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Chalkboard Blackboard Sliding Wardrobe Door (H)2220 mm (W)610 mm
Chalkboard Blackboard Sliding Wardrobe Door (H)2220 mm (W)610 mm
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A classic mirrored sliding door kit which includes 2 mirrored doors and track. Comes with - Track set Track: These doors will only fit the trackset included in the kit.
Create your own sliding wardrobe system, tailor made to your size and style to fit with your space and lifestyle. The double sided range is the perfect choice for creating an walk-in wardrobe or for using as a contemporary room divider. Panel Options: Wood effect Frame: Aluminium Height: 1200-2480 mm ...
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Create your own sliding wardrobe system, tailor made to your size and style to fit with your space and lifestyle. Shaker doors are the perfect way to add traditional style to your furniture. Panel Options: Wood effect Frame: Windsor oak effect, Aida walnut effect, or maple effect Height: 1200-2480 mm ...


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International Tuition Undergraduate
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Dropping courses from your school schedule may have a financial impact on the student fees account. Information on tuition refunds can be found on the OCAD U website, Refunding on Withdrawal.
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25 bikablo® WorkshopCards Heart, Pin-ItFrom: Neuland
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25 bikablo® WorkshopCards, Pin-It in a form of a heart made from recycled paper.
Product information "25 bikablo® WorkshopCards Heart, Pin-It"
Discontinued product - only available until stock lasts!
It has never been easier to use the expressive power of visualization in your own training courses. Our bikablo® WorkshopCards are the next generation of pre-cut forms and text containers for pinboards and a multitude of other uses in training courses, workshops, meetings and conferences.
Set includes 25 cards in a form of a heart.
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Material: made from white recycled paper with a heavy weight of 170 g/m².
Printed with a black border and slight grew shadowing to make colouring easier.
Dimensions: W 9,9 x H 9,4 cm / W 3.9 x H 3.7 inches
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no matter what i do i cant unlock all the cars on midnight run and i mean the cars u wanna drive not the cop car and the meter maid ,im talkin like the hoover craft and the really suped up street cars (Edited by Shawn at 12:00 am on May 12, 2001)
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Parenteral glutamine supplementation in critical illness: a systematic review
DOI: 10.1186/cc13836
© Wischmeyer et al.; licensee BioMed Central Ltd. 2014
Received: 21 October 2013
Accepted: 14 March 2014
Published: 18 April 2014
The potential benefit of parenteral glutamine (GLN) supplementation has been one of the most commonly studied nutritional interventions in the critical care setting. The aim of this systematic review was to incorporate recent trials of traditional parenteral GLN supplementation in critical illness with previously existing data.
All randomized controlled trials of parenterally administered GLN in critically ill patients conducted from 1997 to 2013 were identified. Studies of enteral GLN only or combined enteral/parenteral GLN were excluded. Methodological quality of studies was scored and data was abstracted by independent reviewers.
A total of 26 studies involving 2,484 patients examining only parenteral GLN supplementation of nutrition support were identified in ICU patients. Parenteral GLN supplementation was associated with a trend towards a reduction of overall mortality (relative risk (RR) 0.88, 95% confidence interval (CI) 0.75, 1.03, P = 0.10) and a significant reduction in hospital mortality (RR 0.68, 95% CI 0.51, 0.90, P = 0.008). In addition, parenteral GLN was associated with a strong trend towards a reduction in infectious complications (RR 0.86, 95% CI 0.73, 1.02, P = 0.09) and ICU length of stay (LOS) (WMD –1.91, (95% CI -4.10, 0.28, P = 0.09) and significant reduction in hospital LOS (WMD -2.56, 95% CI -4.71, -0.42, P = 0.02). In the subset of studies examining patients receiving parenteral nutrition (PN), parenteral GLN supplementation was associated with a trend towards reduced overall mortality (RR 0.84, 95% CI 0.71, 1.01, P = 0.07).
Parenteral GLN supplementation given in conjunction with nutrition support continues to be associated with a significant reduction in hospital mortality and hospital LOS. Parenteral GLN supplementation as a component of nutrition support should continue to be considered to improve outcomes in critically ill patients.
Glutamine (GLN) is the most abundant nonessential free amino acid [1] and has traditionally been classified as a nonessential amino acid able to be synthesized de novo in states of health. Glutamine is now commonly described as a conditionally essential amino acid, particularly in catabolic and stress states [2]. In catabolic states, large amounts of GLN are released from muscle tissue [3] as part of the body's conserved evolutionary response to stress. Previous explanations for the release of GLN in periods of stress include use as a fuel source for rapidly dividing cells, a precursor for synthesis of nucleic acids, and a role in renal acid buffering [4, 5]. Recent data has revealed that following illness and injury, GLN plays a vital role in inducing cellular protection pathways, modulation of the inflammatory response, and prevention of organ injury [1]. Contrary to long-held beliefs, not all critically ill patients become markedly deficient in the first few days of ICU admission, although some will present with severe depletion, such as is consistently seen in burn patients [6–8]. Recent data has shown GLN becomes depleted in approximately 25 to 35% of ICU patients at admission to ICU [6–8]. Patients with more prolonged critical illness, and in some studies, those receiving parenteral nutrition (PN) have shown show a greater level of depletion as described in a number of trials of PN-requiring ICU patients [9, 10]. When GLN depletion is present at admission to ICU, it has been associated with increased mortality [7, 8]. Clinical trials from the past 20 years demonstrated that GLN appears to reduce mortality, infectious complications, and ICU/hospital length of stay (LOS) [1]. Most of these previous trials were conducted in a select group of patients with the following characteristics: 1) predominantly receiving complete nutrition support via PN, 2) common exclusion of renal and liver failure based on glutamine product prescribing restrictions, 3) GLN supplementation of PN is often initiated later in the ICU stay (not at ICU admission during the shock phase), as PN is typically started later in the stay when enteral nutrition (EN) is not possible or meeting nutritional needs, 4) enrollment of oncology patients who may be at a greater risk for tumor-mediated GLN depletion, 5) use of GLN dose between 0.3 g/kg/day to a maximum of 0.5 g.kg/day given only via the intravenous route. This is summarized below:
- 1.
Enrolled patients requiring parenteral nutrition in most trials (85% of published trials)
- 2.
Glutamine given as a supplement to nutrition support - not as a separate pharmaconutrient independent of nutrition support
- 3.
GLN supplementation given with the start of PN later in the ICU stay, often when EN was not possible or failing to meet nutritional needs. (Not typically at ICU admission)
- 4.
Common exclusion of renal and liver failure based on glutamine product prescribing restrictions (See Table 1 for specific trial exclusion criteria)
- 5.
Lower GLN doses (0.3 to 0.5 g/kg/day)
- 6.
Combined enteral and parenteral GLN not given
Randomized studies evaluating glutamine (PN) in critically ill patients
Exclusions for renal/liver failure
Methods (score)
Intervention dose of glutamine gm/kg/day
Mortality # (%)†
Infections # (%)‡
Length of stay (days)
Single-center, mixed ICU, patients, N = 84
Not defined
C.Random: yes, ITT: yes, Blinding: yes (11)
PN, 0.26 IV glutamine + PN vs. PN, isocaloric, isonitrogenous
Hospital 18/42(43)
Hospital 25/42(60)
28/42 (67)
26/42 (62)
2) Powell-Tuck 1999 [36]
Single-center, mixed ICU/hospital, patients N = 168
Renal: creatinine >200 μmol/l Liver: if failure resulted in a PTR >1.8 or hepatic encephalopathy
C.Random: yes ITT: yes Blinding: yes (8)
PN, 0.26 IV glutamine + PN vs. PN, isocaloric, isonitrogenous.
Hospital 14/83(17)
Hospital 20/85(24)
Hospital 43.4 ± 34.1 (83)
Hospital 48.9 ± 38.4 (85)
3) Wischmeyer 2001 [40]
Single-center, critically ill burns N = 31
Renal: severe failure, Liver: severe failure
Random: not sure ITT: no Blinding yes (8)
PN, 0.57 IV glutamine + EN or EN + PN vs. AAcids + PN or EN or EN + PN, isocaloric, Isonitrogenous
Hospital 1/12 (8)
Hospital 4/14 (29)
7/12 (58)
9/14 (64)
Hospital 40 ± 10 (12)
Hospital 40 ± 9 (14)
4) Fuentes-Orozco 2004 [25]
Single-center, secondary peritonitis requiring TPN N = 33
Renal: creatinine >180 μmol/l. Liver: bilirubin >40 μmol/l, alanine aminotransferase >100 U/l and aspartate aminotransferase >100 U/l
C.Random: yes, ITT: yes. Blinding: double (11)
PN, 0.27 IV glutamine + PN vs. PN, isocaloric, isonitrogenous
Hospital 2/17 (12)
Hospital 3/16 (19)
4/17 (23)
12/16 (75)
ICU 7.2 ± 9.2 (17), Hospital, 16.5 ± 8.9 (17)
ICU 7.3 ± 4.5 (16) Hospital 16.7 ± 7 (16)
5) Zhou 2004 [42]
Severe burns N = 30
Renal: chronic disease. Liver: chronic disease
C.Random: yes. ITT: yes. Blinding: double (11)
PN, 0.35 IV glutamine + PN vs. PN, isocaloric, isonitrogenous.
3/15 (20)
4/15 (26)
Hospital 42 ± 7.0 (15)
Hospital 46 ± 6.6 (15)
6) Xian-Li 2004 [30]
Single-center, severe acute pancreatitis, N = 69
Renal: renal dysfunction. Liver: liver dysfunction
C.Random: yes. ITT: no Blinding: no (5)
PN, 0.4 IV glutamine + PN vs. PN
Hospital 0/20 (0)
Hospital 3/21 (14)
# Compl 4
# Compl 11
Hospital 25.3 ± 7.6 (20)
Hospital 28.6 ± 6.9 (21)
7) Dechelotte 2006 [9]
Multiple trauma, surgery, sepsis, pancreatitis from 16 ICUs N = 114
Renal: creatinine >250 μmol/L. Liver: Prothrombin time >23.7 sec
C. Random: NR. ITT: yes. Blinding: double (NA)
PN, 0.35 IV glutamine + PN vs. PN, isocaloric, isonitrogenous.
Hospital 2/58 (3), 6-month 16/58 (28)
Hospital 2/56 (3) 6-month 9/56 (16)
All 23/58 (40) Pneumonia 10/58 (17)
All 32/56 (58), Pneumonia 19/56 (34)
ICU 12.5 (1–430), Hospital 30 (1-560)
ICU 11.5 (3–121),* Hospital 26 (4-407)*
8) Palmese 2006 [33]
Single-center, mixed ICU N = 84
Renal: severe renal disease. Liver: severe hepatic disease
C.Random: yes, ITT: yes, Blinding: single (10)
PN, 0.14 IV glutamine + EN with FOS vs. EN without FOS
All 13/42 (31), Pneumonia 2/42 (5)
All 21/42 (50), Pneumonia 6/42 (14)
9) Tian 2006 [38]
Single-center, MODS N = 40
Not defined
C.Random: not sure, ITT: yes, Blinding: none (6)
PN, 0.27 IV glutamine vs. PN
Unspecified 2/20 (10)
Unspecified 5/20 (25)
10) Sahin 2007 [37]
Single-center, acute pancreatitis N = 40
Not defined
C.Random: not sure, ITT: yes, Blinding: single (9)
PN, 0.3 IV glutamine + PN vs. PN, isocaloric, isonitorgenous.
Hospital 2/20 (10)
Hospital 6/20 (30)
Hospital 14.2 ± 4.4 (20)
Hospital 16.4 ± 3.9 (20)
11) Zhang 2007 [43]
