text:
AMITRIPTYLINE HYDROCHLORIDE- amitriptyline hydrochloride tablet, film coated
NuCare Pharmaceuticals,Inc.
Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of amitriptyline hydrochloride tablets or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 and older. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Amitriptyline hydrochloride is not approved for use in pediatric patients. (See WARNINGS: Clinical Worsening and Suicide Risk, PRECAUTIONS: Information for Patients, and PRECAUTIONS: Pediatric Use)
Amitriptyline HCl, a dibenzocycloheptadiene derivative, is a white, or practically white, odorless, crystalline compound which is freely soluble in water and alcohol.
It is designated chemically as 10,11-Dihydro-N,N-dimethyl-5 H-dibenzo[a,d] cycloheptene-Δ 5, γ-propylamine hydrochloride. It has the following structural formula:
Each tablet for oral administration contains 10, 25, 50, 75, 100, or 150 mg amitriptyline hydrochloride. Inactive ingredients include colloidal silicon dioxide, hydroxypropyl cellulose, hydroxypropyl methylcellulose, lactose (monohydrate), magnesium stearate, microcrystalline cellulose, polyethylene glycol, pregelatinized starch (corn) and titanium dioxide. The 10 mg also includes D&C Red #27 Aluminum Lake, D&C Yellow #10 Aluminum Lake and FD&C Blue #1 Aluminum Lake; 25 mg – D&C Yellow #10 Aluminum Lake, FD&C Blue #1 Aluminum Lake and FD&C Red #40 Aluminum Lake; 50 mg – FD&C Blue #2 Aluminum Lake, D&C Yellow #10 Aluminum Lake and FD&C Red #40 Aluminum Lake; 75 mg – D&C Red #7 Calcium Lake and FD&C Blue #2 Aluminum Lake; 100 mg – D&C Red #30 Aluminum Lake and D&C Yellow #10 Aluminum Lake; 150 mg – D&C Yellow #10 Aluminum Lake, FD&C Blue #1 Aluminum Lake and FD&C Red #40 Aluminum Lake.
Amitriptyline HCl is an antidepressant with sedative effects. Its mechanism of action in man is not known. It is not a monoamine oxidase inhibitor and it does not act primarily by stimulation of the central nervous system.
Amitriptyline inhibits the membrane pump mechanism responsible for uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons. Pharmacologically, this action may potentiate or prolong neuronal activity since reuptake of these biogenic amines is important physiologically in terminating transmitting activity. This interference with reuptake of norepinephrine and/or serotonin is believed by some to underlie the antidepressant activity of amitriptyline.
For the relief of symptoms of depression. Endogenous depression is more likely to be alleviated than are other depressive states.
Amitriptyline hydrochloride is contraindicated in patients who have shown prior hypersensitivity to it.
It should not be given concomitantly with monoamine oxidase inhibitors. Hyperpyretic crises, severe convulsions, and deaths have occurred in patients receiving tricyclic antidepressant and monoamine oxidase inhibiting drugs simultaneously. When it is desired to replace a monoamine oxidase inhibitor with amitriptyline hydrochloride, a minimum of 14 days should be allowed to elapse after the former is discontinued. Amitriptyline hydrochloride should then be initiated cautiously with gradual increase in dosage until optimum response is achieved.
Amitriptyline hydrochloride should not be given with cisapride due to the potential for increased QT interval and increased risk for arrhythmia.
This drug is not recommended for use during the acute recovery phase following myocardial infarction.
Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. There has been a long-standing concern, however, that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18 to 24) with major depressive disorder (MDD) and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction with antidepressants compared to placebo in adults aged 65 and older.
The pooled analyses of placebo-controlled trials in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders included a total of 24 short-term trials of 9 antidepressant drugs in over 4400 patients. The pooled analyses of placebo-controlled trials in adults with MDD or other psychiatric disorders included a total of 295 short-term trials (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients. There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied. There were differences in absolute risk of suicidality across the different indications, with the highest incidence in MDD. The risk differences (drug vs placebo), however, were relatively stable within age strata and across indications. These risk differences (drug-placebo difference in the number of cases of suicidality per 1000 patients treated) are provided in Table 1.
Age Range | Drug-Placebo Difference in
Number of Cases of Suicidality per 1000 Patients Treated |
Increases Compared to Placebo |
<18 |
14 additional cases |
18-24 |
5 additional cases |
Decreases Compared to Placebo |
25-64 |
1 fewer case |
≥65 |
6 fewer cases |
No suicides occurred in any of the pediatric trials. There were suicides in the adult trials, but the number was not sufficient to reach any conclusion about drug effect on suicide.
It is unknown whether the suicidality risk extends to longer-term use, i.e., beyond several months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with depression that the use of antidepressants can delay the recurrence of depression.
All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.
The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric. Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.
Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms.
Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to health care providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for amitriptyline hydrochloride should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.
A major depressive episode may be the initial presentation of bipolar disorder. It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown. However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. It should be noted that amitriptyline hydrochloride is not approved for use in treating bipolar depression.
Amitriptyline hydrochloride may block the antihypertensive action of guanethidine or similarly acting compounds.
It should be used with caution in patients with a history of seizures and, because of its atropine-like action, in patients with a history of urinary retention or angle-closure glaucoma. In patients with angle-closure glaucoma, even average doses may precipitate an attack.
Patients with cardiovascular disorders should be watched closely. Tricyclic antidepressant drugs, including amitriptyline hydrochloride, particularly when given in high doses, have been reported to produce arrhythmias, sinus tachycardia, and prolongation of the conduction time. Myocardial infarction and stroke have been reported with drugs of this class.
Close supervision is required when amitriptyline hydrochloride is given to hyperthyroid patients or those receiving thyroid medication.
Amitriptyline may enhance the response to alcohol and the effects of barbiturates and other CNS depressants. In patients who may use alcohol excessively, it should be borne in mind that the potentiation may increase the danger inherent in any suicide attempt or overdosage. Delirium has been reported with concurrent administration of amitriptyline and disulfiram.
The pupillary dilation that occurs following use of many antidepressant drugs including amitriptyline hydrochloride may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy.
Teratogenic effects were not observed in mice, rats, or rabbits when amitriptyline was given orally at doses of 2 to 40 mg/kg/day (up to 13 times the maximum recommended human dose 1). Studies in literature have shown amitriptyline to be teratogenic in mice and hamsters when given by various routes of administration at doses of 28 to 100 mg/kg/day (9 to 33 times the maximum recommended human dose), producing multiple malformations. Another study in the rat reported that an oral dose of 25 mg/kg/day (8 times the maximum recommended human dose) produced delays in ossification of fetal vertebral bodies without other signs of embryotoxicity. In rabbits, an oral dose of 60 mg/kg/day (20 times the maximum recommended human dose) was reported to cause incomplete ossification of cranial bones.
Amitriptyline has been shown to cross the placenta. Although a causal relationship has not been established, there have been a few reports of adverse events, including CNS effects, limb deformities, or developmental delay, in infants whose mothers had taken amitriptyline during pregnancy.
There are no adequate and well-controlled studies in pregnant women. Amitriptyline hydrochloride should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus.
Amitriptyline is excreted into breast milk. In one report in which a patient received amitriptyline 100 mg/day while nursing her infant, levels of 83 to 141 ng/mL were detected in the mother's serum. Levels of 135 to 151 ng/mL were found in the breast milk, but no trace of the drug could be detected in the infant's serum.
Because of the potential for serious adverse reactions in nursing infants from amitriptyline, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
Schizophrenic patients may develop increased symptoms of psychosis; patients with paranoid symptomatology may have an exaggeration of such symptoms. Depressed patients, particularly those with known manic-depressive illness, may experience a shift to mania or hypomania. In these circumstances the dose of amitriptyline may be reduced or a major tranquilizer such as perphenazine may be administered concurrently.
The possibility of suicide in depressed patients remains until significant remission occurs. Potentially suicidal patients should not have access to large quantities of this drug. Prescriptions should be written for the smallest amount feasible.
Concurrent administration of amitriptyline hydrochloride and electroshock therapy may increase the hazards associated with such therapy. Such treatment should be limited to patients for whom it is essential.
When possible, the drug should be discontinued several days before elective surgery.
Both elevation and lowering of blood sugar levels have been reported.
Amitriptyline hydrochloride should be used with caution in patients with impaired liver function.
Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with amitriptyline hydrochloride and should counsel them in its appropriate use. A patient Medication Guide about "Antidepressant Medicines, Depression and other Serious Mental Illnesses, and Suicidal Thoughts or Actions" is available for amitriptyline hydrochloride. The prescriber or health professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document.
Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking amitriptyline hydrochloride.
Patients should be advised that taking amitriptyline hydrochloride can cause mild pupillary dilation, which in susceptible individuals, can lead to an episode of angle-closure glaucoma. Pre-existing glaucoma is almost always open-angle glaucoma because angle-closure glaucoma, when diagnosed, can be treated definitively with iridectomy. Open-angle glaucoma is not a risk factor for angle-closure glaucoma. Patients may wish to be examined to determine whether they are susceptible to angle closure, and have a prophylactic procedure (e.g., iridectomy), if they are susceptible.
Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should be advised to look for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt. Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication.
While on therapy with amitriptyline hydrochloride, patients should be advised as to the possible impairment of mental and/or physical abilities required for performance of hazardous tasks, such as operating machinery or driving a motor vehicle.
Some patients may experience a large increase in amitriptyline concentration in the presence of topiramate and any adjustments in amitriptyline dose should be made according to the patient's clinical response and not on the basis of plasma levels.
The biochemical activity of the drug metabolizing isozyme cytochrome P450 2D6 (debrisoquin hydroxylase) is reduced in a subset of the caucasian population (about 7 to 10% of Caucasians are so called "poor metabolizers"); reliable estimates of the prevalence of reduced P450 2D6 isozyme activity among Asian, African and other populations are not yet available. Poor metabolizers have higher than expected plasma concentrations of tricyclic antidepressants (TCAs) when given usual doses. Depending on the fraction of drug metabolized by P450 2D6, the increase in plasma concentration may be small, or quite large (8 fold increase in plasma AUC of the TCA).
In addition, certain drugs inhibit the activity of this isozyme and make normal metabolizers resemble poor metabolizers. An individual who is stable on a given dose of TCA may become abruptly toxic when given one of these inhibiting drugs as concomitant therapy. The drugs that inhibit cytochrome P450 2D6 include some that are not metabolized by the enzyme (quinidine; cimetidine) and many that are substrates for P450 2D6 (many other antidepressants, phenothiazines, and the Type 1C antiarrhythmics propafenone and flecainide). While all the selective serotonin reuptake inhibitors (SSRIs), e.g., fluoxetine, sertraline, and paroxetine, inhibit P450 2D6, they may vary in the extent of inhibition. The extent to which SSRI-TCA interactions may pose clinical problems will depend on the degree of inhibition and the pharmacokinetics of the SSRI involved. Nevertheless, caution is indicated in the coadministration of TCAs with any of the SSRIs and also in switching from one class to the other. Of particular importance, sufficient time must elapse before initiating TCA treatment in a patient being withdrawn from fluoxetine, given the long half-life of the parent and active metabolite (at least 5 weeks may be necessary).
Concomitant use of tricyclic antidepressants with drugs that can inhibit cytochrome P450 2D6 may require lower doses than usually prescribed for either the tricyclic antidepressant or the other drug. Furthermore, whenever one of these other drugs is withdrawn from co-therapy, an increased dose of tricyclic antidepressant may be required. It is desirable to monitor TCA plasma levels whenever a TCA is going to be coadministered with another drug known to be an inhibitor of P450 2D6.
Monoamine oxidase inhibitors – see CONTRAINDICATIONS section. Guanethidine or similarly acting compounds; thyroid medication; alcohol, barbiturates and other CNS depressants; and disulfiram – see WARNINGS section.
When amitriptyline is given with anticholinergic agents or sympathomimetic drugs, including epinephrine combined with local anesthetics, close supervision and careful adjustment of dosages are required.
Hyperpyrexia has been reported when amitriptyline is administered with anticholinergic agents or with neuroleptic drugs, particularly during hot weather.
Paralytic ileus may occur in patients taking tricyclic antidepressants in combination with anticholinergic-type drugs.
Cimetidine is reported to reduce hepatic metabolism of certain tricyclic antidepressants, thereby delaying elimination and increasing steady-state concentrations of these drugs. Clinically significant effects have been reported with the tricyclic antidepressants when used concomitantly with cimetidine. Increases in plasma levels of tricyclic antidepressants, and in the frequency and severity of side effects, particularly anticholinergic, have been reported when cimetidine was added to the drug regimen. Discontinuation of cimetidine in well-controlled patients receiving tricyclic antidepressants and cimetidine may decrease the plasma levels and efficacy of the antidepressants.
Caution is advised if patients receive large doses of ethchlorvynol concurrently. Transient delirium has been reported in patients who were treated with one gram of ethchlorvynol and 75 to 150 mg of amitriptyline hydrochloride.
Clinical experience has not identified differences in responses between elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic function, concomitant disease and other drug therapy in elderly patients.
Geriatric patients are particularly sensitive to the anticholinergic side effects of tricyclic antidepressants including amitriptyline hydrochloride. Peripheral anticholinergic effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, and exacerbation of narrow-angle glaucoma. Central nervous system anticholinergic effects include cognitive impairment, psychomotor slowing, confusion, sedation, and delirium. Elderly patients taking amitriptyline hydrochloride may be at increased risk for falls. Elderly patients should be started on low doses of amitriptyline hydrochloride and observed closely (see DOSAGE AND ADMINISTRATION).
Safety and effectiveness in the pediatric population have not been established (see BOX WARNING and WARNINGS: Clinical Worsening and Suicide Risk). Anyone considering the use of amitriptyline in a child or adolescent must balance the potential risks with the clinical need.
Within each category the following adverse reactions are listed in order of decreasing severity. Included in the listing are a few adverse reactions which have not been reported with this specific drug. However, pharmacological similarities among the tricyclic antidepressant drugs require that each of the reactions be considered when amitriptyline is administered.
Cardiovascular: Myocardial infarction; stroke; nonspecific ECG changes and changes in AV conduction; heart block; arrhythmias; hypotension, particularly orthostatic hypotension; syncope; hypertension; tachycardia; palpitation.
CNS and Neuromuscular: Coma; seizures; hallucinations; delusions; confusional states; disorientation; incoordination; ataxia; tremors; peripheral neuropathy; numbness, tingling and paresthesias of the extremities; extrapyramidal symptoms including abnormal involuntary movements and tardive dyskinesia; dysarthria; disturbed concentration; excitement; anxiety; insomnia; restlessness; nightmares; drowsiness; dizziness; weakness; fatigue; headache; syndrome of inappropriate ADH (antidiuretic hormone) secretion; tinnitus; alteration in EEG patterns.
Anticholinergic: Paralytic ileus, hyperpyrexia; urinary retention, dilatation of the urinary tract; constipation; blurred vision, disturbance of accommodation, increased ocular pressure, mydriasis; dry mouth.
Allergic: Skin rash; urticaria; photosensitization; edema of face and tongue.
Hematologic: Bone marrow depression including agranulocytosis, leukopenia, thrombocytopenia; purpura; eosinophilia.
Gastrointestinal: Rarely hepatitis (including altered liver function and jaundice); nausea; epigastric distress; vomiting; anorexia; stomatitis; peculiar taste; diarrhea; parotid swelling; black tongue.
Endocrine: Testicular swelling and gynecomastia in the male; breast enlargement and galactorrhea in the female; increased or decreased libido; impotence; elevation and lowering of blood sugar levels.
Other: Alopecia; edema; weight gain or loss; urinary frequency; increased perspiration.
After prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. Gradual dosage reduction has been reported to produce, within two weeks, transient symptoms including irritability, restlessness, and dream and sleep disturbance.
These symptoms are not indicative of addiction. Rare instances have been reported of mania or hypomania occurring within 2 to 7 days following cessation of chronic therapy with tricyclic antidepressants.
Other reactions, reported under circumstances where a causal relationship could not be established, are listed to serve as alerting information to physicians:
Body as a Whole: Lupus-like syndrome (migratory arthritis, positive ANA and rheumatoid factor).
Digestive: Hepatic failure, ageusia.
A syndrome resembling neuroleptic malignant syndrome (NMS) has been very rarely reported after starting or increasing the dose of amitriptyline hydrochloride, with and without concomitant medications known to cause NMS. Symptoms have included muscle rigidity, fever, mental status changes, diaphoresis, tachycardia, and tremor.
Very rare cases of serotonin syndrome (SS) have been reported with amitriptyline hydrochloride in combination with other drugs that have a recognized association with SS.
Deaths may occur from overdosage with this class of drugs. Multiple drug ingestion (including alcohol) is common in deliberate tricyclic antidepressant overdose. As the management is complex and changing, it is recommended that the physician contact a poison control center for current information on treatment. Signs and symptoms of toxicity develop rapidly after tricyclic antidepressant overdose, therefore, hospital monitoring is required as soon as possible.
