text:
Label: BACTRIM DS- sulfamethoxazole and trimethoprim tablet
Contains inactivated NDC Code(s)
NDC Code(s): 54868-0337-0, 54868-0337-1, 54868-0337-3 - Packager: Physicians Total Care, Inc.
- This is a repackaged label.
- Source NDC Code(s): 13310-146
- Category: HUMAN PRESCRIPTION DRUG LABEL
- DEA Schedule: None
- Marketing Status: New Drug Application
Drug Label Information
Updated September 30, 2009
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sulfamethoxazole and trimethoprim DS
(double strength) tablets and tablets USPRx only
To reduce the development of drug-resistant bacteria and maintain the effectiveness of Bactrim (sulfamethoxazole and trimethoprim) tablets and other antibacterial drugs, Bactrim (sulfamethoxazole and trimethoprim) tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
BACTRIM (sulfamethoxazole and trimethoprim) is a synthetic antibacterial combination product available in DS (double strength) tablets, each containing 800 mg sulfamethoxazole and 160 mg trimethoprim; in tablets, each containing 400 mg sulfamethoxazole and 80 mg trimethoprim for oral administration.
Sulfamethoxazole is N1-(5-methyl-3-isoxazolyl)sulfanilamide; the molecular formula is C10H11N3O3S. It is an almost white, odorless, tasteless compound with a molecular weight of 253.28 and the following structural formula:
Trimethoprim is 2,4-diamino-5-(3,4,5-trimethoxybenzyl)pyrimidine; the molecular formula is C14H18N4O3. It is a white to light yellow, odorless, bitter compound with a molecular weight of 290.3 and the following structural formula:
Inactive ingredients: Docusate sodium 85%, sodium benzoate 15%, sodium starch glycolate, magnesium stearate and pregelatinized starch.
BACTRIM is rapidly absorbed following oral administration. Both sulfamethoxazole and trimethoprim exist in the blood as unbound, protein-bound and metabolized forms; sulfamethoxazole also exists as the conjugated form. The metabolism of sulfamethoxazole occurs predominately by N4-acetylation, although the glucuronide conjugate has been identified. The principal metabolites of trimethoprim are the 1- and 3-oxides and the 3'- and 4'-hydroxy derivatives. The free forms of sulfamethoxazole and trimethoprim are considered to be the therapeutically active forms. Approximately 70% of sulfamethoxazole and 44% of trimethoprim are bound to plasma proteins. The presence of 10 mg percent sulfamethoxazole in plasma decreases the protein binding of trimethoprim by an insignificant degree; trimethoprim does not influence the protein binding of sulfamethoxazole.
Peak blood levels for the individual components occur 1 to 4 hours after oral administration. The mean serum half-lives of sulfamethoxazole and trimethoprim are 10 and 8 to 10 hours, respectively. However, patients with severely impaired renal function exhibit an increase in the half-lives of both components, requiring dosage regimen adjustment (see DOSAGE AND ADMINISTRATION section). Detectable amounts of sulfamethoxazole and trimethoprim are present in the blood 24 hours after drug administration. During administration of 800 mg sulfamethoxazole and 160 mg trimethoprim b.i.d., the mean steady-state plasma concentration of trimethoprim was 1.72 µg/mL. The steady-state mean plasma levels of free and total sulfamethoxazole were 57.4 µg/mL and 68.0 µg/mL, respectively. These steady-state levels were achieved after three days of drug administration.1 Excretion of sulfamethoxazole and trimethoprim is primarily by the kidneys through both glomerular filtration and tubular secretion. Urine concentrations of both sulfamethoxazole and trimethoprim are considerably higher than are the concentrations in the blood. The average percentage of the dose recovered in urine from 0 to 72 hours after a single oral dose of sulfamethoxazole and trimethoprim is 84.5% for total sulfonamide and 66.8% for free trimethoprim. Thirty percent of the total sulfonamide is excreted as free sulfamethoxazole, with the remaining as N4-acetylated metabolite.2 When administered together as sulfamethoxazole and trimethoprim, neither sulfamethoxazole nor trimethoprim affects the urinary excretion pattern of the other.
Both sulfamethoxazole and trimethoprim distribute to sputum, vaginal fluid and middle ear fluid; trimethoprim also distributes to bronchial secretion, and both pass the placental barrier and are excreted in human milk.
Geriatric Pharmacokinetics: The pharmacokinetics of sulfamethoxazole 800 mg and trimethoprim 160 mg were studied in 6 geriatric subjects (mean age: 78.6 years) and 6 young healthy subjects (mean age: 29.3 years) using a non-US approved formulation. Pharmacokinetic values for sulfamethoxazole in geriatric subjects were similar to those observed in young adult subjects. The mean renal clearance of trimethoprim was significantly lower in geriatric subjects compared with young adult subjects (19 mL/h/kg vs. 55 mL/h/kg). However, after normalizing by body weight, the apparent total body clearance of trimethoprim was on average 19% lower in geriatric subjects compared with young adult subjects.3
Sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid (PABA). Trimethoprim blocks the production of tetrahydrofolic acid from dihydrofolic acid by binding to and reversibly inhibiting the required enzyme, dihydrofolate reductase. Thus, sulfamethoxazole and trimethoprim blocks two consecutive steps in the biosynthesis of nucleic acids and proteins essential to many bacteria.
In vitro studies have shown that bacterial resistance develops more slowly with both sulfamethoxazole and trimethoprim in combination than with either sulfamethoxazole or trimethoprim alone.
Sulfamethoxazole and trimethoprim have been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section.
Aerobic gram-positive microorganisms:
Streptococcus pneumoniae
Aerobic gram-negative microorganisms:
Escherichia coli (including susceptible enterotoxigenic strains implicated in traveler's diarrhea)
Klebsiella species
Enterobacter species
Haemophilus influenzae
Morganella morganii
Proteus mirabilis
Proteus vulgaris
Shigella flexneri
Shigella sonneiOther Organisms:
Pneumocystis carinii
Susceptibility Testing Methods:
Dilution Techniques:
Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized procedure. Standardized procedures are based on a dilution method4 (broth or agar) or equivalent with standardized inoculum concentrations and standardized concentrations of sulfamethoxazole/trimethoprim powder. The MIC values should be interpreted according to the following criteria:
For testing Enterobacteriaceae: MIC (µg/mL) Interpretation ≤ 2/38 Susceptible (S) ≥ 4/76 Resistant (R) When testing either Haemophilus influenzae* or Streptococcus pneumoniae†: MIC (µg/mL) Interpretation† - *
- These interpretative standards are applicable only to broth microdilution susceptibility tests with Haemophilus influenzae using Haemophilus Test Medium (HTM).4
- †
- These interpretative standards are applicable only to broth microdilution susceptibility tests using cation-adjusted Mueller-Hinton broth with 2% to 5% lysed horse blood.4
≤ 0.5/9.5 Susceptible (S) 1/19 – 2/38 Intermediate (I) ≥ 4/76 Resistant (R) A report of "Susceptible" indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. A report of "Intermediate" indicates that the result should be considered equivocal, and, if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where high dosage of drug can be used. This category also provides a buffer zone which prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of "Resistant" indicates that the pathogen is not likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable; other therapy should be selected.
Quality Control
Standardized susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures. Standard sulfamethoxazole/trimethoprim powder should provide the following range of values:
Microorganism MIC (µg/mL) - *
- This quality control range is applicable only to Haemophilus influenzae ATCC 49247 tested by broth microdilution procedure using Haemophilus Test Medium (HTM).4
- †
- This quality control range is applicable to tests performed by the broth microdilution method only using cation-adjusted Mueller-Hinton broth with 2% to 5% lysed horse blood.4
Escherichia coli ATCC 25922 ≤ 0.5/9.5 Haemophilus influenzae* ATCC 49247 0.03/0.59 – 0.25/4.75 Streptococcus pneumoniae† ATCC 49619 0.12/2.4 – 1/19 Diffusion Techniques:
Quantitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure5 requires the use of standardized inoculum concentrations. This procedure uses paper disks impregnated with 1.25/23.75 µg of sulfamethoxazole/trimethoprim to test the susceptibility of microorganisms to sulfamethoxazole/trimethoprim.
Reports from the laboratory providing results of the standard single-disk susceptibility test with a 1.25/23.75 µg of sulfamethoxazole/trimethoprim disk should be interpreted according to the following criteria:
For testing either Enterobacteriaceae or Haemophilus influenzae*: Zone Diameter (mm) Interpretation - *
- These zone diameter standards are applicable only for disk diffusion testing with Haemophilus influenzae and Haemophilus Test Medium (HTM).5
≥ 16 Susceptible (S) 11 – 15 Intermediate (I) ≤ 10 Resistant (R) When testing Streptococcus pneumoniae*: Zone Diameter (mm) Interpretation - *
- These zone diameter interpretative standards are applicable only to tests performed using Mueller-Hinton agar supplemented with 5% defibrinated sheep blood when incubated in 5% CO2.5
≥ 19 Susceptible (S) 16 – 18 Intermediate (I) ≤ 15 Resistant (R) Interpretation should be as stated above for results using dilution techniques. Interpretation involves correlation of the diameter obtained in the disk test with the MIC for sulfamethoxazole/trimethoprim.
Quality Control
As with standardized dilution techniques, diffusion methods require the use of laboratory control microorganisms that are used to control the technical aspects of the laboratory procedures. For the diffusion technique, the 1.25/23.75 µg sulfamethoxazole/trimethoprim disk1 should provide the following zone diameters in these laboratory test quality control strains:
Microorganism Zone Diameter Ranges (mm) - *
- This quality control range is applicable only to Haemophilus influenzae ATCC 49247 tested by a disk diffusion procedure using Haemophilus Test Medium (HTM).5
- †
- This quality control range is applicable only to tests performed by disk diffusion using Mueller-Hinton agar supplemented with 5% defibrinated sheep blood when incubated in 5% CO2.5
Escherichia coli ATCC 25922 24–32 Haemophilus influenzae* ATCC 49247 24–32 Streptococcus pneumoniae† ATCC 49619 20–28
- 1
- Mueller-Hinton agar should be checked for excessive levels of thymidine or thymine. To determine whether Mueller-Hinton medium has sufficiently low levels of thymidine and thymine, an Enterococcus faecalis (ATCC 29212 or ATCC 33186) may be tested with sulfamethoxazole/trimethoprim disks. A zone of inhibition ≥20 mm that is essentially free of fine colonies indicates a sufficiently low level of thymidine and thymine.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of Bactrim (sulfamethoxazole and trimethoprim) tablets and other antibacterial drugs, Bactrim (sulfamethoxazole and trimethoprim) tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to empiric selection of therapy.