Emergency and neurosurgical ICU, pts requiring PN for >7 days, N = 44
Not defined
C.Random: not sure, ITT: yes, Blinding: no (6)
EN and PN, IV glutamine 0.4 g/kg/day vs. EN and PN alone
12) Cai 2008 [21]
Single-center, elderly, severe sepsis N = 110
Renal: creatinine >220 μmol/L and/or dialysis. Liver: bilirubin >43 μmol/L and/or history of chronic liver disease
C.Random: not sure, ITT: yes, Blinding: no (10)
PN, 0.19 IV glutamine Patients received PN or EN + PN isocaloric, isonitrogenous
28-day 17/55 (31)
28-day 20/55 (36)
13) Duska 2008 [15]∂
Single-center, trauma N = 30
C.Random: not sure, ITT: yes, Blinding: single (8)
PN, 0.3 IV glutamine + PN vs. normal saline + supplemental PN, isocaloric, isonitrogenous
ICU 23 (median)
ICU 24 (median)
14) Estivariz 2008 [24]
Single-center, pancreatic and non pancreatic surgery N = 63
Renal: evolving acute renal failure or dialysis. Liver: total bili >4 mg/dL or >5 fold elevation in serum transaminase concentrations
C.Random: not sure, ITT: no**, Blinding: double (9)
PN, 0.5 IV glutamine + PN vs. PN isocaloric, isonitrogenous
Hospital 1/32 (3)
Hospital 6/31 (19)
Pneumonia 13/30 (43)
Pneumonia 16/29 (55)
ICU 12 ± 2 (32), Hospital 20 ± 2 (32)
ICU 23 ± 6 (31) Hospital 30 ± 6 (31)
17) Perez-Barcena 2008 [35]
Single-center, mixed ICU N = 30
Not defined
C.Random: not sure, ITT: yes, Blinding: single (10)
PN, 0.35 IV glutamine + PN vs. PN isocaloric, isonitrogenous
Hospital 3/15 (20)
Hospital 0/15 (0)
11/15 (73)
13/15 (87)
ICU 22.9 ± 20.6 (15), Hospital, 35.5 ± 33.6 (15)
ICU 20.5 ± 16.0 (15) Hospital 42.9 ± 28.8 (15)
18) Ozgultekin 2008 [32]
Single-center, CHI & GCS pts, ventilated, sedated, mean APACHE II 18-19 N = 60
Not defined
C.Random: not sure ITT: no, Blinding: none (4)
EN, 0.2-0.4 g/kg/d IV glutamine vs. EN
30-day 12/20 (60)
30-day 12/20 (60)
19) Yang 2008 [41]
Single-center, severe pancreatitis N = 61
Not defined
C.Random: not sure, ITT: no Blinding: single (4)
PN, IV glutamine (dose unknown) vs. PN, saline
Hospital 1/25 (4)
Hospital 3/25 (12)
Hospital 13.48 ± 1.42 (25)
Hospital 15.18 ± 1.14 (25)
20) Eroglu 2009 [23]
Single-center, severe trauma, ISS >20 N = 40
Renal: on renal replacement therapy, Liver: none
C.Random: yes, ITT: yes, Blinding: double (12)
EN, 0.5 g/kg/d IV glutamine vs. EN, saline
Overall 8/20 (40) VAP 1/20 (5)
Overall 10/20 (50), VAP 1/20 (5)
21) Perez-Barcena 2010 [34]
Single-center, trauma pt ISS >12, requires PN based on ASPEN N = 43
Not defined
C.Random: not sure, ITT: yes, Blinding: single (6)
PN, 0.35 g/kg/d IV glutamine vs. PN
ICU 4/23 (17), Hospital 0/23 (0)
ICU 2/20 (10), Hospital 1/20 (5)
Pneumonia 11/23 (48)
Pneumonia 8/20 (40)
ICU 21 (17–25),* Hospital 31 (19-42)*
ICU 21 (14-47)* Hospital 40 (24-80)*
22) Andrews 2011 [20]
Multi-center, critically ill adults, 25% medical pts, from 10 centres. N = 502
Renal: estimated GFR <10 ml/min and not receiving renal replacement therapy. Liver: none
C.Random: yes, ITT: yes, Blinding: double (13)
PN, 0.2-0.4 g/kg/day (20.2 g/day x 7 days) IV glutamine vs.PN isocaloric, isonitrogenous
ICU 88/250 (35), 6-month 115/250 (46)
ICU 80/252 (32), 6-month 106/252 (42)
134/250 (54)
131/252 (52)
ICU 15 (7.9-28.4)*, Hospital 32.5 (14.7-55.6)*
ICU 13.4 (8.2-23.9)*, Hospital 28.2 (15.1-52.4)*
23) Cekmen 2011 [22]
Single-center, mixed surgical ICU, ISS >10, APACHE II >10 N = 30
Renal: significant renal dysfunction (evolving acute renal failure or on dialysis). Liver: significant hepatic dysfunction (total bilirubin >4.0 mg/dL or more than fivefold elevation in serum transaminase concentrations)
C.Random: yes, ITT: yes, Blinding: double (10)
PN, 0.5 g/kg IV glutamine vs. PN
ICU (presumed) 3/15 (20)
ICU (presumed) 6/15 (40)
24) Grau 2011 [27]
Multi-center, mechanically ventilated, APACHE II >12, need TPN N = 127
Renal: chronic renal failure requiring dialysis, acute renal failure not treated with hemofiltration or hemodialysis [plasmatic creatinine >2.5 mg/dL]. Liver: hepatic failure with hepatic encephalopathy or portal hypertension
C.Random: not sure, ITT: yes Blinding: double (11)
PN, 0.5 g/kg IV glutamine vs. PN
ICU 9/59 (15), 6-month 16/59 (27)
ICU 13/68 (19), 6-month 23/68 (34)
All 24/59 (41), Surgical, 13/59 (22), Pneu (#/1000 vent days), 13.5, # infect/pt 1.5
All 31/68 (46), Surgical, 17/68 (25), Pneu (#/1000 vent days), 27.2, # infect/pt 2.4
ICU 12 (7-22)*, Hospital 35 (23-56)*
ICU 12 (7-24)*, Hospital, 31 (20-58)*
25) Wernerman 2011 [39]
Multi-center, mixed ICU, APACHE II >10 N = 413
Not defined
C.Random: yes, ITT: yes Blinding: double (11)
EN or PN, 0.28 g/kg/day IV glutamine vs. EN or PN, normal saline IV
ICU 8/205 (4) 28-day 14/205 (7)
ICU 11/208 (5) 28-day 20/208 (10)
26) Ziegler 2012 [44]
Multi-center, N = 150
Renal: history of chronic renal failure requiring dialysis, or significant renal dysfunction (creatinine >2.5 mg/dL and is not receiving continuous renal replacement therapy) or requiring acute hemodialysis postoperatively. Liver: current encephalopathy or known history of cirrhosis or total bilirubin ≥10.0 mg/dL
C.Random: yes ITT: yes, Blinding: double (12)
PN, 0.5 gm/kg/day IV vs. PN, isocaloric. Isonitrogenous.
Hospital, 11/75 (15)
Hospital 13/75 (17)
Any 33/75 (44). Pneumonia, 10/75 (13)
Any, 24/75 (32) Pneumonia, 12/75 (16)
ICU 17.5 ± 14.6 (75). Hospital 33.6 ± 28 (75)
ICU 13.6 ± 10 (75). Hospital 29.7 ± 20.7 (75)
Recently, a new paradigm of pharmacological GLN administration was tested in a large multicenter clinical trial utilizing a combined enteral and intravenous dose of GLN, which averaged between 0.6 to 0.8 g/kg/day independent of the administration of complete nutrition [6]. This study, the REDOXS study, also primarily enrolled patients who, as defined by the inclusion criteria, were required to be in multi-system organ failure within 24 hours of admission. Finally, renal failure and acute liver failure were, for the first time, not excluded and in fact, more than 30% of the patients in REDOXS presented with baseline acute renal failure. The results of this trial surprisingly showed contrary to many previous traditional PN-based GLN trials, that GLN supplementation was associated with an increase in mortality.
Thus, a key question to be answered is whether parenteral GLN administered as a supplement to complete nutrition support (for example via PN) is beneficial or harmful. This question is timely given the large number of (n = 11) of randomized clinical trials of GLN supplementation of PN published since 2009. Recently a number of meta-analysis have been published examining the use of GLN in burn injury, pancreatitis, and surgical and critical illness combined [11–14], however a systematic analysis focused on parenteral GLN supplementation in critical illness has not been performed. Further, these past meta-analysis have not incorporated all of the most recently available trial data. The aim of this current systematic literature review and meta-analysis is to focus on the question of whether the 'traditional' parenteral administration of GLN as part of nutrition support has an effect on relevant clinical outcomes in patients classified with critical illness (as opposed to elective surgery or only single diagnosis groups, such as burn injury).
Study identification
The following databases were searched for articles from 1980 until July 2013: EMBASE, MEDLINE, CINAHL and the Cochrane Controlled Trials Register and Database of Systematic Reviews. The literature search used broad search terms containing 'randomized' , 'blind' , 'clinical trial' , 'nutrition' , 'nutritional support' or 'dietary supplementation' or 'enteral nutrition' or 'parenteral nutrition' or 'parenteral nutrition solutions' and 'critical care' or 'critical illness' or 'intensive care units'. The results were then reviewed to identify articles using parenteral or intravenous GLN supplementation. A unique feature of this meta-analysis is that no language restrictions were placed on the searches. Personal files and reference lists of relevant review articles were also reviewed. As this was a systematic review no ethics board approval or patient consent was required.
Study selection criteria
We only included original studies if they met the following inclusion criteria: a) study design: randomized clinical trials, b) population: critically ill adult patients (>18 years of age), defined as patients admitted to an ICU. When this was unclear, we considered a mortality rate higher than 5% (hospital mortality and if this was not reported we used ICU mortality or 28-day mortality) in the control group to be consistent with critical illness, c) intervention: parenteral GLN versus control (either isonitrogenous amino acid control) or placebo, d) study outcomes: must have included one of the following: mortality, ICU and hospital LOS, infectious complications, and other clinically important complications. Studies of enteral GLN only or combined enteral/parenteral GLN were excluded).
Data abstraction
Randomized trial quality scoring system
Not concealed or not sure
Concealed randomization
Not blinded
Patient selection
Selected patients or unable to tell
Consecutive eligible patients
Comparability of groups at baseline
No or not sure
Extent of follow-up
Treatment protocol
Poorly described
Reproducibly described
Not described
Described but not equal or not sure
Well described and all equal
Not described
Partially described
Objectively defined
Data synthesis
The primary outcome of the systematic review was overall mortality. From all studies, we combined hospital mortality where reported (specified or assumed to be hospital if not specified). If hospital mortality was not reported, we used ICU mortality or, if ICU mortality was not reported, we used 28-day mortality. Secondary outcomes included infection, ventilator-associated pneumonia (VAP), and ICU and hospital LOS. We used definitions of infections as defined by the authors in their original articles. We combined data from all trials to estimate the pooled risk ratio (RR) with 95% confidence intervals (CIs) for mortality, infectious complications, VAP and overall weighted mean difference (WMD) with 95% CIs for LOS data. Pooled RRs were calculated using the Mantel-Haenszel estimator and WMDs were estimated by the inverse variance approach. The random effects model of Der Simonian and Laird was used to estimate variances for the Mantel-Haenszel and inverse variance estimators [16]. All analyses, except the test for asymmetry, were conducted using Review Manager (RevMan) 5.1 software. (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark, 2011) [17].
When possible, studies were aggregated on an ITT basis (Table 2). The presence of heterogeneity was tested by a weighted Mantel-Haenszel chi-square test and quantified by the I2 statistic as implemented in RevMan 5.1 [17, 18]. The possibility of publication bias was assessed by generating funnel plots and testing asymmetry of outcomes using methods proposed by Rucker and colleagues [19]. We considered P <0.05 to be statistically significant and P <0.20 as the indicator of trend.
Subgroup analyses