Critical manifestations of overdose include: cardiac dysrhythmias, severe hypotension, convulsions, and CNS depression, including coma. Changes in the electrocardiogram particularly in QRS axis or width, are clinically significant indicators of tricyclic antidepressant toxicity. In addition, a rightward axis shift in the terminal QRS complex together with a prolonged QT interval and sinus tachycardia are specific and sensitive indicators of first generation tricyclic overdose. The absence of these findings is not exclusionary. Prolonged PR interval, ST-T wave changes, ventricular tachycardia and fibrillation may also occur.
Other signs of overdose may include: impaired myocardial contractility, confusion, disturbed concentration, transient visual hallucinations, dilated pupils, disorders of ocular motility, agitation, hyperactive reflexes polyradiculoneuropathy, stupor, drowsiness, muscle rigidity, vomiting, hypothermia, hyperpyrexia, or any of the symptoms listed under ADVERSE REACTIONS.
Obtain an ECG and immediately initiate cardiac monitoring. Protect the patient's airway, establish an intravenous line and initiate gastric decontamination. A minimum of six hours of observation with cardiac monitoring and observation for signs of CNS or respiratory depression, hypotension, cardiac dysrhythmias and/or conduction blocks, and seizures is necessary. If signs of toxicity occur at any time during the period extended monitoring is required. There are case reports of patients succumbing to fatal dysrhythmias late after overdose; these patients had clinical evidence of significant poisoning prior to death and most received inadequate gastrointestinal decontamination. Monitoring of plasma drug levels should not guide management of the patient.
All patients suspected of tricyclic antidepressant overdose should receive gastrointestinal decontamination. This should include, large volume gastric lavage followed by activated charcoal. If consciousness is impaired, the airway should be secured prior to lavage. EMESIS IS CONTRAINDICATED.
A maximal limb-lead QRS duration of ≥0.10 seconds may be the best indication of the severity of the overdose. Intravenous sodium bicarbonate should be used to maintain the serum pH in the range of 7.45 to 7.55. If the pH response is inadequate, hyperventilation may also be used. Concomitant use of hyperventilation and sodium bicarbonate should be done with extreme caution, with frequent pH monitoring. A pH >7.60 or a pCO 2 <20 mm Hg is undesirable. Dysrhythmias unresponsive to sodium bicarbonate therapy/hyperventilation may respond to lidocaine, bretylium or phenytoin. Type 1 A and 1 C antiarrhythmics are generally contraindicated (e.g., quinidine, disopyramide, and procainamide).
In rare instances, hemoperfusion may be beneficial in acute refractory cardiovascular instability in patients with acute toxicity. However, hemodialysis, peritoneal dialysis, exchange transfusions, and forced diuresis generally have been reported as ineffective in tricyclic antidepressant poisoning.
In patients with CNS depression early intubation is advised because of the potential for abrupt deterioration. Seizures should be controlled with benzodiazepines, or if these are ineffective, other anticonvulsants (e.g., phenobarbital, phenytoin).
Physostigmine is not recommended except to treat life-threatening symptoms that have been unresponsive to other therapies, and then only in consultation with a poison control center.
Dosage should be initiated at a low level and increased gradually, noting carefully the clinical response and any evidence of intolerance.
For outpatients, 75 mg of amitriptyline HCl a day in divided doses is usually satisfactory. If necessary, this may be increased to a total of 150 mg per day. Increases are made preferably in the late afternoon and/or bedtime doses. A sedative effect may be apparent before the antidepressant effect is noted, but an adequate therapeutic effect may take as long as 30 days to develop.
An alternate method of initiating therapy in outpatients is to begin with 50 to 100 mg amitriptyline HCl at bedtime. This may be increased by 25 or 50 mg as necessary in the bedtime dose to a total of 150 mg per day.
Hospitalized patients may require 100 mg a day initially. This can be increased gradually to 200 mg a day if necessary. A small number of hospitalized patients may need as much as 300 mg a day.
In general, lower dosages are recommended for these patients. Ten mg 3 times a day with 20 mg at bedtime may be satisfactory in adolescent and elderly patients who do not tolerate higher dosages.
The usual maintenance dosage of amitriptyline HCl is 50 to 100 mg per day. In some patients, 40 mg per day is sufficient. For maintenance therapy, the total daily dosage may be given in a single dose, preferably at bedtime. When satisfactory improvement has been reached, dosage should be reduced to the lowest amount that will maintain relief of symptoms. It is appropriate to continue maintenance therapy 3 months or longer to lessen the possibility of relapse.
In view of the lack of experience with the use of this drug in pediatric patients, it is not recommended at the present time for patients under 12 years of age.
Because of the wide variation in the absorption and distribution of tricyclic antidepressants in body fluids, it is difficult to directly correlate plasma levels and therapeutic effect. However, determination of plasma levels may be useful in identifying patients who appear to have toxic effects and may have excessively high levels, or those in whom lack of absorption or noncompliance is suspected. Because of increased intestinal transit time and decreased hepatic metabolism in elderly patients, plasma levels are generally higher for a given oral dose of amitriptyline hydrochloride than in younger patients. Elderly patients should be monitored carefully and quantitative serum levels obtained as clinically appropriate. Adjustments in dosage should be made according to the patient's clinical response and not on the basis of plasma levels. 2
Amitriptyline hydrochloride tablets, USP for oral administration are available as:
10 mg: Round, film-coated pink tablets, debossed GG 40 on one side and plain on the reverse side, and supplied as:
Studies in man following oral administration of 14C-labeled drug indicated that amitriptyline is rapidly absorbed and metabolized. Radioactivity of the plasma was practically negligible, although significant amounts of radioactivity appeared in the urine by 4 to 6 hours and one-half to one-third of the drug was excreted within 24 hours.
Amitriptyline is metabolized by N-demethylation and bridge hydroxylation in man, rabbit, and rat. Virtually the entire dose is excreted as glucuronide or sulfate conjugate of metabolites, with little unchanged drug appearing in the urine. Other metabolic pathways may be involved.
Ayd, F.J., Jr.: Amitriptyline therapy for depressive reactions, Psychosom. 1: 320-325, Nov.-Dec. 1960.
Diamond, S.: Human metabolization of amitriptyline tagged with carbon 14, Curr. Therap. Res. 7: 170-175, Mar. 1965.
Dorfman, W.: Clinical experiences with amitriptyline (A preliminary report), Psychosom. 1: 153-155, May-June 1960.
Fallette, J.M.; Stasney, C.R.; Mintz, A.A.: Amitriptyline poisoning treated with physostigmine, S. Med. J. 63: 1492-1493, Dec. 1970 (in Soc. Proc.).
Hollister, L.E.; Overall, J.E.; Johnson, M.; Pennington, V.; Katz, G.; Shelton, J.: Controlled comparison of amitriptyline, imipramine and placebo in hospitalized depressed patients, J. Nerv. andMent. Dis. 139: 370-375, Oct. 1964.
Hordern, A.; Burt, C.G.; Holt, N.F.: Depressive states. A pharmacotherapeutic study, Springfield, Ill., Charles C. Thomas, 1965.
Jenike, M.A.: Treatment of Affective Illness in the Elderly with Drugs and Electroconvulsive Therapy, J. Geriatr. Psychiatry 1989;22(1).77-112.
Klerman, G.L.; Cole, J.O.: Clinical pharmacology of imipramine and related antidepressant compounds, Int. J. Psychiat. 3: 267-304, Apr. 1976.
Liu, B.; Anderson, C.; Mittman, N. et al: Use of selective serotonin-reuptake inhibitors or tricyclic antidepressants and risk of hip fractures in elderly people. Lancet 1998; 351 (91 12):1303-1307.
McConaghy, N.; Joffe, A.D.; Kingston, W.R.; Stevenson, H.G.; Atkinson, I.; Cole, E.; Fennessy, L.A.; Correlation of clinical features of depressed outpatients with response to amitriptyline and protriptyline, Brit. J. Psychiat. 114: 103-106, Jan. 1968.
McDonald, I.M.; Perkins, M.; Marjerrison, G.; Podilsky, M.: A controlled comparison of amitriptyline and electroconvulsive therapy in the treatment of depression, Amer. J. Psychiat. 122: 1427-1431. June 1966 (in Brief Communications).
Slovis, T.; Ott, J.; Teitelbaum, D.; Lipscomb, W.: Physostigmine therapy in acute tricyclic antidepressant poisoning, Clin. Toxicol. 4: 451-459, Sept. 1971.
Symposium on depression with special studies of a new antidepressant, amitriptyline, Dis. Nerv. Syst. 22: 5-56, May 1961 (Sect. 2).
Amitriptyline Hydrochloride Tablets, USP
i trip' tileen)
Antidepressant Medicines, Depression and other Serious Mental Illnesses, and Suicidal Thoughts or Actions
Read the Medication Guide that comes with you or your family member's antidepressant medicine. This Medication Guide is only about the risk of suicidal thoughts and actions with antidepressant medicines. Talk to your, or your family member's, healthcare provider about:
What is the most important information I should know about antidepressant medicines, depression and other serious mental illnesses, and suicidal thoughts or actions?
Call a healthcare provider right away if you or your family member has any of the following symptoms, especially if they are new, worse, or worry you:
What else do I need to know about antidepressant medicines?
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
This Medication Guide has been approved by the U.S. Food and Drug Administration for all antidepressants.
For Medication Guides, please visit www.us.sandoz.com or call 1-800-507-2130.
amitriptyline hydrochloride tablet, film coated |
Labeler - NuCare Pharmaceuticals,Inc. (010632300) |
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NuCare Pharmaceuticlals,Inc. | 010632300 | repack(68071-4348) |