Urinary Tract Infections: For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris. It is recommended that initial episodes of uncomplicated urinary tract infections be treated with a single effective antibacterial agent rather than the combination.
Acute Otitis Media: For the treatment of acute otitis media in pediatric patients due to susceptible strains of Streptococcus pneumoniae or Haemophilus influenzae when in the judgment of the physician sulfamethoxazole and trimethoprim offers some advantage over the use of other antimicrobial agents. To date, there are limited data on the safety of repeated use of BACTRIM in pediatric patients under two years of age. BACTRIM is not indicated for prophylactic or prolonged administration in otitis media at any age.
Acute Exacerbations of Chronic Bronchitis in Adults: For the treatment of acute exacerbations of chronic bronchitis due to susceptible strains of Streptococcus pneumoniae or Haemophilus influenzae when in the judgment of the physician BACTRIM offers some advantage over the use of a single antimicrobial agent.
Shigellosis: For the treatment of enteritis caused by susceptible strains of Shigella flexneri and Shigella sonnei when antibacterial therapy is indicated.
BACTRIM is contraindicated in patients with a known hypersensitivity to trimethoprim or sulfonamides, in patients with a history of drug-induced immune thrombocytopenia with use of trimethoprim and/or sulfonamides, and in patients with documented megaloblastic anemia due to folate deficiency. BACTRIM is also contraindicated in pregnant patients and nursing mothers, because sulfonamides pass the placenta and are excreted in the milk and may cause kernicterus. BACTRIM is contraindicated in pediatric patients less than 2 months of age. BACTRIM is also contraindicated in patients with marked hepatic damage or with severe renal insufficiency when renal function status cannot be monitored.
SULFONAMIDES, INCLUDING SULFONAMIDE-CONTAINING PRODUCTS SUCH AS SULFAMETHOXAZOLE/TRIMETHOPRIM, SHOULD BE DISCONTINUED AT THE FIRST APPEARANCE OF SKIN RASH OR ANY SIGN OF ADVERSE REACTION. In rare instances, a skin rash may be followed by a more severe reaction, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, hepatic necrosis, and serious blood disorders (see PRECAUTIONS). Clinical signs, such as rash, sore throat, fever, arthralgia, pallor, purpura or jaundice may be early indications of serious reactions.
Cough, shortness of breath, and pulmonary infiltrates are hypersensitivity reactions of the respiratory tract that have been reported in association with sulfonamide treatment.
Thrombocytopenia has been reported with both sulfamethoxazole and trimethoprim usage. A case control study found a 124-fold increased risk of severe thrombocytopenia (platelets <30,000 µL, requiring hospitalization) with sulfamethoxazole and trimethoprim in combination with an incidence of 2 cases per 1000 patient-years of exposure.6 The incidence of less severe thrombocytopenia may be higher.
Thrombocytopenia caused by sulfamethoxazole and trimethoprim may be immune-mediated. Drug-induced immune-mediated thrombocytopenia with sulfamethoxazole/trimethoprim is characterized by a drug-dependent antibody that is itself nonreactive, but when soluble drug is present at pharmacologic concentrations, antibody binds tightly to specific platelet membrane glycoproteins, causing platelet destruction.7 Serologic testing for drug-specific antibody is commercially available and may be useful for identifying the specific cause of thrombocytopenia in individual cases. Testing is important because a patient with drug-dependent antibodies should not be re-exposed to BACTRIM (see CONTRAINDICATIONS).
Typically, a patient with immune thrombocytopenia will have taken drug for about 1 week or intermittently over a longer period of time (possibly years) before presenting with petechiae or bruising. Systemic symptoms, such as lightheadedness, chills, fever, nausea, and vomiting, often may precede bleeding events. Thrombocytopenia may be severe. Patients should have risk/benefit re-evaluated in order to continue treatment with BACTRIM. If the drug is stopped, symptoms usually resolve within 1 or 2 days and platelet count returns to normal in less than 1 week. If BACTRIM is not stopped, there is a risk of fatal hemorrhage. The onset of thrombocytopenia may be more rapid upon re-exposure.
Sulfamethoxazole has also been shown to occasionally trigger the production of platelet-specific autoantibodies leading to a clinical picture indistinguishable from spontaneous autoimmune thrombocytopenia. In such cases, autoantibodies remain present for up to 9 weeks after sulfamethoxazole has been stopped, corresponding with a marked reduction in platelet counts for the same period.
The sulfonamides should not be used for treatment of group A β-hemolytic streptococcal infections. In an established infection, they will not eradicate the streptococcus and, therefore, will not prevent sequelae such as rheumatic fever.
Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including BACTRIM, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.
C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.
If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.
General: Prescribing Bactrim (sulfamethoxazole and trimethoprim) tablets in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.
BACTRIM should be given with caution to patients with impaired renal or hepatic function, to those with possible folate deficiency (e.g., the elderly, chronic alcoholics, patients receiving anticonvulsant therapy, patients with malabsorption syndrome, and patients in malnutrition states) and to those with severe allergies or bronchial asthma. In glucose-6-phosphate dehydrogenase deficient individuals, hemolysis may occur. This reaction is frequently dose-related (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).
Cases of hypoglycemia in non-diabetic patients treated with BACTRIM are seen rarely, usually occurring after a few days of therapy. Patients with renal dysfunction, liver disease, malnutrition or those receiving high doses of BACTRIM are particularly at risk.
BACTRIM should be discontinued in case of any signs or symptoms of thrombocytopenia (see WARNINGS).
Hematological changes indicative of folic acid deficiency may occur in elderly patients or in patients with preexisting folic acid deficiency or kidney failure. These effects are reversible by folinic acid therapy.
Trimethoprim has been noted to impair phenylalanine metabolism, but this is of no significance in phenylketonuric patients on appropriate dietary restriction.
As with all drugs containing sulfonamides, caution is advisable in patients with porphyria or thyroid dysfunction.
Use in the Treatment of and Prophylaxis for Pneumocystis Carinii Pneumonia in Patients with Acquired Immunodeficiency Syndrome (AIDS): AIDS patients may not tolerate or respond to BACTRIM in the same manner as non-AIDS patients. The incidence of side effects, particularly rash, fever, leukopenia and elevated aminotransferase (transaminase) values, with BACTRIM therapy in AIDS patients who are being treated for Pneumocystis carinii pneumonia has been reported to be greatly increased compared with the incidence normally associated with the use of BACTRIM in non-AIDS patients.8 The incidence of hyperkalemia appears to be increased in AIDS patients receiving BACTRIM. Adverse effects are generally less severe in patients receiving BACTRIM for prophylaxis. A history of mild intolerance to BACTRIM in AIDS patients does not appear to predict intolerance of subsequent secondary prophylaxis.9 However, if a patient develops skin rash or any sign of adverse reaction, therapy with BACTRIM should be reevaluated (see WARNINGS).
High dosage of trimethoprim, as used in patients with Pneumocystis carinii pneumonia, induces a progressive but reversible increase of serum potassium concentrations in a substantial number of patients. Even treatment with recommended doses may cause hyperkalemia when trimethoprim is administered to patients with underlying disorders of potassium metabolism, with renal insufficiency, or if drugs known to induce hyperkalemia are given concomitantly. Close monitoring of serum potassium is warranted in these patients.
During treatment, adequate fluid intake and urinary output should be ensured to prevent crystalluria. Patients who are "slow acetylators" may be more prone to idiosyncratic reactions to sulfonamides.
Information for Patients: Patients should be counseled that antibacterial drugs including Bactrim (sulfamethoxazole and trimethoprim) tablets should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When Bactrim (sulfamethoxazole and trimethoprim) tablets are prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by Bactrim (sulfamethoxazole and trimethoprim) tablets or other antibacterial drugs in the future.
Patients should be instructed to maintain an adequate fluid intake in order to prevent crystalluria and stone formation.
Diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.
Laboratory Tests: Complete blood counts should be done frequently in patients receiving BACTRIM; if a significant reduction in the count of any formed blood element is noted, BACTRIM should be discontinued. Urinalyses with careful microscopic examination and renal function tests should be performed during therapy, particularly for those patients with impaired renal function.
Drug Interactions: In elderly patients concurrently receiving certain diuretics, primarily thiazides, an increased incidence of thrombocytopenia with purpura has been reported.
It has been reported that BACTRIM may prolong the prothrombin time in patients who are receiving the anticoagulant warfarin. This interaction should be kept in mind when BACTRIM is given to patients already on anticoagulant therapy, and the coagulation time should be reassessed.
BACTRIM may inhibit the hepatic metabolism of phenytoin. BACTRIM, given at a common clinical dosage, increased the phenytoin half-life by 39% and decreased the phenytoin metabolic clearance rate by 27%. When administering these drugs concurrently, one should be alert for possible excessive phenytoin effect.
Sulfonamides can also displace methotrexate from plasma protein binding sites and can compete with the renal transport of methotrexate, thus increasing free methotrexate concentrations.
There have been reports of marked but reversible nephrotoxicity with coadministration of BACTRIM and cyclosporine in renal transplant recipients.
Increased digoxin blood levels can occur with concomitant BACTRIM therapy, especially in elderly patients. Serum digoxin levels should be monitored.
Increased sulfamethoxazole blood levels may occur in patients who are also receiving indomethacin.
Occasional reports suggest that patients receiving pyrimethamine as malaria prophylaxis in doses exceeding 25 mg weekly may develop megaloblastic anemia if BACTRIM is prescribed.
The efficacy of tricyclic antidepressants can decrease when coadministered with BACTRIM.