We utilized predefined subgroup analysis to assess a number of possible influences on the effect of parenteral GLN supplementation on clinical outcomes. We first examined the effect of parenteral GLN supplementation of PN versus EN alone. As trials examining EN alone consistently deliver significantly less total overall energy and protein delivery, we hypothesized that parenteral GLN may have a different effect when complete nutrition support was being given via EN alone or as a component of PN delivery. We next assessed the effect of trial quality on outcome as it is often hypothesized trials of lower methodological quality tend to yield more positive clinical signals for the therapy being tested when compared to trials of higher methodological quality. Utilizing our trial scoring tool, we designated trials with a methodological score of >8 as a 'high-quality trial' for the purposes of this review. Finally, it has been postulated that single-center trials may yield a greater chance of a positive clinical signal versus more rigorous multi-center trials [16], thus we examined the effect of these two types of trials on our clinical outcomes.
Study identification and selection
The literature search yielded 58 potentially eligible randomized controlled trials of which 26 were included in our systematic review. As shown in Table S1 in Additional file 1, a total of 32 studies were excluded for these reasons: 1) patients not considered to be critically ill (n = 18), 2) no clinical outcomes (n = 5), 3) were duplicate studies or subgroups of included studies (n = 3), 4) crossover design studies (n = 2), 5) varying doses of GLN (n = 1), 6) a trial of combined enteral and parenteral GLN (n = 1), 7) questionably low dosage of GLN (0.002 g/kg/day) (n = 1, see Table S1 in Additional file 1) and 8) one trial reported data from a subgroup of its total study population [10], see Table S1 in Additional file 1).
Thus, we included 26 studies of parenteral GLN supplementation performed in ICU patients with diagnosis ranging from pancreatitis, trauma, burns to sepsis described in Table 1[9, 15, 20–44]. While in the majority of the studies, the intervention and control groups received GLN-free parenteral nutrition/amino acids, in four studies, patients received only EN as the sole source of nutrition support [23, 31–33].
Meta-analyses of primary and secondary outcomes
Effect of GLN supplementation on mortality
Effect of GLN supplementation on infectious complications, ICU length of stay and hospital length of stay
Subgroup analysis
Subgroup analyses
Overall mortality
Hospital mortality
Infectious complications
Subgroup analysis
Number of trials
Number of patients
Effect on overall mortality [RR (95% CI), p]
Test for subgroup differences
Number of trials
Number of patients
Effect on hospital mortality [RR (95% CI), p]
Test for subgroup differences
Number of trials
Number of patients
Effect on infectious complications [RR (95% CI), P]
Test for subgroup differences
Number of trials
Number of patients
Effect on ICU LOS [WMD (95% CI), P]
Test for subgroup differences
Number of trials
Number of patients
Effect on VAP [RR (95% CI), P]
Test for subgroup differences
Study Quality
Low quality (<8)
High quality (≥8)
Number of sites
Single center
PN vs. EN
Patients on PN
Patients on EN
Effect of parenteral GLN supplementation of PN versus EN alone
Examining the effect of GLN supplementation of PN versus EN alone, the test for subgroup differences in overall mortality outcomes was not significant (P = 0.66). In the studies in which patients received intravenous (IV) GLN plus PN, GLN supplementation was associated with a trend towards a reduction in overall mortality (RR 0.84, 95% CI 0.71, 1.01, P = 0.07, heterogeneity I2 = 3%; Figure 1, Table 3). Only four studies reported on mortality for GLN supplementation of EN. When the studies in which patients only received IV GLN and EN [23, 31–33] were aggregated, GLN supplementation had no effect on overall mortality (RR 0.94, 95% CI 0.61, 1.47, P = 0.79, heterogeneity I2 = 0%; Figure 1, Table 3). In the subgroup of studies in which patients received IV GLN plus PN, GLN supplementation had no effect on infectious complications (RR 0.89, 95% CI 0.74, 1.06, P = 0.20, heterogeneity I2 = 48%; Figure 3, Table 3). However, for the subgroup of studies in which patients received IV GLN and were on EN alone [23, 33], GLN supplementation was associated with a trend towards a reduction in infectious complications (RR 0.68, 95% CI 0.45, 1.05, P = 0.08, heterogeneity I2 = 0%; Figure 3, Table 3). The test for subgroup differences in infectious morbidity overall in EN alone versus PN studies was not significant (P = 0.27).
For the subgroup of studies in which patients received IV GLN plus PN, GLN supplementation was not associated with a reduction in ICU LOS. Similarly no effect on ICU LOS was observed in patients receiving only EN that received IV GLN [23, 31–33]. The test for subgroup differences in ICU LOS overall was not significant (P = 0.42). None of the studies in which patients only received EN reported on hospital LOS and therefore no subgroup analyses were done.
Effect of study quality on outcomes
Higher quality trials (methodological score of >8) showed a stronger statistical trend towards reduced mortality than trials of lower quality (P = 0.12 versus P = 0.49 respectively), although the effect size was similar between the groups (Table 3). The overall test for subgroup difference was not significant for these subgroups (P = 0.79).
A statistically significant effect for GLN reducing hospital mortality was only seen in the higher quality trials, although there were a smaller number of patients enrolled in the lower quality trials and this reduced the statistical power of the signal (Table 3). Again, overall tests for significance did not reveal statistically significant differences between these subgroups (P = 0.21). There were insufficient numbers of trials reporting on infectious outcomes and LOS data in the low- and high-quality categories to allow for these comparisons to be made.
Role of multi-center versus single-center trials on outcomes
The role of multi-center versus single center trials revealed that only the single center trials demonstrated a significant effect of GLN on overall and hospital mortality and infectious outcomes (Table 3). Only the multi-center trials demonstrated a significant benefit of GLN on the incidence of VAP (Table 3). Overall tests for significance did not reveal statistically significant differences between these subgroups. (P = 0.45 for mortality and P = 0.16 for infectious morbidity, and P = 0.34 for VAP).
Risk of bias across studies
Meta-analysis of the initial randomized controlled trials of parenteral GLN supplementation suggested outcome benefits in the six early trials examining critical illness [45]. Since that time an additional 22 randomized clinical trials have been performed in over 2,000 patients receiving GLN as a component of complete nutrition support, primarily given as PN (85% of trials). In addition, we have a much greater understanding of the potential beneficial mechanisms of GLN in critical illness as summarized in recent reviews [1, 46].
Early trials of GLN were primarily focused on patients receiving full nutrition support primarily by PN at doses falling within the approved prescribing indications for dose in commercially available GLN preparations. Further, as shown in Table 1, patients in these traditional trials were commonly excluded from enrollment if they had pre-existing renal or liver failure. These traditional nutritionally oriented (or non-pharmaconutrition based) GLN supplementation trials have shown a consistent reduction of mortality and benefit on other outcomes as suggested by the 2009 update of the Canadian Critical Care Nutrition Guidelines [47]. However, given the publication of 11 new randomized controlled trials examining the traditional parenteral use of GLN as a component of nutrition support (predominantly PN) since 2009, a new systematic review is indicated.
This need for a new systematic review is further driven by the results of the REDOXS trial, a 1,200-patient, 40-center randomized controlled trial of 'pharmacologically dosed' parenteral and enteral GLN (approximately 0.6 to 0.8 g/kg/day) factorialized with antioxidant supplementation [6]. This trial was distinct from any of the previously published parenteral GLN trials supplementing PN or EN in ICU patients as GLN (and a cocktail of antioxidants) were administered independent of any concomitant nutrition support. In contrast to the design of studies reported in this analysis, the nutritional delivery of energy and protein in the REDOXS trial averaged less than 50% of that prescribed for the patient, and thus was quite insufficient in meeting patient needs. In addition, all patients in the REDOXS trial had documented multi-system organ failure at enrollment, which is a common exclusion criteria in the trials reported in this analysis using parenteral GLN as a supplement to nutrition support. Further, more than 30% of REDOXS patients were found to have baseline renal failure at admission, which was a very common exclusion criteria in the trials reported in the analysis (Table 1). As stated, this is a key difference of REDOXS from all other GLN trials.
Thus, given the many differences in fundamental trial design between REDOXS and traditional GLN supplementation trials, the REDOXS trial has not been included in this systematic review focused on GLN supplementation of nutrition support. However, the publication of the REDOXS trial necessitates a close examination of the many new GLN supplementation trials published recently to examine if there has been a change in the fundamental signal of benefit of GLN supplementation of PN seen in historical trials in the recent era of critical care practice. This was the primary aim of this systematic review.
Overall, our results reveal that GLN supplementation continues to show a significant reduction in hospital mortality. In addition, GLN supplementation of complete nutrition was found to be associated with a strong trend towards a reduction in infectious complications, ICU LOS and a significant reduction in hospital LOS. GLN supplementation as part of nutrition support also continues to show a trend towards reduction of overall mortality in all trials examining both PN and EN nutrition delivery. The signal may be stronger for trials that utilize GLN supplementation as part of PN nutrition delivery. Importantly, no statistically significant signal of publication bias was observed in any of our tests for asymmetry as shown in the funnel plots in Figure 7.
