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There is one thing in this world that may very well be the single most important thing we can give to our children. We can give them a safe home to live in, which would indeed offer them a firm foundation to build their futures on. Their natural needs would all be provided for: shelter, clothing, food & water. A safe home is a tremendous offering for any parent to give any child. Taking it to the next level, sharing healthy meals together can be considered paramount in the same vein, which … [Read more...]
Parent Like You Mean It 17: Give 'Em H€&%!!
Christian Home & Family: Help Your Kids Fight the Condemning Voice in Their Heads
Everyone fights those nagging little voices of condemnation that speak to their own minds. It's part of the human condition. It's that voice in your head that repeats things like: "I am so worthless. I am such a failure. I am not worthy of anything…" We all experience this. Parents, you have to know that your kids are going to struggle with those same issues. In fact, they probably already do, even the younger ones. But for Christians, there is a powerful way to deal with those lies, and it's … [Read more...]
Blending Your StepFamily: Healthy Perspectives Lead to Healthy Families
[display_podcast] From Pam Rohr, author of Blended but not Broken - Hope and Encouragement for Blended Families: Let's talk about perspectives today, what is perspective and how does it influence our attitudes and decisions. Is the glass half full or half empty, it boils down to your perspective. To quote Rick Riordan:"Humans see what they want to see." I recently heard of a study that really explains the importance of perspective. In the experiment, children were divided into two group … [Read more...]
Christian Home & Family: Purposeful Parenting
From Carey Green, author, blogger, speaker, coach and pastor:Parenting is not easy. It takes a lot of hard work if you're going to do it in an effective, God-honoring way."Purposeful Parenting" is a way of viewing your relationship in a proactive way rather than floating through your parenting role, dealing with things as they come up. You need to be keenly aware of what is really going on, on the inside of your child's heart, thoughts and attitudes.The Bible lays out patterns for us … [Read more...]
Real Stuff My Dad Says 80: Vanity Fair Is A Church Issue
[display_podcast] Last week, I was able to enjoy one of life's great pleasures: Dad and I went to a ballgame together. My poor wife and mom endured eight long innings of what they considered monotony, but what Dad and I considered pure joy! I say only eight innings, because I don't care who you are, the ninth inning was a blast – tie game, bases loaded, five-man infield, capped off with a walk-off grand slam by the home team! (It was just a shame that Dad's Pirates were on the losing end). … [Read more...]


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subset: commoncrawl


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Obsidian is a natural volcanic glass formed when viscous lava is rapidly cooled, most commonly by water. Obsidian is less fragile than standard window glass, and was often fashioned into sharp cutting edges by stone age man. Snowflake Obsidian is highly valued for jewelry creation due to its strikingly bold white inclusions giving the stone the appearance of snowflakes against a black sky.
1 ST $2.72 ($2.72 per ST) was $3.40
2 ST $4.08 ($2.04 per ST) was $5.10
10 ST $16.28 ($1.63 per ST) was $20.35
20 ST $31.32 ($1.57 per ST) was $39.15


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Deceptive Business - Firkins Nissan
Posted in the Bradenton Forum
1 - 3 of 3 Comments Last updated Oct 9, 2012
#1 Oct 4, 2012
We traded a vehicle and it was valued thousands less than the vehicle we traded for so we shelled out nearly $5000.00 cash plus our trade in (which was paid for) 2011 GMC Acadia SUV for their 2011 Nissan Maxima. Dean said the value of the Maxima was over $27,000 and ours was worth a little over $23,000. It was after hours so only 3 people there and the sales manager (Dean) left before we were done. But he told us he would add other things to the car (did not) we were charged for a dealer prep we did not get ($587.00) The paper work is incorrect (wrong county listed, wrong color of car (it was dark, color listed as blue and it is gray, Ocean Gray to be correct) Now when we drove the car home (the only time we drove it (no test drive) and we live 2 hours away so it was midnight when we got home and by then found that the car rode too low and caused such pain in my back that I could not move the next day. Tried again to ride in it two days later and was down for 2 days (before everyone thinks this is about pain and suffering it is not) I had a previous old injury from an auto accident in 1986 which has not bothered me in many many years until the ride in this car. So we called them and told them, they hated to hear it. We told them we could not keep the car because we parked it and have not been in it since.(less than a week we have had this car) I wanted my Acadia back but they kept trying to sell me a Hyundai??? I finally insisted and Dean called my husband and tole him we could trade back if we give him an additional $2000.00! Are you kidding me???? We already gave them nearly $5000.00 because he said the Maxima was worth more than our Acadia and boom... over night the value of the Acadia passe the Maxima! But not really, he lied as he had lied in the beginning. AS on the paper work (which was done 3 times because it was late and the girl was tired (10:00 pm) and we were tired, but Dean went home to bed, just us the office girl and Rosie the saleswoman Dean dumped this on. Oh yes, and the janitor. I have tried for a week to get them to resolve this. But they want to continue to rip us off and lie. The contract is breech because we were charge for a service we did not get and we did not get any thing good ole Dean promised. Oh yes, he has been there for two weeks now as sales manager,,, We have not heard from the owners at all. I sent emails to Rosie and one to Dean after he lied to my husband (again) today stating that he valued the Nissan at $23,000 and the Acadia at $22,000 and I have the paper work as to the truth of what he valued the vehicles at (mentioned earlier in my post) So why did he get $5000.00 from us at the time? And why now does he want an additional $2000.00 to trade back? LIES and deceptive practices! The buyers order shows the charge for dealer prep and we never got it! FRAUD! Void contract and trade deal!!!! Florida law is clear on this. Yes, I contacted an attorney today and I also contacted the local news station for an interview and our story to be made public (and I have all the paperwork, emails and documentation to prove the fraud and deceptive business practice! This is just an FYI so no one else gets deceived by them. I posted my negative experience on their facebook page Firkins Nissan and they deleted it so no one could see it and see the comments by others after that. Then they blocked me from making a new post. Why? Because they do not want other to see the negative experiences people have with them just the positive. That in itself is deceptive. SHAME ON YOU! If the owners do not promote this behavior and tactics why have we not heard directly from them? Simple, they can point the finger at just Dean when this gets legal. Except for the fact they saw my comments on their facebook page and deleted it. The car is a beautiful car, not saying it isn't but I cannot ride or drive it. And the whole thing from the paperwork is fraud. My name is Deonna Hampton
#2 Oct 4, 2012
I must report that I just spoke to the general manager, Randy Santos who told me that he would give us our Acadia back and take the Maxima back and refund our money. And there will be no $2000.00 more money that he just wanted a satisfied customer and I am very thankful that he is doing so and resolving the problem which tells me that this was a sales manager problem and the upper management does not go along with that. Thank you Randy Santos and I am now a happy customer. Thanks for making it right.
Saint Petersburg, FL
#3 Oct 9, 2012
I can tell you that I have been dealing with Nissan dealerships for over 12 years although not this one. I am a happy customer.
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Morning Links: RIM's Big Day Has Finally Arrived
Why the new BlackBerry 10 phones won't stop Research In Motion dramatic contraction — Quartz
BlackBerry 10 needs these apps to keep up with the competition — Digits
U.S. economy unexpectedly contracts in fourth quarter — WSJ
Fed seen keeping stimulus spigots wide open — Morning MarketBeat
Fed's long-running show goes on and on — Ahead of the Tape
Bridgewater's Dalio sees "game changer" as money shifts — Bloomberg
Small investors are jumping back into the stock market after abandoning it during the financial crisis – Tom Lauricella
The same people who've spent three years growling about low volume and lack of participation being bearish are now saying that the reversal of that is also bearish. You can't have it both ways — Josh Brown
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Ready in 45 minutes
Sweet cantaloupe, heady port and fresh mint combine in a light dessert ideal for the end of a hearty meal. Try it after the Spiced Beef with Wine Sauce and Roasted Potatoes. (Cooking Light magazine 8-04)
1 people want to try | 3 have favorited
1. Combine port and sugar in a small saucepan; bring to a boil. Reduce heat, and simmer 10 minutes or until reduced to 1/2 cup. Place port mixture in a large bowl; cool. Add salt and cardamom to port mixture; stir to combine. Add cantaloupe balls and chopped mint; toss gently to coat. Cover and chill 1 hour before serving. Garnish with the mint sprigs, if desired.


text: Oiled Up Two cocks, one pussy and a lot of oil. "Party on, Wayne!" Photos: 16 Views: 10411 Date: 7 years ago Rating: (13 votes) 78% Tags: sexy cock ass fuck hot pussy asian wet suck balls shaved oil clit three-way Categories: Asian Group Sex Hardcore Report Add Favorite Comments (0) Add your comment Bold Italic Underline Post comment