Like other sulfonamide-containing drugs, BACTRIM potentiates the effect of oral hypoglycemics.
In the literature, a single case of toxic delirium has been reported after concomitant intake of sulfamethoxazole/trimethoprim and amantadine.
In the literature, three cases of hyperkalemia in elderly patients have been reported after concomitant intake of sulfamethoxazole/trimethoprim and an angiotensin converting enzyme inhibitor.10,11
Drug/Laboratory Test Interactions: BACTRIM, specifically the trimethoprim component, can interfere with a serum methotrexate assay as determined by the competitive binding protein technique (CBPA) when a bacterial dihydrofolate reductase is used as the binding protein. No interference occurs, however, if methotrexate is measured by a radioimmunoassay (RIA).
The presence of sulfamethoxazole and trimethoprim may also interfere with the Jaffé alkaline picrate reaction assay for creatinine, resulting in overestimations of about 10% in the range of normal values.
Carcinogenesis, Mutagenesis, Impairment of Fertility:
Carcinogenesis: Long-term studies in animals to evaluate carcinogenic potential have not been conducted with BACTRIM.
Mutagenesis: Bacterial mutagenic studies have not been performed with sulfamethoxazole and trimethoprim in combination. Trimethoprim was demonstrated to be nonmutagenic in the Ames assay. No chromosomal damage was observed in human leukocytes cultured in vitro with sulfamethoxazole and trimethoprim alone or in combination; the concentrations used exceeded blood levels of these compounds following therapy with sulfamethoxazole and trimethoprim. Observations of leukocytes obtained from patients treated with sulfamethoxazole and trimethoprim revealed no chromosomal abnormalities.
Pregnancy: Teratogenic Effects: Pregnancy Category C. In rats, oral doses of 533 mg/kg or 200 mg/kg produced teratologic effects manifested mainly as cleft palates.
The highest dose which did not cause cleft palates in rats was 512 mg/kg sulfamethoxazole or 192 mg/kg trimethoprim when administered separately. In two studies in rats, no teratology was observed when 512 mg/kg of sulfamethoxazole was used in combination with 128 mg/kg of trimethoprim. In one study, however, cleft palates were observed in one litter out of 9 when 355 mg/kg of sulfamethoxazole was used in combination with 88 mg/kg of trimethoprim.
In some rabbit studies, an overall increase in fetal loss (dead and resorbed and malformed conceptuses) was associated with doses of trimethoprim 6 times the human therapeutic dose.
While there are no large, well-controlled studies on the use of sulfamethoxazole and trimethoprim in pregnant women, Brumfitt and Pursell,12 in a retrospective study, reported the outcome of 186 pregnancies during which the mother received either placebo or sulfamethoxazole and trimethoprim. The incidence of congenital abnormalities was 4.5% (3 of 66) in those who received placebo and 3.3% (4 of 120) in those receiving sulfamethoxazole and trimethoprim. There were no abnormalities in the 10 children whose mothers received the drug during the first trimester. In a separate survey, Brumfitt and Pursell also found no congenital abnormalities in 35 children whose mothers had received oral sulfamethoxazole and trimethoprim at the time of conception or shortly thereafter.
Because sulfamethoxazole and trimethoprim may interfere with folic acid metabolism, BACTRIM should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Nonteratogenic Effects: See CONTRAINDICATIONS section.
Nursing Mothers: See CONTRAINDICATIONS section.
Pediatric Use: BACTRIM is not recommended for infants younger than 2 months of age (see INDICATIONS and CONTRAINDICATIONS sections).
Geriatric Use: Clinical studies of BACTRIM did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.
There may be an increased risk of severe adverse reactions in elderly patients, particularly when complicating conditions exist, e.g., impaired kidney and/or liver function, possible folate deficiency, or concomitant use of other drugs. Severe skin reactions, generalized bone marrow suppression (see WARNINGS and ADVERSE REACTIONS sections), a specific decrease in platelets (with or without purpura), and hyperkalemia are the most frequently reported severe adverse reactions in elderly patients. In those concurrently receiving certain diuretics, primarily thiazides, an increased incidence of thrombocytopenia with purpura has been reported. Increased digoxin blood levels can occur with concomitant BACTRIM therapy, especially in elderly patients. Serum digoxin levels should be monitored. Hematological changes indicative of folic acid deficiency may occur in elderly patients. These effects are reversible by folinic acid therapy. Appropriate dosage adjustments should be made for patients with impaired kidney function and duration of use should be as short as possible to minimize risks of undesired reactions (see DOSAGE AND ADMINISTRATION section). The trimethoprim component of BACTRIM may cause hyperkalemia when administered to patients with underlying disorders of potassium metabolism, with renal insufficiency or when given concomitantly with drugs known to induce hyperkalemia, such as angiotensin converting enzyme inhibitors. Close monitoring of serum potassium is warranted in these patients. Discontinuation of BACTRIM treatment is recommended to help lower potassium serum levels. Bactrim Tablets contain 1.8 mg sodium (0.08 mEq) of sodium per tablet. Bactrim DS Tablets contain 3.6 mg (0.16 mEq) of sodium per tablet.
Pharmacokinetics parameters for sulfamethoxazole were similar for geriatric subjects and younger adult subjects. The mean maximum serum trimethoprim concentration was higher and mean renal clearance of trimethoprim was lower in geriatric subjects compared with younger subjects (see CLINICAL PHARMACOLOGY: Geriatric Pharmacokinetics).
The most common adverse effects are gastrointestinal disturbances (nausea, vomiting, anorexia) and allergic skin reactions (such as rash and urticaria). FATALITIES ASSOCIATED WITH THE ADMINISTRATION OF SULFONAMIDES, ALTHOUGH RARE, HAVE OCCURRED DUE TO SEVERE REACTIONS, INCLUDING STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, FULMINANT HEPATIC NECROSIS, AGRANULOCYTOSIS, APLASTIC ANEMIA AND OTHER BLOOD DYSCRASIAS (SEE WARNINGS SECTION).
Hematologic: Agranulocytosis, aplastic anemia, thrombocytopenia, leukopenia, neutropenia, hemolytic anemia, megaloblastic anemia, hypoprothrombinemia, methemoglobinemia, eosinophilia.
Allergic Reactions: Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis, allergic myocarditis, erythema multiforme, exfoliative dermatitis, angioedema, drug fever, chills, Henoch-Schoenlein purpura, serum sickness-like syndrome, generalized allergic reactions, generalized skin eruptions, photosensitivity, conjunctival and scleral injection, pruritus, urticaria and rash. In addition, periarteritis nodosa and systemic lupus erythematosus have been reported.
Gastrointestinal: Hepatitis (including cholestatic jaundice and hepatic necrosis), elevation of serum transaminase and bilirubin, pseudomembranous enterocolitis, pancreatitis, stomatitis, glossitis, nausea, emesis, abdominal pain, diarrhea, anorexia.
Genitourinary: Renal failure, interstitial nephritis, BUN and serum creatinine elevation, toxic nephrosis with oliguria and anuria, crystalluria and nephrotoxicity in association with cyclosporine.
Metabolic and Nutritional: Hyperkalemia (see PRECAUTIONS: Use in the Treatment of and Prophylaxis for Pneumocystis Carinii Pneumonia in Patients with Acquired Immunodeficiency Syndrome (AIDS).
Neurologic: Aseptic meningitis, convulsions, peripheral neuritis, ataxia, vertigo, tinnitus, headache.
Psychiatric: Hallucinations, depression, apathy, nervousness.
Endocrine: The sulfonamides bear certain chemical similarities to some goitrogens, diuretics (acetazolamide and the thiazides) and oral hypoglycemic agents. Cross-sensitivity may exist with these agents. Diuresis and hypoglycemia have occurred rarely in patients receiving sulfonamides.
Musculoskeletal: Arthralgia and myalgia. Isolated cases of rhabdomyolysis have been reported with BACTRIM, mainly in AIDS patients.
Respiratory: Cough, shortness of breath and pulmonary infiltrates (see WARNINGS).
Miscellaneous: Weakness, fatigue, insomnia.
Acute: The amount of a single dose of BACTRIM that is either associated with symptoms of overdosage or is likely to be life-threatening has not been reported. Signs and symptoms of overdosage reported with sulfonamides include anorexia, colic, nausea, vomiting, dizziness, headache, drowsiness and unconsciousness. Pyrexia, hematuria and crystalluria may be noted. Blood dyscrasias and jaundice are potential late manifestations of overdosage.
Signs of acute overdosage with trimethoprim include nausea, vomiting, dizziness, headache, mental depression, confusion and bone marrow depression.
General principles of treatment include the institution of gastric lavage or emesis, forcing oral fluids, and the administration of intravenous fluids if urine output is low and renal function is normal. Acidification of the urine will increase renal elimination of trimethoprim. The patient should be monitored with blood counts and appropriate blood chemistries, including electrolytes. If a significant blood dyscrasia or jaundice occurs, specific therapy should be instituted for these complications. Peritoneal dialysis is not effective and hemodialysis is only moderately effective in eliminating sulfamethoxazole and trimethoprim.
Chronic: Use of BACTRIM at high doses and/or for extended periods of time may cause bone marrow depression manifested as thrombocytopenia, leukopenia and/or megaloblastic anemia. If signs of bone marrow depression occur, the patient should be given leucovorin 5 to 15 mg daily until normal hematopoiesis is restored.
Not recommended for use in pediatric patients less than 2 months of age.
Urinary Tract Infections and Shigellosis in Adults and Pediatric Patients, and Acute Otitis Media in Children:
Adults: The usual adult dosage in the treatment of urinary tract infections is 1 BACTRIM DS (double strength) tablet or 2 BACTRIM tablets every 12 hours for 10 to 14 days. An identical daily dosage is used for 5 days in the treatment of shigellosis.
