director/singer/all-around talented person Noel Coward, Blithe Spirit is an escapist comedy in which a deceased wife comes back as a ghost to see her former husband, and perhaps cause a little mischief in his current marriage.
While I really enjoyed the technical elements of Blithe Spirit (playing at Walterdale Theatre until February 15th), I found the play a bit too over-the-top for me to fully engage in it. As an audience member, I accept that what's happening on stage is a work of fiction, but while I'm in the theatre I want to be so absorbed in the play that I suspend my disbelief and fully enter in to the world of the play. With over-exaggerated movements, expressions, and vocal tone, the characters in Blithe Spirit were played to such an extreme I couldn't believe that they could be real people and so kept being "thrown out" of the world of the play by the realization that it was a performance. Adding to this was the sense that the characters were more static than dynamic and didn't change much over the course of the play. For example, the interaction between husband and wife Charles and Ruth was exactly the same at their formal dinner party with the Bradman's as their interaction when they were alone. One theme that emerged early on and would have been really interesting to see it carried through was the idea of honesty versus dishonesty and, as the character Charles (played by John Evans) comments – how people are more shocked by honesty than by dishonesty. While the extreme politeness between Charles and Ruth (played by Marsha Amanova) was fitting in the dinner party scenes, when it carried over into the scenes where the couple was alone, it seemed out of place and broke the illusion that I was immersed in something that was really happening. Perhaps it's just me, but I certainly don't act the same with my partner when we're alone versus with our friends. Had more of the scenes been performed in a way that more closely matches how a husband and wife (whether alive or ethereal) truly interact, I think Blithe Spirit would have captured the humour of a situation you know can't possibly happening and the hilarious "anything goes" attitude that develops when it is happening. However, for the most part, the humour in the play came from "cheap laughs" where we were laughing at Madame Arcati's eccentricities (performed by the wonderful Francie Goodwin-Davies, who appeared in Jeannette in The Full Monty last year), but not really the situation, action, and plot of the play.
Parazanda Valois, John Evans, Francie Goodwin-Davies, and Martin Stout in Blithe Spirit. Photo credit: Rad Grandpa Photography
On the other hand, I really loved the costuming of Elvira as a ghost. When I was preparing to see the show, I wasn't sure how the dead former wife would be visually distinguished from the living. Costume Designer Kristen Welker did a fantastic job by dressing Elvira in a grey dress, shoes, wig and lipstick to indicate that she was a ghost, versus the other actors who were clad in rich, bold colors. This simple, understated technique made it immediately obvious Elvira was a ghost without having to rely on special effects like smoke or having the actress suspended and flying around the room, although the patio doors that opened on their own accord when Elvira walked towards them were pretty fantastic as well.
Blithe Spirit runs at Walterdale Theatre February 5 – 15 (except February 10). Performances are at 8:00 pm, except for the 2:00 pm Sunday matinee. Tickets are $11 – $18 depending on the date and time and can be bought at Tix on the Square. Schedule information is also available on YEGlive.ca.
Tagged: Amanda Neufeld Blithe Spirit Doug Verdin Edmonton Theatre Francie Goodwin-Davies John Evans Kristen Welker Noel Coward Walterdale Theatre


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Join WTFoot and discover everything you want to know about his current girlfriend or wife, his shocking salary and the amazing tattoos that are inked on his body. Find out what house the Portuguese left wing-back lives in or have a quick look at his cars!