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With access to the latest rehabilitation technology and treatment for people who have had an amputation, our hospital offers the clinical, technical and professional expertise needed to help patients progress toward total independence. Our goal is to give individuals the skills and equipment they need to overcome obstacles and boundaries to return to the most independent life possible.
Rehabilitation for people who have had an amputation focuses on the unique needs of each individual by providing the following program objectives:
Between 40 and 80 percent of the amputations that occur in the United States each year are preventable. Below are certain risk factors to avoid to prevent amputation.
Patients who have had an amputation are evaluated by a team of our rehabilitation professionals and individualized treatment plans are created and tailored to their specific needs. Each patient's treatment plan is designed to accomplish their goals through a sequence of steps.
Amputee rehabilitation goals may include:
People who have experienced an amputation can benefit from the support of others who have had similar experiences.
They can meet with other people who are making the journey back to independence through the following resource:
By demonstrating compliance with The Joint Commission's national standards for healthcare quality and safety, our hospital is accredited by The Joint Commission.
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Join us for a virtual tour of our hospital where you will see our patient rooms, exercise facilities, and more. You can also set up a personal tour by calling our hospital.
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Everyone in here is terrific. There's not a person in here who doesn't know their job thoroughly.
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subset: commoncrawl


text:
Up until Thursday we had picture perfect warm Spring weather. For two whole weeks the sun Gods were generous and along with peep-toe heels and sunglasses, the weather was perfect for barbeques and bike rides. Soeren spent afternoons with his friends outside playing soccer, enjoying picnics or on the playground.
It was lovely! Then Friday came and brought back the cold and rain – lots of rain! Once again we were confined indoors, playing cards and board games. A taste of summer snatched away from right under our noses. How cruel!
The cold weather did give me some time in the kitchen to try out a few recipes though. I was thinking quiche and wanted to try out a few ideas I had in my head. I had the perfect recipe from Tante Stephanie to start me off - a leek and Roquefort cheese quiche and decided to take it from there.
Caramelized new potatoes with a sprinkling of peppery watercress, slices of delicate leek topped with the distinctive rich, creamy flavor of brie cheese all served in a crispy shortcrust pastry spread with tangy wholegrain mustard. A true delight – and perfect for rainy Fridays at home.
Caramelized Potato Leek and Brie Quiche
Printable version of recipe here.
1 portion shortcrust pastry, enough for a quiche form
Plain flour, to dust
700g new potatoes, thinly sliced and steamed/cooked
2-3 tablespoons sugar
40g + 1 1/2 tablespoons butter
Generous amount watercress
1-2 tablespoons wholegrain mustard
Sea salt and freshly cracked pepper
1 leek, white part only, thinly sliced
200g brie cheese, cubed
3 eggs, lightly beaten
80 ml cream
- To caramelize the potatoes, melt sugar in a heavy skillet without stirring on medium heat. Continue to cook, stirring occasionally until the sugar turns into a golden colored caramel.
- Add the 1 1/2 tablespoons of butter and a pinch of salt. Stir until the butter has melted.
- Add the potatoes slices to the skillet, stirring with a wooden spoon. Scrape from the bottom of the skillet to make sure the potato slices are coated in the caramel. When you add the potatoes to the skillet the caramel will solidify and form clumps – don't worry – as you continue to cook the clumps will begin to melt again – approx 10-15 minutes. Sprinkle with some of the watercress, reserving some for decoration later.
- Preheat oven to 200 degrees C. Butter a quiche form or a fluted tart tin and line it with the pastry. Trim off any excess pastry. Cover the pastry and refrigerate for 30 minutes.
- Meanwhile heat the 40g butter in a large pan over medium heat until it begins to froth. Add the leeks and sauté for 5 minutes until softened. Remove from heat and set aside.
- Line the pastry with baking paper and fill the form with either pie weights or dried kidney beans. Bake for 10 minutes then remove from oven and take away the weights/beans. Bake for a further 6-8 minutes. Take out of the oven and reduce the oven temperature to approx. 160 degrees C.
- Spread the wholegrain mustard on the bottom of the the pastry base. Lay out the caramelized potato slices evenly, then top with leek slices and the brie cubes.
- Rashly whisk eggs and cream together, season with salt and pepper, then pour the egg mixture over the potato-leek-brie mixture.
- Bake quiche in oven for 25-30 minutes, until the egg mixture has set.
- Serve quiche warm sprinkled with the remaining watercress and a green salad.
Work Ahead Tips:
- Potatoes can be sliced and steamed/boiled a few hours ahead of time. Keep covered until required.
- Potatoes can be caramelized 1 hour ahead and then kept covered at room temperature. Once ready to use reheat over moderate heat until warmed through.
- Make shortcrust pastry a day ahead using this recipe and keep in the refrigerator. Keep covered in plastic wrap so that pastry does not dry out.
An absolutely flavor packed quiche - the sweetness of the caramelized potatoes against the sharpness of the tangy mustard, the delicately sautéed leek against the creamy richness of the brie cheese. Both Soeren and Tom loved the touch with the mustard. For me it was the mixture of the brie with the caramelized potatoes that did it!
You might like these ideas from WFLH:
Tomato Olive Tart | Spring Ricotta Vegetable Pot Pie | Tarte Flambée with Tomatoes and Creamy Spinach |
From around the blogs:
- Spinach & Leek Quiche – Bloom.acious
- Spelt Vegetarian Quiche – Sunita's World
- Mini Crustless Chicken & Nut Quiches – Once Upon a Plate
Daily Tiffin Reading Tip:
There's something about yogurt ... written by Deeba
All photographs and written content on What's For Lunch, Honey? © 2006-2009 Meeta Khurana unless otherwise indicated. | All rights reserved | Please Ask First