A number of high-quality multi-center trials of parenteral GLN supplementation have been published recently, driving the need for this new critical care focused systematic review. A number of these key trials have strengths and weaknesses that are in some cases not reflected in the trial quality scoring utilized by this and other systematic reviews. Thus, a brief discussion of some of these key trials is useful. In short, these trials include the Scandinavian GLN trial [39], which examined 413 patients in multiple centers and demonstrated a benefit on ICU survival rates with parenteral GLN. A limitation of this trial was that it was stopped prior to achievement of its predefined enrollment goal due to slow enrollment. Another multi-center trial, the SIGNET trial, showed no benefit of short-term (approximately ≤4 days), low-dose GLN (approximately 0.2 g/kg/d) given parenterally to ICU patients on parenteral feeding [20]. Some concerns with this trial included lack of availability of some key data including issues regarding missing values, dropouts, protocol violations, and complete follow-up data. The actual values for GLN doses based on body weight have not been published and this has been viewed as a significant limitation of the trial. In an attempt to address the effect of quality of the trials and single-center versus multi-center trials included in the systematic review, we performed subgroup analyses to examine the role of these factors. We observed a more significant signal for parenteral GLN supplementation reducing mortality in the higher quality studies versus the lower quality trials. Single-center trials showed a greater benefit of GLN supplementation on mortality and overall infectious morbidity, although no signals of harm were observed in the multi-center trials of GLN on mortality. Interestingly, the beneficial effect of GLN on VAP was greater in the multi-center trials then the single-center trials. This is an endpoint that may deserve more focused examination in future trials of GLN supplementation in the ICU.
A number of other systematic reviews of GLN supplementation in either much broader populations, including noncritically ill patients, or specific populations (pancreatitis, burn injury, or elective surgery) have been published recently [11–14]. To our knowledge, our systematic analysis is the first to focus on the parenteral use of GLN supplementation of standard nutrition support in which all subjects are critically ill. When compared to the largest recent meta-analysis in a broader mixed elective surgery and critical care population many similarities with our data are observed [11]. First, with regard to mortality this recent analysis of GLN showed a very similar trend towards reduction of mortality (RR = 0.89; 95% CI, 0.77 to 1.04 versus RR 0.88, 95% CI 0.75, 1.03, in our analysis) in a patient population with a lower illness severity (where an effect on mortality would be less likely to be observed). No analysis of hospital mortality was reported in this previous analysis. With regard to infectious morbidity, this earlier meta-analysis showed a stronger statistically significant reduction of infectious morbidity (RR = 0.83; 95% CI, 0.72 to 0.95) compared to our data where a nonsignificant trend of similar magnitude for a benefit on infection was observed (RR 0.86, 95% CI 0.73, 1.02). Both the previous and current systematic reviews reported significant reductions on hospital LOSs of approximately 2.5 days (-2.35; 95%, -3.68 to -1.02 versus -2.56, 95% CI -4.71, -0.42 in our analysis). Other key differences of our analysis versus the earlier report was that no direct industry funding was involved in support of our analysis (partial funding by an unrestricted industry grant was used to support this previous analysis), we included all of the world literature (including non-English trials) in our search, and we successfully attempted in all cases to contact the original authors when any questions of missing data or actual ICU patient inclusion was in question. For the first time we also examined the effect of GLN supplementation on VAP. We were also able to incorporate original source data from the unpublished multi-center American 'GLND' trial of GLN-supplementation of PN published in abstract form [44]. Finally, we performed funnel plots for all primary and key secondary endpoints examined by this analysis to examine possible publication bias associated with these endpoints.
The strength of our meta-analysis includes the use of several methods to reduce bias (comprehensive literature search, duplicate data abstraction, specific criteria for searching and analysis) and focus on clinically important primary outcomes. Notwithstanding, we are aware that our meta-analysis has several limitations. The major limitation is the small number of trials included in certain subgroup analyses such as PN-supplementation of EN. We also unfortunately could not perform subgroup analysis for all endpoints due to limited numbers of trials examining the particular endpoints. Another potential weakness of any systematic review of randomized controlled nutrition trials has been pointed out by Vincent et al. recently [48]. This is the potential inability of a controlled nutrition trial to recreate 'real-life' patient conditions in the controlled setting of a trial (that is due to many patient exclusions). That said, we feel this systematic review best reflects all existing data in a wide variety of critical care settings of parenteral GLN supplementation to provide clinicians with most complete data to assist in making clinical decisions. Further, despite our attempts to be fully comprehensive in our search for all available trials we may not have been to include all available trials.
In spite of these limitations, we have demonstrated that traditional GLN supplementation used in the context of standard (predominantly parenteral) nutrition support in the critically ill may significantly reduce hospital mortality and shorten hospital LOS with a trend towards reduction in overall mortality and infectious complications, including VAP, and ICU LOS. Nonetheless, many questions on the ideal dose and timing of GLN supplementation in the ICU still remain unanswered. Further research is warranted to define the optimal dose and timing of supplementation of GLN in patients receiving full nutrition support. Recent data from REDOXS and other trials suggest that parenteral GLN should not be given in patients early in the acute phase of critical illness, in patients with multiple organ failure or in patients with unresuscitated shock requiring significant vasopressor support. Finally, based on the results of the REDOXS trial [6], we believe that high-dose parenteral or parenteral + enteral GLN (doses >0.5 g/kg/d) should not be used during the acute phase of critical illness.
In this comprehensive systematic review, we demonstrate that traditional parenteral GLN supplementation as a component of nutrition support (primarily added to PN) is associated with a significant decrease in hospital mortality and length of hospital stay. GLN supplementation is also associated with trends towards reduced overall mortality, infectious complications and ICU LOS in critically ill patients. The therapeutic effect may be dependent on GLN dose given, with optimal benefit traditionally observed between 0.3 and 0.5 g/kg/d. Thus, we recommend that parenteral GLN supplementation as a component of nutrition support be considered as an approach to improve outcomes of critical illness in selected patients. Our data here suggest that parenteral GLN supplementation, as a component of complete PN and/or EN support, is safe when administered following resolution of shock and multi-organ failure, and with daily doses less the 0.5 g/kg/d. Focused clinical trials on the clinical efficacy of parenteral GLN supplementation combined with adequate and complete specialized nutrition support are needed in critically ill patients at risk of GLN depletion who do not have multiple organ failure or ongoing shock.
Key messages
Critical illness is characterized by severe metabolic stress and glutamine depletion has been associated with increased mortality in some recent studies. In this context, supplementation of parenteral glutamine, predominantly as a component of parenteral nutrition, may improve clinical outcomes when given to appropriate patients as part of complete nutrition support.
Supplemental parenteral glutamine may significantly decrease hospital mortality and shorten hospital LOS in critically ill patients.
Supplemental parenteral glutamine given as a component of nutrition support is associated with a trend towards a reduction in overall mortality, infectious morbidity, and ICU LOS in critically ill patients.
We suggest supplemental glutamine should not be given in a high dose (>0.5 g/kg/day) or in patients early in the acute phase of critical illness in patients with multiple organ failure or unresuscitated shock requiring significant vasopressor support.
When parenteral nutrition is prescribed to critically ill patients, parenteral supplementation with glutamine should continue to be considered safe and may potentially improve outcomes in the ICU in patients without specific contraindications.
confidence interval
enteral nutrition
intensive care unit
intention to treat
length of stay
parenteral nutrition
relative risk
ventilator-associated pneumonia
weighted mean difference.
The authors wish to acknowledge Xuran Jiang (a biostatistician) for assistance with statistical analysis and figure generation for this manuscript.
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- Vincent JL, Preiser JC: Are prospective cohort studies an appropriate tool to answer clinical nutrition questions? Curr Opin Clin Nutr Metab Care 2013, 16: 182-186. 10.1097/MCO.0b013e32835d803eView ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Michael Fuljenz, America's Gold Expert® was honored with four awards in the 23rd annual Excellence in the Media competition conducted by the Press Club of Southeast Texas. The awards were for Fuljenz' consumer education and protection writings about buying and selling rare coins and precious metals.
Mike Fuljenz, recent Beaumont Enterprise Award Winner, discusses gold rising, new Kennedy commemorative coins and states that are sales tax free on precious metal transactions.
Mike Fuljenz discusses the billions that America would save by eliminating the penny and the dollar bill.
Sandwiched between receiving an award, autographing copies of his book and purchasing gold coins to fulfill his customers' orders, America's Gold Expert® , Michael Fuljenz, recently was a keynote speaker at a special training course for Texas law enforcement personnel on the topic of investigating crimes involving rare coins, bullion and jewelry.
Most Americans take those words for granted today and assume they've always been part of our national fabric. Thus, many were surprised when the House of Representatives recently voted to reaffirm that this simple phrase is the official national motto. The story of the motto is an engrossing one, full of fascinating twists and turns…
KFDM-TV Channel 6 in my hometown of Beaumont,Texas recently did a Crime Stoppers story about a Texas dealer who reportedly paid only $16,000 for nearly $250,000 of coins sent to him by an 82-year old California woman. The interviewer asked me for consumer protection advice so other people can avoid encountering this kind of problem.
The fact that since 1986 Mike Fuljenz has won so many major awards in so many diverse categories, including the top NLG award 'The Clemy,' underscores how important his peers in the rare coin and precious metals markets view Mike's excellent analysis and reporting.
The first of the year brought new changes in state and local laws dealing with precious metal buyers. The Texas legislative committee heard from the nationally-known coin dealer Mike Fuljenz whose expertise was invaluable during the drafting of the new legislation.
The success of the Eddie Eagle GunSafe® Program can be attributed to people like Mike Fuljenz. We thank him for his continued support in spreading Eddie's life-saving message to more than 25 million children.