Children: The recommended dose for children with urinary tract infections or acute otitis media is 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim per 24 hours, given in two divided doses every 12 hours for 10 days. An identical daily dosage is used for 5 days in the treatment of shigellosis. The following table is a guideline for the attainment of this dosage:
Children 2 months of age or older: Weight Dose–every 12 hours lb kg Tablets 22 10 – 44 20 1 66 30 1½ 88 40 2 or 1 DS tablet For Patients with Impaired Renal Function: When renal function is impaired, a reduced dosage should be employed using the following table:
Creatinine Clearance (mL/min) Recommended Dosage Regimen Above 30 Usual standard regimen 15–30 ½ the usual regimen Below 15 Use not recommended Acute Exacerbations of Chronic Bronchitis in Adults:
The usual adult dosage in the treatment of acute exacerbations of chronic bronchitis is 1 BACTRIM DS (double strength) tablet or 2 BACTRIM tablets every 12 hours for 14 days.
Pneumocystis Carinii Pneumonia:
Treatment: Adults and Children:
The recommended dosage for treatment of patients with documented Pneumocystis carinii pneumonia is 75 to 100 mg/kg sulfamethoxazole and 15 to 20 mg/kg trimethoprim per 24 hours given in equally divided doses every 6 hours for 14 to 21 days.13 The following table is a guideline for the upper limit of this dosage:
Weight Dose–every 6 hours lb kg Tablets 18 8 – 35 16 1 53 24 1½ 70 32 2 or 1 DS tablet 88 40 2½ 106 48 3 or 1½ DS tablets 141 64 4 or 2 DS tablets 176 80 5 or 2½ DS tablets For the lower limit dose (75 mg/kg sulfamethoxazole and 15 mg/kg trimethoprim per 24 hours) administer 75% of the dose in the above table.
The recommended dosage for prophylaxis in adults is 1 BACTRIM DS (double strength) tablet daily.14
For children, the recommended dose is 750 mg/m2/day sulfamethoxazole with 150 mg/m2/day trimethoprim given orally in equally divided doses twice a day, on 3 consecutive days per week. The total daily dose should not exceed 1600 mg sulfamethoxazole and 320 mg trimethoprim.15 The following table is a guideline for the attainment of this dosage in children:
Body Surface Area Dose–every 12 hours (m2) Tablets 0.26 – 0.53 ½ 1.06 1 -
BACTRIM™ TABLETS are supplied as follows:
BACTRIM™ DS (double strength) TABLETS (white, oval shaped, scored) containing 160 mg trimethoprim and 800 mg sulfamethoxazole –
bottles of 10 (NDC 54868-0337-3), bottles of 20 (NDC 54868-0337-0), bottles of 30 (NDC 54868-0337-1).
Imprint on tablets (debossed): (front) BACTRIM DS
- Kremers P, Duvivier J, Heusghem C. Pharmacokinetic Studies of Co-Trimoxazole in Man after Single and Repeated Doses. J Clin Pharmacol. Feb-Mar 1974; 14:112–117.
- Kaplan SA, et al. Pharmacokinetic Profile of Trimethoprim-Sulfamethoxazole in Man. J Infect Dis. Nov 1973; 128 (Suppl): S547–S555.
- Varoquaux O, et al. Pharmacokinetics of the trimethoprim-sulfamethoxazole combination in the elderly. Br J Clin Pharmacol. 1985;20:575–581.
- Rudoy RC, Nelson JD, Haltalin KC. Antimicrobial Agents Chemother. May 1974;5:439–443.
- National Committee for Clinical Laboratory Standards. Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically; Approved Standard – Fourth Edition. NCCLS Document M7–A4, Vol.17, No. 2, NCCLS, Wayne, PA, January, 1997.
- Kaufman DW, Kelly JP, Johannes CB, Sandler A, Harmon D, Stolley PD, Shapiro S. Acute thrombocytopenic purpura in relation to the use of drugs. Blood 1993; 82: 2714–18.
- Aster RH, Curtis BR, McFarland JG, Bougie DW. Drug-induced immune thrombocytopenia: pathogenesis, diagnosis, and management. J Thromb Haemost 2009; 7: 911–8.
- Hardy DW, et al. A controlled trial of trimethoprim-sulfamethoxazole or aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. N Engl J Med. 1992; 327: 1842–1848.
- National Committee for Clinical Laboratory Standards. Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved Standard – Sixth Edition. NCCLS Document M2–A6, Vol.17, No.1, NCCLS, Wayne, PA, January, 1997.
- Marinella Mark A. 1999. Trimethoprim-induced hyperkalemia: An analysis of reported cases. Gerontol. 45:209–212.
- Margassery, S. and B. Bastani. 2002. Life threatening hyperkalemia and acidosis secondary to trimethoprim-sulfamethoxazole treatment. J. Nephrol. 14:410–414.
- Brumfitt W, Pursell R. Trimethoprim/Sulfamethoxazole in the Treatment of Bacteriuria in Women. J Infect Dis. Nov 1973; 128 (Suppl):S657–S663.
- Masur H. Prevention and treatment of Pneumocystis pneumonia. N Engl J Med. 1992; 327: 1853–1880.
- Recommendations for prophylaxis against Pneumocystis carinii pneumonia for adults and adolescents infected with human immunodeficiency virus. MMWR. 1992; 41(RR-4):1–11.
- CDC Guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with human immunodeficiency virus. MMWR. 1991; 40(RR-2):1–13.
- PRINCIPAL DISPLAY PANEL - 800 mg/160 mg Label
sulfamethoxazole and trimethoprim tabletProduct Information Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:54868-0337(NDC:13310-146) Route of Administration ORAL Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength SULFAMETHOXAZOLE (UNII: JE42381TNV) (SULFAMETHOXAZOLE - UNII:JE42381TNV) SULFAMETHOXAZOLE 800 mg TRIMETHOPRIM (UNII: AN164J8Y0X) (TRIMETHOPRIM - UNII:AN164J8Y0X) TRIMETHOPRIM 160 mg Inactive Ingredients Ingredient Name Strength DOCUSATE SODIUM (UNII: F05Q2T2JA0) SODIUM BENZOATE (UNII: OJ245FE5EU) SODIUM STARCH GLYCOLATE TYPE A POTATO (UNII: 5856J3G2A2) MAGNESIUM STEARATE (UNII: 70097M6I30) STARCH, CORN (UNII: O8232NY3SJ) Product Characteristics Color white Score 2 pieces Shape OVAL Size 19mm Flavor Imprint Code BACTRIM;DS Contains Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 NDC:54868-0337-0 20 in 1 BOTTLE, PLASTIC 2 NDC:54868-0337-1 30 in 1 BOTTLE, PLASTIC 3 NDC:54868-0337-3 10 in 1 BOTTLE, PLASTIC Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA017377 08/26/1997 Labeler - Physicians Total Care, Inc. (194123980) Establishment Name Address ID/FEI Business Operations Physicians Total Care, Inc. 194123980 relabel, repack


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Finding a puppy has never been simpler, Browse through our puppies for sale below. If you have not yet decided upon a particular dog breed then please try out are breed suggestion tool. Using it will enable you to select a range of dog breeds which best matches up with your criteria. If you do not find the puppy for sale that you are looking for then place your request within our dogs wanted area. Doing so will enable registered dog breeders to quickly scan through your requests, and at the same time we ensure your privacy as your email address will always be protected from the general public. You may view all our puppies for sale by selecting the page numbers or if you wish you may select another dog breed below.
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Back to
2004-05 NYSSRC Home
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Captree Elementary School in West Islip Union Free School District 2004-05
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School District and Similar Schools Comparison Group
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Court records show a Cleveland Municipal Court judge on Monday ordered 32-year-old Shena Hardin to stand at an intersection for two days next week.
She will have to wear a sign saying: "Only an idiot drives on the footpath to avoid a school bus."
The judge ordered her to wear the sign from 7.45am to 8.45am both days.
Hardin's licence was suspended for 30 days and she was ordered to pay $US250 ($A242.38) in court costs.
Messages seeking comment were left at a telephone listing for Hardin and at her lawyer's office.


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USA Salon & Spa Mino The Mino is a three section bed that has three motors that control the height, backrest and seat inclination. The footrest is controlled manually and the bed is able to lay flat as well as in a chair like position. The armrests are very flexible and also removable. The face cushion can be removed to reveal a facial hole.
Package Specifications: Packing Size L x W x H (ins | cm) - 67.7 x 25.6 x 25.4 | 172 x 65 x 64.5 Product Size L x W x H (ins | cm) - 74 x 33.1 x 23.2/33.5 | 188 x 84 x 59/85 Max Weight (lbs | kgs) - 330 | 150 No. Motors - 3 Standard Control - Handset Optional Foot Control G.W (lbs | kg) - 167.2 | 76 N.W (lbs | kg) - 140.8 | 64 Voltage - 100V-120V Frequency - 50Hz/60Hz Installation - 2 Person Assembly - No
Adjustable heights, easy-to-use, ergonomic lines, soft textures, easy-to-understand instructions and simple assemblies. These are just some of the factors that make USA Salon & Spa products practical, functional and, above all, comfortable.
All the essentials are provided, no fluff. Our products are technically advanced and designed to work in a more functional way. Shop from our selection of state-of-the-art beauty instruments, therapist stools, trolleys and other equipment.
LIMITED WARRANTY AND EXCLUSIVE REMEDY: USAS&S warrants that during a period of one (1) year from date of shipment of the goods purchased under this contract, such goods shall be free from structural defects under normal use and service. USAS&S may repair or replace at its discretion any product or part deemed to be defective in material or workmanship upon mandatory inspection and/or attempted troubleshooting by an authorized representative of USAS&S. If during such period such goods shall fail to perform in accordance with specifications, USAS&S shall, at its expense and option, repair or replace the goods; provided however, USAS&S shall not be responsible for any removal, installation or reinstallation costs. THE FOREGOING WARRANTIES AND REMEDIES SHALL BE CUSTOMERS SOLE AND EXCLUSIVE WARRANTIES AND REMEDIES under any and all circumstances. Provided further that if any such remedy shall fail of its essential purpose, USAS&S maximum and sole liability arising from or related to this sale of goods contract, or from any attempts to repair or replace defective goods, shall be limited to payment of the purchase price, or the allocable portion of the purchase price which relates to the defective goods furnished under this contract. The foregoing warranty shall be void if damage results from Customers improper installation, repair or use of the goods; any products deemed to be damaged due to misuse, wear and tear, neglect, fire, theft or any attempt to repair or modify by persons other than USAS&S will make the buyer responsible for all repair, replacement and delivery costs thereafter. The USAS&S warranty excludes the cost of all shipment/delivery fees, unless agreed by the USAS&S representative; this includes shipping costs for inspection.
