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Published 01-13-14
Submitted by JPMorgan Chase & Co.
A consortium of investment banks today announced their support of the Green Bond Principles – Bank of America Merrill Lynch, Citi, Crédit Agricole Corporate and Investment Banking, JPMorgan Chase, BNP Paribas, Daiwa, Deutsche Bank, Goldman Sachs, HSBC, Mizuho Securities, Morgan Stanley, Rabobank and SEB. These Principles were developed with guidance from issuers, investors and environmental groups and serve as voluntary guidelines on recommended process for the development and issuance of Green Bonds. They encourage transparency, disclosure and integrity in the development of the Green Bond market.
These Green Bond Principles suggest process for designating, disclosing, managing and reporting on the proceeds of a Green Bond. They are designed to provide issuers with guidance on the key components involved in launching a Green Bond, to aid investors by ensuring the availability of information necessary to evaluate the environmental impact of their Green Bond investments and to assist underwriters by moving the market towards standard disclosures which facilitate transactions.
These Principles build on first-to-market issuances by multilaterals and provide a platform for other future Green Bond issuers to direct funding to Green Projects. They are complemented by an appendix of established definitions of Green Project categories that were developed by multilaterals, non-profit and non-government organizations and other relevant stakeholders. Read more about the Green Bond Principles here.
The four banks that served as a drafting committee for these Principles – Bank of America Merrill Lynch, Citi, Crédit Agricole Corporate and Investment Banking and JPMorgan Chase – will propose in 2014 a governance process that will allow for diverse stakeholder input into the Green Bond Principles. It is anticipated that an independent third party will be designated to serve as a secretariat whose administrative duties will include facilitating information exchange with issuers, investors, underwriters, and other stakeholders such as non-profit environmental organizations, non-government organizations, academics and other thought leaders.
Bank of America
"The development of a robust and liquid market for green bonds is an important progression for debt markets," said Suzanne Buchta, Global Co-head of Green Debt Capital Markets at BofA Merrill. "In co-authoring these principles we attempt to help standardize the product and we hope to catalyze investment into environmentally sustainable projects, something to which our firm is very committed."
"Citi is proud to be a co-founder of the Green Bond Principles as a voluntary guideline for bond issuers who are deploying capital to environmentally beneficial purposes," said Michael Eckhart, Citi's Global Head of Environmental Finance. "Our experience placing Green Bonds to date suggests that this will be a helpful guideline for corporate and public sector issuers."
Crédit Agricole CIB
Tanguy Claquin, Managing Director at Crédit Agricole CIB commented, "We are very pleased to have co-authored and announced the establishment of the Green Bond Principles. This is an important first step towards a more coherent approach to the market of Green and Sustainability Bonds, which will ultimately increase its attractiveness for investors thus encouraging investments into sustainability projects."
JPMorgan Chase & Co.
"Increasing the amount of capital targeted to address pressing environmental challenges such as climate change is critical," said Marilyn Ceci, Managing Director in the Corporate & Investment Bank at JPMorgan Chase. "JPMorgan Chase is pleased to have co-authored the Green Bond Principles, which involved strong collaboration among colleagues in our Corporate & Investment Bank and Environmental Affairs office. By providing transparency and integrity to the Green Bond market and bolstering investor confidence, we expect the Green Bond Principles will expand capital allocation to projects that provide environmental benefits."
BNP Paribas
"BNP Paribas is proud to partner with our fellow institutions to support the development of a robust Green Bond Market. Today's announcement is a crucial early step to foster the creation of a new transparent marketplace for socially responsible capital-raising and investment," said Jim Turner, Head of Debt Capital Markets for North America.
"The GBP is a wake-up call. It will help bring this most important product and its message to the forefront and into the mainstream bond world," said Jose Padilla, Head of US Debt Capital Markets at Daiwa.
Deutsche Bank
"As a carbon neutral bank, Deutsche Bank believes that the new Principles will play an important role in unlocking the green market capital necessary to finance the transformation to a cleaner and more sustainable future. We are pleased to be part of this collaborative effort," said Hakan Wohlin Deutsche Bank's Global Head of Debt Origination.
Goldman Sachs
"We are excited about continued developments in the area of green bonds as an important mechanism through which we can help harness the deep and liquid fixed income capital base for environmentally beneficial solutions," said Martin Weber, Head of SSA and Growth Markets Origination. "Goldman Sachs has had a long standing commitment to furthering market-based solutions to address critical environmental issues and we look forward to helping further catalyze financing and investments."
"The Green Bond market grew fivefold last year, with USD10 billion raised by the public sector, corporates and financial institutions. The Green Bond Principles are an excellent initiative to increase transparency and disclosure in this market, and to foster continued growth in investments which help combat climate change," said Ulrik Ross, Managing Director at HSBC.
Mark Wheatcroft, Head of Debt Capital Markets at Mizuho International commented: "Mizuho is proud to support the development of the Green Bond Principles, which will act as a measure of quality assurance for all involved in this exciting and developing market."
Morgan Stanley
"Morgan Stanley is proud to be one of the leading underwriters of Green Bonds, with USD 4.75 billion of issuance across 7 Supranational, Agency and Corporate deals in 2013," said Navindu Katugampola, Vice President at Morgan Stanley. "We believe that the Green Bond Principles will help act as a catalyst to develop this rapidly growing market, by providing a clear set of voluntary guidelines for issuers, investors and underwriters. We are exceptionally pleased to support this effort as part of our overall commitment to sustainable finance."
"The world faces enormous challenges in the next 40 years. It needs investments that are not only large scale but also focused: financing sustainable food production and supply, growing energy demands, sustainable basic materials and more. Rabobank is proud to be part of the Green Bonds Principles and to be able to contribute to the future developments in this initiative. We will use our knowledge of amongst others sustainable agriculture, food & beverage sectors, renewable energy and developments in the biobased and circular economy. Having been involved in several sustainable Green Bonds we are convinced this will be of help to grow this important market," said Marco Roddenhof, Global Head Capital Markets Rabobank International.
"It has been a great pleasure, as a co- founder of the green bond market, to take part in the ongoing development of the market and thereby acknowledge the trust we have been shown by our investors and the issuers we represent. We believe the principles will secure a common understanding and thereby create the homogenous market development needed to allow further growth," said Christopher Flensborg, Head of Sustainable Products and Product Development at SEB.
Bank of America
Bank of America is one of the world's largest financial institutions, serving individual consumers, small- and middle-market businesses and large corporations with a full range of banking, investing, asset management and other financial and risk management products and services. We serve approximately 51 million consumer and small business relationships with approximately 5,200 retail banking offices and approximately 16,200 ATMs and award winning online banking with 30 million active users and more than 14 million mobile users. Bank of America is among the world's leading wealth management companies and is a global leader in corporate and investment banking and trading across a broad range of asset classes, serving corporations, governments, institutions and individuals around the world. Bank of America offers industry-leading support to approximately 3 million small business owners through a suite of innovative, easy-to-use online products and services. The company serves clients through operations in more than 40 countries. Bank of America Corporation stock (NYSE: BAC) is listed on the New York Stock Exchange.
Kerrie McHugh
Bank of America Merrill Lynch
Citi, the leading global bank, has approximately 200 million customer accounts and does business in more than 160 countries and jurisdictions. Citi provides consumers, corporations, governments and institutions with a broad range of financial products and services, including consumer banking and credit, corporate and investment banking, securities brokerage, transaction services, and wealth management. Additional information may be found at www.citigroup.com | Twitter: @Citi | YouTube: www.youtube.com/citi | Blog: http://new.citi.com | Facebook: www.facebook.com/citi | LinkedIn: www.linkedin.com/company/citi
Tyler Daluz
Crédit Agricole CIB
Crédit Agricole CIB is the Corporate and Investment Banking arm of the Crédit Agricole Group, the world's fifth largest bank by total assets (The Banker, July 2013).
Crédit Agricole CIB offers its clients a comprehensive range of products and services in capital markets, investment banking, structured finance and corporate banking.
The Corporate and Investment Bank is structured around four major divisions:
The Bank provides support to clients in large international markets through its network with a presence in major countries in Europe, America, Asia and the Middle East.
For more information, please visit its website at www.ca-cib.com.
Teresa Wincrantz
Crédit Agricole CIB
JPMorgan Chase & Co.
JPMorgan Chase & Co. (NYSE: JPM) is a leading global financial services firm with assets of $2.5 trillion and operations worldwide. The Firm is a leader in investment banking, financial services for consumers and small businesses, commercial banking, financial transaction processing, asset management and private equity. A component of the Dow Jones Industrial Average, JPMorgan Chase & Co. serves millions of consumers in the United States and many of the world's most prominent corporate, institutional and government clients under its J.P. Morgan and Chase brands. Information about JPMorgan Chase & Co. is available at www.jpmorganchase.com.
Jennifer Kim
JPMorgan Chase & Co.