Vinagre : MONEY LOVE LIFE TATTOO CAR HOUSE MEMES
Birthdate April 9th, 1999
Birthplace Charneca de Caparica, Portugal
Team Wolverhampton Wanderers
Position left wing-back
Nickname Vin Vin Deluxe
Traits Balanced Player
Bio: Rúben Gonçalo da Silva Nascimento Vinagre is a Portuguese footballer who plays as a left wing-back. He was born in 1999 in Charneca de Caparica and started his career at the youth academy of Sporting CP. At the age of 16 the scouts of Monaco knew enough and invited him to come over and play for AS Monaco. And he did! He joined the youth side of AS Monaco in the summer of 2015 and signed his first professional contract at the French club in June 2016. During the summer of 2016 he was part of the Portuguese U17 team who won the tournament after beating Spain in the final. In August 2016 he moved back to Portugal to play one season on loan for Académica de Coimbra. But the FIFA didn't give an approval because the player was under the age of 18 – in January 2017 he moved back to his parent club AS Monaco without playing one single match for Académica. In the summer of 2017 he signed a new and improved contract in Monaco until the summer of 2022. Only a couple of weeks after it was announced that he would move on loan to Wolverhampton to gain some match experience. He made his debut in August 2017 for the EFL Cup against Yeovil Town. The board of the Wolves were convinced of his capabilities and offered him a permanent contract in the summer of 2018. He agreed and signed a five-year-contract for an undisclosed fee.
Vinagre Salary & Net Worth Revealed
In July 2018 the left wing-back signed a contract with Wolverhampton Wanderers that nets him a whopping salary of 1.8 Million Euro (1.5 Million Pound) per year. We have crunched the numbers, this means he earns €4,918 (£4,251) per day and €205 (£177) per hour!
Since you've been viewing this page, Rúben Vinagre has earned...
Wow! This means the average man in the UK needs to work for at least 4 years to earn the same as Vin Vin Deluxe earns in only 1 month.
Net Worth 5 Million Euro (4.3 Million Pound)
This youngster is a promising left back and has a very nice future ahead of him. He proved the Wolves of his capabilities in his first season and then signed a permanent contract un till the summer of 2023. His current market value is estimated at 5 Million Euro (4.3 Million Pound). He is still young but already has a very good contract at the Molineux Stadium: this lad has a estimated net worth of 5 Million Euro (4.3 Million Pound).
Vinagre Tattoo - Does he have one?
This lad from Portugal has no ink's. Why not? Well, he just doesn't like 'em! (Image: Imgur)
Rúben Vinagre - Still Single
Ladies, he the handsome Wolves defender is still available! (Image: Imgur)
Father - João
A picture together with his father João. He is a big fan of Rúben and tries to watch every game of his son! (Image: Imgur.com)
Friend - Cristiano
Cristiano is a good friend of Rúben. He is also an inspiration. One day he hopes to become of the same level as CR7. (Image: Imgur)
Vinagre Car - What does he drive?
No information available about his cars.
Location: Wolverhampton, England
Just chilling in this luxurious bed in his house in... sorry, just kidding. This picture was made in a hospital in Monaco, back in December 2016. He got injured, but as we all know by now, he was back on track in a couple of months! (Image: Imgur)
On what boots does the Portuguese number 29 of Wolverhampton Wanderers play?
Nike Magista Opus II (Season: 2018/2019)
During the 2018/2019 BPL season the Portuguese left wing-back plays on model Nike Magista Opus II.
Check out his crazy skills moves against Manchester City. What a gifted and skilful player!
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Raúl Jiménez


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filed: March 27, 2012 • Ontario
Province 'listened' on wind
Credit: By PEGGY ARMSTRONG, FOR THE LINDSAY POST, www.thepost.ca 27 March 2012 ~~
KAWARTHA LAKES -The province has rejected giving municipalities a veto on wind and solar projects, but will give priority to new projects in communities where there is local support.
"They listened a little bit," Ward 16 Coun. Heather Stauble said in an interview. She's glad for the province's change, but added, "I don't think they've taken it far enough."
She noted that Energy Minister Chris Bentley said the province couldn't permit municipal vetoes. "We'd have 440 different rules around the province," he said in a news report.
"They have 440 different situations already," Stauble said. "The municipalities do their own planning."
"I think they need to respect we are a [duly] elected level of government." She compared the situation to Premier Dalton McGuinty not interfering with the City of Toronto's decision regarding transit and for allowing cities to decide whether or not they want a casino.
The provincial Liberals made the announcement last week in concluding Ontario's first review of its feed-in-tariff plan (FIT) that pays green energy producers above market prices to 'feed' their power into the grid.