DISCLAIMER OF ALL OTHER WARRANTIES: USAS&S makes no warranty other than the limited warranties described or provided above. THESE LIMITED WARRANTIES ARE EXPRESSLY IN LIEU OF ANY AND ALL OTHER EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION ANY IMPLIED WARRANTY OF MERCHANTABILITYOR FITNESS FOR A PARTICULAR PURPOSE, ALL OF WHICHARE HEREBY EXPRESSLY DISCLAIMED. There are no warranties which extend beyond the description on the face hereof. In no event shall USAS&S be liable for, and Customer shall indemnify and hold USAS&S harmless from, (1)any damages, direct, indirect, general, special, incidental or consequential, WHETHER RESULTING FROM USAS&S NEGLIGENCE OR OTHERWISE, arising out of, in connection with, or resulting from the goods contract sold hereunder, and (2) any and all claims, actions, suits and proceedings which may be instituted in respect to the foregoing, including without limitation those made by subsequent owners and users of the goods.
We reserve the right to change our product specifications at any time, in order to make improvements.


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Bouncy Merino - Buzz
This product is sold out
This superwash high twist merino takes dye perfectly for vivid semi-solids as well as artistic colorplay.
It's very bouncy and a dream to work with.
It is great for lightweight sweaters and shawls, scarves.
Colorway - Buzz
Weight - Fingering - 100 grams
Fibre - 100% High Twist Superwash merino
Length - 365 meters / 399 yards
Due to the process of creating this yarn in small batches of 2 skeins, they can vary. However, when purchasing a bigger amount we try to choose the closest items to each other. If working with two or more skeins I recommend alternating strands to obtain a uniform fabric.
Even though this yarn is super wash I recommend a cool hand wash in a mild detergent. Although every effort is made to exhaust the dye bath of color you may find a little color bleed on the first wash.
I try to depict the true color of yarn but please remember each monitor will be different.
If you have any questions regarding the color, feel free to drop me an email.


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Calvinist Corner | www.mslick.com |
Deuteronomy 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 1 Hear, O Israel: Thou art to pass over Jordan this day, to go in to possess nations greater and mightier than thyself, cities great and fenced up to heaven, 2 A people great and tall, the children of the Anakims, whom thou knowest, and of whom thou hast heard say, Who can stand before the children of Anak! 3 Understand therefore this day, that the LORD thy God is he which goeth over before thee; as a consuming fire he shall destroy them, and he shall bring them down before thy face: so shalt thou drive them out, and destroy them quickly, as the LORD hath said unto thee. 4 Speak not thou in thine heart, after that the LORD thy God hath cast them out from before thee, saying, For my righteousness the LORD hath brought me in to possess this land: but for the wickedness of these nations the LORD doth drive them out from before thee. 5 Not for thy righteousness, or for the uprightness of thine heart, dost thou go to possess their land: but for the wickedness of these nations the LORD thy God doth drive them out from before thee, and that he may perform the word which the LORD sware unto thy fathers, Abraham, Isaac, and Jacob. 6 Understand therefore, that the LORD thy God giveth thee not this good land to possess it for thy righteousness; for thou art a stiffnecked people. 7 Remember, and forget not, how thou provokedst the LORD thy God to wrath in the wilderness: from the day that thou didst depart out of the land of Egypt, until ye came unto this place, ye have been rebellious against the LORD. 8 Also in Horeb ye provoked the LORD to wrath, so that the LORD was angry with you to have destroyed you. 9 When I was gone up into the mount to receive the tables of stone, even the tables of the covenant which the LORD made with you, then I abode in the mount forty days and forty nights, I neither did eat bread nor drink water: 10 And the LORD delivered unto me two tables of stone written with the finger of God; and on them was written according to all the words, which the LORD spake with you in the mount out of the midst of the fire in the day of the assembly. 11 And it came to pass at the end of forty days and forty nights, that the LORD gave me the two tables of stone, even the tables of the covenant. 12 And the LORD said unto me, Arise, get thee down quickly from hence; for thy people which thou hast brought forth out of Egypt have corrupted themselves; they are quickly turned aside out of the way which I commanded them; they have made them a molten image. 13 Furthermore the LORD spake unto me, saying, I have seen this people, and, behold, it is a stiffnecked people: 14 Let me alone, that I may destroy them, and blot out their name from under heaven: and I will make of thee a nation mightier and greater than they. 15 So I turned and came down from the mount, and the mount burned with fire: and the two tables of the covenant were in my two hands. 16 And I looked, and, behold, ye had sinned against the LORD your God, and had made you a molten calf: ye had turned aside quickly out of the way which the LORD had commanded you. 17 And I took the two tables, and cast them out of my two hands, and brake them before your eyes. 18 And I fell down before the LORD, as at the first, forty days and forty nights: I did neither eat bread, nor drink water, because of all your sins which ye sinned, in doing wickedly in the sight of the LORD, to provoke him to anger. 19 For I was afraid of the anger and hot displeasure, wherewith the LORD was wroth against you to destroy you. But the LORD hearkened unto me at that time also. 20 And the LORD was very angry with Aaron to have destroyed him: and I prayed for Aaron also the same time. 21 And I took your sin, the calf which ye had made, and burnt it with fire, and stamped it, and ground it very small, even until it was as small as dust: and I cast the dust thereof into the brook that descended out of the mount. 22 And at Taberah, and at Massah, and at Kibrothhattaavah, ye provoked the LORD to wrath. 23 Likewise when the LORD sent you from Kadeshbarnea, saying, Go up and possess the land which I have given you; then ye rebelled against the commandment of the LORD your God, and ye believed him not, nor hearkened to his voice. 24 Ye have been rebellious against the LORD from the day that I knew you. 25 Thus I fell down before the LORD forty days and forty nights, as I fell down at the first; because the LORD had said he would destroy you. 26 I prayed therefore unto the LORD, and said, O Lord GOD, destroy not thy people and thine inheritance, which thou hast redeemed through thy greatness, which thou hast brought forth out of Egypt with a mighty hand. 27 Remember thy servants, Abraham, Isaac, and Jacob; look not unto the stubbornness of this people, nor to their wickedness, nor to their sin: 28 Lest the land whence thou broughtest us out say, Because the LORD was not able to bring them into the land which he promised them, and because he hated them, he hath brought them out to slay them in the wilderness. 29 Yet they are thy people and thine inheritance, which thou broughtest out by thy mighty power and by thy stretched out arm. Return to Bible Online Calvinist Corner |


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Let's put aside the carrot and celery sticks, brussel sprouts and the cranberry juice for a moment. Human misery has never been cheered up with a plate of raw vegetables. No - true misery can only be cured by generous servings of sugar, chocolate, butter and a satisfaction that will never be found in anything really healthy.
A handful of cookies and a glass of cold milk have got to be the most timeless treats ever. Comforting, fulfilling and just plain good, there is nothing better than dunking a good cookie into a tall glass of milk to achieve that perfect degree of sogginess. Of course, there is nothing more tragic than that cookie drifting to the bottom of the glass if held in the milk for just a second too long.
After a hard day at school or a tough day at work, both Soeren and I usually look forward to coming home and getting rid of the days discomfort with a generous serving of chocolate chip cookies, fresh and warm from the oven. We weigh flour, cube butter and chop chocolate, while we discuss "what was good and bad" in the day.
The oven emits a cosy warmth with a sugary scent and soon the distress begins to dissolve. We hungrily grab the first of the warm cookies straight out of the oven, blowing impatiently to cool them enough to take the first big bite. Soft, chewy, chunky and the chocolate makes little streamers after that first bite. Wash it down a gulp of cold milk!
Sugar, chocolate and milk. Add to it a sympathetic hug, a few giggles over something silly, a few more cookies and soon the beastly day is a thing of the past. Gone and forgotten. Expelled to its proper place under the "not so important category" of human history.
We like our cookies chunky, as coarse chunks of deep, dark chocolate delivers a more superior cookie compared to the inferior manufactured chip. We also like playing around adding peanut butter, macadamia nuts, or a handful dried cherries - but in the end we always come back to the pure and simple chocolate chunk cookies.
A while back I happened to stumble over Signe's (Scandilicious) Twitter quest for the perfect chocolate chip cookie. Always curious to hear what tips and tricks people suggest, I eavesdropped a little. Soon afterwards, Signe posted the results of her chocolate chip cookie quest. The journey took her through several books and tweets, allowing her to incorporate her research into the cookie experiments.
I love experiments and often spend hours in the kitchen working on recipes and ideas. Sometimes, however it's nice to have someone else do the legwork! Thanks Sig!
The recipe below is adapted from Signe's blog, the minor changes I made were using organic whole wheat flour, dark muscovado sugar and instead of vanilla extract, I scraped out a vanilla bean.
Printable version of recipe here
Prep Time: 30 minutes
Total Time: 50 minutes
- 300g whole-wheat flour
- 1/2 tsp bicarbonate of soda
- 1/2- 3/4 tsp sea salt
- 180g unsalted butter, melted
- 200g dark brown muscovado sugar
- 100g golden caster sugar
- 1 large egg
- 1 large egg yolk
- 1 vanilla bean, insides scraped
- 150g dark chocolate, coarsely chopped into chunks
- Preheat the oven to 160 degrees C. Line two baking sheets with baking parchment and set aside.
- In a medium bowl sieve the flour, bicarbonate of soda and sea salt together. Stir a few times to distribute the raising agent.
- Whisk together the melted butter with the sugars until creamy, then add the large egg, extra yolk and vanilla innards to the mixture. Whisk again and then add the flour. Continue whisking the mixture for a few minutes to stretch the gluten strands.
- Add the chocolate chips and fold in. The cookie dough should feel almost dry now and look like a solid lump. Make sure the chocolate chunks do not all cluster in one part of the dough.