BNP Paribas
BNP Paribas Corporate and Investment Banking (CIB) is a leading provider of solutions to a wide range of clients including corporates, sovereigns, financial institutions and investors worldwide. Approximately 19,000 professionals in 45 countries provide clients with personalized services for managing their risks and assets, financing and expanding their business and servicing their operational needs.
BNP Paribas CIB excels in:
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Advisory and Capital Markets – where it is a top European house in ECM and a global leader in DCM (bond, convertibles and equity issuance). www.cib.bnpparibas.com
Celeste Brown
Phone: +44-207-595-2436
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Daiwa Capital Markets is the international investment banking arm of Japan's Daiwa Securities Group. Daiwa Capital Markets works in close collaboration with Daiwa Securities in Japan and other Daiwa companies globally. As one of the leading, comprehensive financial service firms in Asia, Daiwa Securities Group operates core businesses such as Retail, Global Markets, Global Investment Banking, Asset Management, and Investment.
Isabel deJesus
Deutsche Bank
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Goldman Sachs
The Goldman Sachs Group, Inc. is a leading global investment banking, securities and investment management firm that provides a wide range of financial services to a substantial and diversified client base that includes corporations, financial institutions, governments and high-net-worth individuals. Founded in 1869, the firm is headquartered in New York and maintains offices in all major financial centers around the world.
Andrew Williams
Tel: +1 212-357-0005
HSBC Holdings plc, the parent company of the HSBC Group, is headquartered in London. The Group serves customers worldwide from around 6,600 offices in 81 countries and territories in Europe, the Asia-Pacific region, North and Latin America, and the Middle East and North Africa. With assets of US$2,693bn at 31 December 2012, the HSBC Group is one of the world's largest banking and financial services organisations.
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OVERVIEW: What every practitioner needs to know
Are you sure your patient has acute otitis media? What are the typical findings for this disease?
Acute onset of signs and symptoms of middle ear effusion (MEE) and middle-ear inflammation, usually within the 48 hours preceding presentation, are required for the diagnosis of acute otitis media (AOM).
The 2013 AAP Guideline on the Diagnosis and Management of Acute Otitis Media emphasizes the need for accurate diagnosis, using strict otoscopic criteria for sound clinical decision-making.
AOM should be diagnosed in children with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea, not due to otitis externa
Continue Reading
AOM should be diagnosed in children with mild bulging of the TM and recent onset of ear pain or intense erythema of the TM
AOM should not be diagnosed in children who do not have MEE based on pneumatic otoscopy and/or tympanometry
Middle-ear effusion signs
Signs of middle ear effusion include the following:
Tympanic membrane (TM) bulging
Limited or absent mobility of the TM on pneumatic otoscopy
Air-fluid level behind TM
The American Academy of Pediatrics and the American Academy of Family Physicians consensus guidelines for the management of AOM (2004) recommend pneumatic otoscopy with or without supplementary tympanometry or acoustic reflectometry to confirm these findings or direct demonstration of fluid by tympanocentesis. The AAP 2013 Guideline reaffirms pneumatic otoscopy as the standard for diagnosis of OM.
Middle-ear inflammation signs and symptoms
Evidence of middle ear inflammation includes the following:
Distinct TM erythema and/or moderate to severe TM bulging
Otorrhea through a perforation or a tympanostomy tube
Distinct otalgia clearly related to the ear(s) interfering with normal activity or sleep
What other disease/condition shares some of these symptoms?
Viral upper respiratory infection may present with acute symptoms that overlap with AOM such as fever and apparent otalgia, i.e., ear pulling, but may not have MEE with signs/symptoms of middle-ear inflammation which are required for the diagnosis of AOM. Otitis media with effusion (OME) presents with MEE, and varying degress of hearing loss, without signs or symptoms of acute ear infection.
Bullous myringitis presents with blisters on the TM but lacks MEE which is required for the diagnosis of AOM.
Acute otitis externa is generalized inflammation of the external ear canal of rapid onset and may present with otalgia and otorrhea, but does not cause MEE or middle-ear inflammation, which are required for the diagnosis of AOM.
Diagnosis of AOM is challenging, because of difficulties in performing otoscopy in young children, who may be uncooperative or have cerumen in the ear canals. A crying child may have TM erythema, but no bulging or middle ear effusion, and AOM should not be diagnosed.
What caused this disease to develop at this time?
Infants and children less than 2 years of age are most likely to develop acute otitis media. Precipitating factors and underlying conditions that contribute to the likelihood of developing acute otitis media include the following:
Genetic predisposition: relative to mother, father, or sibling
Male gender
Native American/Inuit ethnicity
Family history of recurrent otitis media (rAOM) (three AOM episodes in 6 months, or four in 12 months, with at least one episode in the last 6 months)
Premature birth
Viral upper respiratory infection
Influenza infection
Craniofacial defect affecting the eustachian tube function and thus middle ear aeration, such as Down syndrome and cleft palate
Environmental factors associated with an increased likelihood of developing acute otitis media include the following:
Low socioeconomic status
Siblings in the household
Day care or child center attendance
Tobacco smoke exposure
Supine bottle feeding
Not breast fed
What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
AOM is diagnosed clinically based on otoscopic findings and history. Children with AOM refractory to therapy, or who have overt or impending complications of OAM, may require tympanocentesis or myringotomy for drainage and culture of the middle ear.
Children with recurrent AOM or persistent OME may require comprehensive audiologic testing to assess hearing and to determine candidacy for tympanostomy tube replacement.
Would imaging studies be helpful? If so, which ones?
Imaging studies are not useful for diagnosis of AOM in children. Children with intratemporal or intracranial complications of AOM, require imaging with contrast-enhanced computed tomography and/or magnetic resonance imaging.
Confirming the diagnosis
The diagnosis of AOM requires (1) acute onset of signs and symptoms of (2) middle ear effusion (MEE) and (3) middle-ear inflammation, usually within the 48 hours preceding presentation.
Evidence is limited on clinician accuracy and precision in identifying the three required clinical criteria for the diagnosis of AOM. In one study, of those children with MEE diagnosed by tympanocentesis, 97% had a type B tympanogram and all had an otoscopic exam consistent with AOM. In another study, 78% of AOM cases diagnosed by a general practitioner were confirmed by an otolaryngologist.
Symptoms: in a systematic review of four studies, ear pain and ear rubbing were reported to be modestly associated with the diagnosis of AOM though a more recent study suggests severity of parent-reported symptoms, including ear rubbing, ear pain, and fever, were not associated with AOM diagnosis.
Otoscopic signs: a cloudy, bulging, immobile, or red tympanic membrane on otoscopy have been found to be positively associated with AOM.
If you are able to confirm that the patient has acute otitis media, what treatment should be initiated?
The child with AOM should be assessed for pain. The mainstay for treatment of pain from AOM is administration of acetaminophen and/or ibuprofen.
The American Academy of Pediatrics and the American Academy of Family Physicians published consensus guidelines for the management of AOM in 2004, and this was updated by the AAP in 2013. The guidelines in 2004, introduced the concept of observation without initial antibiotic therapy for some children with AOM, and the recommedations regarding observation versus prompt treatment were refined in the 2013 guideline. The differences in the recommendations of the 2004 and 2013 guidelines are listed in Table I (See Table I).
Table I.
|Certain Diagnoses;
|Uncertain Diagnosis
|Severe illness†
|Nonsevere illness
|Severe illness
|Nonsevere illness
|<6 months
|Antibacterial therapy
|Antibacterial therapy
|Antibacterial therapy
|Antibacterial therapy
|6 months to 2 years
|Antibacterial therapy
|Antibacterial therapy
|Antibacterial therapy
|Observation option‡
|>=2 years
|Antibacterial therapy
|Observation option
|Observation option
|Observation option
;Certain diagnosis: All 3 criteria met, i.e. rapid onset, MEE, middle-ear inflammation.
†Severe illness: moderate to severe otalgia and 339°C
‡Observation option: otherwise healthy children observed of antibacterial therapy with symptomatic relief measures, e.g. analgesia, with follow-up ensured either by family-initiated visit or phone call, scheduled follow-up appointment, phone follow-up, or antibiotic prescription filled by the family if symptoms persist or worsen; antibacterial therapy if symptoms persist 48-72 hours or worsen
The decision to use antibiotics at the time of initial diagnosis of AOM depends on the patient's age, whether AOM is unilateral or bilateral, the severity of symptoms, and whether otorrhea is present. These issues are listed below.
The decision to treat AOM with antibiotics at the time of diagnosis OR to observe with close follow up (and treatment for persistent symtoms / signs) should include:
Parental / caregiver input for shared decision making.
Ability to clinically assess patients in follow up for improvement or worsening.
Understanding that children under 6 months of age, children with bilateral AOM, and children with AOM causing otorrhea should be treated with antbiotics at the time of diagnosis.
Understanding that children with severe symptoms, such as prolonged or severe pain, or high fever should be treated with antibiotics at the time of diagnosis.
Understanding the controversies about the need to use antibiotics initially in chidren between the ages of 6 and 24 months, who have AOM with mild or moderate symptoms.