text: I got 4 new stunning Angels for my 60 gl tank yesterday. I am not sure what kind they are, I think the blk/white is marble, not sure on the rest. Do you know?The one on ( last 3 photos) so not sure what that one is .. Stunning in real life.Much paler than the others. Sorry I took them with my iphone.. Also, I am new to Angels.. is this common for them to just say in a group and not really swim around.? I got them from a quality fish store yesterday.


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DoubleTree by Hilton Hotel Pittsburgh - Green Tree - Pittsburgh
- Free WiFi in lobby and free parking
Main amenities
- 460 guestrooms
- Restaurant and bar/lounge
- Indoor pool and outdoor pool
- Breakfast available
- Free airport shuttle
- 24-hour fitness center
- 24-hour business center
- Area shuttle
- 24-hour front desk
- Air conditioning
- Daily housekeeping
- Garden
For families
- Free cribs/infant beds
- Refrigerator
- Connecting/adjoining rooms available
- Private bathroom
- Premium TV channels
- Free toiletries
What's around
- Off the Wall Theater (2 mi / 3.3 km)
- James Gallery (2.6 mi / 4.2 km)
- Duquesne Incline (3.3 mi / 5.3 km)
- Monongahela Incline (4.3 mi / 6.9 km)
- PNC Park (4.7 mi / 7.6 km)
DoubleTree by Hilton Hotel Pittsburgh - Green Tree - Pittsburghfrom Rs4,698
- One King Bed, Non-Smoking, Roll In Shower
- Two double beds
- Presidential Suite, Non Smoking
- Suite, Accessible, Non Smoking
- Suite, 1 King Bed, Accessible, Non Smoking
- Suite, One King Bed, Non-Smoking
- Two Queen Beds, Non-Smoking
- Room, 1 King Bed, Accessible, Non Smoking
- King bed
- Two double beds smoking
More great choices
At a glance
Key facts
Hotel size
- This hotel has 460 rooms
- This hotel is arranged over 7 floors
- Check-in time 3 PM-2 AM
- Check-out time is noon
- Express check-in/out
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Children (18 years old and younger) stay free when occupying the parent or guardian's room, using existing bedding
- Pets not allowed
- Free WiFi in public areas
- WiFi in rooms *
- Free airport shuttle (available 24 hours) *
- Free extended parking
- RV/bus/truck parking
- Area shuttle *
Nearby Three Star Pittsburgh hotels
In the hotel
- Breakfast daily (surcharge)
- Restaurant
- Bar/lounge
- Coffee shop/café
- Snack bar/deli
- Room service (during limited hours)
- Indoor pool
- Outdoor seasonal pool
- 24-hour fitness facilities
- Spa tub
- Golfing nearby
- Outdoor pool
- Use of nearby fitness center (discount)
- 24-hour business center
- Number of meeting rooms - 26
- Conference space
- Meeting rooms 26
- Conference space size (feet) - 29999
- Conference space size (meters) - 2787
- Conference center
- Computer station
- 24-hour front desk
- Dry cleaning/laundry service
- Free newspapers in lobby
- Luggage storage
- Wedding services
- Multilingual staff
- Porter/bellhop
- Elevator/lift
- ATM/banking
- Safe-deposit box at front desk
- Designated smoking areas
- Garden
- Fireplace in lobby
- Accessible bathroom
- In-room accessibility
- Roll-in shower
In the room
- In-room climate control (air conditioning)
- Air conditioning
- Coffee/tea maker
- Iron/ironing board
- Premium bedding
- Private bathroom
- Shower/tub combination
- Free toiletries
- Hair dryer
- Premium TV channels
- Desk
- Free newspaper
- WiFi (surcharge)
- Refrigerator
- Daily housekeeping
- In-room safe
- Connecting/adjoining rooms available
Top Pittsburgh hotels
Recently reviewed hotels in Pittsburgh
- Hampton Inn Pittsburgh University/Medical CenterFrom
"THE RECEPTION PEOPLE AND ALL THE STAFF WERE KIND AND EXCELLENT SERVICE. LIKE TO STAY AGAIN THERE ..."Dec 12, 2016
- Shadyside Inn All Suites HotelFrom
"We stayed for four nights during May 15. We had gone to attend the graduation event of our son from CMU. The stay was very nice and comfortable. Since the proximity to CMU was…"May 21, 2015
- HYATT house Pittsburgh-South SideFrom
"Comfortable stay, spacious suites, good breakfast, hotel shuttle for drop and pick up."May 28, 2014
Nearby hotels
Recommended hotels
Special features
DiningSeasons Restaurant - This restaurant serves breakfast, lunch, and dinner. Open daily.
Champions Club - This sports bar serves light fare only. Open daily.
Bistro & Marketplace - This cafe serves light fare only. Guests can enjoy drinks at the bar. Open daily.
DoubleTree by Hilton Hotel Pittsburgh - Green Tree - Pittsburgh's small print
Also known as
- DoubleTree Hilton Hotel Pittsburgh Green Tree
- DoubleTree Hilton Pittsburgh Green Tree
- Pittsburgh Radisson
- Radisson Green Tree
- Radisson Hotel Pittsburgh
- Radisson Pittsburgh
The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation.
For transfers, guests must contact the property 24 hours prior to arrival at the number on the booking confirmation.
Optional extras
Breakfast is offered for an extra charge of USD 15.99 per person (approximately)
WiFi is available in guestrooms for USD 9.95 per day (rates may vary)
Area shuttle service is offered for an extra charge
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Recent reviews
Excellent 4.2 /5 from 440 reviews
Great hotel! staff was sooo nice and welcoming! pool and exercise room really nice. very clean rooms! Great bar in lobby area! wld def stay again!
My family of 4 with 2 toddler boys needed a night away with fun and swimming. Was extremely disappointed with the temperature of the pool area and water temperature. It was so cold. The thermastat was set at 62° in mid January. The water was also pretty cold but unknown exact temp. Considering we only had planned to swim all day BC my boys love swimming, it was so disappointing to not be able to spend a lot of time in the pool. Probably won't be back. Told a man that worked at the hotel about how cold the pool area was, but nothing was done.
Very quick to check in. Compared to other locations, this place is dirtier when compared. They also offer the warm cookies at check in which is amazing following our flight from 80 degrees to -degrees with windchill. Our room was very clean and neat. Not a thing out of place. BUT that's when the problems occurred. The hot water took forever to heat up. The toilet didn't flush, three tries before anything would happen, and even then you have to hold it in. The coffee maker in our room was corrupted. Made a mess everywhere and didn't even pour a cup of coffee. After midnight the room above us was throwing furniture around and screaming so we had to listen to that and to staff or police, no sure who walk around talking so loudly about trying to locate the room: I'm so annoyed it's after midnight! I still have a house in Pittsburgh and we could have stayed there for free, instead we wanted to treat ourselves when coming back to town. What a joke! The Champions restaurant inside was dirty and run down. Mediocre food, and the hostess could have cared less that we wanted to dine in! I'm so disappointed!!! Check out my review. This place needs to be examined. This is not up to standards of other Hilton DoubleTree locations!!
Pros: fitness center, attached restaurant & free parking. Cons: shower never worked & the room felt cramped.
Wonderful stay for New Year's Weekend. Tub was dated but room was clean and comfortable.
Is the description of this hotel not correct? Tell us