- Using a ice cream scoop, scoop small chunks of dough on the baking sheets, spacing them about 5 cm apart. To be on the safe side, space them further than 5cm as the cookies have a tendency to merge together while baking.
- Bake on the upper-middle shelf of the oven for 15-18 minutes until the cookies are golden, the sides feel firm to the touch but the centre is still quite soft.
- Cool the cookies on the baking sheets (helps keep their chewy consistency) and then remove with a pallet knife or very flat spatula. Store in a cookie tin.
I am not preaching giving up crunchy vegetables for sugary cookies, but let's face the truth - sometimes only a really good chocolate chunk cookie can be so truly gratifying.
The whole-wheat flour makes this slightly nuttier and provides a wonderful crispy exterior and a perfectly chewy center. The chocolate chunks are scattered liberally and are pure pleasure to bite into. This experiment passed the toughest of judges - the 8 year old gave it an all thumbs up.
Milk and cookies anyone? Which cookie makes you crumble?
Have a fantastic week and weekend folks - make sure it's sweet, crumbly, chocolaty and always with a glass of cold milk!
Cookie craze on WFLH:
Sugar and Spice Cookies with Cardamom, Lavender, Pistachio and Sprinkles | Almond and Pink Praline Spekulatius | Milan Cookies |
All photographs and written content on What's For Lunch, Honey? © 2006-2011 Meeta Khurana Wolff unless otherwise indicated. | All rights reserved | Please Ask First


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So I FINALLY did the Debbie Harry recreation-and let me tell you, it was more difficult than I had predicted. I had some good pieces but didn't really know how to match them. Not my favorite outfits, but it did give me a chance to rediscover some clothes I had forgotten about.
Anyways, without further ado...
The inspiration. One of my records, my sailor hat, and a page in Fashion Rocks magazine: The product (click to enlarge): These are all pretty repetitive, like the pencil skirt, and most are pretty simple. But I am fond of the all black with the gold chains (thrifted for $1 each. Eat my cheap ass dust, American Apparel!)
Unfortunately my red wayfarers in #5 broke because I stepped on them. My feet have always been so harmless and small! I plan on getting another pair, but I already have 2 other pairs of red sunnies and plan for another color. Which color do you think I should get? I'm considering yellow or mint green...(FredFlare)


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One Ball Golf Pouch
Sold out
Original price
Original price
Original price
Current price
by Hide & Drink
- HIDE & DRINK'S 101 YEAR WARRANTY: Each one of Hide & Drink's rustic, durable leather products is made with care and craftsmanship, with every item handmade to the highest standard. Our confidence in our products knows no bounds, so we include each product that you purchase with a 101 Year Warranty. We aim for nothing but 100% satisfaction when it comes to our products, so if you're not satisfied, just get in touch with us and we'll help you as quickly as possible.
- HANDMADE FROM SOFT & ATTRACTIVE FULL GRAIN LEATHER: All of Hide & Drink's products are hand cut and handcrafted using the highest quality of leather that you will find, namely Full Grain Leather. The quality of this leather ensures a long-lasting life and durability. After time and use, the leather will attain a beautiful and unique patina that will show age and grace.
- FINELY HAND STITCHED: We are proud that each and every one of our products is handmade by expert local artisans of Pastores, Guatemala, a town wholly dedicated to the crafting of leather goods. Each item is hand cut and finished with a fine stitching method than not only looks good, but also makes for a durable finish that will give you a lifetime of use. Any loose ends are passed over with an open flame to ensure no unravelling during its lifetime.
- MAKES A GREAT GIFT: Hide & Drink swears by its leather, and knows that this fine, rustic Full Grain Leather product will make an excellent gift for friends, family and loved ones. Built to last a lifetime, this item will make a thoughtful, long-lasting gift for anyone and everyone.
Length: in.
Height: in.
Width: in.
Full Grain Leather.
Over time and with use, the leather will assume a unique patina. If desired, condition with mineral oil or beeswax leather conditioner.


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Sedation Dentistry in Fort Myers, FL
There's so much dentistry can do these days to make your mouth healthier and your smile more beautiful. Yet many people don't take advantage of this because of a long-standing fear of dental treatment. If you are one of these people, rest assured that it's possible to have an experience that's free of anxiety and pain. This can be accomplished by blocking your sensations of pain with local anesthetics or by giving you medication that can help you relax. Sometimes both are needed to ensure maximum comfort, especially if you are someone for whom the injections that deliver local anesthetics are themselves a major source of anxiety.
When you are afraid of dental treatment, your guard goes up and your pain threshold goes down; anticipating that something will hurt makes you hypersensitive to every sensation — even sound. If this describes your experience in the dental chair, then you might benefit from sedatives that can be given during your visit to make that anxiety melt away.
Before any particular sedative is recommended, you will be asked to provide your complete health history, including any medications you are currently taking — both prescription and over-the-counter. It is also important to know if you smoke or drink. On the day of your treatment, you may need to have someone drive you to and from your appointment as certain medications take time to wear off.
Ways to Relieve Anxiety
Oral Sedation — Oral sedation (given by mouth) is a popular option for many people precisely because it does not require the use of needles. Oral sedatives are either swallowed whole in pill form or can be dissolved under the tongue. Both methods work in a matter of minutes. A variety of oral sedative and anxiolytic (anxiety-dissolving) medications have been developed through extensive research and testing to make your experience of dental treatment as comfortable and relaxing as possible. All have long safety records after decades of use, and several even have "amnesic" properties, meaning you will remember little to nothing, even though you are conscious throughout the treatment. Commonly prescribed medications include Valium®, Halcion®, Sonata®, Ativan®, Vistaril®, and Versed®. To learn more, view our chart on Types of Oral Sedatives
Inhalation Conscious Sedation — Nitrous oxide, a sedative you inhale, has been used in dental offices for nearly 100 years. It is a relatively poor pain reliever but a very good anti-anxiety medication. It is administered through a nasal hood, which resembles a small cup that is placed over your nose. The oxygen mixed with nitrous oxide provides a light-headed or even euphoric feeling, which is quick to wear off so there is no "hangover" effect. All bodily functions remain essentially normal during the use of this sedative, which is very safe.
IV Conscious Sedation — Sedatives delivered directly into the bloodstream intravenously (into the vein) are more potent than when taken orally, and the amnesic effects may be more profound. Because IV sedation has an almost immediate effect on the body and its functions — including heart rate, blood pressure and breathing — there is a higher degree of risk associated with it than with other types of sedatives. There is also a higher level of training required for those who administer it. As with all sedation (except nitrous oxide), you must be monitored with specialized equipment throughout your IV sedation treatment. The main advantage is that drugs administered this way work immediately and the level of sedation can be adjusted more quickly and easily. And with most sedatives, you won't remember a thing about your dental procedure after the sedative wears off.
For more information on Sedation Dentistry, call Ryan J. Donovan, D.M.D., M.S., P.A. in Fort Myers, FL at (239) 931-4141!
Related Articles on Sedation Dentistry
Oral Sedation Dentistry Step out from under the shadow of fear and into the calm of sedation dentistry. There are safe and time-tested options available to ensure that you have a positive and painless dental experience. Your apprehension and hypersensitivity to pain melt away, yet you remain awake and in control... Read Article
Overcoming Dental Fear & Anxiety Do you feel relatively calm before your dental appointment or are you a little nervous about a visit to the dental office? Do you worry about it days or weeks before the appointment? Are you actually terrified of it? Whichever end of this spectrum you might be on, you are not alone. It's possible, even for those who are the most afraid, to reduce that fear and to learn to have treatment in a way that feels calm and safe. Here's how... Read Article
Local Anesthesia for Pain-Free Dentistry Local anesthesia is one of the most effective tools in dentistry and medicine. It is safe, effective and has totally revolutionized pain control. Without local anesthesia, some dental procedures would be quite stressful for all involved. It's good for you and for your dental professionals... Read Article


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Warranty: 6 months
Relevant Industries: Producing Plant, 3D Printer Accessories 2GT Black Timing Belt Pulley GT2 6mm Width 20 Teeth 5mm8mm Bore Measurement Pulley Equipment Mend Retailers
Weight (KG): 28.7
Customized support: OEM
Gearing Arrangement: Helical
Output Torque: a hundred and eighty-1080
Input Speed: 540rpm
Output Velocity: -10000NM
Merchandise: agricultural machinery tractor apply use gearbox for sale
Packaging Information: NUDE Package
Port: ZheJiang
ITEM | EP-fifty five |
Ratio | 1:1.six |
Teeth | 15/24 |
Module | 6 |
Power(HP) | 50 |
Rated Input | 540rpm |
Input/output description | 1 3/8 Z6Cone foundation aequilate spline |
Weight(kg) | 28.7 |
Application | mower |
Types of Vehicle Gearboxes
In a vehicle, there are many types of gearboxes available. There are planetary gearboxes, Coaxial helical gearboxes, and skew bevel helical gearboxes, among others. In this article, we'll cover all of them and help you determine which type of gearbox would be right for your vehicle. Also, we'll discuss how each differs from the others.
planetary gearbox
A planetary gearbox is composed of three main components: a sun gear, an input bevel gear, and an output shaft. A planetary gearbox can have different output torques and ratios. The basic model of a planetary gearbox is highly efficient and transmits 97% of the power input. There are several kinds of planetary gearboxes, depending on the type of operation. In general, there are three types: the simple, the intermediate, and the complex.
The price of a planetary gearbox can vary a lot, and it's important to know what you'll need. Different manufacturers produce different planetary gearboxes, so check with a manufacturer to see what they have available. Make sure to check the quality of the planetary gearbox before making a final purchase. In addition, be sure to compare the prices and the availability of a particular product. A quality planetary gearbox will provide years of trouble-free operation and will not break your bank.
Planetary gears feature an integer number of teeth. Each planet has teeth that must mesh with its ring or sun. The number of planets, ring, and tooth count of each gear determine whether the teeth mesh. Some planets have fewer teeth than others, so they mesh better than others. However, compound planets can be more flexible and achieve higher reduction ratios. If you're looking for a planetary gearbox for your next project, consider getting in touch with a manufacturer who specializes in this technology.