If antibiotic therapy is selected for treatment of a child with AOM, the AAP 2013 Guidelines recommend:
First-line treatment: High dose amoxicillin (80-90mg/kg/day), with consideration of amoxicillin-clavulanate (amoxicillin 90 mg/kg/day-clavulanate 6.4mg/kg/day) for children who have received amoxicillin in the previous 30 days or who have the otitis-conjunctivitis syndrome.
Alternatives for penicillin allergic patients, include cephalosporins such as cefnidir or cefuroxime.
Antibiotic treatment for children with apparent treatment failure of initial antibiotic therapy after 48-72 hours include amoxicillin-clavulanate or ceftriaxone IM (three daily injections).
Alternative treatments for children who fail initial therapy, include ceftriaxone IM, combined therapy with clindamycin and a third-generation cephalosporin.
Tympanocentesis/myringotomy can be performed for treatment failures to obtain cultures to direct antimicrobial therapy.
Recurrent AOM (rAOM)
Some children diagnosed with AOM have a history recurrent AOM (rAOM) as previously defined.
Prophylactic or suppressive antibiotics are not recommended for children with rAOM. RCTs suggest that long-term antibiotics will decrease the episodes of AOM by only 0.09 episodes per month.
Tympanostomy tube placement has been used to prevent rAOM in some children. The benefits of tube placement for prevention of AOM episodes are small. A recent guideline on the use of tympanostomy tubes in children has recommended: 1) Otherwise healthy children with a history of rAOM who have normal ear examination at the time of assessment for tubes should NOT have tympanostomy tubes placed and 2) Otherwise healthy children with a history of rAOM who have middle ear effusions in one or both ears at the time of assessment can be offered tympanostomy tubes. This reflects the small benefit of tubes for rAOM, the favorable natural history of rAOM in children, and the uncertainties in diagnosis of AOM in general.
AOM with an indwelling tympanostomy tube will present with otorrhea
A recent guideline from the American Academy of Otolaryngology-Head and Neck Surgery strongly recommends use of ototopical antibiotic drops, and NOT oral antibiotics, for acute tube otorrhea. Antibiotic drops are effective and have fewer adverse reactions.
Systemic oral antibiotics can be considered for tube otorrhea in the following circumstances: persistent otorrhea despite treatment with drops, impaired delivery of drops by an obstructed ear canal or an uncooperative child, contralateral otitis media behind an intact TM, and concern for more severe disease (severe symptoms, immune compromise, other site of bacterial infection, etc.).
What are the adverse effects associated with each treatment option?
Various adverse effects with the use of antibacterial therapy for AOM have been reported dependent on the specific antibiotic, including:
Gastrointestinal: stomatitis, taste perversion, vomiting, abdominal pain, abdominal discomfort, abdominal distension, gastrointestinal distress, diarrhea, abnormal stool, constipation
Dermatologic: rash, urticaria, erythema multiforme, moniliasis, pruritis, sweating
Respiratory: respiratory disorder, cough
Neurologic: headache, dizziness, otalgia, nervousness, somnolence, burning, crying, pain
Otolaryngologic: ear discomfort, ear irritation, ear discharge, ear debris, ear precipitate, eardrum edema, eardrum hyperemia, ear pruritis, tinnitus, rhinitis
Systemic: fever
The risks associated with antibiotic therapy depend on the specific antibiotic, but the evidence is incomplete. Based on the available literature, the following significant differences in antibiotic risks were identified:
With amoxicillin therapy 3 to 10 children out of 100 with uncomplicated AOM will develop a rash and 5 to 10 will develop diarrhea
Amoxicillin (14%) is associated with a lower rate of diarrhea than cefixime (21%)
Amoxicillin-clavulanate (20%) is associated with a higher rate of diarrhea than single-dose ceftriaxone (9%)
Amoxicillin-clavulanate (26%) is associated with a higher rate of any adverse event compared with 5 days of azithromycin (9%)
The adverse effects of tympanostomy tube placement, include adverse reaction to anesthetic agents, need for repeated tube placement, otorrhea, persistent tympanic membrane perforation, and long-term TM changes such as retraction/tympanosclerosis.
The risks of anesthesia in an otherwise healthy child is remote
The need for replacement of tympanostomy tubes post-extrusion can approach 25%
Tympanosclerosis has been seen in 32% of patients followed long-term after tube placement
TM perforation can occur in 2-18% of patients after tube extrusion, depending on the type of tube used and clinical circumstances
What are the possible outcomes of acute otitis media?
Prognosis: approximately 80 children out of 100 with uncomplicated AOM will get better in 3 days without antibiotics, while with immediate treatment with amoxicillin an additional 12 children would improve.
Two recent studies suggest that children 6-23 and 6-35 months of age respectively, with AOM, may have greater benefit with antibacterial therapy than placebo. These RCTs used amoxicillin-clavulanate in the treatment arms and had strict criteria for diagnosis of AOM.
While resolution of AOM is the rule, some children will:
Develop intracranial or intratemporal suppurative complications (see below)
Experience recurrent AOM
Fail to clear middle ear effusion and develop OME with possible associated conductive hearing loss
What causes this disease and how frequent is it?
AOM is a viral or bacterial infection of the middle ear and is one of the most common childhood infections treated with antibiotics in the United States.
In a study done in 1991-1994, that followed children through the first 6 months of life, 39% of infants0 had an episode of AOM and 20% had recurrent otitis media (ROM) by 6 months of age. Eight million, eight hundred thousand children (11.8%) under the age of 18 years were reported to have ear infections in the United States inn 2006, with an estimated total treatment cost of $2.8 billion.
Bacterial pathogens found in middle ear effusions of children with AOM include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Since the introduction of heptavalent pneumococcal conjugate vaccine non-type b H. influenzae has become more prevalent as a cause of AOM, though S. pneumoniae remains an important etiologic agent with a greater proportion of episodes caused by non-vaccine serotypes. The 13-valent pneumococcal vaccine was licensed in 2010, and may additonally shift the microbiology of AOM.
How do these pathogens/genes/exposures cause the disease?
Viral upper respiratory infections can cause functional impairment of Eustachian tube function, leading to middle ear effusion and bacterial infection.
Children with craniofacial defects affecting the Eustachian tube and the middle ear, such as children with Down Syndrome or cleft palate, and children with immunodeficiencies are predisposed to infection of the middle ear by these pathogens. One twin study found genetic predisposition for time with middle ear effusion and frequency of AOM.
What complications might you expect from the disease or treatment of the disease?
Serious complications of AOM are rare and include:
Systemic complications, such as bacteremia
Intratemporal complications, such as facial nerve paralysis, mastoiditis, lateral sinus thrombosis, labyrinthitis
Intracranial complications, such as meningitis, brain abscess, otitic hydrocephalus
AOM may cause a TM perforation, but healing is the rule with appropriate therapy for AOM. Other complications include hearing loss, tympanosclerosis, middle ear atelectasis, and cholesteatoma, when AOM is severe, recurrent, or accompanied by long-term Eustachian tube dysfunction.
The adverse effects of medical and surgical treatment of AOM are discussed in prior sections.
How can acute otitis media be prevented?
A variety of measures have been reported to reduce the frequency of AOM in childhood. They include the following:
Influenza vaccines had more than 30% efficacy in AOM prevention in children older than 2 years.
The heptavalent pneumococcal conjugate vaccine was associated with an efficacy in preventing AOM from all causes of 5.8% and 8.3%. A decrease in OM visits in children older than 2 years of age was associated with the introduction of the 13-valent pnuemococcal vaccine in 2010.
Behavioral factors:
Reduction or elimination of pacifier use in the second 6 months of life is postulated to reduce AOM in infancy.
Nutritional factors:
Breastfeeding for the first 6 months helps prevent early episodes of AOM.
Avoidance of supine bottle feeding is postulated to reduce AOM in infancy.
Environmental factors:
Alteration of child care center attendance patterns can reduce recurrent AOM incidence.
Elimination of exposure to tobacco smoke is postulated to reduce AOM in infancy.
What is the evidence?
Lieberthal, AS, Carroll, AE, Chonmaitree, T, Ganiats, TG. "The diagnosis and treatment of acute otitis media". Pediatrics. vol. 131. 2013. pp. e964-999. (Updated clinical practice guideline on AOM from the American Academy of Pediatrics.)
Marom, T, Tan, A, Wilkinson, GS, Pierson, KS, Freeman, JL, Chonmaitree, T. "Trends in otitis media related health care use in the United States, 2001-2011". JAMA Pediatr. vol. 168. 2014. pp. 68-75. (Analysis of an insurance claims database demonstrates a downward trend in OM-related healthcare use over the study period, with a decrease in OM-related use in children under 2 years associated with introduction of Prevnar-13.)