text:
Lamentations 3
1. I am the man that hath seen affliction by the rod of his wrath.
2. He hath led me, and brought me into darkness, but not into light.
3. Surely against me is he turned; he turneth his hand against me all the day.
4. My flesh and my skin hath he made old; he hath broken my bones.
5. He hath builded against me, and compassed me with gall and travail.
6. He hath set me in dark places, as they that be dead of old.
7. He hath hedged me about, that I cannot get out: he hath made my chain heavy.
8. Also when I cry and shout, he shutteth out my prayer.
9. He hath inclosed my ways with hewn stone, he hath made my paths crooked.
10. He was unto me as a bear lying in wait, and as a lion in secret places.
11. He hath turned aside my ways, and pulled me in pieces: he hath made me desolate.
12. He hath bent his bow, and set me as a mark for the arrow.
13. He hath caused the arrows of his quiver to enter into my reins.
14. I was a derision to all my people; and their song all the day.
15. He hath filled me with bitterness, he hath made me drunken with wormwood.
16. He hath also broken my teeth with gravel stones, he hath covered me with ashes.
17. And thou hast removed my soul far off from peace: I forgat prosperity.
18. And I said, My strength and my hope is perished from the Lord:
19. Remembering mine affliction and my misery, the wormwood and the gall.
20. My soul hath them still in remembrance, and is humbled in me.
21. This I recall to my mind, therefore have I hope.
22. It is of the Lord's mercies that we are not consumed, because his compassions fail not.
23. They are new every morning: great is thy faithfulness.
24. The Lord is my portion, saith my soul; therefore will I hope in him.
25. The Lord is good unto them that wait for him, to the soul that seeketh him.
26. It is good that a man should both hope and quietly wait for the salvation of the Lord.
27. It is good for a man that he bear the yoke in his youth.
28. He sitteth alone and keepeth silence, because he hath borne it upon him.
29. He putteth his mouth in the dust; if so be there may be hope.
30. He giveth his cheek to him that smiteth him: he is filled full with reproach.
31. For the Lord will not cast off for ever:
32. But though he cause grief, yet will he have compassion according to the multitude of his mercies.
33. For he doth not afflict willingly nor grieve the children of men.
34. To crush under his feet all the prisoners of the earth,
35. To turn aside the right of a man before the face of the most High,
36. To subvert a man in his cause, the Lord approveth not.
37. Who is he that saith, and it cometh to pass, when the Lord commandeth it not?
38. Out of the mouth of the most High proceedeth not evil and good?
39. Wherefore doth a living man complain, a man for the punishment of his sins?
40. Let us search and try our ways, and turn again to the Lord.
41. Let us lift up our heart with our hands unto God in the heavens.
42. We have transgressed and have rebelled: thou hast not pardoned.
43. Thou hast covered with anger, and persecuted us: thou hast slain, thou hast not pitied.
44. Thou hast covered thyself with a cloud, that our prayer should not pass through.
45. Thou hast made us as the offscouring and refuse in the midst of the people.
46. All our enemies have opened their mouths against us.
47. Fear and a snare is come upon us, desolation and destruction.
48. Mine eye runneth down with rivers of water for the destruction of the daughter of my people.
49. Mine eye trickleth down, and ceaseth not, without any intermission,
50. Till the Lord look down, and behold from heaven.
51. Mine eye affecteth mine heart because of all the daughters of my city.
52. Mine enemies chased me sore, like a bird, without cause.
53. They have cut off my life in the dungeon, and cast a stone upon me.
54. Waters flowed over mine head; then I said, I am cut off.
55. I called upon thy name, O Lord, out of the low dungeon.
56. Thou hast heard my voice: hide not thine ear at my breathing, at my cry.
57. Thou drewest near in the day that I called upon thee: thou saidst, Fear not.
58. O Lord, thou hast pleaded the causes of my soul; thou hast redeemed my life.
59. O Lord, thou hast seen my wrong: judge thou my cause.
60. Thou hast seen all their vengeance and all their imaginations against me.
61. Thou hast heard their reproach, O Lord, and all their imaginations against me;
62. The lips of those that rose up against me, and their device against me all the day.
63. Behold their sitting down, and their rising up; I am their musick.
64. Render unto them a recompence, O Lord, according to the work of their hands.
65. Give them sorrow of heart, thy curse unto them.
66. Persecute and destroy them in anger from under the heavens of the Lord.