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Within minutes of the casinos, shopping and entertainment of Atlantic City, this Galloway, New Jersey motel features all-suite accommodations with full kitchens and a free daily continental breakfast....
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This Galloway motel is within a 10-minute drive of Atlantic City casinos. The motel offers a continental breakfast, free Wi-Fi and free on-site parking.
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This hotel in Atlantic City–Galloway is 15 minutes from the Atlantic City Boardwalk and Casinos. It features a 24-hour front desk, whirlpool and rooms with a wall-mounted flat-screen TV.
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This New Jersey motel is 6 miles from Atlantic City International Airport. Red Carpet Inn Absecon serves complimentary coffee each morning and has guest rooms with free Wi-Fi and cable TV.
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The Atlantic City Boardwalk is a 15 minute drive from this Galloway, New Jersey motel. It features an outdoor pool with a deck and offers cable TV with HBO in every room.
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The Econo Lodge is convenient to the Garden State Parkway and Atlantic City Expressway, just six miles from the world-famous Atlantic City Boardwalk and Atlantic City beaches.
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This Galloway, New Jersey motel is 20 minutes from downtown Atlantic City and the casinos. It offers on-site laundry facilities, a 24-hour front desk and rooms with cable TV and HBO channels.
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Just a 15-minute drive from Atlantic City, this hotel features free Wi-Fi access and a daily continental breakfast. It is just a half mile off the Garden State Parkway.
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Aryans of Iran
Audhubillah himn ash shaytaan ar rajim Bismillah ar-Rahmaan ar-Raheem Allahu Masalle ala Muhammadin{sawawa} wa Aal-e-Muhammad{a.s} To counter the propaganda of the baboons of Europe who beli
By: AjamiPride | Comments: 340 | Views: 6209 | Votes: 7 | Shared: 3
Location: Iran | Leaked: May-25-2016 in Syria, Iraq, Iran
North Korea News: World's Smallest Man Buried
North Korea Comedy: World's Smallest Man Buried There were terribly sad scenes in the Pyongyang, North Korea Martyrs Cemetery today, as the world's smallest man was finally laid to rest. Mun Kyo
By: AlunHill | Comments: 17 | Views: 1794 | Votes: 1 | Shared: 0
Location: Pyongyang, Pyongyang, Korea (North) | Leaked: May-3-2013 in WTF
Nelson De La Rosa, world's smallest man
Nelson Aquino de la Rosa (June 1968 – October 22, 2006) was one of the shortest men of the twentieth and twenty first centuries and an actor from the Dominican Republic. Nelson measured 54 centimeters
By: smartt | Comments: 18 | Views: 28304 | Votes: 2 | Shared: 5
Leaked: Jun-16-2007 in Other
Size Matters as World's Tallest Man Meets World's Smallest
Size Matters as World's Tallest Man Meets World's Smallest
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World's Smallest V12 Engine
this man put 12000 hours of work into this project but does it work? Yes
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The New World's Tallest Man And Smallest Man Meet
The recently crowned world's tallest man, Sultan Kosen, meets the man who currently holds the title of the world's smallest man — He Pingping. The Turkish farm laborer, Kosen, with height 246.5 c
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World's Smallest Man Steps On A Beach For The First Time (Raw Video)
Bahadur Dangi chillin' @ Bondi Beach Australia - May 15th, 2012 .
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The World's Smallest Man
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Russia: World's tallest man & smallest woman arrive in Moscow
The world's tallest man and the world's smallest woman took part in the opening ceremony of the 'Kunsevo Plaza' shopping mall in Moscow, Saturday. Video ID: 20151003-041 Video on Demand: htt
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India: See man ride world's SMALLEST electric motorbike
Indian engineer Afroz Shaikh showed off what is possibly the world's smallest electric motorcycle at the IIT Techfest in Mumbai, Saturday. The 10 inch (25 centimetre) high vehicle is made of parts fr
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Location: Mumbai, Maharashtra, India | Leaked: Jan-3-2015 in WTF, Other Entertainment, Vehicles
China: Man creates world's SMALLEST car to dodge crazy Shanghai traffic
Video ID: 20141210-025 W/S Xu Zhiyan starting up the car C/U Xu Zhiyan starting up the car M/S Xu Zhiyun driving his mini car W/S Xu Zhiyun driving his mini car M/S Xu Zhiyun driving
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UK Man Builds World's Smallest Car Out of Toy
And you thought the Smart fortwo was small: An enterprising 47-year-old fellow named Perry Watkins took a Postman Pat--a popular toy car in Europe--and converted it into a 39-inch-tall, 26-inch-wide v
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Leaked: May-16-2009 in Arts and Entertainment
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The relationship of the avant-garde
of the modern with wallpaper was ambivalent. On the one hand, there was an
extremely deep aversion to wallpaper with its historicizing motifs and
architectural spatial illusions as an expression of bourgeois home décor in the
19th century. On the other hand, representatives of Jugendstil and
the Viennese Modern or the circles of the Deutscher Werkbund (German Work
Federation) made use of wallpaper in order to put their colourfully floral,
figurative or abstract worlds of shapes on the wall.
In more precise terms, wallpaper's radical image as the foe was limited to a very restricted period of the 1920s in which New Building fought for its breakthrough. Wallpaper simply stood in the way of the architect's new concepts of space. Their goal was the visible use of the building materials and components. Colourful coats of paint and special surface treatments did not serve as a substitute for wallpaper but as supporting elements in the architectural concept and perception of space. Prime examples of this are the Dessau Bauhaus structures, especially the school building according to the design of Walter Gropius with the participation of the Bauhaus workshops. The people at the Weimar Bauhaus did not have such a radical attitude against wallpapers and wall decorations. Ornamental wall decor and reliefs were realised as a matter of course. The Masters' Council of the Bauhaus discussed wallpaper patterns during this period.
The wallpaper industry watched this development with much concern. With the progressing establishment of New Building and the New Objectivity, it was threatened by a drop in sales. In addition, it was difficult for the wallpaper industry to the access the new market of the large settlement projects under such preconditions.
Friend or Foe? The Bauhaus and the Wallpaper
Friend or Foe? The Bauhaus and the Wallpaper
Summary of lecture held by Werner Möller at the Mies van der Rohe Haus, Berlin, 21/09/2011
from 5.10.2011
The relationship of the avant-garde
of the modern with wallpaper was ambivalent. On the one hand, there was an
extremely deep aversion to wallpaper with its historicizing motifs and
architectural spatial illusions as an expression of bourgeois home décor in the
19th century. On the other hand, representatives of Jugendstil and
the Viennese Modern or the circles of the Deutscher Werkbund (German Work
Federation) made use of wallpaper in order to put their colourfully floral,
figurative or abstract worlds of shapes on the wall.
In consideration of this background,
Emil Rasch introduced himself to the Bauhaus in 1928 for the purpose of
cooperating in a new wallpaper collection. The contact was ultimately
established by his sister Maria. She had studied at the Bauhaus in Weimar from
1919 to 1923 and had subsequently worked for Walter Gropius. The new Bauhaus
director Hannes Meyer was initially quite sceptical about the request. What
tipped the scales for the decision to risk offering a Bauhaus wallpaper with
Rasch was probably the political and economic pressure that weighed upon Meyer
and the Bauhaus. Otherwise, wallpaper did not even play a role in the Bauhaus
structures that were built under his direction: the ADGB school in Bernau and
the Laubenganghäuser (apartments with balcony access) in Dessau.
Already in autumn of 1929, the blue Rasch Book presented the first Bauhaus collection with 14 designs and 145 pages for the wallpaper season of the year 1930. The collection was characterised by fine line and dot patterns, as well as grids in light and friendly colours. The experiences gained in the workshop for murals were translated to the medium of wallpaper and taken into mass production, completely corresponding with the motto by Hannes Meyer of "the people's needs instead of the need for luxury." This was because not only the settlement wallpapers from Rasch's company did justice to the standards of New Building with this step as a full-fledged building element. The training at the Bauhaus for this cooperation was also an important experience on the path from artistic or craftsmanship drafts to the applied designs for the industrial mass production.
However, this modern form of settlement wallpaper was not an invention of the Bauhaus. For example, Hans Leistikow had already realised the settlement solid colours and grids as an employee for the Marburg wallpaper factory Das Neue Frankfurt (The New Frankfurt) under Ernst May in 1927/28.
The reason why Emil Rasch absolutely wanted to win the Bauhaus for a cooperation was because it already had a significant market value as a trendsetter. In retrospect, Emil Rasch described this as follows in 1952: "… The exponent of the modern direction was the Bauhaus (...) and it was correspondingly hostile to wallpaper. (...) I instinctively sensed that the greatest danger for our industry was developing in Dessau, and I thought that if it was possible to cause our main adversary to bring out a collection under its own name, such a circumstance would be the most effective signal for a change in mood among the wallpaper opponents."
The Bauhaus card initially proved to be a flop: Just four dealers added it to their programme. But Emil Rasch did not become discouraged; instead, he started an offensive by bypassing the intermediary trade and strengthening the advertising activities. Consequently, the sales figures increased dramatically and the Bauhaus wallpaper already became the company's supporting pillar and the main source of income for the Bauhaus GmbH during its initial year.
Due to the economic dependence on the Bauhaus wallpaper, the company also became directly affected by the political differences between the Bauhaus and the City of Dessau. In January of 1930, the National Socialists rose to become the leading political force in Dessau and the conflict with the Bauhaus – which had become more Communist-oriented under Hannes Meyer – was decided. As of 1 August 1930, Meyer was fired without notice and Ludwig Mies van der Rohe assumed his office as the new director in the winter semester of 1930.
The change could hardly have been
more conspicuous for Rasch: from the architect of the "people's needs" to the
major building artist of the Classic Modern. In Mies' concepts of space,
materiality and surfaces, there was no room for wallpapers. Only the
contractual obligations and the indispensable profits from the provisions of
the wallpaper business secured the continuation of the cooperation.
For Mies van der Rohe, the cooperation became necessary for survival starting on 22 August 1932 with the resolution of the Dessau city council to close the Bauhaus as of 1 October. When dissolving the contracts with the city, Mies succeeded in having the rights to the name of Bauhaus and the licence income assigned to him, as well as a partial continued payment of the teacher salaries until 1935. Under these conditions, he assumed the risk of taking over the Bauhaus as a private institute under his own responsibility. Nevertheless, the newly founded institute was searched and sealed by the police on 11 April 1933 – once again at the instigation of the Dessau National Socialists.
Emil Rasch, who had a law degree, took action once again. Two weeks after the police seizure, Rasch and Mies van der Rohe cancelled the contract between the wallpaper company and the Bauhaus GmbH. All rights, including the right of use for the name of Bauhaus wallpaper were signed over to the company in Bramsche for 6,000 Reichsmarks. This meant that the Bauhaus wallpaper escaped the state access during the liquidation of the Bauhaus on 19 July 1933. In front of the Magdeburg district court on 6 September of that same year, Rasch additionally won the verdict that prohibited the reviling of the Bauhaus wallpaper as degenerate – which would have been the same fate that had befallen the artistic work of his sister and Bauhäusler Maria Rasch.
As a further measure for securing and obtaining better placement of the product on the market, Emil Rasch already alluded to the new Maria-May collection of 1932 as the supplement to the Bauhaus wallpaper. This was a typical double strategy for Rasch: On the one hand is the emancipatory act of presenting the modern woman as a new actor of the wallpaper business; on the other hand, there is the intention of advertising the woman as traditional keeper of the home and kitchen for the sober Bauhaus wallpaper in combination with the more feminine May card.
In the following year, Emil Rasch even went a step further in his business politics. The merchant not only announced that the 1934 Bauhaus card was produced by the company itself and had been fundamentally redesigned but made an almost Faustian move. Based on the designs by Paul Schultze-Naumburg, he introduced a new Weimar collection that was sold and advertised together with the collections by Maria May and the Bauhaus in a harmonious triad until the factory had to be closed due to the war. Parallel to these strategically motivated but morally dubious activities for the safeguarding of the company, Emil Rasch still supported Mies van der Rohe with commissions from the business with the Bauhaus wallpaper for a number of years after the closing of the Bauhaus.
Rasch resumed the wallpaper production in 1948. Already in 1949, the first post-war collection of the Bauhaus wallpaper appeared for the year 1950. The design of the updated collection was in the hands of the former director of the mural workshop at the Bauhaus, Hinnerk Scheper, as well as Werner Schriefers, who later became the director of the Cologne School of Applied Arts. Rasch continued to follow his well-known dual strategy. He juxtaposed the Bauhaus wallpaper with the collection of the Rasch Artist Wallpaper in which more than 25 artists from ten countries participated. Following the sinister years of the NS regime, German industry once again focused on internationality and open-mindedness. In the striving to build bridges between politics, business and modern design, Emil Rasch was one of the most important personalities of the early post-war period in West Germany. Soon after he resumed production of the wallpapers, he sought contact with the former Bauhaus directors Walter Gropius, Hannes Meyer and Ludwig Mies van der Rohe.
Werner Möller
For additional information and sources see:
Tapetenfabrik Gebr. Rasch GmbH & Co. and Bauhaus Dessau Foundation (Publ.):
Bauhaustapete. Reklame & Erfolg einer Marke (Bauhaus Wallpaper: Advertising & Success of a Brand), Burckhard Kieselbach, Werner Möller, Sabine Thümmler (Ed.), Cologne, 1995.
Tapetenfabrik Gebr. Rasch GmbH & Co. (Publ.): Rasch-Buch/Book. 1897-1997, Burckhard Kieselbach (Ed.), Bramsche, 1998.