Rosenfeld, RM, Schwartz, SR, Pynonnen, MA, Tunkel, DE. "Clinical practice guideline: tympanostomy tubes in children". Otolaryngol Head Neck Surg. vol. 149. 2013. pp. S-35. (AAOHNS published this guideline about evaluation and indications for tympanostomy tubes and after care for children with indwelling tubes.)
Rettig, E, Tunkel, DE. "Contemporary concepts in management of acute otitis media in children". Otolaryngol Clin North Am. vol. ; 47. 2014. pp. 651-772. (Review of trends in AOM management based on recent evidenced based guidelines.)
"American Academy of Pediatrics and American Academy of Family Physicians. Diagnosis and management of acute otitis media". Pediatrics. vol. 113. 2004. pp. 1451-1465. (The AAP and AAFP published this consensus guideline on diagnosis and management of AOM based on the best evidence available through September 2003 and addressed issues related to diagnosis; pain assessment; management with and without antibiotics; prevention; and complementary and alternative medicine. This guideline advanced the concept of initial observation before antibiotic therapy for some with AOM.)
Shekelle, PG, Takata, G, Newberry, SJ, Coker, T, Limbos, M, Chan, LS. "Management of Acute Otitis Media: Update. Evidence Report/Technology Assessment No. 198. (Prepared by the Southern California Evidence-Based Practice Center under Contract No. 290 2007 10056 I)". November 2010.
Coker, TR, Chan, LS, Newberry, SJ, Limbos, MA, Suttorp, MJ, Shekelle, PG, Takata, GS. "Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children". JAMA. vol. 304. 2010 Nov 17. pp. 2161-2169. (The technical report describes in detail and the article summarizes the systematic review requested by the AAP to serve as the evidence base for the AAP's update of the 2004 AAP/AAFP consensus guideline on diagnosis and management of AOM and addresses issues related to diagnosis; epidemiology; and management with and without antibiotics.)
Hoberman, A, Paradise, JL, Rockette, HE, Shaikh, N, Wald, ER, Kearney, DH. "Treatment of acute otitis media in children under 2 years of age". N Engl J Med. vol. 364. 2011. pp. 105-15.
Tahtinen, PA, Laine, MK, Huovinen, P, Jalava, J, Ruuskanen, O, Ruohola, A. "A placebo-controlled trial of antimicrobial treatment for acute otitis media". N Engl J Med. vol. 364. 2011. pp. 116-26.
The Hoberman and Tahtinen studies show small benefits of amoxicillin-clavulanate therapy for young children with AOM.
Ongoing controversies regarding etiology, diagnosis, treatment
The 2013 AAP AOM guideline eliminated the "uncertain diagnosis" category contained in the 2004 AOM guideline. This brings to light difficulties in accurate diagnosis of AOM in a "real world" clinical setting, requiring experience with cerumen management and pneumatic otoscopy in young children.
Debate continues about initial observation, versus immediate antibiotics at the time of diagnosis for some children with AOM. Two recent studies referenced above showed measureable benefits for active treatment with antibiotics, but the clinical relevance of these benefits are debated in the background of favorable natural history of AOM, side effects of antibiotic therapy, and the concerns about bacterial resistance from widespread use of antibiotics.
The role of tympanostomy tubes for recurrent AOM is debated, as the impact is small, with some cost and risk. The benefits of tympanostomy tubes are more plausible in children with OME and hearing loss from middle ear effusion, and for children who have sensory, cognitive, or craniofacial/syndromic issues that put them at risk for the effects of prolonged middle ear disease.
Originally written by Drs. Glenn Takata and David Tunkel. Revised by Drs. Eleni Rettig and David Tunkel.
Table II.
|At Diagnosis for Initial Antibacterial Therapy
|Observation Option Clinical Failure at 48-72 Hours
|Antibacterial Therapy Clinical Failure at 48-72 Hours
|>=39°C and/or Severe Otalgia
|Penicillin Allergy
|Penicillin Allergy
|Penicillin Allergy
|Amoxicillin, 80-90 mg/kg per day
|Non-type 1: cefdinir, cefuroxime, cefpodoxime
type 1: azithromycin, clarithromycin
|Amoxicillin, 80-90 mg/kg per day
|Non-type 1: cefdinir, cefuroxime, cefpodoxime
type 1: azithromycin, clarithromycin
|Amoxicillin-clavulanate, 90 mg/kg per day of amoxicillin with 6/4 mg/kg per day of clavulanate
|Non-type 1: ceftriaxone, 3 days
type 1: clindamycin
|Amoxicillin-clavulanate, 90 mg/kg per day of amoxicillin with 6/4 mg/kg per day of clavulanate
|Ceftriaxone, 1 or 3 days
|Amoxicillin-clavulanate, 90 mg/kg per day of amoxicillin with 6/4 mg/kg per day of clavulanate
|Ceftriaxone, 1 or 3 days
|Ceftriaxone, 1 or 3 days
|Tympanocentesis, clindamycin
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
- OVERVIEW: What every practitioner needs to know
- Are you sure your patient has acute otitis media? What are the typical findings for this disease?
- What other disease/condition shares some of these symptoms?
- What caused this disease to develop at this time?
- What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
- Would imaging studies be helpful? If so, which ones?
- Confirming the diagnosis
- If you are able to confirm that the patient has acute otitis media, what treatment should be initiated?
- What are the adverse effects associated with each treatment option?
- What are the possible outcomes of acute otitis media?
- What causes this disease and how frequent is it?
- How do these pathogens/genes/exposures cause the disease?
- What complications might you expect from the disease or treatment of the disease?
- How can acute otitis media be prevented?
- What is the evidence?

subset: commoncrawl


text:
Nikola is Pluginificated.
Yes, I know that's not a real word.
So, the git master of Nikola now has plugins. In fact, not only does it have plugins, but is basically made of plugins.
You see, the code used to mostly be inside a class (called Nikola), and ... it had grown. That class had grown up to around 2000 lines of code. Which is completely ridiculous.
So, using Yapsy I turned the code inside out: almost all the code that was in that monster class was moved into plugins and the class turned into a smart plugin loader.
This has brought several advantages:
Now you can extend Nikola for your own purposes. Just create a plugin folder in your site, and put the extra functionality there.
Support for whole categories of things is now modular. Want to support a different markup? A different template system? Just write a plugin.
Want to add completely new functions to Nikola? Like, say, a way to import data from another blog tool, or something like planet software? Well, just add a "command plugin".
What has changed for the user?
You can delete
dodo.pyfrom your site.
nikola buildinstead of
nikola serveinstead of
doit serve
Some minor things still need doing in this area (notable, fixing the docs), but the main refactoring is there.