text:
Going To 5 0 - Spiral Notebook
Previous NextMany in stock
Spiral Notebook
Returns Policy
We want you to be satisfied with your purchase. If for any reason your item arrives damaged we would be happy to send you another item at no additional cost, upon receipt of your damage item, and once the insurance claim is complete. THE FOLLOWING ITEMS ARE FINAL SALE ITEMS: - Original Paintings, on paper or canvas. Because we want to ensure your happiness in particular circumstances, a partial refund or full refund may be provided solely on the discretion of the artist.
We appreciates your support of Tasha's art and want you to receive your purchases within a timely manner, which is why we ship your order within 5-7 business days of your purchase. We ship original canvas paintings via UPS and USPS to ensure reliable tracking, fast and safe shipping. UPS and USPS tracking information will be provided via email at time of shipment. - Most shipping will be shipped by UPS, unless otherwise indicated. Shipping options from our partners (canvas prints, framed canvas prints, rolled canvas prints and apparel) may vary. - Once shipped, it usually takes between 2-5 business days for receipt for of items. - All items shipped are packaged with quality shipping supplies, such as bubble wrap, double layered cardboard, and ultra strong shipping tape to ensure safe arrival. - If in the unfortunate situation your package happens to get lost, or arrives damaged, we will investigate and create a claim with carrier. - Shipping at this time is only available in the United States.


text:
Diamond Detail:
- diamond_name 2.0 Carat Oval Lab Diamond
- Shape Oval
- Carat 2
- Cut Excellent
- Color F
- Clarity VS1
- Polish Excellent
- Symmetry Excellent
- Fluorescence None
- Table 60.0%
- Depth 59.2%
- L/W Ratio 1.50
- Depth 59.2
- Certificate type IGI
- Certificate Number 621414039
- Price 1628
- Compare Price 1809
- Cert_url https://www.igi.org/verify-your-report/?r=621414039
- Vault Discount False
Stone Details
Shipping & Returns
With Clarity is dedicated to bringing you a jewelry experience that brings you joy, now and forever. We offer complimentary insured shipping, providing peace of mind with shipment tracking and signature upon delivery. Our insured shipping covers any loss, damage, or theft during transit. In the rare event of such occurrences, we make every effort to recover the item(s) and, if unrecoverable, we offer a replacement of equal quality. Returns within 30 days are hassle-free and free of charge within the US, ensuring a smooth and convenient experience for our valued customers.
Lifetime Warranty
With Clarity is committed to creating the highest quality jewelry that lasts a lifetime. Our goal is to make you happy with your jewelry now and forever. We offer complimentary lifetime cleaning and replacement of stones under 0.10ct due to everyday wear and tear. However, diamonds above 0.10ct and center stone diamonds/gemstones on engagement rings are not covered by the warranty. Damage, loss, and theft are also not covered. Repair fees apply based on the requirements determined by our jewelers. For warranty validity, we recommend all work be done by With Clarity.
Try our home preview
Still thinking? Try this ring at home for free.
Our dedicated gemologists offer comprehensive support throughout your diamond selection process. Unsure of your budget or preferences? No problem. They'll assist you in clarifying your criteria and budget constraints. Once defined, they'll handpick three stones that align with your specifications and budget. With meticulous evaluation and expert insights, they'll guide you to the perfect choice. Need help with setting options? They're here for that too. Count on our experts to refine their search until you're absolutely delighted. Connect with them via live chat, email, or phone for a seamless and personalized experience.
At With Clarity, we hold ourselves to the highest ethical standards because we understand the significance of the diamonds we offer as symbols of love and commitment. That's why we ensure that every diamond, whether natural or lab-grown, is free from conflict and human rights abuses. Our commitment to ethical responsibility means adhering strictly to the Kimberley Process and United Nations Resolutions, guaranteeing that our jewelry meets international laws and human rights policies from mine to market. With generations-long supplier relationships, we maintain transparency into sourcing and operations, partnering only with reputable suppliers dedicated to conflict-free practices and ethical conduct.
Discover a stress-free way to find your dream ring with With Clarity's unique approach: Browse. Try. Buy. With our at Home Preview service, you can explore over 8000 customization options from the comfort of your own home. Select two rings to try on, customized to your preferences in metal, shape, and carat. Whether you're lounging in pajamas or out for drinks, take your time to truly connect with your options. Consult with your partner or friends, snap some selfies, and return within 3 days. After experiencing the rings firsthand, decide what resonates with you and what adjustments you'd like to make. When you're ready, simply return to our site to order the perfect ring that reflects your unique style and love story.
Finding the right size for a ring or band can be simple. Use our easy guide to determine a comfortable fit. Women's ring sizes typically range from 3 to 9 within the United States. The most common women's ring sizes are from size 6 to 7. The most popular men's U.S. ring size is size 9. Refer to our international ring sizing chart (link) or this printable guide to to make finding the right size an easy process for your band or ring. You can also speak to our expert gemologists for more on the right finger sizing. At With Clarity, we offer complimentary resizing for engagement rings and wedding bands within 30 days of receipt.


text:
While human rights groups and other watchdogs have put the civilian death toll in the hundreds, Pakistan's Ministry of Defense announced Wednesday that just 3 percent of the deaths from U.S. drone strikes since 2008 were noncombatants.
The ministry says 317 drone strikes have killed 2,160 Islamic militants and 67 civilians in the last five years.
According to Pakistan's Dawn newspaper, the ministry also says there hasn't been a single civilian death from a U.S. drone since January 2012 — a time period that saw 300 such strikes carried out in Pakistani territory.
Dawn says:
"[This] year has witnessed the lowest number of drone strikes which are 14 as compared to 2010 when the US hit Pakistan's Federally Administered Tribal Areas 115 times through drone attacks."
Even so, the strikes have been publicly condemned by Islamabad and were reportedly the subject of discussions last week between Prime Minister Nawaz Sharif and President Obama during the Pakistani leader's visit to Washington.
The Pakistan Defense Ministry's conclusion is similar to one reached by the U.S. Army War College in a report that we wrote about last month. The War College report said 26 militants were killed for every confirmed civilian death, a ratio that comes out to just under 4 percent.
A United Nations expert said earlier this month, however, that at least 400 civilians had been killed since 2004, or about 18 percent of the total 2,200 drone strike deaths.
Copyright 2021 NPR. To see more, visit https://www.npr.org.