text:
Olivia Hussey giving us a look at the side of her left breast and her ass as some kids watch her walk nude over...
Romeo and Juliet
Olivia Hussey
Olivia Hussey rolling over in bed, quickly exposing her large breasts as she turns on her side. The scene is then repeated in slow motion. Hi-res DVD capture from Romeo and Juliet.
- type:
- Nude
- length:
- 0:04
- filesize:
- 1.10 mb
- resolution:
- 704x400 px
- posted:
- Oct 17, 2005 @ 05:08pm
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text:
Well we didn't get our swallow study like I thought we were going to. :( They said they are trying to schedule it, tho, and that it will probably be about two weeks before they can get Tristan in. I'm supposed to find out on Monday when it will be.
All the docs at the clinic seemed to be worried about Tristan's weight. They haven't seen him in pulmonology/gi since he first got his feeding tube so they hadn't seen what his weekly gains were (I stupidly didn't think to bring that info in with me) He has been gaining really good since they put the tube in... most weeks like 5 to 6 ounces which is totally normal for a baby his age... but they don't like that he's below the 5th percentile. So we get to start fortifying his milk with formula to try to get him back on the charts and he's been spitting up like crazy ever since! Which is very unlike him. I called his GI doc and he said to give him four or five days to get used to it. Anyone else's LOs spit up a lot after a change like that?
I don't like the new GI doc that we saw very much. The pulmonologist, ENT doc, dietition, and speech and occupational therapists all want to see his reflux under a lot better control. Right now he's only on Prevacid and the pulmonologist upped his dosage to try and help protect his esophagous more but they all said that it's pretty much up to the GI doc on what to do about the GERD. So we saw the GI doc last and he seemed to think that as long as he could keep most of the volume of milk down that he wasn't too worried about trying anything else to help. Tristan has silent reflux, so a majority of the time it comes up but goes back down... But I'm worried about the damage it may be causing (which the ENT was worried about) and his breathing gets really bad the more he reflux's (which the pulmonologist was worried about.) The GI doc has an extremely heavy accent, so I don't know if he just didn't understand my concerns, or that he really wasn't that worried about it. We are supposed to see him again in a month and he told us he may consider putting him on Reglan if he gets worse... but he really just wants to wait to see if he gets better on his own after he's six months old. He's only two months old now, so he wants us to wait another four months before trying anything else! He told us that lots of babies have reflux and it's just something we have to deal with. .
Should I keep calling them to try and get them to at least try the Reglan? I'm not sure what I should be doing here... :/


text:
Titanfall artbook detailed, pictured
Titanbooks has shown of a limited edition Titanfall art book. Based on a run of 500, the release is described as a "companion" to the 2014 Respawn shooter, and comes with a print signed by 17 members of the development team.
The 192-page book will provide "an in-depth, no-holds barred look at Respawn Entertainment's hugely anticipated multiplayer shooter, featuring exclusive concept and development art, as well as detailed creator insights and commentary throughout, showcasing the all-out warfare between the agile pilots and lethal Titans of the Interstellar Manufacturing Corporation and the M-COR militia, as well as the war-torn science fiction battlefields found within the game."
There's no word on price.
A Titanfall beta was confirmed today, but is yet undated. It's rumoured for a February start. The game itself will release for PC, Xbox 360 and Xbox One in March.
Sometimes we include links to online retail stores. If you click on one and make a purchase we may receive a small commission. For more information, go here.


text:
I am programming an application to be monitored with (net)snmp.
So when I run
snmpget it will trigger a request for my program in C to get the data. The only problem is my program uses libcurl.
The function
getSettings below uses libcurl:
HttpData* s = getSettings("max_ul_rate");
snmp_set_var_typed_value(requests->requestvb, ASN_OCTET_STR, (u_char *) &s->ptr, s->len+1);
When a I run netsnmp make it gives me an error that it doesn't find CURL. How can I add LIBCURL to NET-SNMP's Makefile?


text:
New beginnings are exciting! I am reconnecting with a big and important portion of my past in the form of a new beginning. It is coming back to Montreal enriched with experience and……tons of vintage clothes! I can't wait to start showing them. It is also a revival of my half dead blog.
I am wearing a 1960s vintage psychedelic purple print button down shirt with an impressive jabot bell sleeves and pearl buttons.
New beginnings are so exciting. Photographed by Ramona Pal-Kovacs