text:
Photo courtesy Josiah Duggar/duggarfamily.com
Wednesday, January 2, 2019
Lauren and Josiah's Tree
Photo courtesy Josiah Duggar/duggarfamily.com
138 comments:
- AnonymousJanuary 2, 2019 at 10:11 AM
Look at that tiny waist! Good for you Lauren for staying slim! My resolution is to loose weight and maybe start wearing some dresses...JaneReplyDeleteReplies
- AnonymousJanuary 2, 2019 at 1:53 PM
She's 18.Delete
- AnonymousJanuary 2, 2019 at 7:02 PM
Actually 19Delete
- AnonymousJanuary 2, 2019 at 10:38 PM
I've seen a lot of overweight 18 and 19 year olds, so age doesn't really matter. You can be overweight at any age.Delete
- AnonymousJanuary 3, 2019 at 2:42 PM
Some women have a naturally slim build and some don't. It's likely she's just built that way. Nothing wrong with those who are not.Delete
- AnonymousJanuary 3, 2019 at 8:19 PM
It's probably in part her celiacs. She could be naturally thin but some people with celiacs, like myself, have so much damage to their intensitinal track that it limits them further on what they can eat and tolerate and/or the absorption of their food. It took a lot of hard work for me to gain enough weight to be in a good range. Just saying. Dont judge either way as you dont know individual circumstances.Delete
I totally forgot about her having celiacs!Delete
- AnonymousJanuary 6, 2019 at 6:37 PM
Wait til the babies come!Delete
- AnonymousJanuary 7, 2019 at 11:33 PM
Life isn't about having a tiny waist. I'm a young mother of 3, just as thin as when I was 16. Really, be thankful you have some weight, my husband would love that for me.Delete
- AnonymousJanuary 2, 2019 at 10:13 AM
Modest clothing supporters - please explain how a dress like this (or her wedding dress) could be considered modest. It shows every curve. So did the wedding dress. Just because the body is covered doesn't mean it's modest. When clothing fits against the body like that, modesty goes out the window. The boys are just as guilty of this with their tight shirts and pants. The Duggars and their kin don't follow their own stated modesty guidelines any more!ReplyDeleteReplies
- AnonymousJanuary 2, 2019 at 2:10 PM
Oh please... The dress isn't tight and you can tell it flares starting at the wasteline. These people get ripped on for the silliest things.Delete
- AnonymousJanuary 2, 2019 at 2:10 PM
Oh brother there is not a thing wrong with that dress and I'm a modesty supporter. It's better than what those members of the K and J family!Delete
- AnonymousJanuary 2, 2019 at 2:15 PM
Lauren looks beautiful - shame on you for even suggesting she is not being modest.Delete
The human body has curves - we have been created a certain way - "created by God in his likeness>"
- AnonymousJanuary 2, 2019 at 2:24 PM
I think she's modest and comments like this reflect a skewed way of believing!!!.Delete
- AnonymousJanuary 2, 2019 at 2:25 PM
I honestly have no idea what you are seeing as immodest? And, Lauren was a spectacular bride! Her hair is still my favorite with those cascading flowers.Delete
- AnonymousJanuary 2, 2019 at 2:32 PM
Ok...just went back to peek at Lauren's wedding dress thinking I may have remembered it wrong. Nope. It was beautiful. Classy. Tasteful. Elegant. I could go on. I suggest you adhere to the words of Thumper.."if you can't say something nice, don't say nothing at all".Delete
- AnonymousJanuary 2, 2019 at 2:58 PM
Be quiet. She looks great! There is absolutely nothing wrong with what Lauren is wearing!Delete
- AnonymousJanuary 2, 2019 at 3:19 PM
It's clear from the way you worded this that you aren't coming from a conservative pro modest point of view. So my question is, since when does the average liberal not believe in choice? Are you saying as an adult woman she can't make her own decisions? Are you trying to say that Josiah and her in-laws should force her to wear what they want? Wow, that's not very open minded of you to expect her to get permission for her wardrobe choices. Plus, by current cultural standards this is definitely modest.Delete
Lauren is a beautiful girl & though I'm not seriously into modest dressing to the degree of the Duggars I feel Lauren looks lovely in her red dress, very festive & smart & lets be honest why should a girl of 19 wear a shapeless tunic, she still looks modest to me, & even if she didn't, it's up to her how she dresses & it certainly doesn't stop her being a nice godly young woman. I love Lauren & feel her & Josiah bring a breath of fresh air to counting on as a couple.Delete
- AnonymousJanuary 2, 2019 at 4:12 PM
As adults, they get to make their own choices with their clothing style. No need to judge them. Each branch of the family tree that has grown up has developed their own interpretation of modest.Delete
Stop it!! Do you want them to look like the 1890's? They look adorable and get their message out without looking weird,Delete
- AnonymousJanuary 2, 2019 at 4:21 PM
You can be modest and still show that you are a woman. Nothing wrong with wanting to be attractive and dress pretty for your husband. Being modest doesn't mean being frumpy.Delete
- AnonymousJanuary 2, 2019 at 4:28 PM
The Duggars are growing up and creating their own rules and guidelines as they go. Like most of us do in this world.Delete
- AnonymousJanuary 2, 2019 at 4:30 PM
Lauren isn't a born Duggar so probably follows her own families set of ideas for modesty unitl she was old enough to decide for herself. They're adults now and can interpret the teachings in any way they like,as most adults do.Delete
- AnonymousJanuary 2, 2019 at 4:31 PM
I understand that is your opinion, but why do you care what other people wear? She is so tiny that if she wore it any bigger she would look like shes drowning in it... I personally think she looks nice, and shes not showing anything. She is comfortable with her body and what she is wearing... so who are we to judge her choice of clothes? There is only one judge!! 🙏Delete
- AnonymousJanuary 2, 2019 at 4:38 PM
Loren looks great though!Delete
- AnonymousJanuary 2, 2019 at 4:38 PM
I think she looks beautiful, but I have the same question.Delete
- AnonymousJanuary 2, 2019 at 4:46 PM
Seriously? Her outfit is beautiful. Nothing immodest about it. What, is she supposed to wear frumpy clothing or a paper sack?Delete
Modest clothing CAN be well-tailored.
- AnonymousJanuary 2, 2019 at 4:52 PM
Would you rather she wore a sack . She is a married woman and looks classy and elegant. Leave her be!Delete
Her dress isn't exactly form fitting. Her skirt is flared. Nothing wrong and why spew ridicule over a Christmas picture? Did you have a bad holiday? Wishing everyone a Happy New Year and less criticism for this familyDelete
This is a completly unnecessary & unkind comment. She's an adult and capable of setting her own modesty standards. Certainly when she's in her own home! I think she looks lovely.Delete
It comes to the knee and covers the arms that is modest..not showing shoulders or thigh is called modest...it looks very nice on herDelete
Her dress is flattering, not immodest. I don't find anything wrong with her dress .Delete
- AnonymousJanuary 2, 2019 at 6:08 PM
Just because she married into the family, doesn't mean she has to follow their rules. She is her own woman and can make her own choices. My husband doesn't attended church and never has or has a desire to. Yet I go and take our son with us, just because he doesn't attended. Doesn't mean I should stop going or not be allowed to take our son. My husband and I agree that I can take our children to church and be allowed to raise them to go there, until they are old enough to make up their own minds. When you marry someone doesn't mean you need to change yourself to fit their life style, nor should having a different life style stop you from marrying someone you love.Delete
As woman who has a conviction to wear long modest dresses, I believe God gives each of us convictions on what is modest and what is not. The Lord has changed my views on modesty the last 17 years. While Laurens dress fits her, it's not low cut showing cleavage and it's at her knees. I feel it is modest. Why judge her and the others because they do not have the same convictions as someone else? I know within my own small church, the various families have their own modesty standards. What one family allows, another would never let their girls wear. For instance, one family feels jumpers are not modest.Delete
- AnonymousJanuary 2, 2019 at 6:54 PM
I think it's just as "Nike!" to look at a girl in a dress like this as it is to look at a girl in a dress with a short hemline or a low neckline.Delete
- AnonymousJanuary 2, 2019 at 7:02 PM
6:54, so if a girl looks pretty it's immodest? There is nothing inappropriate about her clothing, you need to get a grip.Delete
- AnonymousJanuary 2, 2019 at 7:27 PM
This is a tight dress and you can almost see outlines of what's under it. I agree that it is not the most modest type of dress.Delete
[6] This they said, tempting him, that they might have to accuse him. But Jesus stooped down, and with his finger wrote on the ground, as though he heard them not. [7] So when they continued asking him, he lifted up himself, and said unto them, He that is without sin among you, let him first cast a stone at her.Delete
Look who's trying to stir stuff up. It clearly is modest. A modest dress can be fitted. If the skirt was tightly fitted, it would be risky but it's not. The skirt flares, it has sleeves and the dress almost reaches past her knees. Let's stop the drama.Delete
- AnonymousJanuary 2, 2019 at 8:36 PM
So you can tell she's a woman under that dress. Why is that so upsetting to you? Tell me, do you wear a long bag with eye holes cut out so as not to tempt any man? There is NOTHING wrong with what she's wearing!Delete
- SamanthaJanuary 2, 2019 at 9:18 PM
Some people just wouldn't be happy if they didn't have something to complain about.Delete
Modest, immodest, WHATEVER!!! I was impressed with Lauren looking so dressed up to do chores. When I took my decorations down (a necessary move as my daughter's kittens were climbing the tree and trying to sit in the manger scene) I was elegantly attired in my old sweatpants and a T-shirt.Delete
- AnonymousJanuary 2, 2019 at 11:44 PM
Listen, the OP got exactly what he/she wanted - to rile up Duugar fans. The best way to handle people who just want to cause trouble is to ignore them. If no one reacts and responds to them, what fun will that be! Maybe they would stop baiting us who are geuine Duggar fans.Delete
- AnonymousJanuary 3, 2019 at 12:34 AM
Lauren is a beautiful girl and her parents, particularly her mom, do not dress like the Duggars. That being said, the dress is very form-fitting at the top but flares at the bottom. I see both sides of the debate. But she's so young and I think it's like the "best of both worlds" so to speak. It covers, yes, but does it conceal, no.Delete
- AnonymousJanuary 3, 2019 at 4:56 AM
I think the OP's point is that the Duggar's have modified some of their standards over the years, now that the next generation are adults, and they've never really addressed this. IMO, some people or churches get too caught up in legislating man-made prescriptive rules. I dress according to what makes me feel good, not someone else. I wear pants almost exclusively because I don't find dresses or skirts comfortable. Wear what you want, because it's impossible to please everyone. It's all subjective anyway and men are responsible for their own thoughts and actions.Delete
- AnonymousJanuary 3, 2019 at 7:51 AM
Spirituality is a personal matter and what others do to express their own should not be looked upon as a gold standard for everyone else, including this hot button issue of wardrobe "modesty." Wear whatever you like. Just understand that it doesn't make you any more Godly than the next person, just because you choose to dress a certain way.Delete
- AnonymousJanuary 3, 2019 at 9:56 AM
I feel so bad for these girls. If she had worn anything less form fitting there would be a bunch of comments about how she "looks" pregnant. It's too bad people cant keep their mouths shut or fingers still when it comes to Duggar women's bodies.Delete
- AnonymousJanuary 3, 2019 at 9:58 AM
Lauren has said on the show that she has the same modesty standards as the Duggars.Delete
Lauren looks amazing. The dress is figure flattering and is a beautiful color. The cut and style of the dress is modest and does fit to their standards. I think that the fabric is thin so that it does cling a little and emphasizes her shape. It would flare out more if the fabric was thicker. That Lauren is also reaching up may also affect the lay of the fabric. If she was photographed straight on there wouldn't be any debate about whether this dress is modest.