Ontario will now pay 20% less to new solar energy producers and 15% less to new wind producers. The impact for new small solar projects is that the government will pay 54.9 cents a kilowatt, down from 80.2 cents. For large solar projects, the rate drops to 35 cents from 44.3 cents a kwh. Wind power rates go down to 11.5 cents per kwh from 13.5 cents.
The government said the lower rates reflect the lower costs for solar panels and wind turbines.
Tim Burke, chief operating officer at Evergreen Power in Lindsay, said it's good that the government has made a decision on the FIT rates because there was about a six-month period of limbo on what was going to happen. But he said he had anticipated a 20% reduction and the actual amount to the smaller solar projects, Micro-FIT projects, is about 30%.
"It will force us to be very cost competitive, " he said. "Green energy is still a good investment," he added. "Overall we're satisfied that the government is continuing the program. It provides jobs in the area."
Existing projects are not affected by the rate changes. They will continue to receive their contracted amount for 20 years.
Stauble said the government didn't do enough to address concerns about wind turbine projects, such as those in her ward, that have been approved. "There are still no environmental assessments," she said. "They still don't have a low frequency noise test" that would check for noise level compliance at a wind turbine.
However, she did see one bright spot. "The projects that have been offered contracts can withdraw without penalities and get their fees back. The fact that they're letting them pull out is a good thing."
The FIT program was started by the province in 2009 as a way to replace coal plants and create jobs during the global recession.
The president of the Association of Municipalities of Ontario said in a press release that "AMO welcomes clarity on where renewable projects will not be permitted, such as on prime agricultural lands and subdivisions. The changes announced today should have the effect of gravitating green energy projects toward communities that support them."
[rest of article available at source]
Source: By PEGGY ARMSTRONG, FOR THE LINDSAY POST, www.thepost.ca 27 March 2012


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Now there were four supports at the four corners of each stand; its supports were part of the stand itself. On the top of the stand there was a circular form half a cubit high, and on the top of the stand its stays and its borders were part of it. He engraved on the plates of its stays and on its borders, cherubim, lions and palm trees, according to the clear space on each, with wreaths all around.read more. Bible Verse Wall Art
He also made two capitals of molten bronze to set on the tops of the pillars; the height of the one capital was five cubits and the height of the other capital was five cubits. There were nets of network and twisted threads of chainwork for the capitals which were on the top of the pillars; seven for the one capital and seven for the other capital. So he made the pillars, and two rows around on the one network to cover the capitals which were on the top of the pomegranates; and so he did for the other capital. The capitals which were on the top of the pillars in the porch were of lily design, four cubits. There were capitals on the two pillars, even above and close to the rounded projection which was beside the network; and the pomegranates numbered two hundred in rows around both capitals. Thus he set up the pillars at the porch of the nave; and he set up the right pillar and named it Jachin, and he set up the left pillar and named it Boaz. On the top of the pillars was lily design. So the work of the pillars was finished. Now he made the sea of cast metal ten cubits from brim to brim, circular in form, and its height was five cubits, and thirty cubits in circumference. Under its brim gourds went around encircling it ten to a cubit, completely surrounding the sea; the gourds were in two rows, cast with the rest. It stood on twelve oxen, three facing north, three facing west, three facing south, and three facing east; and the sea was set on top of them, and all their rear parts turned inward. It was a handbreadth thick, and its brim was made like the brim of a cup, as a lily blossom; it could hold two thousand baths. Then he made the ten stands of bronze; the length of each stand was four cubits and its width four cubits and its height three cubits. This was the design of the stands: they had borders, even borders between the frames, and on the borders which were between the frames were lions, oxen and cherubim; and on the frames there was a pedestal above, and beneath the lions and oxen were wreaths of hanging work. Now each stand had four bronze wheels with bronze axles, and its four feet had supports; beneath the basin were cast supports with wreaths at each side. Its opening inside the crown at the top was a cubit, and its opening was round like the design of a pedestal, a cubit and a half; and also on its opening there were engravings, and their borders were square, not round. The four wheels were underneath the borders, and the axles of the wheels were on the stand. And the height of a wheel was a cubit and a half. The workmanship of the wheels was like the workmanship of a chariot wheel. Their axles, their rims, their spokes, and their hubs were all cast. Now there were four supports at the four corners of each stand; its supports