When it comes to construction, a planetary gearbox is no exception. It's extremely important to choose the right planetary gear for your application, because an imbalance in the planet gear can cause increased wear and failure. Moreover, the compact size of a planetary gear ensures maximum heat dissipation. However, a planetary gear box may require cooling in some applications. A planetary gearbox will make your life easier, and it will give you years of trouble-free operation.
Straight bevel helical gearbox
The Straight bevel helical gearbox has a number of advantages, but it has a relatively short manufacturing process. Its most popular application is in the automotive industry, where it is used in many types of vehicles. Other applications include heavy and light equipment and the aviation and marine industries. Below is a brief introduction to this gearbox type. Read on to learn about its benefits. This type of gearbox is one of the easiest to manufacture.
The spiral bevel gear has larger teeth than straight bevel gears, resulting in a smoother, quieter rotation. It can handle high-speed heavy loads with less vibration. Spiral bevel gears are classified by their tooth form and cutting method. Straight bevel gears are easier to design and manufacture, but spiral bevel gears are more expensive. Both designs are suitable for high-speed, heavy-load operations, and general manufacturing applications.
In addition to being easy to install, the modular bevel gears have many advantages. They have an exceptionally high degree of interchangeability and feature the highest standards of component integrity. They can also be tailored to meet your specific requirements. The advantages of this gearbox type include high precision, optimum performance, and low noise. And because they are modular, they can be produced in a variety of finishes. These include stainless steel, titanium, and bronze.
Straight bevel helical gearbox manufacturers are committed to a high degree of precision in their designs. The radii, torques, and tooth profiles of straight bevel gears are more precisely measured than those of cylindrical bevel gears. The same calculations are used for all traditional bevel gear generators. This ensures that your 5-axis milled bevel gear sets have the same calculations and layout.
Coaxial helical gearbox
The Coaxial helical gearbox is a highly efficient transmission system that is well suited for light-duty applications. Compared to spur-type gearboxes, the real pitch of a Coaxial helical gearbox is low at all helix angles. This is because the coaxial type has the same number of teeth and center gap as the spur gearbox. Coaxial helical gearboxes also have a smaller footprint and are compact.
Several nations have implemented lockdown regulations for Industrial Gearbox trade, threatening the global economy. Several factors have been implicated in COVID-19, including supply chain, market, and financial markets. Experts are monitoring the situation globally and project remunerative prospects for gearbox manufacturers after the crisis. This report depicts the latest scenario and offers a comprehensive analysis of COVID-19's impact on the entire industry.
This Coaxial helical gearbox features a compact structure and high precision gear. Its three-stage design combines two-stage gears with a single-stage gear, forging high-quality alloy steel for high precision and durability. The gears are serially-designed for easy interchangeability. They are also available in high-frequency heat-treated steel. A Coaxial helical gearbox is the perfect solution for many applications.
Coaxial helical gearboxes have the added benefit of using cylindrical gears instead of shafts. They operate quietly, and have more surface area to interact with. Their fixed angles make them suitable for heavy-duty applications, like in conveyors, coolers, and grinders. Compared to other gearbox types, Helical gearboxes have higher power-carrying capacity. Listed below are the benefits of a Coaxial Helical Gearbox
Skew bevel helical gearbox
A Skew bevel helical gear box is a common type of industrial gearbox. These gearboxes are rigid and compact and can be used in a variety of applications. They are commonly used in heavy-duty applications such as grinding mills, conveyors, and coolers. They are used in many applications to provide rotary motions between non-parallel shafts. They also have the added benefit of high-efficiency in a variety of industries.
Skew bevel helical gear boxes are suitable for heavy loads and are monolithic in construction. This type of gearbox combines the benefits of bevel and helical gears for right-angle torque, which makes it a popular choice for heavy-duty applications. In addition to being a robust and reliable gearbox, these gearboxes are highly customizable and can meet almost any industrial need.
To maximize the efficiency of bevel gears, FE-based tooth contact analysis is used to develop a sophisticated geometry optimization algorithm. The software also allows users to define optimal flank topography by introducing application-specific weightings for specific load levels. With this data, a manufacturing simulation is conducted to determine the best variant. A robust variant combines the benefits of efficiency, load-carrying capacity, and low excitation behavior.
The helical gear can be angled at 90 degrees. This is similar to a spur gear but produces less noise. It can achieve a nine-to-one speed reduction with one stage. However, a helical gear requires a larger driver gear for higher reductions. This gearbox is suitable for speeds from 1:1 to three times. They are often used in the manufacture of motors and generators.
Extruder helical gearbox
An extruder helical gearbox is one of the most common industrial gears. It is compact in size and low-power consuming, making it ideal for heavy-duty applications. Extruder helical gearboxes are suitable for a variety of industrial applications, including cement, plastics, rubber, conveyors, and coolers. In addition to its use in plastics and rubber manufacturing, this gearbox is also useful in other low-power applications such as crushers, coolers, and conveyors.
CZPT SG series Extruder Helical Gearboxes are available in Single Screw and Twin Screw Variations. These gears feature a compact design, high power density, and long service life. Axial bearing housing and thrust bearings are mounted on the input shafts. Extruder helical gearboxes can be installed in various positions, including horizontal, vertical, and inclined.
Helicoidal gears are often produced in a modular manner. This design provides multiple benefits, including engineering and performance advantages, modular production, and the highest level of component integrity. A single helical gearbox can be assembled into a larger gearbox if needed, but modular production ensures consistent performance and economy. This modular design is also cost-effective. It is a versatile and reliable solution for a wide range of applications.
In addition to its efficiencies, Extruder helical gearboxes also have a low noise profile. They have no squeal sounds, and they are silent when running. They can transfer more power than conventional gearboxes. This type of gear has been used in the manufacturing of high-quality plastic products for years. They are often used for applications in automotive transmissions. Aside from being quiet, helical gears have higher contact levels and lower vibration.
editor by czh 2023-02-08


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Find clinic locations for Fort HealthCare and affiliated clinics and services in Jefferson County, Wisconsin.
Find services offered by Fort HealthCare and affiliated clinics in Jefferson County, Wisconsin.
We encourage you, our patient, concerned family member, or area employer to review Fort HealthCare's information
We coordinate community education and health-related events and screenings for the Fort HealthCare service area.
Rheumatoid arthritis (RA) is a long-term (chronic) disease that causes inflammation of the joints. The inflammation can be so severe that it affects how the joints and other parts of the body look and function. In the hand, RA may cause deformities in the joints of the fingers. This makes moving your hands difficult. Lumps, known as rheumatoid nodules, may form anywhere in the body.
Juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis (JRA), is a form of arthritis in children ages 16 or younger. It causes inflammation and joint stiffness that last for more than 6 weeks. Unlike adult RA, which lasts a lifetime, children with JIA may have symptoms that come and go. Or the symptoms may go away completely. Getting diagnosed and treated early may help prevent joint damage. Some children with JIA will continue to have arthritis into adulthood.
Healthcare providers don't know the exact cause of RA. RA is an autoimmune disorder. That means the body's immune system attacks its own healthy cells and tissues. RA causes inflammation in and around the joints. It may damage the skeletal system. RA can also damage other organs, such as the heart and lungs. Researchers think certain factors, including heredity, may play a role.
RA most often occurs in people from ages 30 to 50, but it can occur at any age. It happens more in women than in men.
The joints most often affected by RA are in the hands, wrists, feet, ankles, knees, shoulders, and elbows. The disease often causes inflammation in the same areas on both sides of the body. Symptoms may start suddenly or slowly over time. Each person's symptoms may vary. They may include:
Joint pain
Stiffness, especially in the morning
Swelling over the joints
Decreased movement
Pain that is worse with joint movement
Bumps over the small joints
Trouble doing activities of daily living, such as tying shoes, opening jars, or buttoning shirts
Trouble grasping or pinching things
Tiredness and lack of energy (fatigue)
Occasional fever
These symptoms can seem like other health conditions. Always see your healthcare provider for a diagnosis.
Diagnosing RA may be difficult in the early stages. Symptoms may be very mild, and signs of the disease may not be seen on X-rays or in blood tests. Your healthcare provider will take your health history and give you a physical exam. You may need tests. such as:
X-ray. This test uses a small amount of radiation to create images of internal tissues, bones, and organs onto film.
Joint aspiration. For this test, a small fluid sample is taken from a swollen joint. It is done to look for signs of infection or gout.
Nodule biopsy. Tiny tissue samples are taken to look at under a microscope. This helps to check for cancer or other abnormal cells.
Blood tests. These tests are done to find certain antibodies called rheumatoid factor, cyclic citrullinated antibody, and other signs of RA.
Ultrasound or MRI. These imaging tests can look for bone damage and inflammation.
Treatment will depend on your symptoms, age, and general health. It will also depend on how severe the condition is.
There is no known cure for RA. The goal of treatment is often to limit pain and inflammation, and help you retain function. You may have 1 or more types of treatments. Treatment may include:
Medicines. Some medicines may be used for pain relief or to treat inflammation. Other types of medicines can help slow the disease from getting worse. Early treatment slows progression of the disease. Medicines should be managed by a rheumatologist. This healthcare provider specializes in arthritis and rheumatic diseases. You may need regular blood tests to check how the medicines affect your blood cells, liver, and kidneys.
Splints. Splints may be used to help protect the joints and strengthen weak joints.
Physical therapy. Physical therapy may be used to help increase the strength and movement of the affected areas.
In some cases, you may need surgery if other treatments don't work. Surgery does not cure RA. It helps correct the deformities caused by the disease. After surgery, RA can still cause problems. You may even need more surgery. Joint repair or reconstruction can be done in many ways, including:
Surgical cleaning. This surgery removes inflamed and diseased tissues in the hands to help increase function.
Joint replacement (arthroplasty). This type of surgery may be used in cases of severe arthritis of the hand. It may be done on older adults who are not so active. Joint replacement may reduce pain and help increase joint function. During the surgery, a joint that has been destroyed by the disease is replaced with an artificial joint. The new joint may be made out of metal, plastic, or silicone rubber. Or it may be made from your own tissue, such as a tendon from another part of your body.