- AnonymousJanuary 3, 2019 at 2:27 PM
People you need to remember that a lot of people who come on this blog were no doubt fans of the Duggar s from way back and so the older girls in the family were always dressed with not form fitting dresses like this. So why do you people get so worked up when people comment on the change in how they dress now. There are a lot of conservative men and women who aren't use to seeing the tighter dresses, the pants on the women etc. Most of us got use to the way Michelle and Jim Bob lived and dressed and their kids lived and dressed, so it is different seeing this kind of change in things. Lauren wasn't raised by the Duggar s but her husband is one. So lighten up on people. The Duggar s ultra conservative ways while raising a large family and Christian views were the main reason people watched the show in the first place.Delete
- AnonymousJanuary 3, 2019 at 2:48 PM
My family and I don't follow these same modesty standards, but I have to make an observation and ask for clarification from those claiming this outfit is "modest." The dress is skin-tight through the waist, totally shows her form. It doesn't look modest to me. Looks like something from a mall shop. Are you guys saying it's okay to wear skin tight, form-fitting clothing over the bust and waist, as long as you don't show your shoulders, arms, thighs, knees??? I feel she should wear whatever she wants, but am trying to understand how this outfit is modest.Delete
- AnonymousJanuary 3, 2019 at 5:27 PM
2:48, it just depends on what your standards are for what is modest. Personally I don't believe showing your arms or legs is wrong. That is an ultra conservative mindset that most Christians don't follow. Some outfits are promiscuous, and it's very easy to see when they are. This one is not.Delete
- AnonymousJanuary 3, 2019 at 5:55 PM
Absolutely agree with both of you, 2:27 and 2:48. You both make excellent points.Delete
- AnonymousJanuary 3, 2019 at 11:05 PM
Dugfan at 10:20 - That was cute, too funny!Delete
- AnonymousJanuary 3, 2019 at 11:09 PM
wow, lots of comments on her clothing, I wish the focus could be away from that once in awhileDelete
- AnonymousJanuary 4, 2019 at 5:17 AM
(Anonymos again.)Delete
Sorry Ellie for ranting about unanswered questions while you are just about to deliver your baby boy.
Hoping for a safe birth :).
- AnonymousJanuary 4, 2019 at 2:37 PM
The tree is beautiful and so is Lauren! She looks beautiful in her red dress. It is a cute dress and nothing immodest about it. It just shows that she has a tiny waist nothing wrong with that!Delete
- AnonymousJanuary 4, 2019 at 10:31 PM
Oh my goodness! I cannot believe the amount of texts concerning a 19-year-old married woman's dress. It makes the Lincoln-Douglas or Kennedy-Nixon debates pale in comparison. Don't bother us with matters such as immigration, racism, or global warming. We have the "modest/immodest red dress" issue before us.Delete
- AnonymousJanuary 5, 2019 at 5:50 AM
9:56- I think the Duggars brought this controversy on themselves to a certain extent. Early on, they made dressing modestly, whatever that means,Delete
a big part of their media image. They went so far as to coach their sons to avert their eyes downward if another family member called, "Nike". This was to avoid seeing a woman wearing questionable clothing, like a swimsuit at the beach. The daughters talked about this topic in their book. Now that they've grown up and some have left home, it's obvious that they've modified their stance on this, but they never directly address it. It's a good example of how easy it is to paint oneself into a corner with such legalistic doctrine, which is pretty much based on subjective interpretations of the Scriptures in the first place. It makes no difference to me how people choose to practice their faith. However, if you're a public figure and people see things that don't add up or seem inconsistent with your message, don't be surprised when they start asking questions.
- AnonymousJanuary 6, 2019 at 8:19 AM
@10:31 So true, I wonder sometimes what people think is really important.Delete
Funny comment about the 1890's. I believe that was when the style was for women to wearca shiftand corset and extremely form-fitting, waist-cinching, tight bodices with flaring skirts that reached to the floor, often with a bustle in back. Nobody talked about modesty then.Delete
What a beautiful tree.ReplyDelete
- AnonymousJanuary 2, 2019 at 1:00 PM
Beautiful tree and lady, hope it was a wonderful holiday for you bothReplyDelete
- AnonymousJanuary 2, 2019 at 1:58 PM
Lauren and her tree are beautiful. Looking forward to seeing Si and Lauren and their home in the new season. Happy New Year to you both.ReplyDelete
Wishing them a very blessed 2019! They are such a sweet beautiful couple...ReplyDelete
- AnonymousJanuary 2, 2019 at 4:35 PM
Christmas doesn't end till Epiphany, Jan 6. The "world" starts it in October/November. December 26 the Christmas music is off the radio!! Don't give in to society! Celebrate the 12 days of Christmas.ReplyDeleteReplies
- AnonymousJanuary 2, 2019 at 7:06 PM
People who celebrate it will, people who don't will not... simple as that.Delete
- AnonymousJanuary 2, 2019 at 8:05 PM
12 days of Christmas is between 1-12 and we make candies and puddings. Have you heard of the twelfth night cake?Delete
- Jackie BJanuary 2, 2019 at 8:28 PM
I totally agree with you. Until the Epiphany, it is still the Christmas season!Delete
- AnonymousJanuary 2, 2019 at 8:51 PM
I agree. It is still the Christmas season. Why do people put away their decorations so soon? I think it's sad.Delete
- AnonymousJanuary 2, 2019 at 8:58 PM
a friend of mine collects nativity sets. when she sets hers up for the holidays, she waits until christmas to put in the baby jesus and january 6th to add the wise menDelete
- AnonymousJanuary 3, 2019 at 4:32 AM
There are no universal rules for how one celebrates Christmas. I like decorating right after Thanksgiving and putting it all away by New Years. If you want to observe it differently, you are free to do so, as well as listen to holiday music whenever you wish.Delete
My friends husband is an Anglican bishop here in England & he is very vehement on the 12 days of Christmas. Their family never ever take their tree & decorations down till the epiphany. He also leaves the Christmas tree & manger up in the cathedral he works out of until the 6th Jan. I used to leave my tree up till 12th night too but iv a little 8 month old kitten this year & she has been constantly climbing up the tree so I decided to take it down yesterday (2nd Jan) 😢Delete
- AnonymousJanuary 3, 2019 at 2:49 PM
We leave up the nativity scenes and lights until after Jan 6.Delete
- AnonymousJanuary 3, 2019 at 3:32 PM
I still have my decorations up and will take them down this weekend. I hate taking it down, as I always feel a little sad.Delete
- AnonymousJanuary 3, 2019 at 9:39 PM
We're Catholic and leave things up through the Epiphany- this year on Sunday. Churches remain decorated also and Christmas hymns are sung. Then I become depressed for a week because it's over!!😄😄Delete
- AnonymousJanuary 4, 2019 at 8:49 AM
Earlier this week, I drove past a house that still had its Halloween pumpkins out front. Is there a rule about pumpkin removal time, too? Maybe there should be, because they looked pretty strange along with their Christmas decorations.Delete
- AnonymousJanuary 4, 2019 at 2:25 PM
@4:35 Different strokes for different folks. One way is no better than another. It's all about personal preferences and/or different religious beliefs. There are no laws mandating conformity to certain holiday celebrations or traditions, thank goodness!Delete
- AnonymousJanuary 5, 2019 at 12:57 PM
Do whatever makes you happy. I'm in the mood for Christmas right after the Thanksgiving dishes are washed and put away. By New Years, our tree is losing needles and has to go. By then, I'm sick of Christmas music. No way I want to keep things going another week.Delete
Our family tradition has been tree and decor up day after Thansgiving. Tree and decor put away January 7th. I recently attended Epiphany Sunday near Boston, and was so excited to see decor still up and hear carols sung.Delete
- AnonymousJanuary 2, 2019 at 4:37 PM
Cute dress!ReplyDelete
- AnonymousJanuary 2, 2019 at 4:41 PM
Well, the pregnancy rumors are untrue! ❤ReplyDeleteReplies
- AnonymousJanuary 2, 2019 at 7:08 PM
She is only 19Delete
- AnonymousJanuary 2, 2019 at 11:10 PM
7:08 - Kendra has her first at 19Delete
- AnonymousJanuary 3, 2019 at 2:58 PM
I hope she waits a few years before adding children.Delete
- AnonymousJanuary 3, 2019 at 7:52 PM
@2:58-she married a Dugger so she'll be pregnant soon.Delete
- AnonymousJanuary 4, 2019 at 10:43 AM
She is pretty young and in shape. I have no idea if she is pregnant, but a first pregnancy could be not noticeable up to 16 weeks.Delete
- AnonymousJanuary 2, 2019 at 5:49 PM
apparently if you don't have anything nice to say don't say anything at all means nothing to you.ReplyDelete
So pretty. I love seeing them all. Can't wait for the next season.ReplyDelete
Is the baby here, Ellie?ReplyDeleteReplies
Not yet. Still waiting. Thanks for asking!Delete
- AnonymousJanuary 2, 2019 at 9:00 PM
what a pretty tree! they are such a cute coupleReplyDelete
are there any pictures of how the other couples spent christmas that you can share?