were part of the stand itself. On the top of the stand there was a circular form half a cubit high, and on the top of the stand its stays and its borders were part of it. He engraved on the plates of its stays and on its borders, cherubim, lions and palm trees, according to the clear space on each, with wreaths all around. He made the ten stands like this: all of them had one casting, one measure and one form. He made ten basins of bronze, one basin held forty baths; each basin was four cubits, and on each of the ten stands was one basin. Then he set the stands, five on the right side of the house and five on the left side of the house; and he set the sea of cast metal on the right side of the house eastward toward the south. Now Hiram made the basins and the shovels and the bowls. So Hiram finished doing all the work which he performed for King Solomon in the house of the LORD: the two pillars and the two bowls of the capitals which were on the top of the two pillars, and the two networks to cover the two bowls of the capitals which were on the top of the pillars; and the four hundred pomegranates for the two networks, two rows of pomegranates for each network to cover the two bowls of the capitals which were on the tops of the pillars; and the ten stands with the ten basins on the stands; and the one sea and the twelve oxen under the sea; and the pails and the shovels and the bowls; even all these utensils which Hiram made for King Solomon in the house of the LORD were of polished bronze. In the plain of the Jordan the king cast them, in the clay ground between Succoth and Zarethan. Solomon left all the utensils unweighed, because they were too many; the weight of the bronze could not be ascertained. Solomon made all the furniture which was in the house of the LORD: the golden altar and the golden table on which was the bread of the Presence; and the lampstands, five on the right side and five on the left, in front of the inner sanctuary, of pure gold; and the flowers and the lamps and the tongs, of gold; and the cups and the snuffers and the bowls and the spoons and the firepans, of pure gold; and the hinges both for the doors of the inner house, the most holy place, and for the doors of the house, that is, of the nave, of gold. Thus all the work that King Solomon performed in the house of the LORD was finished And Solomon brought in the things dedicated by his father David, the silver and the gold and the utensils, and he put them in the treasuries of the house of the LORD. Christian Canvas Art
The porch which was in front of the house was as long as the width of the house, twenty cubits, and the height 120; and inside he overlaid it with pure gold. He overlaid the main room with cypress wood and overlaid it with fine gold, and ornamented it with palm trees and chains. Further, he adorned the house with precious stones; and the gold was gold from Parvaim.read more. Christian Gifts
Then Moses said to the people of Israel, "See, the Lord has called by name Bezalel the son of Uri, son of Hur, of the tribe of Judah; and he has filled him with the Spirit of God, with skill, with intelligence, with knowledge, and with all craftsmanship, to devise artistic designs, to work in gold and silver and bronze, in cutting stones for setting, and in carving wood, for work in every skilled craft. And he has inspired him to teach, both him and Oholiab the son of Ahisamach of the tribe of Dan. ... Christian Gifts
Glory of ChristChrist AtoningThe Effect Of The Word Of GodChrist's Own GloryimagepersonalityThe Beauty Of NatureGod On HighRight Hand Of GodRadiancyGod Sustaining CreationPower Of Christ, ShownHand Of GodGod, Living And Self sustainingRight SidesSalvation, Nature OfKnowledge, Of Jesus ChristCreatorGod's Glory In Jesus ChristMediatorGod, Power OfGod, Glory Of
Glory of ChristOther BlindingChrist's Own GloryAgeControlling Your ThoughtsUnbelieversPerfection, DivineCommitment, to the worldChrist, Names ForSatan, Kingdom OfSatan, Titles ForThe Light Of ChristDarkness, As A Symbol Of SinCultsRevelation, In Ntevil, origins ofSpiritual Warfare, Causes OfHeart, Fallen And RedeemedBlindingSpiritual Blindness, Results Of Sin Bible Verse Wall Art
"Then bring near to you Aaron your brother, and his sons with him, from among the people of Israel, to serve me as priests—Aaron and Aaron's sons, Nadab and Abihu, Eleazar and Ithamar. And you shall make holy garments for Aaron your brother, for glory and for beauty. You shall speak to all the skillful, whom I have filled with a spirit of skill, that they make Aaron's garments to consecrate him for my priesthood. These are the garments that they shall make: a breastpiece, an ephod, a robe, a coat of checker work, a turban, and a sash. They shall make holy garments for Aaron your brother and his sons to serve me as priests. They shall receive gold, blue and purple and scarlet yarns, and fine twined linen. ... Bible Verse Wall Art


Over the road driver needed to run Produce from Michigan to points Mid West as far as Fargo, ND / various cities in Minnesota and Wisconsin / Omaha, NE and Northern Illinois with various return loads to various cities in Northern, IN and Michigan. Must be able to be gone at least every other weekend. Pay dependent upon years experience, produce experience, MVR, CSA score. 95% no touch freight. Generally gone 3-4 days depending on stops. We currently have 2 positions available. Must have cell phone with Nationwide service plan. No Alcohol related violations on MVR in past 6 years.