text:
When Californians go to the polls in November, they will very likely have the chance to make California the first state in the nation to require labeling of genetically engineered food. That's according to California Right to Know, which filed a petition to force a statewide vote.
And the group is pretty confident it will succeed. "Polls show that nine out of ten California voters agree that they want labeling," Stacy Malkan, spokeswoman for the group, tells The Salt.
But a new analysis of the labeling initiative suggests that if it passes, it would create a complex mandate for food companies that may make it harder — not easier — for consumers to figure out what's really in their food. That's because the initiative muddies the definition of a "natural" food.
The word "natural" on a food label is already pretty controversial. It's more of a marketing tool than anything else — seducing consumers into thinking it means healthier, or nearly organic, although it may simply mean minimally-processed and free from artificial ingredients. The federal government has so far declined to make the term clearer, which has led to many processed foods using the "natural" label.
The activists behind the labeling initiative say they want California consumers to know what they're eating. So they're calling for any processed food or raw agricultural commodity (like corn) that has been or may have been partially or wholly produced with genetic engineering to be labeled as such. And they want to prevent processed foods with GE ingredients from using the "natural" label, too.
But Peggy Lemaux, a cooperative extension specialist at the University of California, Berkeley who manages an informational website on biotechnology, says her analysis of the document concluded that "natural" — as the Right To Know group wants it — could be interpreted two different ways.
One way is that processed foods could be labeled "natural" only if they are free of GE ingredients. But Lemaux says the initiative could also be interpreted as saying that no processed food can be labeled "natural", whether or not it is GE or contains GE ingredients.
However, Malkan, of Right to Know, says the initiative merely intended to keep food with GE ingredients from being called "natural." "The language is clear that non-GE processed foods could still be labeled 'natural,'" says Malkan.
Activists have been calling for labeling of GE food for many years, but recent petition drives and polls suggest support for labeling is greater than it has ever been. As we reported in March, a coalition calling itself Just Label It commissioned a survey from a national pollster, which found that 91 percent of voters favor labeling.
Some 40 countries around the world now require labels for GM foods. But the U.S. Food and Drug Administration has maintained a firm stance since 2009 that GM labeling is unnecessary. The agency says genetically modified food is essentially the same as other food and poses no safety risk.
Lemaux, who has done extensive reviews of the scientific literature on GE foods, agrees with the FDA.
"This [labeling measure] is not going offer any additional safety to people; it's really not a food safety issue because there's no real evidence this stuff is unsafe," says Lemaux.
What's more she says, the GE and natural labels may scare less savvy consumers away from affordable, healthful foods. And, as we've reported before, Americans really don't understand what genetically engineered food is all about.
"If you're looking to know what's in your food, well there's a lot of stuff in your food, and there's already a lot of stuff on the label," says Lemaux. "And a lot of people already don't read the label."
UPDATED EDITOR'S NOTE 5:00 pm, Wednesday:
Peggy Lemaux initially told NPR she thought that the passage of the labeling initiative would mean that no processed food could be labeled "natural" unless it was a processed organicfood. She later revised her analysis. In her second take, she concluded that the section on labeling "natural" could be interpreted different ways, and that the interpretation will ultimately be decided in the courts.
Copyright 2021 NPR. To see more, visit https://www.npr.org.


text:
Layout variation Left | Center | Innerright
- Details
This is also 3 columns layout with content presented at center, but the right side column was designed to present content of secondary importance comparing to those in left side column. On side columns you can present modules with equal importance. The width of side columns can be adjusted conveniently via template parameters.


text:
Black Customized Mirror View Flip Case for Xiaomi Redmi 9A
The Black Colored Mirror View Flip Customized Case for Xiaomi Redmi 9Ais compatible withXiaomi Redmi 9A and made up of glossy poly carbonate material. It offers complete protection to your mobile phone device and can be personalized as per your preference. You can add any image, text or design on the cover.
Material: Glossy Poly Carbonate
Form Factor: Semi Transparent Flip Cover
Sample Image(s)


text:
Rubicon Classics Ltd
17 Leeward Quay
East Sussex
United Kingdom
References and links
Rubicon Classics Ltd hereby expressly dissociates itself from the contents of all linked or connected pages. This statement applies to all links and references within our own Internet offerings as well as to external entries in guest books, discussion forums or mailing lists generated by Rubicon Classics Ltd. For any illegal, inaccurate or incomplete contents, and especially for damages arising from the use or non-use of such forms of presented information, liability is borne solely by the provider of the page in question, not by the party merely referring via links to the respective publication.
Terms and Conditions
Please see our Privacy Policy and Conditions of Use.
All website design, text, graphics, audio sound recordings, the selection and arrangement thereof are copyright of Rubicon Classics Ltd. All rights reserved. Any use of materials on this website, including modification, distribution or re-publication without the prior permission of Rubicon Classics Ltd is prohibited.
Design, programming and hosting: White Label Productions Ltd, London
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This website uses Google Analytics, a web analytics service provided by Google, Inc. ("Google"). Google Analytics uses "cookies", which are text files placed on your computer, to help the website analyse how users use the site. The information generated by the cookie about your use of the website (including your IP address) will be transmitted to and stored by Google on servers in the United States. Google will use this information for the purpose of evaluating your use of the website, compiling reports on website activity for website operators and providing other services relating to website activity and internet usage. Google may also transfer this information to third parties where required to do so by law, or where such third parties process the information on Google's behalf. Google will not associate your IP address with any other data held by Google. You may refuse the use of cookies by selecting the appropriate settings on your browser, however please note that if you do this you may not be able to use the full functionality of this website. By using this website, you consent to the processing of data about you by Google in the manner and for the purposes set out above.


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May Meeting of the Historic Preservation Commission of South Bend and St. Joseph County, Indiana. The Commission reviews applications for projects in local historic districts and local designated landmarks. More information about the Historic Preservation Commission can be found here. AGENDA
Innovation Park @ Notre Dame 1400 E. Angela Blvd. (Use building's south entrance. Off street parking available). May 17 https://us06web.zoom.us/j/86833888974?pwd=bDN6MUZaMHo4eUtHNktzTDFCNFVoQT09
Innovation Park @ Notre Dame 1400 E. Angela Blvd. (Use building's south entrance. Off street parking available) https://us06web.zoom.us/j/85229894838?pwd=aVZPeWlQQkxUSUdST2tjeWZQZlNKZz09
We've redesigned the website with an emphasis on better connecting you with services, facilities, and information pertaining to everyday life in South Bend. Click on the left and right arrows to navigate these quick tips to make the most of your first experience.
Browse topics, answer questions, and get information about City services and departments. Take me there.
South Bend's city government aims to make the basics easy, deliver good government, and invest in people and places. Learn about how our elected officials are working for you. Learn more.
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Our goal is to continue evolving this service to better meet your needs. Please provide feedback on how we're doing at the bottom of any page.


text:
About Les Schwab Tire Center
At Les Schwab, every purchase of car, SUV or light truck tires comes with a tire warranty including free services that give you more for your money. Our warranty, among the industry's best, is good at any of our more than 510 Les Schwab Tire Centers.
- Unlimited flat repairs for the life of Les Schwab tires
- All of our more than 510 locations offer free tire repair
- FREE tire replacement for damaged tires that qualify
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text:
Town Center Locksmith Shop - Mobile Locksmith 72223 - 501-270-7212
When we laid our foundation stone in Little Rock, AR 72223 almost 10 years ago, we realized that the people of the city have been desperately missing the services of a professional locksmith company. Over the years, we gave our absolute best to deliver quality locksmith services to the people of Zip Code 72223 at an affordable price. Today, be it a simple lock repair or duplication of high-security keys, people rely on only one name – Town Center Locksmith Shop.
Skilled professionals
We hire the finest locksmiths from the best finishing schools in the country and hone their skills with regular training programs.
Always up-to-date
With the advent of modern technology and high-security locking systems, the entire locksmithing craft has undergone a major transformation. We consider it absolutely necessary that our all locksmiths stay up-to-date on the modern developments and educate them continuously on the latest locking systems. Moreover, we ensure that they are assisted with state-of-the-art tools and fully-equipped techie vans.
Mobile locksmiths
Stuck in an emergency situation or require our locksmith services at a specific location? We have a fleet of fully-equipped mobile vans that operate throughout Little Rock, AR 72223, so all you need to do is call our numbers and our mobile locksmiths will reach you at the drop of a hat.
- Emergency lockout aid
- Lock replacement or repair
- Ignition switch repair
- Key cutting
- Installation of high-security locks
- Spare key development
- Creating of high-security keys
- Digital lock troubleshooting, installation
- Emergency eviction services
- Trunk unlock service
- Door installation and repair
- Security recommendation
- File Cabinet locks
- Transponder car keys
Our technicians have mastered the craft of locksmithing and can solve a broad range of issues with remarkable swiftness and dexterity. Each one of our staff members is a true professional and delivers nothing short of the very best when it comes to providing emergency, residential, commercial, or automotive locksmith services.
We can comprehensively cover the entire length and breadth of Zip code 72223 with the help of our hi-tech mobile vans and offer a wide range of services, from common ones like lock repair and lock rekeying to reprogramming the digital locks at your workplace. Experiencing a locksmith issue? Pick up the phone now and call us on 501-270-7212. Our team of experts is available 24x7 to bring a resolution to your problem.


text:
Scope of this test is to verify that the system is installed, you can login into it and the mail server is up and running.
Proceed in your native language if you wish. Instructions will remain in English
If all actions produce the expected results listed, please submit a 'passed' result. If an action fails, or produces an unexpected result, please submit a 'failed' result and file a bug. Please be sure to include the bug number when you submit your result.