Well, it's clear that Lauren is NOT pregnant. But, it's nice to know that they had a good Christmas, and look set to have a good 2019.ReplyDeleteReplies
- AnonymousJanuary 3, 2019 at 1:36 PM
It's clear at all. Some women don't show at all during the first trimester. It would be her first so it doesn't show a lot at first.Delete
I'm currently 11 weeks pregnant with my third baby and I don't show.
We'll know for sure when they announce it.
- AnonymousJanuary 3, 2019 at 2:50 PM
She maybe pregnant! Some people are nauseous &/or sick a lot and lose weight in first few months of pregnancy. Who knows?!!Delete
Yea, who knows if she's pregnant or not! I keep thinking there will be an announcement soon from someone in the Duggar family as there hasn't been a pregnancy announcement for a full year now!!!! And the youngest grandbaby is nearly 6 months old ta boot!Delete
- AnonymousJanuary 7, 2019 at 4:59 PM
Oh my goodness! What will we ever do if no one is pregnant?!?Delete
- AnonymousJanuary 2, 2019 at 11:20 PM
She looks great!ReplyDelete
- AnonymousJanuary 3, 2019 at 3:38 AM
It's a beautiful tree and I love the dress. Happy holidays. Natasha B.ReplyDelete
- AnonymousJanuary 3, 2019 at 5:50 AM
Beautiful tree and lovely dress Lauren !ReplyDelete
I hope we'll get to see a new season of counting on to be able to follow them throught their firt year of married life and also see John and Abby ! I'm worried it got cancelled since we didn't hear about a new season coming...
- AnonymousJanuary 3, 2019 at 10:46 AM
I thought they got married September 30th, which would only be 3 monthsReplyDeleteReplies
- AnonymousJanuary 3, 2019 at 1:27 PM
No they got married June 30Delete
- AnonymousJanuary 3, 2019 at 1:33 PM
Theu got married on june 30thDelete
- AnonymousJanuary 3, 2019 at 2:42 PM
They got married June 30Delete
- AnonymousJanuary 3, 2019 at 11:06 AM
Lauren looks beautiful in that lovely dressReplyDelete
- AnonymousJanuary 3, 2019 at 11:07 AM
I love your dress and the color, Lauren. People are just jealous.ReplyDeleteReplies
- AnonymousJanuary 3, 2019 at 5:56 PM
Jealous is not the right word.Delete
- AnonymousJanuary 4, 2019 at 2:42 PM
I agree people are jealous that she looks so pretty in that dress. Guess they want her to wear fumpy old baggy long dress? Glad to see her dress cute as married young woman!Delete
- AnonymousJanuary 4, 2019 at 6:25 PM
I don't think jealous is the right word. I really think some Duggar fans are a bit taken back because yes Lauren is beautiful so is this dress but in all honesty it isn't very modest at all. Well not modest for a Duggar woman. The dress is very formDelete
Fitting, hugging every single curve of her body. Granted she's technically an adult and can wear whatever she wants, but unfortunately she will be judged a bit harsher due to the family she married into. I think the general consensus is that she shouldn't be wearing immodest clothing due to her strict religious belief system that frowns upon dressing in a way that doesn't draw attention to her countenance. This dress can certainly cause a mans attention to be drawn to her body, which can lead to lustful thoughts. This is why women aren't supposed to dress that way.
- AnonymousJanuary 5, 2019 at 4:06 PM
Anon 6:25. It isn't what women wear that cause men to have "lustful thoughts". They seem able to do that no matter WHAT a woman wears. lolDelete
- AnonymousJanuary 8, 2019 at 10:23 AM
Yes. Jealous IS the right word. Stop belittling these people. Just stay off of their page.Delete
- AnonymousJanuary 3, 2019 at 11:07 AM
Lovely dress on a lovely woman!ReplyDeleteReplies
I COULD NOT SAY IT BETTER!!!!!!!!!!!!!!! I AGREE 100%%%%!!!!!Delete
- AnonymousJanuary 3, 2019 at 7:23 PM
What a lovely tree. Lauren looks beautiful in that gorgeous dress. Wishing all the Duggars a blessed,healthy,happy and peace filled 2019. God Bless.ReplyDelete
Joan,Marion and Marilyn
Nice picture of herReplyDelete
- AnonymousJanuary 4, 2019 at 4:46 PM
Well I guess we know what kind of tops she'll be wearing when she's pregnant....and then there will go the modest/immodest discussion all over again! :PReplyDeleteReplies
- AnonymousJanuary 5, 2019 at 11:22 AM
Lauren has what used to be called an "hour glass" figure. The dress she's wearing suits her well and is becoming. Who knows what she'll wear while pregnant. And does it really matter?Delete
- AnonymousJanuary 6, 2019 at 10:15 PM
Um, Lauren does not have an hourglass figureDelete
- AnonymousJanuary 4, 2019 at 7:18 PM
ALERT! ALERT!! Shocking news!!!!!ReplyDelete
Women can actually be decently dressed in a variety of ways!!!! I know this is a brand new revelation, but please pay attention!! Whether a dress is knee-length, ankle-length, calf-length, or even if she has on pants, does NOT—I repeat—does NOT determine if a woman is decent or not!!! If you are feeling flabbergasted, please keep reading for even more jaw-dropping info!
It has been uncovered that scaling women's decency by your own personal preferences of clothing does not produce accurate results!!!! Yikes!!! In fact, many women are quite humble and moral even if they wear items you may not!! Are you still with me?!
Furthermore, it's been unclassified that God calls for women to be humble in heart, not seeking attention, to have a quiet spirit, and to not waste money on finery. And apparently all of that can be obeyed with a variety of wardrobe choices!! Who knew?!?!
So calling a flared, knee-length dress "immodest," or calling a loose-fitting, long dress "frumpy" are both highly ridiculous and only reflect your own proud vanities. This has been a friendly PSA. Have a good day.
- AnonymousJanuary 5, 2019 at 11:26 AM
Hayley, I completely agree with your statements. However the Issue others are having is that the Duggars don't believe this way. Research their belief system and it specifically states women are to dress in a way that draws attention to their face and not their body. ( ie no formDelete
Fitting attire, no jeans, being covered from neck to knee) Lauren's dress is beautiful and so is she but she is not dressing modest by her beliefs. She is drawing attention to her body and creating lustful desires in men, which is why she shouldn't be flaunting her figure even though she is a very pretty young lady.
- AnonymousJanuary 5, 2019 at 2:20 PM
Love this! So trueDelete
- AnonymousJanuary 7, 2019 at 11:30 AM
Anon @ 11:26,Delete
You're right. I remember watching the Duggars way back when I was 16 or 17, when they had their first tv special. I will totally agree with you that the Duggars have slipped farther and farther away from what they once were. It's very obvious that they all—the women and men both—desire for their bodies to be found attractive by the public and dress in a way that is not "modest" by their own definition.
My post was strictly for the commenters who feel the revelations God has given them about dress should be the basis for accusing others of dishonoring God. But like you said, I think you and I agree totally. Have a really good day!