text:
Written on: 30/04/2014 by larkum (1 review written)
I have been a Customer of 123-reg.co.uk for about 6 years
Up until now I have only used for Domain Name hosing and there DNS servers.
I have just bought a VPS, I went for them as its all under 1 roof, and at an affordable price, with good reviews for what I could find on there VPS's.
There are cheaper options out there, but I find if a service is worth paying for then pay it. I have trailed 3 VPS companies before 123-reg and they all let me down.
The Key Feature that makes 123-reg better is there connection speed is of good quality and speed there VPS managing control panel is easy, clean and smart. And there support is good, and always happy to answer your questions.
Will be a loyal customer if they keep up the great work.
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text:
BHIVA Hepatitis B and C Guidelines Subcommitte members: Dr Gary Brook, Dr Janice Main (Co-Chairs), Dr Richard Gilson, Mr Nigel Hughes, Dr Gayle Mathews, Dr Mark Nelson, Dr Caroline Sabin, Dr Ed Wilkins
BHIVA Guidelines: coinfection with HIV and Chronic hepatitis B virus
Version of Record online: 26 SEP 2003
DOI: 10.1046/j.1468-1293.4.s1.1.x
HIV Medicine
Volume 4, Issue S1, pages 42–51, October 2003
Additional Information
How to Cite
Brook, M., Gilson, R., Wilkins, E. and on behalf of the British HIV Association (2003), BHIVA Guidelines: coinfection with HIV and Chronic hepatitis B virus. HIV Medicine, 4: 42–51. doi: 10.1046/j.1468-1293.4.s1.1.x
†I=Meta-analysis or RCT, II=Other good quality trial, III=Observational studies/Case Reports, IV=Expert Opinion.
Publication History
- Issue online: 26 SEP 2003
- Version of Record online: 26 SEP 2003
- Accepted 29 July 2003
- Abstract
- Article
- References
- Cited By
Key recommendations (I–IV levels of evidence)†
- Top of page
- Key recommendations (I–IV levels of evidence)
- Audit standards
- Background
- Assessment and investigations
- Management
- References
Assessment of all HIV+ patients
- 1All HIV-positive patients should have anti-HBc and/or anti-HBs tests within a month of diagnosis (II).
- 2All those negative for hepatitis B markers should be immunised, although response to vaccine may be reduced if the CD4 count is less than 500 cells/μL (I).
- 3Following successful immunisation, anti-HBs levels should be checked yearly and booster doses of vaccine should be given to those with an anti-HBs level < 100 iu/L (IV).
- 4Persons who fail to seroconvert to HBV vaccine and are at continuing risk of HBV infection should have annual HBV markers performed (HBsAg and anti-HBc) (IV).
- 5All patients who are anti-HBc positive but HBsAg negative are at risk of reactivation. Re-check HBsAg (and HBV-DNA if the HBsAg is still not detectable) if the liver function tests (LFT; AST/ALT) become abnormal (II).
- 6All HIV-infected persons should be assessed for HBV status before ARV therapy is commenced and then reassessed periodically according to HBV risk and immune status. Decisions on appropriate antiretroviral therapy combinations can then be made (IV).
Assessment and management of HIV/HBV coinfected patients
- 7All HIV/HBV coinfected patients should have an assessment of disease status and risk of progression which includes a clinical history, examination and blood tests including LFT, clotting studies and HBV serology (including HBV-DNA level if HBeAg negative with abnormal LFTs) (IV).
- 8Liver biopsy should be considered, unless contraindicated (e.g. haemophilia), for those with HBV replication (HBeAg positive or HBV-DNA >105 copies/mL) and any of: • history or signs suggestive of cirrhosis or a history of decompensated liver disease, • HDV or HCV (PCR-positive) coinfection, • deranged LFTs of uncertain aetiology. For patients with HBV-DNA levels <105 copies/mL and normal ALT, a liver biopsy is not necessary but regular clinical monitoring should be performed (III).
- 9Consider other causes of liver disease if LFT out of proportion to the HBV-disease (IV).
- 10All persons not immune to hepatitis A should receive 2 doses of hepatitis A vaccine 6–12 months apart, although the response to vaccine may be reduced if the CD4 count is less than 500 cells/μL (III).
- 11Patients should be counselled about the dangers of alcohol consumption. Abstinence or only limited use of alcohol is recommended for those with abnormal liver function tests (III).
- 12Carriers should be counselled regarding prevention of transmission of HBV (I).
- 13Sexual and household contacts should be tested for HBV markers and receive HBV immunisation if susceptible (II).
- 14Newborns of coinfected mothers should receive HBIG and HBV vaccine at delivery, in addition to postnatal HIV prophylaxis, and complete the recommended vaccination programme (I). This requires optimal liaison between hospital and community staff.
- 15Consider HCC screening in patients with established cirrhosis by 6-monthly α-FP and USS (III).
- 16There should be close liaison between the HIV physician and a local hepatology team with links to a transplant centre to ensure optimal care (IV).
Anti-HBV therapy in HIV/HBV coinfection
- 17The optimal time for initiating anti-HBV therapy in coinfected patients has not been established but HBV-specific treatment should be considered for all patients who are HBeAg positive, or are HBeAg negative but with an abnormal LFT (ALT > 1.5× upper limit of normal) and HBV-DNA>105 copies/mL (I).
- 18Interferon or adefovir can be considered for patients not on antiretroviral therapy with a high CD4 count (I) although there is a theoretical risk that adefovir may induce tenofovir resistant-HIV.
- 19Treatments with antiretroviral activity (e.g. lamivudine and tenofovir) must only be given as part of, or in addition to, an effective antiretroviral regime (II).
- 20As both lamivudine and tenofovir are licensed for HIV therapy, and both have anti-HBV activity, there may be utility in using both drugs as part of the same antiretroviral therapy regimen in HIV/HBV coinfected patients although the best use of these agents in this situation remains to be evaluated and such patients are best entered into a clinical trial (III).
- 21If there is a need to change the antiretroviral therapy in coinfected patients on lamivudine and/or tenofovir who have shown an HBV response, these latter agents should be continued in addition to the new regimen irrespective of any resistant HIV (III).
- 22New therapies which normally should be used under clinical trial conditions include entecavir, emtricitabine, clevudine (L-FMAU), l-dT and pegylated interferon.
- 23There is no evidence supporting the use of antiviral therapy in acute HBV infection.
Audit standards
- Top of page
- Key recommendations (I–IV levels of evidence)
- Audit standards
- Background
- Assessment and investigations
- Management
- References
- 1All HIV+patients should be screened for HBV markers.
- 2All HBV nonimmune patients at continuing risk should be vaccinated.
- 3All patients with abnormal ALT/AST levels who are anti-HBc-positive should have a serum HBV-DNA level measured irrespective of the HBsAg/HBeAg status.
- 4All patients should have their HBV status measured before commencement of antiretroviral therapy.
- 5All HBV infected patients should be vaccinated against hepatitis A if nonimmune.
- 6All HBV-infected patients should have documented evidence in their case-notes of a discussion on alcohol avoidance and how to reduce the risks of transmission.
- 7Case-notes should contain clear evidence of an attempt to contact household and sexual contacts and offer vaccination to those who are nonimmune.
- 8All patients who are HBsAg-positive with abnormal LFTs should have a clear management plan written in their notes.
- Top of page
- Key recommendations (I–IV levels of evidence)
- Audit standards
- Background
- Assessment and investigations
- Management
- References
- •There are approximately 350 million hepatitis B carriers and over 40 million HIV-infected people worldwide [1,2]. As the routes of transmission for these infections are similar, there is a significant rate of coinfection in patients. Underlying HIV infection increases the chance of HBV chronicity [3]. There are no comprehensive data from the UK defining HIV/HBV coinfection rates.
- •A study in 631 HIV-positive people in London, most of whom were gay men, showed a dual HIV/HBV infection rate of 6% [4].
- •In many parts of Africa, HIV/HBV coinfection is common, as seen in Malawi (13%) or the Ivory Coast (10%) [5,6]. Recent immigrants from Africa represent the largest group of newly diagnosed HIV-positive people in the UK [7] and therefore high coinfection rates are to be expected. A recent survey of 165 consecutive HIV-positive patients of African origin showed a HBV carriage rate of 5.5% (M.G. Brook, 2002, unpublished data).
- •Very high rates of hepatitis B infection are seen in intravenous drug users and therefore HIV/HBV is common – one study in Germany found 8% of an HIV clinic cohort, over half of whom were IVDUs, were chronically infected with HBV [8].
Natural History
- •Hepatitis B virus is immunopathic (the immune response to the virus causes most of the liver damage) and therefore in HIV infection there is often a decrease in the serum aminotransferase values and a decrease in the histological inflammatory indices [9,10]. However, at very high levels of viral replication the virus may have a direct cytopathic effect. Coinfection with HIV is generally accompanied by an increase in HBV replication [9,10] and there is some evidence for an increased rate of progression to cirrhosis [10].
- •Since the introduction of combination antiretroviral therapy and the dramatic improvement in the prognosis of people with HIV, liver disease due to chronic viral hepatitis has become an important cause of morbidity and mortality in coinfected patients [11,12].
- •
- •HBV reactivation and reinfection can also occur and patients who appeared to have cleared HBV infection can present with a further episode of acute or, more commonly, be found to have abnormal liver function tests and chronic hepatitis [15,16]. The risk of reactivation is higher in patients who are positive for anti-HBc antibody but negative for other markers of HBV infection. In one long-term follow-up study of anti-HBc-antibody positive, HIV-positive patients, transient HBsAg-positivity developed in 24%, HBV-DNA became positive in 60% and about a third of these had active liver disease [17].
- •
- •Hepatitis B is preventable by vaccination. However, HIV positive patients respond less well to the vaccine, especially if the CD4 count is below 500 cells/mL, and lose protective antibodies quickly [20].
- •All newly diagnosed HIV patients should have an anti-HBc test and additionally an anti-HBs test if they have previously been immunised. If negative for both they should receive a course of vaccination and subsequent boosters up to a further three doses until they have detectable serum anti-HBs antibodies, ideally greater than 100 iu/L.
- •
- •Persons who fail to seroconvert to HBV vaccine [22] should have annual HBV markers performed (HBsAg and anti-HBc).
Delta Hepatitis (hepatitis D virus)
- •This virus can only replicate in the presence of HBV as it requires the HBV surface protein for its own structure. HDV is seen mainly in IVDUs and their sexual partners in the UK although it can be found in other HBV-positive patients.
- •It is not clear if HIV coinfection influences the course of HBV/HDV disease but there is some evidence that it leads to a more rapidly progressive form of hepatitis and fulminant liver failure [23].
Assessment and investigations
- Top of page
- Key recommendations (I–IV levels of evidence)
- Audit standards
- Background
- Assessment and investigations
- Management
- References
HBV-related liver disease is mostly confined to patients with evidence of ongoing viral replication, usually with HBeAg-positivity and high HBV-DNA levels detectable by PCR or a comparable nucleic acid amplification test.
The initial evaluation should include history and clinical examination [24].
- •History – should include enquiring about injection drug use (current and remote), past immunisation for hepatitis A/B, episodes of jaundice, travel abroad and potential risk activity there (blood transfusion, intravenous drug use, sexual), alcohol use (current and past), family history of HBV infection, liver disease or hepato- cellular carcinoma, and previous investigation for hepatitis.
- •Clinical examination for evidence of chronic liver disease (peripheral stigmata, portal hypertension, decompensation).
- •Patients should be counselled about the significance of coinfection, lifestyle modifications that may be necessary (alcohol, injection drug use), modes and prevention of transmission, and treatment options. The development of ESLD in HBV infection occurs at younger age in heavy drinkers [25].
Initial work-up for an HBsAg-positive individual should include tests for
- •liver disease – full biochemical profile including bilirubin, albumin and liver enzymes; prothrombin time and full blood count;
- •HBV replication – HBeAg, anti-HBe. HBV-DNA is useful in anti-HBe-positive patients with abnormal LFTs;
- •exclusion of other viral liver disease – anti-HCVAb and anti-HDV Ab if particular risk;
- •HAV immunity – anti-HAV IgG Ab.
Additional tests may be indicated depending on these results
- •liver biopsy – consider for those with HBV replication [HBeAg positive or HBV-DNA positive (>105 copies/mL)] and likely ESLD, HDV or HCV (PCR-positive) coinfection, or with deranged LFTs of uncertain aetiology. For patients with HBV-DNA levels <105 and normal ALT, a liver biopsy is not necessary but regular monitoring should be performed;
- •AFP and USS (USS on all HBeAg-positive patients and all anti-HBe-positive who have abnormal liver function tests) – especially for patients with suspected advanced liver disease. An OGD to exclude varices is indicated if portal hypertension is suggested on USS or cirrhosis on liver biopsy or there has been an episode of heamatemesis;
- •3TC resistance – may be useful for patients with 3TC exposure and detectable HBV-DNA but is not widely available and its utility remains to be determined;
- •HBV genotyping – the significance of genotype with regard to risk of progressive liver disease, development of HCC, and response to treatment is being explored. Currently, there is no indication to perform an HBV genotype;
- •autoimmune screen, sopper/caeruloplasmin and iron/ferritin if other features consistent with autoimmune hepatitis, Wilson's Disease or haemachromatosis (plus HFE gene test if subsequently indicated).
Follow-up tests
- •All persons should have regular full biochemical profile including bilirubin, albumin and liver enzymes; and full blood count performed a minimum of every 6 months. Repeat prothrombin time if clinical or biochemical evidence of progression.
- •Patients who have an unexpected rise in ALT should be re-screened for HBV replication (HBeAg and HBV-DNA) and other causes of hepatitis [HAV, HCV, (HDV if at risk)].
- •Consider screening patients with cirrhosis for HCC with 6-monthly ultrasounds and α–FP. Physicians and patients need to be aware, however, that even with more frequent screening the chance of detecting a treatable HCC is small [26,27].
Test interpretation
- •Abnormal LFTs indicate liver inflammation and/or dysfunction. In coinfected patients, they may result from several causes: ♦ reactivation of HBV related to worsening immune function; ♦ improved immune response directed against HBV as a result of HAART; ♦ hepatitis flare on withdrawal of 3TC as part of HAART associated with WT virus repopulation; ♦ hepatotoxicity as a result of ARV agents or other drugs. Coinfected patients have more ARV-related liver toxicity; ♦ inflammation as a result of other hepatotropic virus infections (HCV, HDV, HAV).
- •HBV-DNA is a reliable marker of active HBV replication. ♦ Detection and quantification can be achieved by signal amplification or target amplification methods. Units of measurement have now been defined. Minor variations (up to half a Log) exist between assays and as a result of the intrinsic variability of the test and can be ignored. It is advisable the same assay is used for patient monitoring. Sensitivity of assays is down to 200–400 copies/mL. Nested PCRs can increase sensitivity but there can be difficulties in accurate quantification [28,29]. ♦ The HBV-DNA cut-off level in HIV-negative HBV-infected patients that is associated with progressive liver disease is unknown although a threshold of 105 copies/mL has been generally accepted. However, most patients with inactive liver disease (HBeAg negative, anti-HBeAb positive and normal ALT) have levels of 103–104 copies/mL and a lower cut-off of 3×104 has been proposed. In coinfected patients, however, HBV-DNA levels are higher and may change with immune function [30,31].
- •Histological examination of the liver remains the most sensitive tool for assessing the severity of liver disease and thereby establishing prognosis and the need or urgency for treatment. It also excludes other aetiologies of liver disease in a patient with HBV infection. ♦ Several numerical scoring systems exist (Ishak, METAVIR, Knodell) which grade the degree of necroinflammatory activity and stage/extent of fibrosis. Concordance between the different scoring systems is good [32–35]. ♦ On the basis of histology (scored by Ishak), the liver damage can be categorised as mild when the necroinflammatory score is ≤3/18 and the fibrosis stage is ≤2/6. In these circumstances, treatment may not be indicated. Higher scores may indicate the need for treatment (see later).
- •Lamivudine resistance mutations can be identified by either direct sequencing or line probe assay although this is only a research tool at the moment [36]. ♦ HIV/HBV coinfected patients treated with 3TC accumulate resistance mutations at 20–25% per year. This is conferred by a mutation in the YMDD motif in the HBV DNA polymerase gene [37,38]. ♦ At present, laboratory testing for lamivudine resistance is unlikely to influence patient management. Any patient who has detectable (or rising after an initial fall) HBV-DNA levels can be assumed to have lamivudine resistance. The place of resistance testing is likely to become more important as newer agents are developed and therapeutic options increase.
- •There should be close liaison with the local hepatology team (gastroenterologist specialising in hepatology or hepatologist), virologist, and established contacts with the regional transplant centre. It is expected that in the developing HIV service networks, protocols detailing clear referral pathways will be developed so that all patients with HIV/HBV coinfection with have equity of access to specialist care by a team of doctors and Nurse Specialists, irrespective of their main site of HIV care.
- Top of page
- Key recommendations (I–IV levels of evidence)
- Audit standards
- Background
- Assessment and investigations
- Management
- References
Hepatitis A Vaccination
- •All persons not immune to hepatitis A should receive 2 doses of hepatitis A vaccine 6–12 months apart [39].
- •Carriers should be counselled regarding prevention of transmission of HBV in terms of safer sex, avoidance of transmission through blood, partner vaccination and neonatal vaccination as appropriate [40]. Contacts of patients with chronic HBV at risk of infection, which includes sexual partners, household contacts and people at risk from parenteral exposure should be offered testing for HBV and vaccination if nonimmune.
General principles of hepatitis B therapy
Treatment is aimed at suppressing viral replication and improving liver histology. If treatment is associated with HBeAg to anti-HBe seroconversion there may be a durable treatment effect and HBV treatment may be withdrawn. This occurs in up 10–40% of HIV-negative patients, depending on the agent used and the type of patient treated, but is lower in HIV-positive patients. Once initiated, long-term suppressive treatment will be required in most patients. The approach to treatment depends on the following factors:
- •markers of HBV replication – candidates for treatment are usually HBeAg-positive (see below);
- •the activity and stage of liver disease – patients with normal, or near normal LFTs are less likely ever to develop clinically significant liver disease, and are less likely to respond to treatment;
- •stage of HIV disease – for those with advanced HIV disease, treatment of chronic hepatitis may not be a priority, and a sustained response is very unlikely to be achievable, but viral suppression, and improvement in liver function is achievable even in late stage disease;
- •HIV treatment status – whether someone is on antiretroviral treatment affects the choice of HBV treatments available (see below).
Who to treat
- •Patients with normal or near-normal LFTs (ALT/AST < 1.5 times the upper limit of normal) and who are HBeAg-negative are unlikely to have active liver disease or viral replication and should be treated conservatively. Regular monitoring should be continued to detect reactivation of viral replication (usually accompanied by reappearance of HBeAg) or of liver disease (rise in transaminase levels).
- •Patients who are HBeAg-positive have higher levels of viral replication and are at greater risk of progressive liver disease and are more infectious. They are the principal candidates for treatment. Higher LFTs or more active inflammation on liver biopsy increase the probability of a treatment response.
- •Treatment should be considered for HBeAg-negative patients with abnormal LFTs and in whom other possible causes of the abnormal LFTs have been excluded. These patients are likely to be infected with a precore mutant virus that prevents the translation of HBeAg but is still replication competent. Plasma viral load provides a measure of viral replication; levels are lower than in HBeAg-positive patients. In some patients it may be appropriate to treat in order to reduce infectivity.
When to start treatment
- •The treatment options for chronic HBV infection are limited, but improving. HBV treatments can be categorised according to whether or not they have anti-HIV activity as well. If they have anti-HIV activity they must be used in conjunction with an effective antiretroviral regimen in order to prevent the emergence of HIV drug resistance. Drugs with HBV activity may either form part of an antiretroviral regimen, or be in addition. When patients have to change anti-HIV treatments, because of intolerance or lack of efficacy, the anti-HBV component should be continued, even if it is not part of the subsequent anti-HIV regimen.
- •The optimal time to initiate anti-HBV treatment in HIV coinfected patients is not known. Response rates may be higher with treatment given earlier, when the CD4 count is well preserved, but the options are limited and long-term antiviral treatment is likely to be needed. There is insufficient evidence to conclude that anti-HBV therapy should always be included when antiretroviral therapy is initiated. If it is not, then HBV treatment should be delayed until HIV replication is controlled and the maximum CD4 count response obtained, or until there is evidence of liver disease progression.
Current treatment options
- •Interferon-α (IFN-α) can be used in patients with coinfection, whether or not they are on antiretroviral therapy; it has some anti-HIV effect but this is not clinically significant. ♦ Side effects (most commonly 'flu-like symptoms, malaise, weight loss) are common, and the response rate for HBeAg to anti-HBe seroconversion is low. Interferon may lower CD4 counts. Few physicians therefore use IFN-α in this setting. ♦ In HIV-negative patients the HBeAg to anti-HBe seroconversion rate is 5–10%, but up to 40% in those with raised transaminase levels and low HBV-DNA levels. The data in HIV-positive patients is limited, with conflicting evidence suggesting either a lower response rate [41,42], or a similar response compared to HIV-negative patients [43]. ♦ Treatment is not recommended in patients with cirrhosis or a history of decompensated liver disease because of the risk of further decompensation (excluding advanced liver disease is the strongest indication for liver biopsy in this setting).
- •Lamivudine is licensed for the treatment of chronic hepatitis B in patients who are HBeAg-positive with evidence of active liver disease. The effective dose for hepatitis B treatment is 100 mg daily, a dose at which it also has anti-HIV activity and should not be used except in combination with effective combination antiretroviral therapy. ♦ In both HIV-negative and coinfected patients, lamivudine treatment is associated with viral suppression and improvement in liver function tests [44–46], however, mutations in the polymerase YMDD motif, analogous to that in HIV, results in antiviral resistance in up 69% after 5 years' treatment [47]. This develops more rapidly in coinfected patients with up to half of all patients showing resistance after 2 years [45,48,49]. With relapse of viral replication, liver disease activity increases [49,50]. ♦ Withdrawal of lamivudine may result in an acute exacerbation of hepatitis that may be sufficient to precipitate liver decompensation [50,51]. Use of lamivudine in coinfected patients may therefore more appropriately be reserved for those patients with evidence of progressive liver disease. ♦ The value of treating anti-HBe-positive carriers with normal liver function and low or undetectable viral load pre-emptively, to prevent reactivation, has not been established. ♦ In HIV-negative patients who are anti-HBe/HBV-DNA-positive, lamivudine suppresses viral replication and improves LFTs, but this effect is not durable [52].
- •Adefovir, a nucleotide analogue, has recently been licensed in the US and Europe. At a dose of 10 mg once daily, adefovir has been shown to suppress HBV replication and improve histology both in chronic HBV carriers who are HBeAg-positive, and anti-HBe-positive [53,54]. ♦ Adefovir has no significant antiretroviral effect at this dose (although it does at higher dose) and therefore could be given to HIV coinfected patients not on antiretroviral therapy [55]. However, there remains a theoretical danger of inducing HIV resistance which needs further research. ♦ Adefovir could also be used in HIV coinfected patients receiving antiretroviral therapy if tenofovir is not being used (there is no rationale for combining them). There are very limited clinical trial data in HIV coinfected patients [56], although they were included in the first clinical trial in HBV carriers [57] in whom viral suppression was similar in both HIV-positive and HIV-negative patients. ♦ Adefovir is active against lamivudine-resistant strains of HBV [58,59]. In HIV-negative patients it has been shown that treatment can be switched from lamivudine to adefovir in lamivudine-resistant cases; there is no benefit in continuing the lamivudine as well [60]. ♦ Whether there is any advantage of combining adefovir with lamivudine is unknown for either HIV-coinfected or HIV-negative patients.
- •Tenofovir is a nucleotide analogue similar to adefovir. Although there are no randomised trials in chronic hepatitis B, there is evidence that it suppresses HBV replication [61]. ♦ Recent open-label studies of 6 and 20 tenofovir-treated coinfected patients, most of whom were lamivudine-experienced, showed a reduction in HBV-DNA viral load (of 4 log10), fall in ALT levels and loss of HBeAg (25%) [62,63]. ♦ However, there is still insufficient evidence to confirm its long-term utility in coinfected patients. As with lamivudine, tenofovir should be continued if the patient has shown an HBV response (reduction in AST/ALT and HBV-DNA levels) even if there is a need to change the other components of antiretroviral regimen. ♦ Lamivudine/tenofovir can be used in combination for coinfected patients as part of, or in addition to an effective antiretroviral regimen but there is insufficient evidence to say whether this confers any advantage. Patients should be encouraged to join clinical trials.
Other treatment options
- •Other nucleoside reverse transcriptase inhibitors are currently in clinical trials including entecavir, emtricitabine, clevudine (L-FMAU) and l-dT, which is the beta-L configuration of the natural nucleoside, thymidine [64].
- •
- •A trial of pegylated interferon will investigate whether it is associated with an improved response rate compared with conventional interferon, as has been demonstrated in chronic hepatitis C. How this agent may be used in HIV coinfection remains to be determined although it seems likely that it will replace conventional interferon.
- •Famciclovir has anti-HBV activity but only at high doses and is not recommended treatment outside clinical trials. Adding famciclovir in patients with lamivudine resistant infection is of no value [69].
- •Other experimental therapies have included ribavirin and thymosin alpha but there is no place for these therapies outside of clinical trials.
Acute hepatitis B
Even in HIV-positive patients, most cases of acute hepatitis B resolve spontaneously and without complications. No specific therapy has been shown to improve the outcome or reduce the risk of developing chronic infection. Treatment is supportive. Antiretroviral treatment may have to be interrupted if there is marked LFT elevation.
- Top of page
- Key recommendations (I–IV levels of evidence)
- Audit standards
- Background
- Assessment and investigations
- Management
- References
- 1WHO. Hepatitis B. Fact Sheet. WHO/. http://www.who.International/inf-fs/en/fact204.html.
- 2UNAIDS Report of the global HIV/AIDS epidemic 2002. http://www.unaids.org.
- 3Co-infection and superinfection of hepatitis B virus in patients infected with immunodeficiency virus: no evidence for faster progression to AIDS. Scand J Infect Dis 1997, 204 October 2000; 29: 111–115., , et al.
- 4Case-control study of sexually transmitted diseases as cofactors for HIV-1 transmission. Int J STD AIDS 1996; 7: 34–38., ,
- 5Seroprevalence of hepatitis B and C and HIV in Malawian pregnant women. J Infect 1998; 37: 248–251., , et al.
- 6Hepatitis B and C infections, human immunodeficiency virus and other sexually transmitted infections among women of childbearing age in Cote D'Ivoire, West Africa. Trans Roy Soc Trop Med Hyg 2001; 95: 493–496., , et al.
- 7PHLS AIDS Centre and Scottish Centre for Infection. AIDS/HIV Quarterly Surveillance Tables, No. 55: 02/2 Jul 2002. http://www.phls.co.uk.
- 8Chronic hepatitis B and C in HIV infected patients. Dtsche Med Wochenschr 1998; 123: 753–760., , et al.
- 9Interactions between HIV and hepatitis B virus in homosexual men: effects on the natural history of infection. AIDS 1997; 11: 597–606., , et al.
- 10Influence of human immunodeficiency virus infection on chronic hepatitis B in homosexual men. Hepatol 1999; 29: 1306–1310., , et al.
- 11Mortality for liver disease in patients with HIV infection: a cohort study. J AIDS 2000; 24: 211–217., , et al.
- 12Increased impact of chronic viral hepatitis on hospital admissions and mortality among HIV-infected patients. AIDS Res Hum Retrovirol 2001; 17: 1467–1471., , et al.
- 13Hepatotoxicity development during antiretroviral therapy containing protease inhibitors in patients with HIV. The role of hepatitis B and C. J AIDS 2002; 29: 41–48., , et al.
- 14Hepatotoxicity associated with nevirapine or efavirenz-containing antiretroviral therapy: role of hepatitis C and B infections. Hepatology 2002; 35: 182–189., , et al.
- 15Reactivation of hepatitis B in a long-term anti-HBs-positive patient with AIDS following lamivudine withdrawal. J Hepatol 1998; 29: 306–309., , et al.
- 16Reactivation of hepatitis B virus replication accompanied by acute hepatitis in patients receiving highly active antiretroviral therapy. Clin Infect Dis 2001; 32: 144–148., , et al.
- 17Frequent chronic hepatitis B virus infection in HIV-infected patients positive for antibody to hepatitis B core antigen only. Swiss cohort study. Eur J Clin Microbiol Infect Dis 1998; 17: 6–13., , et al.
- 18The interaction of human immunodeficiency virus infection and hepatitis B virus infection in homosexual men. J Clin Gastroenterol 1996; 22: 299–304., , et al.
- 19Hepatitis B seroconversion in HIV-HBV coinfected patients treated with highly active antiretroviral therapy. J AIDS Hum Retrovirol 2000; 23: 356–357., , et al.
- 20Increasing the number of hepatitis B injections augments anti-HBs response rate in HIV-infected patients. Effect on viral load. Vaccine 2000; 18: 1161–1165., , et al.
- 21European consensus group on hepatitis B. immunity. Are booster immunisations needed for lifelong hepatitis B immunity? Lancet 2000; 355: 561–565.
- 22
- 23Fatal liver failure in haemophiliacs with HIV-induced immunodeficiency: observation of six patients. Haemophilia 1999, 2002; 5: 109–114., , et al.
- 24Practice Guidelines Committee, American Association for the Study of Liver Diseases. Chronic hepatitis B. Hepatology 2001; 34: 1225–1239.,
- 25Interaction between hepatitis B virus and alcoholic consumption in liver cirrhosis: an epidemiological study. Gastroenterology 1983; 85: 141–145., , et al.
- 26Screening for hepatocellular carcinoma in Alaska Natives infected with chronic hepatitis B: a 16-year population-based study. Hepatology 2000; 32: 842–846., , et al.
- 27Screening for hepatocellular carcinoma in chronic carriers of hepatitis virus B: incidence and prevalence of hepatocellular carcinoma in a North American urban population. Hepatology 1995; 22: 432–714., ,
- 28Clinical utility in quantifying serum HBV DNA levels using PCR assays. J Hepatol 2002; 36: 549–551.,
- 29Global control of hepatitis B virus infection. Lancet Infect Dis 2002; 2: 395–403.,
- 30Management of Hepatitis B: 2000 – Summary of Workshop. Gastroenterology 2001 2000; 120: 1828–1853., ,
- 31Serum HBV DNA levels in inactive hepatitis B carriers. Gastroenterology 2002; 122: 2092–2093., ,
- 32Formulation and application of numerical scoring system for assessing histological activity in asymptomatic chronic hepatitis. Hepatology 1981; 1: 431–435., , et al.
- 33Histological grading and staging of hepatitis. J Hepatol 1995; 22: 696–699., , et al.
- 34The French Metavir Cooperative Study Group. Intraobserver and interobserver variations in liver biopsy interpretation in patients with chronic hepatitis C. Hepatology 1994; 20: 15–20.Direct Link:
- 35Histopathological study of chronic hepatitis B and C: a comparison of two scoring systems. J Hepatol 2003; 38: 223–229.et al.
- 36Monitoring drug resistance in chronic hepatitis B virus (HBV) – infected patients during lamivudine therapy: evaluation of performance of INNO-LiPA HBV DR assay. J Clin Microbiol 2002; 40: 3729–3734., , et al.
- 37
- 38Long-term incidence of hepatitis B virus resistance to lamivudine in human immunodeficiency virus-related patients. Hepatology 1999; 30: 1302–1306., , et al.
- 39Centers for Disease Control and Prevention. Prevention of hepatitis A though active or passive immunisation: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996; 45: 1–30.
- 40CDC. Hepatitis B virus: a comprehensive strategy for limiting transmission in the United States through universal childhood vaccination. Recommendations Immunization Practices Advisory Committee (ACIP). MMWR 1991; 40: 1–25.
- 41Interferon alfa treatment of chronic hepatitis B: randomized trial in a predominantly homosexual male population. Gastroenterology 1995; 108: 165–171., , et al.
- 42The treatment effect of alpha interferon in chronic hepatitis B is independent of pre-treatment variables. Results based on individual patient data from 10 clinical controlled trials. European Concerted Action on Viral Hepatitis (Eurohep). J Hepatol 1994; 21: 646–655., , et al.
- 43Alpha-interferon for chronic active hepatitis B in human immunodeficiency virus-infected patients. Gastroenterol Clin Biol 1996; 20: 968–971., , et al.
- 44Dual efficacy of lamivudine treatment in human immunodeficiency virus/hepatitis B virus-coinfected persons in a randomized, controlled study (CAESAR). The CAESAR Coordinating Committee. J Infect Dis 1999; 180: 607–613., , et al.
- 45Long-term incidence of hepatitis B virus resistance to lamivudine in human immunodeficiency virus-infected patients. Hepatology 1999; 30: 1302–1306., , et al.
- 46Evaluation of chronic hepatitis B virus (HBV) infection in coinfected patients receiving lamivudine as a component of anti-human immunodeficiency virus regimens. Clin Infect Dis 2001; 32: 963–969., , et al.
- 47Treatment of chronic hepatitis B. case selection and duration of therapy. J Gastroenterol Hepatol 2002; 17: 409–414.
- 48Evolution of lamivudine resistant-hepatitis B virus and HIV-1 in co-infected individuals: an analysis of the CAESAR study. CAESAR co-ordinating committee. AIDS 2000; 14: 1111–1116., , et al.
- 49Development of hepatitis B virus resistance for lamivudine in chronic hepatitis B patients co-infected with the human immunodeficiency virus in a Dutch cohort. J Clin Virol 2002; 24: 173–181., , et al.
- 50Chronic active hepatitis B exacerbations in human immunodeficiency virus-infected patients following development of resistance to or withdrawal of lamivudine. Clin Infect Dis 1999; 28: 1032–1035., , et al.
- 51Fulminant hepatitis B due to a lamivudine-resistant mutant of HBV in a patient coinfected with HIV. Gastroenterology 2002; 122: 244–245., , et al.
- 52Long-term follow-up of patients with anti-HBe/HBV DNA-positive chronic hepatitis B treated for 12 months with lamivudine. J Hepatol 2000; 32: 300–306., , et al.
- 53GS-98–437: a double-blind, randomized, placebo-controlled study of adefovir dipivoxil (ADV) for the treatment of patients with HBeAg+ chronic hepatitis B infection: 48 week results. Hepatology 2001; 34: 340A., , et al.
- 54GS-98–438: a double-blind, randomized, placebo-controlled study of adefovir dipivoxil (ADV) for presumed precore mutant chronic hepatitis B. 48 week results. 37th Annual Meeting of the European Association for the Study of the Liver (EASL). Madrid, Spain, 17–21 April, 2002: Abstract, 648., , et al.
- 55Human immunodeficiency virus (HIV) Type 1 reverse transcriptase resistance mutations in hepatitis B virus (HBV)-HIV-coinfected patients treated for HBV chronic infection once daily with 10 milligrams of adefovir dipivoxil combined with lamivudine. Antimicrob Agents Chemother 2002; 46: 1586–1588., , et al.
- 56Safety and efficacy of adefovir dipivoxil in patients co-infected with HIV-1 and lamivudine-resistant hepatitis B virus: an open-label pilot study. Lancet 2001; 358: 718–723., , et al.
- 57A placebo-controlled phase I/II study of adefovir dipivoxil in patients with chronic hepatitis B virus infection. J Viral Hep 1999; 6: 387–395., , et al.Direct Link:
- 58Mutations in hepatitis B DNA polymerase associated with resistance to lamivudine do not confer resistance to adefovir in vitro. Hepatology 1998; 28: 1669–1673., , et al.
- 59Adefovir dipivoxil for the treatment of lamivudine-resistant hepatitis B mutants. Hepatology 2000; 32: 129–134., , et al.
- 60
- 61
- 62Tenofavir Disoproxil Fumarate therapy for chronic hepatitis B in Human Immunodeficiency Virus/Heptitis B Virus-coninfected individuals for whom interferon-α and lamivudine therapy have failed. J Infect Dis 2002; 186: 1844–1847., , et al.
- 63An open-label study of tenofavir in HIV-1 and Heptitis B virus co-infected individuals. AIDS 2003; 17: F7–F10., , et al.
- 64
- 65Safety and efficacy of oral entecavir given for 28 days in patients with chronic hepatitis B virus infection. Hepatology 2001; 43: 578–582., , et al.
- 66Dose range study of pharmacokinetics, safety, and preliminary antiviral activity of emtricitabine in adults with hepatitis B virus infection. Antimicrob Agents Chemother 2002; 46: 1734–1740., , et al.
- 67Molecular modeling and biochemical characterization reveal the mechanism of hepatitis B virus polymerase resistance to lamivudine (3TC) and emtricitabine (FTC). J Virol 2001; 75: 4771–4779., , et al.
- 68The polymerase L528M mutation cooperates with nucleotide binding-site mutations, increasing hepatitis B virus replication and drug resistance. J Clin Invest 2001; 107: 449–455., , et al.
- 69Failure of combination therapy with lamivudine and famciclovir following lamivudine monotherapy for hepatitis B virus infection in patients coinfected with human immunodeficiency virus-1. Clin Infect Dis 2001; 33: 2049–2054., , et al.