text:
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Forum:RC Painting, Detailing & Bodies


text:
Tabs for our Facebook Page
This project received 7 bids from talented freelancers with an average bid price of ₹3357 INR.Get free quotes for a project like this
Project BudgetN/A
Total Bids7
Project Description
We are almost on the verge of launching our first e-commerce venture - [url removed, login to view]
I need people who can develop our Facebook page for us. By that I mean development of Tabs such as a 'Welcome Tab', 'Customer Testimonials' tab, a 'Promotions' tab etc.
The invitation is ONLY for INDIAN designers who:
1. Can create visually stunning and professional tabs.
2. Time efficient punctual. No delays or dilly-dallying.
3. Will provide excellent phone support. NOT e-mail or chat support but excellent phone support.
The project is ONLY for Freelancers or people with a small team (max 2-3 people). Companies please excuse.
It will be an ongoing project and not just a one-time project.
PM me.
Skills Required
Looking to make some money?
- Set your budget and the timeframe
- Outline your proposal
- Get paid for your work
Hire Freelancers who also bid on this project
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- Forbes
- The New York Times
- Time
- Wall Street Journal
- Times Online


text:
Wordpress Layout - Map - CSS
This project was awarded to superior5 for $350 USD.Get free quotes for a project like this
Project Budget$250 - $750 USD
Total Bids8
Project Description
A WordPress website re-designed, I will provide graphics and text contents. Project is to implement new design, tweak CSS and implement Java Script to handle a Map. Map will show the americas and when people click on a place a window will popup showing details of a branch office. We will provide the graphics. Site has a homepage with a photo-slider, 4 info boxes with a mouse over effect and footer. Each internal pages have their own homepage with big photo and info boxes. One of the internal pages will have a photo-slider. Website is around 20 pages.
Current theme is mobile responsive but probably you will have to do some extra work to tweak and make sure site will work properly.
Awarded to:
Skills Required
Looking to make some money?
- Set your budget and the timeframe
- Outline your proposal
- Get paid for your work
Hire Freelancers who also bid on this project
Looking for work?
Work on projects like this and make money from home!Sign Up Now
- Forbes
- The New York Times
- Time
- Wall Street Journal
- Times Online


text:
Smith & Nephew ® Profore ® Lite Reduced Compression Bandaging System
Profore ® Lite is a multi-layer compression bandaging system comprised of a wound contact layer and three bandages, offering reduced compression from the original Profore ® Multi-layer High Compression Bandaging System. Specifically designed for the management of "mixed" etology leg ulcers where the patient has been identified to have some degree of arterial impairment which prevents the use of full compression. Kit contains everything necessary for the application of graduated compression therapy.
Customer Reviews
Write Your Own Review
Shipping Information, click here
View our easy return policy, click here
To log in to your account and request an RMA, click here