- AnonymousJanuary 7, 2019 at 12:44 PM
11:26 is the one who's so true. The problem isn't that she doesn't look good. The problem is that this goes against all their religious dress standards that we've been told about over and over, both in print and on TV. If those have completely changed for everyone following that religion, tell us so, Duggars!Delete
- AnonymousJanuary 7, 2019 at 4:47 PM
Anon 12:14 I tend to agree with your observation. I don't think there's anything wrong with how the Duggars dress now, but it is a far cry from what they used to preach. This is one of the things that I'll never understand about them. If they've changed their standards then they should say so publicly. Otherwise they seem a bit hypocritical.Delete
- AnonymousJanuary 7, 2019 at 5:34 PM
I think this second generation is nothing like their parents. A lot of people I know do not watch the Duggar s or follow any news about them because they are not the same people anymore. The Bates are headed down this same road too. The frugal, community serving, conservative dressing that they always talked about are gone now. So I guess it comes down to if you don't mind this new lifestyle and belief system that you see now then keep watching, but if you don't like it then I guess do what most people I know did and just ignore them.Delete
- AnonymousJanuary 7, 2019 at 7:15 PM
Anon 5:34. I agree. I don't watch them now. I see how fame and fortune has changed both families. I don't follow the Bates, but the Duggars now seem preoccupied with their appearance, getting married, having babies and traveling to visit family members.Delete
- AnonymousJanuary 7, 2019 at 8:26 PM
@ 5:34 Why would you ignore something that is so obviously different than it used to be? What if everyone ignored hypocrisy and nobody spoke up for what was right?Delete
- AnonymousJanuary 4, 2019 at 10:45 PM
Why all of the negativity? Lauren looks great. What if Lauren reads all of that and it hurts her. What would the Lord say about that? We are supposed to treat others like we want to be treated. And Abbie's hair looks great too.ReplyDelete
- AnonymousJanuary 5, 2019 at 5:45 PM
Why would any Duggar want to share any pics at all after all the criticism?ReplyDelete
- AnonymousJanuary 5, 2019 at 6:31 PM
Lauren looks amazing in her pretty red dress. I believe the ones commenting otherwise are jealous, that`s is usually how it goes. Her life, her choices. Easy to sit behind a screen and type mean things about others, when you are usually spewing more about how you feel about yourself. All of the girls in this family are beautiful and can dress how they see fit. Are any of you buying their clothes or footing the bill for the clothes, there babies or their life? Then you don`t have a dog in that race. Sad people are always critical of others. All the D girls are beautiful including Mom D. I can`t wait until you all come back on TV and in the meantime, Blessings to you all!!ReplyDelete
- AnonymousJanuary 7, 2019 at 7:40 PM
It is nobody's business what they wear. Please stop judging. It's not christlike and shows one's immaturity.ReplyDelete
- AnonymousJanuary 8, 2019 at 10:22 AM
Even if the duggars DID change their dress style, which they really HAVEN'T it is nobody else's business. Why does anyone care!? People need to worry about their own lives.ReplyDelete
- AnonymousJanuary 8, 2019 at 11:07 AM
Well said 7:18!!ReplyDelete
- AnonymousJanuary 8, 2019 at 12:08 PM
Pretend for a second that the duggars changed the way they dress. They do not "owe" their fans any sort of explanation. They are under no obligation to anyone!! Some of these people making comments seem a bit too obsessed with the duggars'lifestyle.ReplyDelete
- AnonymousJanuary 11, 2019 at 1:10 AM
Kind of a late post, but I just wanted to say that the Duggars DID change their style, and THEY DID SAY SO! In 19 Kids they often talked about their new "modern modest" style, which is fine! I personally find that Lauren's dress is fine - perhaps a bit tighter than I would wear, but nothing to criticize for sure.ReplyDelete
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text:
Event Type: Story Time
Age Group(s): Toddlers, Pre-schoolers, Babies
Date: 6/2/2022
Start Time: 10:15 PM
End Time: 10:45 PM
Join us in the community room Thursday morning for singing, playing, and other age appropriate activities during children's storytime. We will engage their curiosity, while developing important literacy skills and fostering a life-long love of reading and learning. For babies through preschoolers. No registration necessary.Library: Great River Regional Library - Little Falls Map
In accordance with Minnesota Statute 13.40 Subd. 2. all Great River Regional Library circulation and other records which indicate the identity of library users, especially as they connect library users with materials or services used, are confidential. This confidentiality extends to information sought or borrowed, database search records, Internet sites, reference interviews, circulation records, registration records (except name), and all other personally identifiable uses of library materials, facilties or services. A library may release reserved materials to a family member or other person who resides with a library patron and who is picking up the material on behalf of the patron. A patron may request that reserved materials be released only to the patron.


text:
Let's say you park your car in an area frequented by urban entrepreneurs who gather intoxicant-obtainment resources by harvesting car audio equipment from vehicles… yet you still want some tunes in your ride.
It presents quite the dilemma, because even the crappiest cassette deck serves as an irresistible lure, tempting some crackhead to smash your side window with a spark plug and then gouge the hell out of your dash with a prybar while removing his $2 prize. Fortunately, Jalopnik Cheapskate Tips™ have the solution! These days, all you really need is a means of connecting an MP3 player- or even a cellphone with music-playback functionality- into an amplifier driving a couple of speakers.
4-time DOTS honoree WhatWouldJesseDo leaves his super-clean '83 Toyota 4x4 in the parking lot of a local train station each day, and the truck has had its stereo torn out by thieves three times in as many months. Each time, Jesse installed a cheaper, less appealing stereo, and each time he returned to his truck to find the window smashed and a hole in the dash. All he wanted was a way to plug in his iPhone and have music while behind the wheel, yet the truck had to appear completely bereft of anything that might be readily converted into hubba rocks, 40-ouncers, black tar, DMT, or Ibogaine.
I found the solution when rigging up 2-way radio communication for the Black Metal V8olvo race car; we didn't have the money to buy fancy radios with in-helmet headsets, so I rigged a cheapo GMRS walkie-talkie with a modified CB radio microphone and fed the audio to this no-frills audio amplifier, which drove a couple of door-mounted junkyard speakers. When the spotter called out a yellow flag into his walkie-talkie, the driver- as well as drivers of other cars and, occasionally, spectators in the bleachers- heard him loud and clear!
The thing has "MP3 IN" printed right on the case, so that was all the inspiration I needed. This little amp, sporting an alleged 360 watts of power (ha ha ha!), is sold under countless brand names, but all are the same; I assume there's some town in southeast China that's made up entirely of huge factories churning out these little blue boxes. They're crap, but they get the job done and the sound quality doesn't suck as much as you'd expect; you get RCA and 3.5mm lines in, two speaker outputs, volume, bass, and treble controls (which feature a really cheezy multicolored flashing LED setup). They're all over eBay, and you can get yourself one for under $15 shipped.
Jesse opted for the prestigious Cheng Sheng version, which boasts an impressive 400 watt output (I'm guessing it's more like 25). He stopped by Chez Murilee yesterday, while I was working on wiring the 20R Sprite, so I just grabbed my implements of Wiring Hell and shifted operations to his Hilux.
Since the last car thief owned wire cutters, enough of the old stereo's wiring harness was still present to make hookup of the Cheng Sheng Amp a simple task. I had a stash of inline noise filters I'd picked up during junkyard expeditions, so I added one to the power circuit; without such a filter, ignition noise is liable to come through with such a cheapo amp.
Just to make sure everything worked, we rigged up a temporary wires-twisted-together installation and tested it out with an iPod. Sounds good!
If your car lacks speakers, no problemo! Just head over to the nearest self-service junkyard when it's having a Half Off sale and grab some factory speakers for $2 apiece. I prefer high-end Japanese cars for my junkyard speaker selection; why go with Nissan when you could have Infiniti for the same price?
Since portable music players all have volume and EQ controls, there's no need to install the Cheng Sheng where prying eyes might spot it- just wire it so it's powered up when the ignition is hot and leave the volume knob cranked, then adjust the sound on the music player. In Jesse's truck, the best out-of-view location was under the seat. Rather than drill holes to mount it, we just used self-adhesive Velcro.
A 3.5mm stereo plug to dual male RCA cable can be had for next to nothing, so the budget so far remained under 20 bucks. We ran the cable under the seat and to the center console. All systems go when plugged into Jesse's iPhone!
But the dash didn't quite look wretched enough. To convince would-be thieves that they'd be better off moving on to the next vehicle in the lot, the Toyota's dash had to look thoroughly de-stereoized, preferably with a tangle of sliced wires hanging out of a gaping hole where a stereo once lived. Here's a shot from the junkyard to provide inspiration.
By a stroke of good fortune, I'd just torn out the last vestiges of Prince Of Darkness wiring from my Austin-Healey; what could possibly look more disreputable a-dangling from a jagged dashboard hole? Quickly, I fished some of Lucas Electric's finest from the trash can. You know what they say about Lucas Electrics: Get home before dark!
Some work with the cutters and a few zipties, and it looks just horrible! The only concern here is that the Quantum Unreliability Field of the Prince Of Darkness wires might destabilize the Toyota wiring harness at the quark level, but we figure the Warlord Grade™ construction of the Hilux can handle it.
Now, some of you are probably saying to yourselves, "Well, that's all well and good for when I want to listen to Foghat's Fool For The City on my $12 iPod Shuffle knockoff, but what if I want to listen to the radio, eh? What then, smarty-pants?" Well, of course you want to listen to the radio, and you can totally do it with this setup. Just pick up a $6 portable AM/FM and plug the audio cable right into the headphone jack. Hell, you can even use a Walkman cassette player. Mission accomplished!


text:
Climate change will affect fish and their habitats. Warmer temperatures will influence the abundance, migratory patterns and mortality rates of wild fish stocks and determine what species can be farmed in certain regions.
While most work on climate change in fisheries has focused on fisheries science, OECD highlights the economic and policy aspects of adapting the fisheries sector to climate change. Fisheries policy makers need to develop adaptation strategies that take into account the economic consequences of climate change - strategies that must themselves be adaptable to the uncertainty of climate change.
OECD analysis and policy advice aims to ensure that the fishing and aquaculture sectors are environmentally and economically sustainable.
Further reading
The Economics of Adapting Fisheries to Climate Change (March 2011)
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