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Jessica is a former editorial fellow at Mother Jones and currently an education reporter at the Newark Star-Ledger. She has covered education for U.S. News & World Report where she wrote about everything from the hazards of heroin addiction to the existence of gay-friendly public high schools. Her work has also been published by the Record Journal, USA Today, and UPI. A Jersey girl at heart, though not in accent, Jessica knows her Turnpike exit number by heart.Get my RSS
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Sandor Nagyszalanczy
How to Upholster a Tufted Seat
Learn how to upholster a tufted bench seat. You'll learn how to make the matching buttons, how to attach the cover material and how to secure the buttons to create the tufting.
Upholstered Ottoman Chest
A multipurpose furniture piece that can serve as a leg rest, a storage chest, a coffee table and even a padded bench.
Best Apps and Calculators for Woodworkers
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What kind of screws should you use on your project? From heads to drives, points to threads, platings to coatings, we show you everything you need to know about the world of modern screws.
Building an Animated Carousel
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Moveable storage that keeps your tools organized and readily at hand.
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Sandor Nagyszalanczy demonstrates how he used Rockler's tandem door hinges to mount the doors to his Portable Tool Storage Cabinet.
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This hand-cranked music making machine taps out a short tune on a xylophone.
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Learn how to make the wood drum that holds the pins that operate the mallets that play the tune inside our wooden music box project.
Making the Toy Carousel Segmented Roof
Sandor Nagyszalanczy describes the step-by-step process he used to create the segmented roof for his unique and fun Carousel Toy project.