Spring Break 2018 is here. While your former self may have been off to Cancun at this time of the year, you're now a family man or woman, and the mid-March trip looks a lot different than it used to. For one, you probably plan a lot more road trips to keep you from coughing up for three, four, or five (more?) plane tickets. While more economical, road trips require a LOT more preparation to ensure a safe, efficient, and enjoyable experience and to bring it all together you need the right SUV. That SUV, is the Toyota Highlander.
The 2018 grade options really set the Highlander apart from both the competition and its own predecessors. This affords households access to some remarkably efficient options. For instance, the sporty SE has an available 3.5-liter V6 direct-injection engine and available Direct Shift-8-speed automatic transmission, to provide you with the power and efficiency to make dreams of a cross country or cross continent journey a reality. And when you venture into the traffic jammed cities along the way, you'll appreciate the available Stop and Start Engine System.
Things get a lot more efficient if you opt for the new Highlander Hybrid, which generates up to 306 hybrid system net horsepower, while keeping the EPA-estimate at just 30 mpg. Trust us when we say that this is not your dad's hybrid (yes, we can say that now), especially when you consider the capability of the Electronic On-Demand AWD system with intelligence that not only delivers the aforementioned horsepower and fuel efficiency, it affords you a towing capacity of up to 3500 lbs (5000 lbs in the non-hybrid). Simply put, the new Highlander is ready to take your family on the long haul for many spring breaks to come.
The biggest challenge of a spring break family road trip is keeping the family unit comfortable and enthused during those long stretches. Well, consider the roomy Highlander like an extension of your home.
For starters, the available high end saddle-tan leather trimmed seating will have your family feeling like they've wandered into the sofa section of Restoration Hardware. Bring a healthy dose of natural light into the cabin while providing passengers with day and nighttime gazing opportunities with the available panoramic moonroof.
Of course, comfort is just one part of the equation. Your family demands the conveniences of home too, which includes entertainment. Thankfully, the auto-infotainment suite in the SUV is downright sweet! Five conveniently placed USB ports provide everyone within fully charged access to their smartphones and tablets. The kids (and family dog?) will be thoroughly entertained between destinations, thanks to the available rear-seat Blu-ray entertainment system that comes complete with a 9-inch display screen, RCA jacks, a remote, and two wireless headphones.
The weather may be better at this time of the year, but the roads and highways are packed with hoards of individuals and households all heading to and from their spring break destinations. Once again we see where the Highlander is a perfect match for family units that place safety first.
Control. But it doesn't stop there. Every grade of the 2018 Highlander also comes standard with the with Toyota's renowned Star Safety System. This is a state-of-the-art system that integrates safety technologies including Enhanced Vehicle Stability Control, Traction Control, Anti-lock Brake System, Electronic Brake-force Distribution, Brake Assist, Smart Stop Technology, and eight standard airbags.
In addition, Toyota has made their Safety Connect system available in the new Highlander, which connects you to a 24/7 response center at the touch of a button. Rest assured, you'll have full peace of mind during your family spring break when you're all tucked into the Toyota Highlander.
View more on the 2018 Highlander and be sure to come on down with the family for a fun test drive from our Greater Vancouver dealership. Contact us at your earliest convenience.


Are we seeing the revitalization of Christian civilization?
For decades, the world has been dominated by a process known as globalization, a secularizing economic and political system that hollows out and erodes a culture's traditions, customs, and religions, all the while conditioning populations to rely on the expertise of a tiny class of technocrats for every aspect of their social and economic lives.
All over the world, there's been a massive blowback against the anti-cultural processes of globalization and its secular aristocracy. From Russia to Europe and now in the U.S., citizens are rising up and reasserting their religion, culture, and nation as mechanisms of resistance against the dehumanizing tendencies of secularism and globalism.
I believe that the secular world is at its brink, and a new conservative age is rising.
Join me each week as we examine these worldwide trends, discover answers to today's toughest challenges, and together learn to live in the present in light of even better things to come.
As our body cannot live without nourishment, so our soul cannot live without prayer." In this FREE eBook, you will discover a treasure trove of prayers that will inspire and enrich your devotional life.
Steve Turley (PhD, Durham University) is an internationally recognized scholar, speaker, and classical guitarist. He is the author of over 20 books, including Classical vs. Modern Education: A Vision from C.S. Lewis, Awakening Wonder: A Classical Guide to Truth, Goodness, and Beauty, and The Ritualized Revelation of the Messianic Age: Washings and Meals in Galatians and 1 Corinthians. Steve's popular YouTube channel showcases weekly his expertise in the rise of nationalism, populism, and traditionalism throughout the world, and his podcasts and writings on civilization, society, culture, education, and the arts are widely accessed at TurleyTalks.com. He is a faculty member at Tall Oaks Classical School in Bear, DE, where he teaches Theology and Rhetoric, and Professor of Fine Arts at Eastern University. Steve lectures at universities, conferences, and churches throughout the U.S. and abroad. His research and writings have appeared in such journals as Christianity and Literature, Calvin Theological Journal, First Things, Touchstone, and The Chesterton Review. He and his wife, Akiko, have four children and live in Newark, DE, where they together enjoy fishing, gardening, and watching Duck Dynasty marathons.
Thank you so much for considering me as a speaker for your event. I am thrilled and delighted to serve you and your event in any way that I can. The next thing for you to do is check out my availability, which you can do by contacting me by clicking the button below.


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Call to ban personal fireworks over New Year's
Submitted by Janene Pieters on October 25, 2017 - 09:26
. (Fireworks (Source: Wikimedia Commons/Ulillillia))
The foundation for society and safety SMV wants to ban individuals lighting fireworks over New Year's. The use of New Year's fireworks must only take place within controlled events in professional fireworks shows, SMV director Ingrid de Jong said in the Telegraaf on Wednesday.
"With 482 fireworks accidents that had to be treated in the emergency room, 31 lost fingers, four (partially) amputated hands, 176 people with eye injuries, you can not talk about a pleasant evening", De Jong said to the newspaper. According to SMV, the damage to houses and cars caused by fireworks amounted to 15 million euros over the previous New Year's, and 344 people were caught committing crimes during the celebrations. "If you add 10,016 fireworks related incidents, then it's clear to us that it has to change", De Jong said.
The foundation calls for New Year's celebrations at key points in cities and towns, and prohibiting consumers from lighting fireworks on their own.
The fireworks industry, on the other hand, thinks that small-scale fireworks displays is a tradition that should not be allowed to disappear. "It must not turn into a massive event with thousands of people, which involves very different dangers", a spokesperson for Pyrotechnics Netherlands said to NU.nl. According to the industry, illegal banging fireworks are the major problem that cause the most accidents.
The Dutch Safety Board is currently investigating the use of fireworks over New Year's, according to NU.nl. Several municipalities already implemented fireworks free zones and organize central celebrations with a professional fireworks show.
Ingrid de Jong
Pyrotechnics Netherlands
consumer fireworks
firework injuries


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All of which invites the question: Why do these rail barons hate paid leave so much? Why would a company have no problem handing out 24 percent raises, $1,000 bonuses, and caps on health-care premiums but draw the line on providing a benefit as standard and ubiquitous throughout modern industry as paid sick days?
The answer, in short, is "P.S.R." — or precision-scheduled railroading.
P.S.R. is an operational strategy that aims to minimize the ratio between railroads' operating costs and their revenues through various cost-cutting and (ostensibly) efficiency-increasing measures. The basic idea is to transport more freight using fewer workers and railcars.
The second problem with P.S.R., from the shippers' standpoint, is that its scheduling is less precise than advertised. Eliminating spare labor or train cars may render railroads more efficient mechanisms for translating investment into profits. But such fragile systems aren't necessarily efficient for bringing freight from one place to another, especially in a world where natural disasters and public-health crises exist.
In early 2021, when the acute phase of the COVID pandemic ended and economic demand spiked, freight carriers' operations were derailed by their own "efficiencies." For a week last July, Union Pacific had to suspend service between Chicago and Los Angeles while it reopened shuttered rail ramps and reconfigured operations in order to keep pace with rising orders. Similar disruptions afflicted the other major carriers, as The American Prospect details.
This is another instance where myopic 2000s micro efficiency actually makes the whole system less efficient. The only reason for PSR is maximum extraction of value. If you do that at the lower level of a complex system, there is no resiliency at upper levels, and the system really isn't efficient.
Rail workers deserve paid leave as human beings. It's the ethical thing to do. It's also the pragmatic thing to do if we want a functioning rail system going into the 2030s that can handle the system shocks from future pandemics and climate disasters. This itself is a climate story.
Previous PostThe Politics of Clean Energy is changingNext PostWhat Climate Change Is Already Doing to Children's Brains | Time


The meal that became "the Last Supper" for Jesus, the Gospel of Mark says, was to be a Passover meal. The Passover celebration is to be a reminder that God's people were freed from slavery. At Passover the people have said for generations, "Why is this night different than other nights?" And the response is "We were slaves in Egypt and God brought us forth with a mighty hand." We were slaves. Now we're free. We… This is our story too. The life, death, and resurrection of Jesus is an added testament, to the God who seeks to make us free. Free from slavery, free from sin.
God has set us free. The problem is that we so often bind ourselves up again. We enslave ourselves again to things that are not life-giving, things that are not God… What are you enslaved by? Technology perhaps? Addictions? Insecurities? Resentment? What in your life is holding you down and keeping you from a life of freedom in Christ?


Manipal Hospitals is one of India's foremost multi-speciality healthcare providers catering to both Indian and international patients. We are a part of the Manipal Education and Medical Group (MEMG) – a leader in the areas of education and healthcare. With more than 5000 operational beds, our commitment to the overall well-being of an individual is at the core of everything we do. Through our network of hospitals and experienced team of medical professionals, we provide quality and affordable healthcare to everyone.
Manipal Hospital Dwarka, is a multi super speciality tertiary care healthcare facility, delivering world-class healthcare, at an optimum cost. Our aim is to deliver Affordable, Accessible and Accurate healthcare to all sections of the society, without bias. With prominent doctors from across the globe all under one roof, cutting edge infrastructure of global standards in radio-diagnosis, research and clinical practices, and latest revolutionary and technological advancements, Manipal Hospital Dwarka is ready to set new benchmarks in medical care. Preventive, diagnostic and therapeutic services are the core of our eminent specialists who carry decades of expertise, making Manipal Hospital Dwarka, the best place for treatment for medical problems across all age groups.
With cutting-edge infrastructure, 24X7 emergency and trauma services, 380 beds with 13 modular state-of-art OTs, 118 critical care beds, along with technological advancements like automated pneumatic chute system, telemedicine, remote monitoring, artificial intelligence, virtual reality, augmented thinking, EMR, etc. Our prime target is to create a 'Digital Hospital', with seamless integration and paperless services.