text:
Job Overview
The Bureau of Indian Affairs is the lead agency for the United States in carrying on a government-to-government relationship with the tribal nations. A challenging and dynamic place to work, it enhances the quality of life, promotes economic opportunity, and carries out the responsibility to protect and improve the trust assets of American Indians, Indian tribes and Alaska Natives.
#3300008A, Bureau of Indian Affairs,
Great Plains Regional Office, Division of Indian Services,
Branch of Human Services,
Aberdeen, South Dakota
GS-12: $69,497 - $90,344 Per Annum
GS-11: $57,982 - $75,376 Per Annum
GS-09: $47,923 - $62,297 Per Annum
INDIAN PREFERENCE: Preference in filling vacancies is given to qualified Indian candidates in accordance with the Indian Preference Act of 1934 (Title 25, USC, Section 472). Verification of Form BIA-4432 must be submitted with the application if claiming Indian Preference. Indian Preference eligibles that are not currently employed with the Federal service will be appointed under the Excepted Service Appointment Authority Schedule A, 213.3112(A)(7).
VETERANS EMPLOYMENT OPPORTUNITIES ACT (VEOA): Preference eligibles may apply for permanent positions (career or career-conditional appointments) under merit promotion procedures for VEOA appointments; however, veterans preference is not a factor in these appointments. To be eligible for a VEOA appointment, a veteran must be a preference eligible OR veteran separated after 3 or more years of continuous active service performed under honorable conditions. Applicants must submit a copy of their DD-214 for verification of eligibility. For more information, click here: http://www.fedshirevets.gov/job/shav/index.aspx#veoa
FORMER FEDERAL EMPLOYEES: Former Federal Employees are required to indicate whether they received a Voluntary Separation Incentive Payment (VSIP) buyout in their previous employment with the Federal government, and are required to submit a copy of the applicable Notification of Personnel Action (SF-50) regarding the VSIP. The majority of individuals, who accept reemployment with the Federal government within 5 years of receiving the VSIP amount, must repay the gross amount of the separation pay prior to reemployment.
NOTE: If the position is filled at a
lower grade level, subsequent promotion to the next grade level will be
processed without competition under the Merit Promotion Program at such time as
performance and qualification requirements are met and classification review discloses
the duties being performed properly warrant classification to the next higher
grade level.
SUMMARY OF DUTIES: The incumbent provides regional level direction for protective services for adults and children in need of protection. This includes the completion of assessments in accordance with 25 CFR 20.404, the development of distribution plans for supervised Individual Indian Money (IIM) accounts, and long range planning to meet the ongoing needs of the individual:
· Develops and monitors professional social work standards for a large geographical area.
· Provides essential technical assistance and training to field staff in areas of child and family services, protective services to eligible Indian clients, and tribal court involvement in protective services cases.
· Coordinates the work of child and family service program with the Office of Trust Funds Management, Tribal Operations and other activities of the Regional Office.
· Interprets broad Human Services policies, and works with tribal courts on the social factors to be considered in guardianships and assistance to children and adults in need of assistance.
· Provides direct Human Services, technical assistance and consultation to agencies and tribally contracted programs as needed.
· Participates in regional program reviews and evaluation of P.L. 93-638 tribal programs and recommends changes as needed.
· Conducts case reviews of supervised IIM accounts and reviews cases to determine the validity of individual case decisions and the adequacy of casework services.
· Provides consultation to superintendents with information and interpretation regarding Bureau Human Services regulations, procedures and advice and guidance in adopting these policies and procedures to local situations.
· Provides regional level director concerning information and referral services to individuals in utilizing the services of other agencies, and to programs in developing their own resources.
Travel Required
- Occasional Travel
- Occasional travel to attend to field work, meetings, and/or training.


text:
Restaurants, Davis Junction, IL
Countryside Meat's & Deli Inc
781 Highgrove Pl, Rockford, IL 61108
12.3 Miles
"build ur own sammy?really? best intown & great customer service! nicepriceon prochutto d...">
Alvarez Mexican Restaurant
205 E Riverside Blvd, Loves Park, IL 61111
14.7 Miles
"The best orignal mexican food in Rockford. Not all mexican restauarants have the service tha...">
Franchesco's Ristorante
7128 Perry Creek Pkwy, Rockford, IL 61107
14.6 Miles
"Had dinner there for the first time since they opened and wished I had gone sooner. I had t...">
City BBQ And Subs
5839 Forest Hills Rd, Rockford, IL 61114
14.5 Miles
"City BBQ & Subs offers fresh made to order BBQ and Subs. Many items to choose from at af...">
Panda Express
7046 Walton St, Rockford, IL 61108
12.7 Miles
"Great food, clean atmosphere, friendly & pleasant employees...what more could you ask fo...">
Sunrise Family Restaurant
5683 Wansford Way, Rockford, IL 61109
10.2 Miles
"We ate there on Wednesday night and waited in line for 45 min. which would be fine but they ...">
5611 E State St, Rockford, IL 61108
11.9 Miles
"I have been going to Lino's every since I can remember. In fact, there was not doubt where ...">
Deli Italia
507 E State St, Rockford, IL 61104
11.3 Miles
"If authentic means everything is pre-made or comes in a can - then yum. For me I'm on to the...">
Deli Italia II
3004 N Main St, Rockford, IL 61103
14.0 Miles
"This place is a poor attempt at authentic anything. You can go to Logli's and buy a can of p...">
Imperial Palace
3415 E State St, Rockford, IL 61108
11.5 Miles
"The food is just bad. there are no words to express how far you should stay away.">
Happy Wok
3137 N Main St, Rockford, IL 61103
14.1 Miles
"possibly the worst food I ever paid for. I did not eat more than a couple bites and it was D...">
Capri Restaurant & Pizza
313 E State St, Rockford, IL 61104
11.4 Miles
"I've always heard good things about this place, and just recently moved about a mile away fr...">
Subway Sandwiches
5655 N Junction Way, Davis Junction, IL 61020
.4 Miles
Number 1 Oriental Buffet
1229 Sandy Hollow Rd, Rockford, IL 61109
8.3 Miles
Taco John's
3269 S Alpine Rd, Rockford, IL 61109
9.1 Miles


text:
Chicken With Mushrooms, Mustard & Lemon
|Canned chicken broth
|6 Cup (96 tbs)
|3 Cup (48 tbs)
|2 , chopped
|Stalk celery
|1 , chopped
|1 Medium, sliced
|Whole chicken breasts
|Small white mushrooms
|1⁄2 Pound
|2 Teaspoon
|Lemons juice
|Ground pepper
|To Taste
|Flat anchovy fillets
|4 , chopped
|Olive oil
|1⁄2 Cup (8 tbs)
|To Taste
|Freshly ground pepper
|To Taste
Place broth, water, carrots, celery and onion in a large saucepan.
Bring to a boil.
Add chicken breasts.
Cover saucepan and reduce heat.
Simmer 40 to 50 minutes or until chicken is tender.
Wash and dry mushrooms thoroughly and slice thin.
Remove chicken from broth, reserving broth for other uses.
Set chicken aside until cool.
Bone and skin cooled chicken.
Slice meat into thin strips.
Place sliced chicken in a large salad bowl.
Add sliced mushrooms.
Combine mustard, lemon juice and salt and pepper in a small bowl.
Add anchovies and oil; mix to blend.
Taste and adjust anchovy dressing for seasoning, then pour over chicken mixture.
Toss gently.
Recipe Summary
Rate It
Nutrition Rank
Nutrition Facts
Serving size: Complete recipe
Calories 2074 Calories from Fat 1157
% Daily Value*
Total Fat 130 g200.6%
Saturated Fat 19.6 g98%
Trans Fat 0.1 g
Cholesterol 323.8 mg107.9%
Sodium 3095.9 mg129%
Total Carbohydrates 72 g23.9%
Dietary Fiber 12.3 g49.2%
Sugars 24.3 g
Protein 168 g335.8%
Vitamin A 414.2% Vitamin C 147.8%
Calcium 37.7% Iron 60.9%
*Based on a 2000 Calorie diet


text:
Scalloped Potatoes and Pork Chops RecipeRead Reviews Be the first to add a review
- 5 cups thinly sliced peeled potatoes
- 1 cup chopped onion
- Salt and pepper to taste
- 1 can (10-3/4 ounces) condensed cream of mushroom soup, undiluted
- 1/2 cup sour cream
- 6 pork loin chops (1 inch thick)
- Chopped fresh parsley
- In a greased 13-in. x 9-in. baking dish, layer half of the potatoes and onion; sprinkle with salt and pepper. Repeat layers. Combine the soup and sour cream; pour over potato mixture. Cover and bake at 375° for 30 minutes.
- Meanwhile in a nonstick skillet, brown pork chops on both sides. Place chops on top of casserole. Cover and bake for 30 minutes. Uncover and bake 15 minutes longer or until chops are tender. Sprinkle with parsley. Yield: 6 servings.
Medium-Bodied White Wine
Enjoy this recipe with a medium-bodied white wine such as Riesling or Gewürtztraminer
Reviews for Scalloped Potatoes and Pork Chops
"Delicious, one pan, easy, and very filling....just perfect for my family. Will make this recipe a part of our regular menu."
"My family enjoyed. An easy dish to make. Definitely a comfort meal.Field Editor"
"This is very good. I love scalloped potatoes. This recipe is much easier and faster than making a bechamel sauce from scratch. The onions and sour cream are very good."
"did not like the taste"
"Good, easy weeknight recipe. I added a little bit of milk to the sour cream/mushroom soup mixture."
"Delish and so easy, made this at least 15 times."
"This is a super easy & very tasty recipe. My hubby loves it as does everyone who comes over for a hearty meal. While the cream of mushroom soup may not be the healthiest option (that is one long list of ingredients on the can!), it is still a great standby recipe with ingredients that can easily be on hand at minimal expense. I've also found success in upping the cooking temp to make up for not enough alloted cooking time, which has worked perfectly. All around a great one!"
"Personally my best dish to make. Very simple and tasty. Made this plenty of times and has always been a personal favotite of mine and my family. Would recommend (don't let the mushroom soup scare you) !!!"