text:
I am signaling you through the flames.
The North Pole is not where it used to be.
Manifest Destiny is no longer manifest.
Civilization self-destructs.
Nemesis is knocking at the door.
What are poets for, in such an age?
What is the use of poetry?
The state of the world calls out for poetry to save it.
If you would be a poet, create works capable of answering the challenge of apocalyptic times, even if this meaning sounds apocalyptic.
You are Whitman, you are Poe, you are Mark Twain, you are Emily Dickinson and Edna St. Vincent Millay, you are Neruda and Mayakovsky and Pasolini, you are an American or a non-American, you can conquer the conquerors with words....
From Poetry as Insurgent Art by Lawrence Ferlinghetti. Copyright © 2007 by Lawrence Ferlinghetti. Used by permission of New Directions. All rights reserved.
The changing light at San Francisco is none of your East Coast light none of your pearly light of Paris The light of San Francisco is a sea light an island light And the light of fog blanketing the hills drifting in at night through the Golden Gate to lie on the city at dawn And then the halcyon late mornings after the fog burns off and the sun paints white houses with the sea light of Greece with sharp clean shadows making the town look like it had just been painted But the wind comes up at four o'clock sweeping the hills And then the veil of light of early evening And then another scrim when the new night fog floats in And in that vale of light the city drifts anchorless upon the ocean
From How to Paint Sunlight by Lawrence Ferlinghetti. Copyright © 2000 by Lawrence Ferlinghetti. Reprinted by permission of New Directions Publishing Corp. All rights reserved.
What thoughts I have of you tonight, Walt Whitman, for I
walked down the sidestreets under the trees with a headache self-
conscious looking at the full moon.
In my hungry fatigue, and shopping for images, I went into the
neon fruit supermarket, dreaming of your enumerations!
What peaches and what penumbras! Whole families shopping
at night! Aisles full of husbands! Wives in the avocados, babies in
the tomatoes!—and you, García Lorca, what were you doing
down by the watermelons?
I saw you, Walt Whitman, childless, lonely old grubber, poking
among the meats in the refrigerator and eyeing the grocery boys.
I heard you asking questions of each: Who killed the pork
chops? What price bananas? Are you my Angel?
I wandered in and out of the brilliant stacks of cans following
you, and followed in my imagination by the store detective.
We strode down the open corridors together in our solitary
fancy tasting artichokes, possessing every frozen delicacy, and
never passing the cashier.
Where are we going, Walt Whitman? The doors close in a hour.
Which way does your beard point tonight?
(I touch your book and dream of our odyssey in the
supermarket and feel absurd.)
Will we walk all night through solitary streets? The trees add
shade to shade, lights out in the houses, we'll both be lonely.
Will we stroll dreaming of the lost America of love past blue
automobiles in driveways, home to our silent cottage?
Ah, dear father, graybeard, lonely old courage-teacher, what
America did you have when Charon quit poling his ferry and you
got out on a smoking bank and stood watching the boat disappear
on the black waters of Lethe?
—Berkeley, 1955
From Collected Poems 1947–1980 by Allen Ginsberg, published by Harper & Row. Copyright © 1984 by Allen Ginsberg. Used with permission.
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For Carl Solomon
I saw the best minds of my generation destroyed by madness, starving hysterical naked,
dragging themselves through the negro streets at dawn looking for an angry fix,
angelheaded hipsters burning for the ancient heavenly connection to the starry dynamo in the machinery of night,
who poverty and tatters and hollow-eyed and high sat up smoking in the supernatural darkness of cold-water flats floating across the tops of cities contemplating jazz,
who bared their brains to Heaven under the El and saw Mohammedan angels staggering on tenement roofs illuminated,
who passed through universities with radiant cool eyes hallucinating Arkansas and Blake-light tragedy among the scholars of war,
who were expelled from the academies for crazy & publishing obscene odes on the windows of the skull,
who cowered in unshaven rooms in underwear, burning their money in wastebaskets and listening to the Terror through the wall,
who got busted in their pubic beards returning through Laredo with a belt of marijuana for New York,
who ate fire in paint hotels or drank turpentine in Paradise Alley, death, or purgatoried their torsos night after night
with dreams, with drugs, with waking nightmares, alcohol and cock and endless balls,
incomparable blind streets of shuddering cloud and lightning in the mind leaping toward poles of Canada & Paterson, illuminating all the motionless world of Time between,
Peyote solidities of halls, backyard green tree cemetery dawns, wine drunkenness over the rooftops, storefront boroughs of teahead joyride neon blinking traffic light, sun and moon and tree vibrations in the roaring winter dusks of Brooklyn, ashcan rantings and kind king light of mind,
who chained themselves to subways for the endless ride from Battery to holy Bronx on benzedrine until the noise of wheels and children brought them down shuddering mouth-wracked and battered bleak of brain all drained of brilliance in the drear light of Zoo,
who sank all night in submarine light of Bickford's floated out and sat through the stale beer afternoon in desolate Fugazzi's, listening to the crack of doom on the hydrogen jukebox,
who talked continuously seventy hours from park to pad to bar to Bellevue to museum to the Brooklyn Bridge,
a lost battalion of platonic conversationalists jumping down the stoops off fire escapes off windowsills off Empire State out of the moon,
yacketayakking screaming vomiting whispering facts and memories and anecdotes and eyeball kicks and shocks of hospitals and jails and wars,
whole intellects disgorged in total recall for seven days and nights with brilliant eyes, meat for the Synagogue cast on the pavement,
who vanished into nowhere Zen New Jersey leaving a trail of ambiguous picture postcards of Atlantic City Hall,
suffering Eastern sweats and Tangerian bone-grindings and migraines of China under junk-withdrawal in Newark's bleak furnished room,
who wandered around and around at midnight in the railroad yard wondering where to go, and went, leaving no broken hearts,
who lit cigarettes in boxcars boxcars boxcars racketing through snow toward lonesome farms in grandfather night,
who studied Plotinus Poe St. John of the Cross telepathy and bop kabbalah because the cosmos instinctively vibrated at their feet in Kansas,
who loned it through the streets of Idaho seeking visionary indian angels who were visionary indian angels,
who thought they were only mad when Baltimore gleamed in supernatural ecstasy,
who jumped in limousines with the Chinaman of Oklahoma on the impulse of winter midnight streetlight smalltown rain,
who lounged hungry and lonesome through Houston seeking jazz or sex or soup, and followed the brilliant Spaniard to converse about America and Eternity, a hopeless task, and so took ship to Africa,
who disappeared into the volcanoes of Mexico leaving behind nothing but the shadow of dungarees and the lava and ash of poetry scattered in fireplace Chicago,
who reappeared on the West Coast investigating the FBI in beards and shorts with big pacifist eyes sexy in their dark skin passing out incomprehensible leaflets,
who burned cigarette holes in their arms protesting the narcotic tobacco haze of Capitalism,
who distributed Supercommunist pamphlets in Union Square weeping and undressing while the sirens of Los Alamos wailed them down, and wailed down Wall, and the Staten Island ferry also wailed,
who broke down crying in white gymnasiums naked and trembling before the machinery of other skeletons,
who bit detectives in the neck and shrieked with delight in policecars for committing no crime but their own wild cooking pederasty and intoxication,
who howled on their knees in the subway and were dragged off the roof waving genitals and manuscripts,
who let themselves be fucked in the ass by saintly motorcyclists, and screamed with joy,
who blew and were blown by those human seraphim, the sailors, caresses of Atlantic and Caribbean love,
who balled in the morning in the evenings in rosegardens and the grass of public parks and cemeteries scattering their semen freely to whomever come who may,
who hiccuped endlessly trying to giggle but wound up with a sob behind a partition in a Turkish Bath when the blond & naked angel came to pierce them with a sword,
who lost their loveboys to the three old shrews of fate the one eyed shrew of the heterosexual dollar the one eyed shrew that winks out of the womb and the one eyed shrew that does nothing but sit on her ass and snip the intellectual golden threads of the craftsman's loom,
who copulated ecstatic and insatiate with a bottle of beer a sweetheart a package of cigarettes a candle and fell off the bed, and continued along the floor and down the hall and ended fainting on the wall with a vision of ultimate cunt and come eluding the last gyzym of consciousness,
who sweetened the snatches of a million girls trembling in the sunset, and were red eyed in the morning but prepared to sweeten the snatch of the sunrise, flashing buttocks under barns and naked in the lake,
who went out whoring through Colorado in myriad stolen night-cars, N.C., secret hero of these poems, cocksman and Adonis of Denver—joy to the memory of his innumerable lays of girls in empty lots & diner backyards, moviehouses' rickety rows, on mountaintops in caves or with gaunt waitresses in familiar roadside lonely petticoat upliftings & especially secret gas-station solipsisms of johns, & hometown alleys too,
who faded out in vast sordid movies, were shifted in dreams, woke on a sudden Manhattan, and picked themselves up out of basements hung-over with heartless Tokay and horrors of Third Avenue iron dreams & stumbled to unemployment offices,
who walked all night with their shoes full of blood on the snowbank docks waiting for a door in the East River to open to a room full of steam-heat and opium,
who created great suicidal dramas on the apartment cliff-banks of the Hudson under the wartime blue floodlight of the moon & their heads shall be crowned with laurel in oblivion,
who ate the lamb stew of the imagination or digested the crab at the muddy bottom of the rivers of Bowery,
who wept at the romance of the streets with their pushcarts full of onions and bad music,
who sat in boxes breathing in the darkness under the bridge, and rose up to build harpsichords in their lofts,
who coughed on the sixth floor of Harlem crowned with flame under the tubercular sky surrounded by orange crates of theology,
who scribbled all night rocking and rolling over lofty incantations which in the yellow morning were stanzas of gibberish,
who cooked rotten animals lung heart feet tail borsht & tortillas dreaming of the pure vegetable kingdom,
who plunged themselves under meat trucks looking for an egg,
who threw their watches off the roof to cast their ballot for Eternity outside of Time, & alarm clocks fell on their heads every day for the next decade,
who cut their wrists three times successively unsuccessfully, gave up and were forced to open antique stores where they thought they were growing old and cried,
who were burned alive in their innocent flannel suits on Madison Avenue amid blasts of leaden verse & the tanked-up clatter of the iron regiments of fashion & the nitroglycerine shrieks of the fairies of advertising & the mustard gas of sinister intelligent editors, or were run down by the drunken taxicabs of Absolute Reality,
who jumped off the Brooklyn Bridge this actually happened and walked away unknown and forgotten into the ghostly daze of Chinatown soup alleyways & firetrucks, not even one free beer,
who sang out of their windows in despair, fell out of the subway window, jumped in the filthy Passaic, leaped on negroes, cried all over the street, danced on broken wineglasses barefoot smashed phonograph records of nostalgic European 1930s German jazz finished the whiskey and threw up groaning into the bloody toilet, moans in their ears and the blast of colossal steamwhistles,
who barreled down the highways of the past journeying to each other's hotrod-Golgotha jail-solitude watch or Birmingham jazz incarnation,
who drove crosscountry seventytwo hours to find out if I had a vision or you had a vision or he had a vision to find out Eternity,
who journeyed to Denver, who died in Denver, who came back to Denver & waited in vain, who watched over Denver & brooded & loned in Denver and finally went away to find out the Time, & now Denver is lonesome for her heroes,
who fell on their knees in hopeless cathedrals praying for each other's salvation and light and breasts, until the soul illuminated its hair for a second,
who crashed through their minds in jail waiting for impossible criminals with golden heads and the charm of reality in their hearts who sang sweet blues to Alcatraz,
who retired to Mexico to cultivate a habit, or Rocky Mount to tender Buddha or Tangiers to boys or Southern Pacific to the black locomotive or Harvard to Narcissus to Woodlawn to the daisychain or grave,
who demanded sanity trials accusing the radio of hypnotism & were left with their insanity & their hands & a hung jury,
who threw potato salad at CCNY lecturers on Dadaism and subsequently presented themselves on the granite steps of the madhouse with shaven heads and harlequin speech of suicide, demanding instantaneous lobotomy,
and who were given instead the concrete void of insulin Metrazol electricity hydrotherapy psychotherapy occupational therapy pingpong & amnesia,
who in humorless protest overturned only one symbolic pingpong table, resting briefly in catatonia,
returning years later truly bald except for a wig of blood, and tears and fingers, to the visible madman doom of the wards of the madtowns of the East,
Pilgrim State's Rockland's and Greystone's foetid halls, bickering with the echoes of the soul, rocking and rolling in the midnight solitude-bench dolmen-realms of love, dream of life a nightmare, bodies turned to stone as heavy as the moon,
with mother finally ******, and the last fantastic book flung out of the tenement window, and the last door closed at 4 A.M. and the last telephone slammed at the wall in reply and the last furnished room emptied down to the last piece of mental furniture, a yellow paper rose twisted on a wire hanger in the closet, and even that imaginary, nothing but a hopeful little bit of hallucination—
ah, Carl, while you are not safe I am not safe, and now you're really in the total animal soup of time—
and who therefore ran through the icy streets obsessed with a sudden flash of the alchemy of the use of the ellipsis catalogue a variable measure and the vibrating plane,
who dreamt and made incarnate gaps in Time & Space through images juxtaposed, and trapped the archangel of the soul between 2 visual images and joined the elemental verbs and set the noun and dash of consciousness together jumping with sensation of Pater Omnipotens Aeterna Deus
to recreate the syntax and measure of poor human prose and stand before you speechless and intelligent and shaking with shame, rejected yet confessing out the soul to conform to the rhythm of thought in his naked and endless head,
the madman bum and angel beat in Time, unknown, yet putting down here what might be left to say in time come after death,
and rose reincarnate in the ghostly clothes of jazz in the goldhorn shadow of the band and blew the suffering of America's naked mind for love into an eli eli lamma lamma sabacthani saxophone cry that shivered the cities down to the last radio
with the absolute heart of the poem of life butchered out of their own bodies good to eat a thousand years.
What sphinx of cement and aluminum bashed open their skulls and ate up their brains and imagination?
Moloch! Solitude! Filth! Ugliness! Ashcans and unobtainable dollars! Children screaming under the stairways! Boys sobbing in armies! Old men weeping in the parks!
Moloch! Moloch! Nightmare of Moloch! Moloch the loveless! Mental Moloch! Moloch the heavy judger of men!
Moloch the incomprehensible prison! Moloch the crossbone soulless jailhouse and Congress of sorrows! Moloch whose buildings are judgment! Moloch the vast stone of war! Moloch the stunned governments!
Moloch whose mind is pure machinery! Moloch whose blood is running money! Moloch whose fingers are ten armies! Moloch whose breast is a cannibal dynamo! Moloch whose ear is a smoking tomb!
Moloch whose eyes are a thousand blind windows! Moloch whose skyscrapers stand in the long streets like endless Jehovahs! Moloch whose factories dream and croak in the fog! Moloch whose smoke-stacks and antennae crown the cities!
Moloch whose love is endless oil and stone! Moloch whose soul is electricity and banks! Moloch whose poverty is the specter of genius! Moloch whose fate is a cloud of sexless hydrogen! Moloch whose name is the Mind!
Moloch in whom I sit lonely! Moloch in whom I dream Angels! Crazy in Moloch! Cocksucker in Moloch! Lacklove and manless in Moloch!
Moloch who entered my soul early! Moloch in whom I am a consciousness without a body! Moloch who frightened me out of my natural ecstasy! Moloch whom I abandon! Wake up in Moloch! Light streaming out of the sky!
Moloch! Moloch! Robot apartments! invisible suburbs! skeleton treasuries! blind capitals! demonic industries! spectral nations! invincible madhouses! granite cocks! monstrous bombs!
They broke their backs lifting Moloch to Heaven! Pavements, trees, radios, tons! lifting the city to Heaven which exists and is everywhere about us!
Visions! omens! hallucinations! miracles! ecstasies! gone down the American river!
Dreams! adorations! illuminations! religions! the whole boatload of sensitive bullshit!
Breakthroughs! over the river! flips and crucifixions! gone down the flood! Highs! Epiphanies! Despairs! Ten years' animal screams and suicides! Minds! New loves! Mad generation! down on the rocks of Time!
Real holy laughter in the river! They saw it all! the wild eyes! the holy yells! They bade farewell! They jumped off the roof! to solitude! waving! carrying flowers! Down to the river! into the street!
From Collected Poems 1947-1980 by Allen Ginsberg, published by Harper & Row. Copyright © 1984 by Allen Ginsberg. Used with permission.


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Pink Rose and Lily Hand Tied
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Material | Solid Wood |
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More than 15 years ago, a small group of families, community activists, and civil servants in New York came together to form an organization called HealSoul. They provide services for those struggling to care for a loved one who did not "fit" into traditional health systems: stroke, Parkinson's, Alzheimer's disease, traumatic brain injury, debilitating disorders, etc. The diagnoses were different, but the families shared common challenges: few community resources, isolation, lack of information, and drastic changes in family roles.
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99% of Experts Agree: Home Prices Will Increase
Some believe that the combined effects of the new tax code and rising mortgage rates will have an adverse impact on residential real estate prices in 2018. However, the clear majority of recently surveyed housing experts believe that home values will continue to rise this year.
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Almost ninety-nine percent of the top experts studying residential real estate believe that prices will appreciate this year, and over 93% believe home values will appreciate by at least 3%.


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Attention: Some models may have several different mirror features. Please make sure that you confirm the dimensions listed for this mirror glass match the dimensions of your existing factory mirror glass. Failure to do so can result in your receiving the incorrect mirror. (Ex: Heated or Non Heated, Power or Manual, etc.)
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