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Garlic Quinoa
Total Time
Prep 2 mins
Cook 18 mins
Quinoa is a very high protein grain which originated in the Andes mountains of Bolivia and Peru as a staple food of the Incas. It's gluten-free and rich in L-lysine, phosphorus, calcium, iron, B vitamins, and vitamin E. A yet untried recipe submitted for Zaar World Tour II.
Ingredients Nutrition
- 14.79 ml olive oil
- 118.29 ml chopped onion
- 9.85 ml minced garlic
- 236.59 ml quinoa, rinsed well and drained
- 473.18 ml water or 473.18 ml broth
- 1.23 ml salt
- Sauté onion in olive oil for 2-3 minutes; add garlic and continue sautéing for another 30 seconds or so.
- Add quinoa, water and salt to pan; bring to boil then reduce heat then cover and simmer 15 minutes until liquid is absorbed.
Most Helpful
This was really good! I used vegetable broth instead of water, and I had to cook mine for 20 minutes to absorb all of the liquid. It was tasty and I'll make it again...thank you!
Like another reviewer, I added extra garlic (love the stuff), chicken stock and salt/pepper. Love it!
Used chicken stock and extra garlic..Perfect.


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•January 1, 1970
Celebrity, television, film and music photos
Celebrity, television, film and music photos
Javier: The Khans have picked a fight with Donald Trump...I don't recall Mr. Trump ever saying ANYTHING AT ALL ABOUT THESE TWO PEOPLE..He didn't even know them. THIS ARTICLE IS COMPLETE BULL***T...The headline is COMPLETELY MISLEADING AND FALSE. You mean these two people are the only ones who've lost their sons in war??? Uh excuse me, what about the THOUSANDS OF other American fathers and mothers, do you hear them complaining like these two? I think they should be quiet. Would they be better off in their country of origin??? Probably not...They've been given a lot...They should say thanks and be quiet.


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|"Thomas Mueller (JIRA)" <j...@apache.org>
|[jira] Commented: (JCR-1233) Create org.apache.jackrabbit.core.id
|Fri, 07 Mar 2008 13:03:46 GMT
[ https://issues.apache.org/jira/browse/JCR-1233?page=com.atlassian.jira.plugin.system.issuetabpanels:comment-tabpanel&focusedCommentId=12576172#action_12576172 ] Thomas Mueller commented on JCR-1233: ------------------------------------- Why does it break persistence managers implementations? > Create org.apache.jackrabbit.core.id > ------------------------------------ > > Key: JCR-1233 > URL: https://issues.apache.org/jira/browse/JCR-1233 > Project: Jackrabbit > Issue Type: Improvement > Components: jackrabbit-core > Reporter: Jukka Zitting > Priority: Minor > > I'd like to create a separate package for the identifier interfaces and classes in jackrabbit-core. Currently all the identifiers are in org.apache.jackrabbit.core, which makes almost all the other packages have dependencies to o.a.j.core and causes trouble for various package-level code quality and dependency analysis tools. > For now the package would contain the ItemId, NodeId, and PropertyId classes. -- This message is automatically generated by JIRA. - You can reply to this email to add a comment to the issue online.
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Amazing food! breaks my heart when people tell me they hated it. Best food I have ever had! You should go there if you want quality pizza!
Crust is so thin and choice of Pizza is so large that you cannot enjoy this tiny Pizza in La Cotiniere. A good address
both starters where great nice fresh oysters but the main courses were a huge let down my fish kebab was mostly salmon while sitting oppsite a port that has all types of fish landed daily but not I think salmon the sauce was horrible my partners chicken was realy stingy ice creams were very good as was service sadly screaming...
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text: Hottest Yoga Pants Ever (This Week) By GuySpeed Editors June 19, 2014 9:54 AM | GuySpeed Share on Facebook Share on Twitter NEXT: CLICK HERE TO SEE A DEFINITIVE COLLECTION OF KATY PERRY GIFS Source: Hottest Yoga Pants Ever (This Week) Category: Hot Stuff | Lists Share on Facebook Share on Twitter More Send to a friend! Print this page Pin it! Reddit This! Share on Tumblr! Best of WBLM Tommy's Coffee Break Calendar for July 29th Angels Walk-Off Sox On Hanley Error [VIDEO] Classic Lunch: "What's Your Name", Volume 14… MAINE STORIES: College Student Helps Reel in Giant Bluefin Tuna Off Maine Coast Recommended for You ZergNet Best of the Web ZergNet


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Cancer Health Center
Radiation-Free Cancer Scans: Coming Soon?
"If treatment decisions had been made based on either of these scans, the decision would have been the same," Daldrup-Link said.
The costs for the two kinds of scans are similar, she said.
What about side effects? MRIs use radio waves instead of radiation to peer inside the body, Daldrup-Link said. There are no side effects to MRI scans, she said, although some patients might be allergic to the contrast agent.
More research and perhaps more attempts to discover how the treatment works in older adults are now needed. Physicians are beginning a study of the scanning technique in at least six major children's hospitals throughout the country, Daldrup-Link said.
The study is set for publication in the Feb. 19 issue of the journal The Lancet Oncology.
In the big picture, several questions need to be answered before the approach is ready for prime time, Slovis said. The goal -- the "holy grail" -- is to be able to find a way to scan children for cancer without using radiation or sedation. For now, though, "there's not enough information to say we have it," he said.
Dr. Marta Hernanz-Schulman agreed. She is a professor of radiology and pediatrics at Vanderbilt University Medical Center and medical director of diagnostic imaging at Vanderbilt Children's Hospital in Nashville, Tenn.
"It's a great step forward in the quest for the ideal test, but it needs to be evaluated," she said. And she cautioned that the side effects -- allergic reactions to the contrast agent -- could be quite serious.
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Prices, specials, features and availability subject to change.
Contact for details
Contact for details
The Apartments at Wellington Trace offers you the best of everything, including lovely mountain views of historic Frederick, MD! These one-, two-, and three-bedroom apartments for rent feature fully equipped kitchens with a separate dining room, in-home washer/dryer, walk-in-closets, and a balcony or patio. Select apartments come with a cozy fireplace and all buildings have new thermal-pane windows. But that's not all! You'll also enjoy a modern clubhouse with free Wi-Fi, 24-hour fitness center, business center, on-site parking with car care area, swimming pool, and playground. Pets are welcome, too. * Our controlled building access at The Apartments at Wellington Trace will help you and your family feel comfortable in your home. And when you venture out, you'll enjoy convenient access to I-270 and I-70, as well as U.S. Route 15, U.S. Route 340, and Route 85. Getting to DC, Baltimore, Bechtel, and Ft. Detrick, plus countless shopping and dining options, will be easier than ever!
Our lease terms are: 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months (Please note that lease terms may vary, are subject to change without notice, and are based on availability. Inquire with property staff for complete details).
Pet Policy: Cats and dogs are welcome. Maximum two pets per apartment. No weight limit. Monthly fees: $30 first pet, $20 second pet. Refundable deposit: $300 (first pet only). Breed restrictions and other limitations apply.
Dogs Allowed. Cats Allowed. Pets Accepted. Call for service animal policy.
240 units
Contact Propertyor call
Great living area
February 12, 2016
Living here has been very pleasurable. I have had many compliments from friends about the apartment layout, t Read Morehe appearance of the neighborhood and the security system. The staff has always been professional and courteous. It's a wonderful place to live.
November 20, 2015
Thank you for your nice review. I'll be sure to pass this onto the staff since I'm they will be delighted to hear this. If we can help you in the future, please let us know. Sincerely, Bill Hume, Property Manager
The property is nice the only compliant is there are never events scheduled to get to know your neighbors. W Read Morehen I go to the web site to check activities for the month for the last two years it says happy new year, happy memorial day, happy 4th, happy labor day, and so on. For resident appreciation month remember to drop a card in a box for a gift card that was it for the month. I really felt appreciated! Lack of interactions with residents.
October 15, 2015
Dear Certified Resident, Thank you for the 5 star review. I'm sorry you weren't happy with our resident appreciation events. Please feel free to offer suggestions. I'd love to hear them. I can be contacted at 301-644-8000. Sincerely, Bill Hume, Property Manager
Overall I'm pleased with the location and staff, very disappointed with the apartment (old) and especially the Read More smell and maintanance of the building (inside), it smells bad
February 17, 2015
Great floor plan and office personnel, maintanence staff. Nice living experience.
October 30, 2014
Monday-Friday: 9:00am-6:00pm
Saturday: 10:00am-5:00pm
Sunday: 12:00pm-5:00pm
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text:
Sorry, this item sold. You may also like:
Cute wall peg shelf with two hearts and three pegs. I painted this a ballet slipper pink,perfect for a little girl's room. Measures 18" long x 3 1/2" wide and 3 1/4" deep (how far it sticks out from wall). Please convo me with questions prior to checkout. I ship in clean recycled shipping materials. Thank you! This item's been treasured! http://www.etsy.com/treasury/listing/79410098
TREASURY ITEM-Heart Peg Shelf-Pink -Girls Room-Princess Room-Shabby Chic.
- Handmade item
- Only ships within United States.
- Feedback: 340 reviews
- Favorited by: 36 people
- Listed on Apr 19, 2012
- 213 views
- 36 favorites
- 7 treasury lists
- Add item to treasury


text:
Tequila Slammer
Mixing instructions:
When the two ingredients are in the shot glass, take a folded paper towel and put over the top. Slam the shot glass on the table, bar, etc. Make sure the drink fizzes. Turn up and drink while its still fizzing.
Creator/contributor's comments:
The 7-Up should not be cold.
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