Joint fusion. For this surgery, a joint is removed, and the 2 ends of bones are fused together. This makes 1 large bone without a joint. This is usually done on people with advanced RA. After the bone fusion, the fused joint can't move.
Because RA damages joints over time, it causes some disability. It can cause pain and movement problems. You may be less able to do your normal daily activities and tasks. That can lead to problems, such as depression and anxiety.
RA can also affect many nonjoint parts of the body, such as the lungs, heart, skin, nerves, muscles, blood vessels, and kidneys. These complications can lead to severe illness and even death.
There is no known cure for RA. But it is important to help keep your joints working well by reducing pain and inflammation. Work on a treatment plan with your healthcare provider that includes medicine and physical therapy. Work on lifestyle changes that can improve your quality of life. Lifestyle changes include:
Getting activity and rest. To reduce stress on your joints, switch between activity and rest. It can help protect your joints and ease your symptoms.
Using assistive devices. Canes, crutches, and walkers can help to keep stress off certain joints and to improve balance.
Using adaptive equipment. Reachers and grabbers let you extend your reach and reduce straining. Dressing aids help you get dressed more easily.
Managing use of medicines. Medicines for this condition have some risks. Work with your healthcare provider to create a plan to reduce this risk.
Seeking support. Find a support group that can help you deal with the effects of RA.
Tell your healthcare provider if your symptoms get worse or you have new symptoms.
RA is a long-term (chronic disease) that causes joint inflammation.
RA can also affect many nonjoint areas, such as the lungs, heart, skin, nerves, muscles, blood vessels, and kidneys.
RA may cause deformities in the joints of the finger, making movement difficult.
The joints most often affected by RA are in the hands, wrists, feet, ankles, knees, shoulders, and elbows.
Symptoms may include joint pain, stiffness, and swelling; decreased and painful movement; bumps over small joints; and fatigue or fever.
Tips to help you get the most from a visit to your healthcare provider:
Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis and any new medicines, treatments, or tests. Also write down any new directions your provider gives you.
Know why a new medicine or treatment is prescribed and how it will help you. Also know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.


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Why You Should Receive Chiropractic Care After an Auto Accident
- Created in Newsletter Library
Receiving Chiropractic Care After Suffering Auto Injuries
Even seemingly minor motor vehicle accidents can cause whiplash, back pain, and other ailments. Visiting your chiropractor as soon as possible after an accident will help ease your pain and prevent long-term complications.
Chiropractic Treatment Eases Whiplash Pain
Whiplash is a common injury after an accident. In fact, the American Chiropractic Association reports that approximately two-thirds of people involved in motor vehicle accidents develop whiplash symptoms. The injury occurs when your neck "whips" back and forth suddenly. The movements strain or damage muscles, ligaments, discs, and may force the vertebrae in your neck out of alignment.
Although you may feel fine immediately after the accident, your neck might begin to hurt hours or days later if you have whiplash. Chiropractic treatment relieves your neck pain naturally, realigns your spine, and improves movement in your neck. Treatments also improve blood flow, reduce inflammation, and speed up healing time.
Back and Body Pain and Muscle Spasms Also Improve After Treatment
Your chiropractor uses a variety of therapeutic techniques to treat the aches and pains that can occur all over the body following a motor vehicle accident. Massage eases spasms, improves range of motion, and reduces pain by triggering the releases of endorphins, natural chemicals produced by your body to reduce pain.
If your back is sore and stiff, spinal manipulation, in addition to massage and other therapies may be part of your treatment plan. The hands-on treatment uses quick thrusts to realign the vertebrae in your spine. Misaligned vertebrae can cause muscle tension and increase pain if muscles or bones press on nerves. Although a misalignment may actually occur in your neck or back, you may feel pain that extends to your arms or legs if a nerve is involved.
Chiropractic Treatment Helps You Avoid Stiffness Due to Scar Tissue
Depending on its location, scar tissue can prevent joints, muscles, and tissues from moving freely. Decreased range of motion, stiffness, and pain can occur due to the buildup of scar tissue. Luckily, you can avoid or reduce these issues simply by visiting your chiropractor soon after your accident.
Massage, instrument-assisted soft tissue manipulation, and other therapies break down and stretch scar tissue, restoring your flexibility and range of motion. In addition, your chiropractor may also recommend exercises that will strengthen your muscles, decrease inflammation, and improve your range of motion.
Treatment can be helpful even if it's been months or years since your accident. In a case study published in the Journal of Chiropractic Medicine, a 61-year-old woman sought treatment for neck and back pain three years after an accident. After six months of spinal manipulation treatment, she reported improvements in pain and quality of life and was able to stop taking opioid medication.
Treatment Reduces or Eliminates the Need for Over-the-Counter or Prescription Pain Relievers
Medications temporarily ease pain after an accident, but the drugs can cause a variety of unpleasant side effects. Nausea, vomiting, dizziness, upset stomach, and abdominal pain can occur when taking pain medication. In some cases, even short-term use of opioid pain medication can cause addiction.
Over-the-counter pain medications aren't necessarily any safer than prescription drugs. In fact, ibuprofen and acetaminophen can cause liver or kidney damage if you take high doses of these medications or take them for a long period of time.
Chiropractic treatment offers a natural pain relief method that can help you avoid these side effects. As your treatment progresses, you may be able to stop taking prescription or over-the-counter drugs completely or reduce the amount of the medication you need to take.
Chiropractic Care Helps You Avoid Lifelong Pain
Treating injuries promptly with chiropractic care prevents motor vehicle accident injuries from becoming long-term problems. You may be more likely to develop chronic pain, arthritis, migraines, headaches, and other symptoms that may make getting through the day difficult if you don't seek treatment soon after your accident. Chiropractic care may even help you avoid surgery.
Have you recently been in a motor vehicle accident? Chiropractic treatment can ease your pain and help you recover more quickly. Contact our office to schedule your first appointment.
American Chiropractic Association: Whiplash: More than Standard Neck Pain, 3/15


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Video length is 7:39
Dual Curve Pricing with Financial Instruments Toolbox
Perform dual curve pricing using functionality from MATLAB® and Financial Instruments Toolbox™. Learn about the need for dual curve pricing following the 2008 financial crisis.
Published: 17 Feb 2015
Featured Product
Financial Instruments Toolbox
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100% Certified ESA Letters in Dallas
Take Your Pet Wherever You Go with a Certified ESA Letter in Dallas
Live and Move Freely with a 100% Certified ESA Letter from a Licensed Mental Health Professional
Avoid Unfair Pet Deposits
You shouldn't have to pay high pet deposits because you need an ESA. With a legitimate ESA Letter from a licensed mental health professional, you can avoid these costs.
Avoid Breed/Size Restrictions
If you have a legitimate ESA letter for your animal then property owners cannot discriminate against your animal's size and breed.
Avoid Unfair Airline Fees
Various Airlines charge anywhere between $75 and $125 each way for your ESA to travel with you. You don't have to pay these fees with a legitimate ESA letter from a licensed mental health professional.
1 Online Physician Visit
1 ESA letter for Travel or Housing | Phone Verifications As Needed
Be the Best Version of You!
Our process is simple and designed to save you money and get your ESA Letter as fast as possible.
Step 1.
Health Questionnaire
The health questionnaire is easy and quick to complete. Answer a few questions about you and your pet and then you're ready to move on to Step 2.
Step 2.
Choose Your Plan and Pay
You choose the plan that fits you and your pal. Then enter your payment information and pay. Then choose a date and time to meet with the Doctor. 100% Secure Payment Gateway
Step 3.
Talk with a Licensed Physician
A licensed mental health professional will contact you through a video call at the time you have selected. In order to comply with the law we must complete a video call.
"Making an appointment same day was easy. I needed to renew my ESA letter to travel with my pet. The customer service was great, everyone was kind and comforting."
Ashley M
"I went in first to get my bunny as an emotional support animal. They gave me so much more than that; comfort, relaxation and security. They genuinely helped. I'd definitely recommend this place if you want a quick and straightforward solution."
Iciss Gutierrez
"I spoke with Dr. Stacie Daniels and she was so patient and I didn't feel rushed! She definitely knows how to be empathetic with others. I got my ESA letter easily and I really enjoyed talking with her."
Sam S


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Alabama Crimson Tide & Snoopy Hawaiian Shirt
Product Information
ITEM TYPE: Alabama Crimson Tide & Snoopy Hawaiian Shirt is Suitable for all men and women, Summer Short Sleeve Hawaiian Beach Shirt. Casual/Dating/Sun Beach Party/Hawaiian/suitable for a variety of occasions/Perfect Gift for Families, friends.
MATERIAL: 100% kate silk
FEATURE: Casual button down shirts / Soft decent Regular fit / Breathable / Good Quality / Good Choice for Summer, Christmas.
WASHING CONDITION: Machine Wash Cold Inside Out / Washed without Fading / Do not bleach
COLOR DIFFERENCE: there may be slight color difference between pictures and objects due to differences in light and dark contrast display of personal monitors.
ABOUT QUALITY: Customer satisfaction is our highest priority: If you are not satisfied, please contact us to solve a problem, wish you have a good shopping experience here.


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This is a list of all destinations and flights from Zhaosu (ZFL) with Gestair Airlines.
FlightsFrom.com is a useful website for finding airline routes and flight schedules globally. The idea is being able to explore destination opportunities through non-stop flights from a specific airport. It's a tool to set up your business meeting or weekend holiday based on your timeschedule and your closest airport.
Part of its appeal is that it just makes trips easier to plan; you see the departure times of every non-stop flight in a list.
I always wondered where you could fly direct from a particular airport (Burbank, I'm looking at you) and those answers can be tough to find. Not anymore!
Many mainstream sites don't list low-cost carriers or link transoceanic flights to regionally based carriers that can provide less expensive options. For that, you need a bigger tool kit… (Hint: search by destination airport at FlightsFrom.com)
Many low-cost carriers airlines prevent their flights from showing up on some of these (read Vayama or Google Flights) third-party travel websites. If you want a chance to view all local departures, try using FlightsFrom.com