text:
Continuing to tweak the visual design for my app. Much happier now that I was in my last shot (rebounded). All of this is live in the app.
Check out the full version!
Feedback, comments, thoughts all welcome.
Also, come say hi on Twitter. I want to meet more cool people from Dribbble!
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Copyright © 2009–2017 Dribbble LLC. All screenshots © their respective owners. Shipped from Salem, Mass. USA.


text:
CLONESPACE is a 2D platformer with a projectile clone mechanic allowing you to create clones where you need them to solve puzzles. Take control of the Archetype and use your clones to advance through Professor Van Leech's test chambers and ultimately confront your creator.
*Please note that you can jump after falling from a tile/ledge. So you can effectively "air jump"*
Art & Design by FlashChaz
Programming by CKPEngine


text:
Let us know when your receive great advice so we can thank our lawyers and point others with similar questions in the right direction.Got it!
Our L1, L2 and EAD applications were filed concurrently. The current I-94 expiration date for both L1 and L2 applicants is July 31st, 2014. On July 30th, EAD application status changed to Card Production but both the L1 and L2 status are still showing as Initial Review. What could be the reason that EAD is approved before L1 and L2 extension? Thanks.
The EAD can not be approved unless the L-2 is approved.
Stop wasting time looking at the online 'status' system ... it is broken and inaccurate.
Start talking to the company's immigration lawyer.
Stay away from non-attorneys in HR.
PROFESSOR OF IMMIGRATION LAW for over 10 years -- This blog posting is offered for informational purposes only. It does not constitute an attorney-client relationship. Also, keep in mind that this is an INTERNET BLOG. You should not rely on anything you read here to make decisions which impact on your life. Meet with an attorney, via Skype, or in person, to obtain competent personal and professional guidance.
Post a free question on our public forum.Ask a Question
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text:
The tangible benefits of the Uruguay Round may not be felt for years, but the deal banishes the threat of a descent into protectionism and tit-for-tat trade wars.
In the next few years, some 400,000 jobs, according to one plausible survey, could be created in Britain. Economic research asserts that businesses and consumers in the European Union will emerge as the world's biggest beneficiaries from the new trade regime.
Further downward pressure on prices may emerge. The pounds 300-per-head cost of sustaining food mountains in the EU will, for instance, tumble and take food prices down in its wake. Tariffs on foreign goods will also subside, reducing prices for a whole range of goods for European consumers. A Gatt deal, in addition, removes the risk of higher prices which would follow increased protectionism.
If the Gatt talks had failed, confidence would have been the first victim as uncertainty over government trade policies grew. Crumbling confidence would probably have meant lower investment and eventually weakening consumption.
Now, however, businesses which held back investment and expansion plans as the Gatt talks dragged on are more likely to press ahead with their plans. Ultimately, a rise in business optimism should feed through to consumer sentiment as uncertainty over the future diminishes. Research by the Massachusetts Institute of Technology showed that the greatest period of 20th century trade liberalisation, from 1950 to 1973, saw not only the quickest rate of growth in world trade but also the fastest growth rates for output, capital investment and productivity for more than a century.
There is plenty of historical evidence to support the conclusion that, in the long term, the benefits to the world economy from freer trade are significant. The Organisation for Economic Co-operation and Development and the World Bank estimate that the annual gain in global income could range between dollars 210bn (pounds 141bn) and dollars 270bn by the year 2002. Even these figures, derided by some economists as 'science fiction', may prove to be underestimates because the studies do not take account of the liberalisation of trade in services, increasingly the mainstay of most industrialised economies, under the Uruguay Round.
But in the short run, fresh worries over job prospects could emerge as industries are forced by a more liberal trade regime and more intensive competition to become lean and low-cost.
The dismantling of trade barriers under the new Gatt regime is, moreover, likely to speed up the globalisation of the world economy. Although barriers to trade are still being broken down, capital can move more or less freely across the globe. Over the past few years, capital has become increasingly footloose, moving rapidly to countries or regions where the greatest profits are available. The speed with which capital now moves offers little time for societies to adjust to the resulting economic and social upheaval. The coal industry has taken decades to expire in Britain, but the severe impact of Gatt and globalisation on the unprofitable high-cost European car industry may be swifter.
- More about:
- Europe
- Oecd
- Productivity
- Protectionism


text:
Dell executives, industry leaders, global customers and channel partners share insights and perspectives on our end-to-end strategy for meeting customers' needs.
Simplify complex database technologies and ensure optimal database performance across physical, virtual and cloud environments. Our award-winning Database Management solutions help you automate routine tasks, provide high-quality data, standardize database performance monitoring, drive greater data availability and become more agile. Learn how in this short video.
Duration: 02:25
Learn why Dell Software is the leader in Active Directory, Exchange, SharePoint and Office 365 with modernization solutions that help organizations get future ready and keep pace with evolving business priorities.
Duration: 01:58
More than 180 million users have trusted Quest solutions to migrate, manage and secure data across their Active Directory, Exchange, SharePoint, Skype for Business and Office 365 platforms. Whether your platforms are on-premises, in the cloud or hybrid, Quest solutions make infrastructure migration and management easy – so you spend less time on maintenance and more innovation.
Duration: 02:40
The amount network-connected devices you manage is quickly multiplying – but are they secure, provisioned and tracked? Quest's endpoint systems management solutions provision, manage, secure and service every single device faster than you thought possible.
Duration: 01:45
Learn how governance, risk and compliance solutions you easily assess, audit, remediate and manage system and user activity across multiple platforms.
Duration: 02:19
The new Quest has arrived – but how did we get here, and what does that mean to you? See how we're building upon an exceptional past for an unprecedented future – and how you can join the innovation.
Duration: 04:02
Join the Innovation with Quest.
Duration: 00:30
Bill Evans, One Identity's Senior Director of Product Marketing, shares what's changed, what hasn't and what to expect from the new One Identity
Duration: 02:03
With you, we begin our journey towards boundless innovation aimed at reducing administration. We'll deliver solutions that ensure that productivity, simplicity and value are synonymous, not exclusive. This is who we are and how we do business. And we invite you to join the innovation.
Duration: 01:48
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Springbok hooker Bismarck du Plessis has moved to end the furore surrounding referee Romain Poite following last week's loss to NZ.
Springbok hooker Bismarck du Plessis has moved to end the furore surrounding referee Romain Poite following last week's controversial loss to the All Blacks.
Du Plessis insists he bears no hard feeling towards the French official following his incorrect yellow card for a tackle on Dan Carter that eventually led to the hooker being sent off for a second yellow later in the game.
"I have no hard feelings and bear no grudges," Du Plessis told The Star.
"The reaction of world rugby has been extensive and with so much emotions being part of the game and part of being a rugby spectator it is understandable. It needs to be mentioned though that I am in no position to criticise anyone.
"I do not expect an apology. I have no doubt that Mr Poite had no ill intentions towards the Springboks or me. It must have been a great occasion for him to have been awarded a Test match viewed as arguably the greatest clash in world rugby.
"The commentary in the media must have an immense impact on him. I feel sorry for him and I do not want him to be banished from the rugby fraternity or to be viewed as a 'villain'. I bear no grudges against him and I have no doubt that he tried his best out there on the field."


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Creating a Custom Payment Form with Stripe.js
This tutorial helps you build your first payment form with Stripe. If you need help after reading this, check out our answers to common questions or chat live with other developers in #stripe on freenode.
Processing payments with Stripe has two components:
- Securely collecting the payment details
- Using the collected payment method in a charge request
This tutorial explains how to use HTML and Stripe.js, our foundational JavaScript library, to implement the first component. There are three steps:
- Collecting credit card information with Stripe.js
- Converting those payment details to a single-use token
- Submitting that token, with the rest of your form, to your server
The above steps assume you have a typical HTML payment form:
<form action="/your-charge-code" method="POST" id="payment-form">

Card Number
<input type="text" size="20" data-stripe="number">

Expiration (MM/YY)
<input type="text" size="2" data-stripe="exp_month">
 /
<input type="text" size="2" data-stripe="exp_year">

<input type="text" size="4" data-stripe="cvc">

Billing ZIP Code
<input type="text" size="6" data-stripe="address_zip">
<input type="submit" class="submit" value="Submit Payment">
The HTML is fairly standard, but note how every input for sensitive data—number, CVC, expiration, and ZIP code—omits the
name attribute. By omitting a
name, the user-supplied data in those fields won't be passed to your server when the form is submitted. Each element also includes a
data-stripe attribute, to be discussed later.
With Stripe.js, you never have to handle sensitive card data. It's automatically converted to a representative token that you can safely send to your servers and use to charge your customers.
Step 1: Collecting credit card information
To securely collect the credit card information, first include Stripe.js in your page:

To prevent problems with some older browsers, put the script tag in the page
 or as the final line in the
 at the end of your code.
To best leverage Stripe's advanced fraud functionality, include Stripe.js on every page on your site, not just the checkout page.
In a separate script tag, after the above, set your publishable key: