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1. Criteria for choice of drug in acutely ill patients
a) Evidence of prior response to the same drug (C)
b) Avoid side-effects experienced with a drug in the past (C)
c) Planned mode of administration (C)
d) Side-effect profiles (A)
e) Small differences in antipsychotic efficacy (A)
f) Patient's preference for a specific drug determined by shared-decision making (A-)
g) Cost (C)
ad a) If a patient has responded to an antipsychotic in the past this could be a predictor that he will respond to it again.
Ad b) Similarly, side-effects experienced in the past might be avoided by choosing another antipsychotic.
Ad c) If it is clear that a patient will receive a depot for maintenance treatment, choosing the oral form of the same drug can facilitate the later transition.
Ad d) Antipsychotics differ largely in side-effects (e.g. Leucht et al., 2013a; Leucht et al., 2009b). This also applies to long-acting injectable formulations of antipsychotics (McEvoy et al., 2014), which have side-effect profiles that closely resemble their oral versions (Fleischhacker et al., 2014). Table 1 provides an overview of the side-effect profiles of second-generation antipsychotic and the two prototypal first-generation antipsychotics haloperidol and chlorpromazine that might be used for the selection (Table 1).
Ad e) Meta-analyses found that some antipsychotics (clozapine, amisulpride, olanzapine, risperidone, (zotepine, paliperidone)) are somewhat more efficacious than others (Davis et al., 2003; Geddes et al., 2000; Leucht et al., 2009b). We highlight that apart from clozapine, which is restricted to treatment resistant patients, the superiorities were small and overall smaller than differences in the major side-effects.
Ad f) A variety of antipsychotics with different profiles is available. Some patients may want to avoid weight gain, others EPS or sexual side-effects, and again others might even want an only slightly more efficacious drug, irrespective of side-effects. We, therefore, recommend involving patients in the decision where feasible. Involving patients in the decision making progress is simply good clinical practice and may also improve compliance and long-term outcome – despite limited evidence there is at least one RCT suggesting positive effects on some outcomes (Hamann et al., 2007; Hamann et al., 2003).
Ad g) New antipsychotics are generally more expensive than older ones, but medication cost will differ between countries (e.g. newer antipsychotics become generic and usually cheaper at some stage) and settings. Therefore, no general statement can be made, but it certainly is a criterion for choice, as well.
2. Patients should be started on monotherapy with one drug (A)
Polypharmacy can be associated with more side-effects and drug-drug interactions (Fleischhacker and Uchida, 2014). If two antipsychotics are started simultaneously it is difficult to disentangle which drug was efficacious, making it difficult to stop one of them once the patient has responded. Similarly, if side effects emerge, it is unclear, which medication or dose may need to be changed. Moreover, non-adherence is an enormous problem in schizophrenia, and the more drugs patients receive the more difficult it could be to comply with the regimen. There is no randomized evidence supporting the immediate start of combination therapy apart from a meta-analysis of Chinese trials that was mainly based on combinations of clozapine with other antipsychotics (Correll et al., 2009b), but in most countries clozapine is restricted to refractory patients. The rationale of combining antipsychotics is also limited by the fact that they all have the same main putative mechanism of action for psychosis, which is dopamine blockade (Goodwin et al., 2009).
3. Factors that need to be checked before non-response is assumed
a) Is the underlying psychiatric diagnosis correct and have psychiatric comorbidities, including substance abuse, as well as somatic comorbidities or somatic causes been adequately excluded? (C)
b) Have ongoing environmental or psychological stressors as a cause of non-response been excluded? (C)
c) Has response been measured objectively and quantitatively? (C)
d) Do side effects mask a response, mimic non-response? (C)
e) Has a sufficient dose been given? (A)
f) Was treatment given for an adequate duration (change of treatment only if less than minimal response despite at least 2-4 weeks with full dose)? (A)
g) Has compliance been checked/optimized? Optimize compliance-transparency by obtaining antipsychotic plasma-levels (C), or use of liquids or rapidly-dissolving tablets (especially in inpatients (C)), or depot drug. (B)
h) Has an adequate plasma level been reached? If not (and therapeutic windows are available), check for cytochrome-P-450 polymorphism, effect of smoking or drug-drug interactions. (C)
Ad a) For example, a psychotic depression/mania or severe personality disturbances can be difficult to distinguish from schizophrenia. Similarly, many neuropsychiatric disorders such as encephalitis, neurosyphilis can mimick schizophrenia and heavy cannabis or alcohol abuse can explain non-response, as well.
Ad b) Ongoing severe stressors, such as homelessness, poor housing, severe financial difficulties, violence and personal conflict will interfere with the therapeutic effect of antipsychotic medication.
Ad c) Unfortunately, the assessment of response to antipsychotic medication often remains subjective and qualitative, resulting in ambiguous judgments. Response should be assessed in a standard fashion, ideally both qualitatively as well quantitatively using validated psychometric instruments (e.g. at least the CGI or the 8 PANSS items on which the remission criteria by Andreasen et al., 2005 are based).
Ad d) For example, akathisia can be confused with psychotic agitation or parkinsonism can mimic negative symptoms. Such confounding factors need to be ruled out and addressed before non-response is established.
Ad e) It should be checked whether the patient has received a dose within the recommended dose range. If possible, a dose at the upper limit of these ranges should be given before non-response is determined. Guidelines differ slightly in their recommendations. The numbers presented below are according to those of the International Consensus Study on Antipsychotic Dose (Gardner et al., 2010). Equivalent dose tables based on various methods have also been published elsewhere (Leucht et al., 2015a; Leucht et al., 2014). We emphasize that the optimum doses for newer antipsychotics have been established by appropriate dose finding studies, while much less is known about the optimum doses of older antipsychotics, including haloperidol one of the few older drugs for which a real dose/response study exists (Zimbroff et al., 1997). For haloperidol, for example, a Cochrane review (Waraich et al., 2002) concluded that doses up to 7.5 mg/day should usually be sufficient in uncomplicated patients with schizophrenia. While there is evidence for some of these medications that doses below this range (e.g. risperidone 1 mg/d; aripiprazole 2 mg/d) are ineffective; there is no good randomized evidence that doses higher than these ranges show a further increase in response (also see paragraph on increasing the dose in case of non-response below). The main concern on the higher end is an increase in side-effects and cost.
Table 2a: Dose recommendations for antipsychotic drugs (Gardner et al., 2010)
|Starting dose
|Target dose
|Maximum dose
|Median recommendation
All doses are presented in mg/day. Target doses were defined as the "doses considered to be effective and acceptably tolerated by most patients", and maximum doses as the "dose at which no further benefits are expected if exceeded or at which when exceeded the harms usually outweigh the benefits in patients". N.i. = not indicated. Please note that for first-episode patients and elderly patients usually lower doses are sufficient (see respective passage of this algorithm).
Table 2b: Dose recommendations for short-acting intramuscular antipsychotics (Gardner et al. 2010)
|Initial dose (mg)
|Dose per Injection (mg)
|Maximum 24h dose (mg)
|Chlorpromazine HCl
|Clotiapine injectable
|Fluphenazine HCl
|Haloperidol lactate
|Loxapine HCl
|Mesoridazine besylate
|Olanzapine tartrate
|Perphenazine USP
|Prochlorperazine mesylate
|Promazine HCl
|Trifluoperazine HCl
|Triflupromazine HCl
|Ziprasidone mesylate
|Zuclopenthixol acetate
All doses are presented in mg. Respondents were asked to indicate their usual initial intramuscular dose, the dose range per injection, and the maximum intramuscular dose per 24 hours for the reference case. Range of doses/injection reflects the median lower and upper doses of ranges recommended. The reference case was an adult man with DSM-IV schizophrenia not treated for 2 weeks, presenting with delusions, auditory hallucinations, agitation, poor cooperation, threatening behavior, and who is refusing oral medications (modified from Gardner et al. 2010)
Table 2c: Dose recommendations for long-acting intramuscular injectable antipsychotics (Gardner et al. 2010)
|Dosing interval (days)
|Initial dose (mg/injection)
|Target dose (mg/injection)
|Maximum dose (mg/injection)
|Clopenthixol decanoate
|Flupenthixol decanoate
|Fluphenazine decanoate
|Fluphenazine enanthate
|Haloperidol decanoate
|Perphenazine enanthate
|Pipotiazine palmitate
|Risperidone microspheres
|Zuclopenthixol decanoate
Respondents were asked to indicate their usual dosing interval, initial dose, target dose range, and maximum dose for the reference case. The reference case was a moderately symptomatic adult man with DSM-IV schizophrenia, not considered treatment-refractory with ≥2 years of antipsychotic treatment with poor treatment adherence to oral antipsychotics. Target dose range reflects the median lower and upper doses of the ranges recommended (modified from Gardner et al. 2010)
Ad f) The onset of response to treatment of individual patients is highly variable. Nevertheless, recent meta-analyses rejected the long-held hypothesis that there is a general 'delay of onset of action' of antipsychotic drugs of several weeks. The largest part of the drug effect occurred in the first week and got consistently smaller thereafter (Agid et al., 2003; Leucht et al., 2005). An early response pattern has also been shown for clozapine (Sherwood et al., 2012). Moreover, several studies suggested that patients who had not improved at two weeks were unlikely to respond to the same antipsychotic at a later stage (Ascher-Svanum et al., 2007; Chang et al., 2006; Correll et al., 2003; Jager et al., 2009; Kinon et al., 2008a; Leucht et al., 2007a; Leucht et al., 2008; Lin et al., 2007). While one study (Lambert et al., 2009) was not consistent with the other evidence, and while analyses in first-episode populations were also not consistent with the findings of multiple-episode populations (Gallego et al., 2011; Schennach-Wolff et al., 2010), a diagnostic test meta-analysis of 32 trials confirmed the predictive value of less than 20% PANSS/BPRS total score reduction at two weeks as a predictor of non-response at six weeks (Samara et al., 2015). Still, little evidence is available that switching, a major dose increase or combination treatment is effective (see below). We, therefore, recommend, at least in multi-episode patients, unless the clinical situation demands an earlier intervention, that a 2- to 4-week antipsychotic trial at a therapeutic dose in the upper dose range is appropriate before considering a specific antipsychotic ineffective for a patient. The notion "at a therapeutic dose in the upper dose range" is important, because some drugs, in particular clozapine, require slow titration. We nevertheless feel that previous claims to try clozapine for at least six months were mainly based on an uncontrolled case series (Meltzer et al., 1989) although continued treatment with clozapine beyond 4 weeks leads to an increased likelikhood of achieving response (Kane et al., 2001).
Ad g) In the case of suspected compliance problems these can be addressed by switching to liquid medication or rapidly dissolving tablets and/or supervised drug intake. Depot medication is another option (see paragraph on depot antipsychotics below). Plasma-levels can help in determining non-compliance and in monitoring compliance. The use and the determination of a patient's Cytochrom-P-450 status (Muller et al., 2013) can also be useful in certain circumstances as detailed below.
Ad h) The relationship between plasma-levels and response to antipsychotic drugs is not strong enough to recommend the titration into therapeutic concentration windows. Hiemke et al., 2011 present an overview of the levels for different psychotropic drugs. It might be most useful for clozapine (Buchanan et al., 2010). If available, antipsychotic plasma level measurements can be indicated in the following situations:
– Suspicion of non-compliance
– Lack of response in spite of taking usually sufficient doses to rule out ultra-rapid excessive metabolization of the antipsychotic due to a polymorphism of the cytochrom-P450 enzyme system (Muller et al., 2013).
– Pronounced side effects despite the administration of a usual dose to rule out "poor metabolizers" due to too little production of cytochrom-P450 enzymes.
– The genetically determined metabolizer status, medication interactions, smoking, etc. which can also lead to elevated or lowered plasma levels via effects on the Cytochrom-P450 system.
4. Initial non-response: The antipsychotic may be switched (A-) or the dose may be increased beyond the officially indicated range (C). The evidence supporting both strategies is very limited. If the dose is increased, it should be decreased back to the original dose in case of lack of effect of the higher dose (C). If the drug is switched, choose an antipsychotic with a different receptor binding profile than the previous one (A-). Also consider the general selection criteria described above (see 1).
The evidence for both strategies is limited with a certain advantage for switching.
a) Switching the drug (Leucht et al., 2015b): One trial found that when patients, who had at best minimally improved after two weeks treatment with risperidone, were switched to olanzapine, their outcome was significantly better than that of those who stayed on risperidone, but the difference was small (Kinon et al., 2010). In patients who had not responded to a four week trial of 20mg/day fluphenazine, Kinon et al., 1993 found no difference between a) continuation with fluphenazine 20mg/day (control group), b) dose increase to fluphenazine 80mg/day or switch to haloperidol 20mg/day.The limitation was the switch to a very similar high-potency antipsychotic (from fluphenazine to haloperidol, the study was conducted before more different newer drugs were available) and the fluphenazine dose in the run-in phase which is nowadays considered to be a high dose. Shalev et al., 1993 and Suzuki et al., 2007, randomized patients to three different antipsychotics. Non-responders were re-randomised to one of the two remaining two antipsychotics. If they failed to respond again they were switched to the remaining antipsychotic. At the end of both studies, the majority of participants had responded, but both studies had the major limitation of not having a control group that stayed on the initial drug to rule out that the improvement was simply an effect of time. In two small studies Hatta et al., 2011 randomised non-improvers to two weeks of treatment with risperidone/olanzapine to either staying on the same drug or switching to the other one. Switching did not lead to higher response rates, but the authors emphasize that the trials were underpowered. In a post hoc analysis of CATIE phase 1, patients taking olanzapine or risperidone before entering the trial stayed on treatment longer if they were assigned to stay on the same treatment (Essock et al., 2006). I.e. for these groups 'sticking' was better than 'switching'. One reason might have been that some of the chronic patients in CATIE were relatively stable at baseline and might have been destabilized by a switch. In summary, the evidence for switching antipsychotics is limited, but stronger than that for dose increase (see next chapter).
A later CATIE phase provides suggestive information on how to choose a new antipsychotic when switching. Stroup et al., 2007 analyzed those 114 participants who had received perphenazine in CATIE phase 1, but discontinued it. Participants who were randomized to quetiapine or olanzapine in phase 2 stayed on the antipsychotic longer than those randomized to risperidone. A possible explanation is that because perphenazine and risperidone have similar receptor-binding profiles, switching from one to the other has little effect. Thus, if the antipsychotic drug is changed, it is reasonable to choose a compound with a different receptor-binding profile. This pragmatic recommendation is based on the underlying assumption that patients who have not responded to one drug might respond to or have less adverse effects on another drug with a very different pharmacologic profile. If there has been non-response to at least two antipsychotics, we recommend a trial of clozapine (See below).
b) Substantial dose increase: The aforementioned study by Kinon et al., 1993 showed no incremental efficacy of increasing fluphenazine 20mg/day to 80mg/day. McEvoy et al., 1991 randomized patients who had not responded to neuroleptic threshold doses of haloperidol (mean 2.3 mg/day) to either continuation of threshold doses or doses up to 10 times. The dose increase was not associated with better efficacy. Hatta et al., 2012 found no significant difference between switching to olanzapine and increasing the risperidone dose in two week non-improvers to risperidone (Hatta et al., 2012). Kinon et al., 2008b found no efficacy difference between 10mg/day, 20mg/day and 40mg/day olanzapine in patients with suboptimal response to previous treatment. 40mg/day olanzapine was only somewhat (but statistically significantly) better in a severely-ill subgroup. Two small RCTs did not find a superiority of high dose quetiapine (1200mg/day) compared to 800mg/day and 600mg/day (Honer et al., 2012; Lindenmayer et al., 2011). A meta-analysis of the currently available studies also showed no superiority of increasing the dose in non-responsive patients (Dold et al., 2015). Thus, the evidence supporting doses above the therapeutic ranges is scarce, but as there are so few RCTs more trials are clearly needed. Some individuals respond only to very high doses and such a history should be considered, these may be also ultra-rapid metabolizers. We strongly discourage excessive doses as a general strategy. It is very important that if a dose increase beyond the optimum doses was not effective, the dose is again reduced to previous levels. Patients should never be exposed to unnecessarily high doses of antipsychotic medication.
5. Drugs should be switched applying an "overlap and taper" or "cross-over" strategies, especially when switching from sedating to less sedating and from high affinity full dopamine antagonists to lower affinity dopamine antagonists or to a partial agonist (A).
Different switch strategies have been used clinically, but only few have been compared head to head. "Stop-start" means that the original drug is stopped abruptly and the next one immediately started. "Cross-over" means that the original drug is gradually tapered while the dose of the next one is gradually increased. "Overlap and taper" means that the full dose of the original drug is maintained until the next one reaches its therapeutic dose. Only then is the original drug gradually tapered. Finally, in one study the original antipsychotic was tapered entirely and the next drug (olanzapine) was started only one week afterwards (Kinon et al., 2000). This strategy was slightly less efficacious and carries a risk of loss of efficacy and of rebound symptoms, but should theoretically be associated with the fewest side-effects. There are theoretical pros and cons of the other three strategies: "Stop-start" is fast, but there could be withdrawal effects from the discontinuation of the original antipsychotic and efficacy problems, as the following drug has not developed its full effects. In "cross-over" there may be drug-drug interactions and a point when no drug develops its full efficacy. "Overlap and taper" is the safest procedure efficacy-wise, but if antipsychotics have similar adverse effects, these could be additive, and sometimes patients might be doing better when they have the combination making it difficult to stop one drug. Initial studies of second-generation antipsychotics and an earlier meta-analysis (Remington et al., 2005) did not find significant differences between abrupt or gradual initiation of the new antipsychotic, or between abrupt or gradual discontinuation of the pre-switch antipsychotic (Remington et al., 2005). However, a recent, larger meta-analysis found that abrupt stopping of the prior antipsychotic and abrupt starting of the new antipsychotic were each associated with significantly greater all-cause discontinuation than gradual switches. Moreover, cross over and overlap and taper procedures were associated with significantly lower all-cause discontinuation rates than little or no overlapping strategies (Correll et al., 2011). The advantage of overlapping switches was strongest when switching to aripiprazole or ziprasidone. Although there were no differences in PANSS total scores between the switch strategies, patients were relatively stable and patients who dropped out were often not available for psychopathology ratings. Thus, if time allows and when a switch is performed to reduce adverse effects, we would recommend "cross-over" or "overlap and taper". However, in acutely exacerbated patients or when speed of the switch is important, "stop-start" switching is also possible, especially when concomitant benzodiazepines can be used to mitigate any relevant rebound or withdrawal effects and when the initial drug has not been taken for more than two weeks. In addition, it must also be considered that these recommendations do not hold true for all drugs. For example clozapine needs to be titrated slowly. And when the original medication is a depot antipsychotic, it can simply be stopped because due to the long half-life it will take considerable time until it is washed out. Conversely, if the new medication is a depot, in some circumstances (e.g. risperidone and aripiprazole long-acting injectable) the oral medication needs to be continued past the initiation of the depot, as the latter takes a few weeks to establish therapeutically efficacious levels.
6. Clozapine is the antipsychotic of choice for treatment resistant patients (A).
It should be used if at least 2 other antipsychotics given in sufficient doses (see above) and duration (at least 4 weeks) have failed (C).
Clozapine has been shown to be significantly more efficacious than first-generation antipsychotics for treatment resistant patients in single RCTs and meta-analyses (Kane et al., 1988; Leucht et al., 2009b; Rosenheck et al., 1997; Wahlbeck et al., 1999). Although the evidence compared to second-generation antipsychotics is less clear (Leucht et al., 2009d), it remains the drug of choice for these people. The recommendation that at least 2 other drugs should have been used before clozapine is started is a pragmatic one doing justice to the increased risk of agranulocytosis and related increased blood test requirements, as it is implemented in most labels.
7. Combinations of antipsychotics: No strong evidence supports the use of polypharmacy over monotherapy for efficacy (A-). A reduction of hyperprolactinemia when adding aripiprazole to haloperidol or risperidone and the reduction of body weight, lipid and glucose levels when adding aripiprazole to clozapine or olanzapine (but not when adding it to quetiapine or risperidone) has been shown (A).
Various systematic reviews have examined the effects of combining antipsychotic drugs. Most of them found a small, but statistically significant superiority of the combining antipsychotics, but the evidence was never convincing. Correll et al., 2009b meta-analysed all combinations of antipsychotics irrespective of the drugs used. Combination therapy was more efficacious than monotherapy, but the effect was mainly driven by Chinese trials, in which combination treatment was given right from the start, rather than only in the case of non-response. Three other systematic reviews specifically examined combinations of clozapine plus another antipsychotic: Sommer et al., 2011 who analysed each antipsychotic added to clozapine separately found only sulpiride augmentation to be effective, but this finding was based on a single trial. Taylor et al., 2012 analysed all antipsychotics added to clozapine as one group and found a small but statistically significant superiority of the combination strategy. In another meta-analysis by Barbui et al., 2009, the same combination strategy was, however, only superior to clozapine monotherapy in open RCTs, but not in double-blind ones. In choosing an antipsychotic that is added to clozapine, it might be considered that clozapine has a low affinity to dopamine receptors. Therefore, drugs that are selective for dopamine receptors, such as amisulpride or sulpiride, but also aripiprazole (mainly a partial dopamine agonist) or risperidone or haloperidol, may be more reasonable choices than adding another multi-receptor antagonist, but we emphasize that this theory based on receptor binding is very weak. Another pragmatic aim should be to avoid additive side effects in particular weight gain, orthostatic hypotension and anticholinergic load.
However, although we do not recommend antipsychotic combination treatments and these are generally associated with the risk for increased adverse effects, some isolated combinations have been associated with specific reductions in adverse effects in open label as well as randomized controlled trials (Gallego et al., 2012). This includes the reduction of hyperprolactinemia and amenorrhea when adding aripiprazole to haloperidol or risperidone and the reduction of body weight, lipid and glucose levels when adding aripiprazole to clozapine or olanzapine (but not when adding it to quetiapine of risperidone).
8. Combinations of antipsychotics with other drugs: There is no evidence that would strongly support the use of any adjunctive agent for refractory positive symptoms (C). Adjunctive agents might be used for their target symptoms (e.g. benzodiazepines for sedation and anxiety, anti-manic drugs for manic symptoms, at best, knowing that even the evidence for such indications is extremely limited (C).
Numerous augmentation strategies that have been examined to improve the positive symptoms of schizophrenia, but there was no clear effect of benzodiazepines (apart from sedation, (Dold et al., 2012)), beta-blockers (Cheine et al., 2003), lithium (Leucht et al., 2007b), carbamazepine (Leucht et al., 2007c) and valproate (Basan and Leucht, 2004). The largest valproate study (249 participants) showed a more rapid onset of improvement in the augmentation group at two weeks (Citrome et al., 2004), but even this effect was not replicated in another trial with 402 participants (Casey et al., 2009). Lamotrigine is a promising adjunct, but the results on each efficacy outcome in a Cochrane review were only based on two studies (Premkumar and Pick, 2006), and lamotrigine's superiority in meta-analyses restricted to clozapine non-responders was driven by an outlier (Sommer et al., 2011; Tiihonen et al., 2009, also see below). Moreover, the latter meta-analyses were relatively small and possibly not robust (Trikalinos et al., 2004). The effects of other augmentation strategies, such as polyunsaturated fatty acids (Omega-3 and Omega-6 fatty acids (Joy et al., 2006), glutamatergic agents (Tuominen et al., 2006), estrogens (Chua et al., 2005), dehydroepiandrosteron (DHEA) (Elias and Kumar, 2007), amphetamines (Nolte et al., 2004), cyclooxygenase-2(COX-2) inhibitors such as celecoxib (Akhondzadeh et al., 2007) and erythropoietin (Ehrenreich et al., 2007) are either still in the experimental stage or inconclusive. In their meta-analysis of five trials Sommer et al., 2012 found a significant effect of adding non-steroidal anti-inflammatory drugs to antipsychotics, but they could not include a large unpublished trial that contained more patients than all 5 included studies together that showed no significant effects (Rappard and Müller, 2004). Therefore, adjunctive agents might at best be used for their target symptoms, e.g. benzodiazepines for sedation or mood-stabilisers for severe manic symptoms, keeping in mind that the evidence is even more limited, because many studies did not even address these target symptoms.
Concerning more information on the effects of adjunctive agents on specific symptoms, such as depression, negative symptoms or cognitive dysfunction, see below.
9. When clozapine fails: consider lamotrigine or topiramate (C), combine with other antipsychotics (C), consider ECT (C).
Evidence for efficacy of augmenting clozapine is currently scarce. In a systematic review that analysed each adjunct individually (for example all antipsychotics added to clozapine were analysed individually rather than as one group) only adding lamotrigine or topiramate was associated with higher efficacy than placebo, but both results were driven by single outlier studies (Sommer et al., 2011). A meta-analysis on adding another antipsychotic to clozapine in non-response that pooled all antipsychotics as one group found a small but statistically significant superiority of the combination strategy (Taylor et al., 2012), but it left it unclear which combination is beneficial. In another meta-analysis by Barbui et al., 2009, the same combination strategy was, however, only superior compared to clozapine monotherapy in open RCTs.
In choosing an antipsychotic that is added to clozapine, it might be considered that clozapine has a low affinity to dopamine receptors. Therefore drugs that are selective for dopamine receptors such as amisulpride or sulpiride, but also aripiprazole (mainly a partial dopamine agonist), risperidone or haloperidol are more reasonable choices than adding another multi-receptor antagonist. As the evidence for these strategies is scarce the avoidance of additive side effects is another important goal. In this context, randomized controlled data may warrant consideration showing that aripiprazole augmentation of clozapine was associated with significant reductions in body weight and fasting glucose and triglyceride levels, even when keeping the clozapine dose stable (Zhang et al., 2010).
10. ECT may be considered as a last resort (A).
The evidence of ECT in treatment resistant patients is very limited. Tharyan and Adams, 2005 found a significant superiority of adding ECT to antipsychotics which was based only on a single small trial. But as ECT has a different mechanism of action than antipsychotic drugs, it may be considered as a last resort if all other attempts have failed. Moreover, a recently published randomised, open trial showed a clear advantage of clozapine non-responders who received ECT (Petrides et al., 2015). It is well possible that this trial changes the overall results of the Cochrane review once it has been updated.
11. If adding and antipsychotic or other adjunct was not effective, it should be tapered off (C).
As summarized above, the evidence of all combination strategies is limited. If such a combination is still tried, the response should be assessed and if it was ineffective it should be stopped to avoid side-effects, drug-drug-interactions and unnecessary cost.


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300: Rise Of An Empire (2014)
March 4, 2014 Leave a comment
When her husband is slain during the Battle of Marathon in 490BC, Artemisia (Eva Green), hell-bent on revenge, uses magic to turn Persian ruler Xerxes (Rodrigo Santoro) into the god-King. The man responsible, Themistocles (Sullivan Stapleton), a naval commander, travels to Sparta in an attempt to unite Greece in their fight against the invading forces of Persia. He gets a cold reception from Queen Gorgo (Lena Headey), whose husband — on advice from an oracle — has already left with three hundred Spartan soldiers to fight Xerxes' forces. When Leonidas (Gerard Butler, in recycled footage from the first movie) falls and his army is slain, however, Gorgo has a change of heart and agrees to help. At the Battle of Artemisium, as Athens burns in the distance, Themistocles — with help from Scyllias (Callum Mulvey), his son Calisto (Jack O'Connell), and Aesyklos (Hans Matheson) — battlesto the last for the future of the Greek Empire.
Or something like that. It's not always entirely clear what's going on in 300: Rise Of An Empire; it's almost impossible to get to grips with the characters' archaic names, let alone untangle the indistinguishable fight scenes and identical armaments that make it difficult to tell what battle you're watching or who's actually fighting in it. In fact, unless you're au fait with Grecian history (or have watched the first film on repeat since its release) it may even take the first act just to work out who you're supposed to be rooting for. The first film kept things relatively simple: Gerard Butler and Michael Fassbender vs. the massive bald guy; but here there are innumerable villains, as Artemisia dispenses a seemingly never-ending array of generals to fight an equally never-ending series of naval battles.
A pseudo-sequel of sorts, dealing with the events before, during and after the Battle of Thermopylae from 300 (but no later than the first film's epilogue, confusingly), the stage was set for 300: Rise Of An Empire to disappoint all who didn't know better. After all, Butler had declined to return, the novelty of historical fantasy had long since worn off and Rise Of An Empire's release had already been delayed for six months — it doesn't take an oracle to predict disaster. Surprisingly — not least considering the incoherentness of the film's plot — new director Noam Murro has put together a film that is bigger, undoubtedly, but also arguably better than Zack Snyder's original. If anything, there's even more slow-motion, gore and nudity than before, and yet Murro's commitment to making the most preposterous movie he can results in a film that is strangely pure and even admirable.
He's not the only one who seems determined to giving the film their all. Eva Green seems drunk on testosterone as Artemisia, punctuating every line with a massacre and indulging in one of the strangest, most impassioned and downright alarming sex scenes of recent memory. Lena Headey is another woman on a mission, getting to utter the franchise's "this is Sparta" tagline and ultimately save the day as Queen Gorgo. The male cast look a little lost by comparison — perhaps they're all still constipated from their last brick of protein — but they still impress in their ability to loose limbs with little more than a light swing of their swords and ride horses across a navy in the heat of battle. Santoro had to shoot most of his scenes in isolation because of the effects work needed to make him a giant, and one of the film's biggest joys is watching his character try to interact with others. The only greater enjoyment comes from listening to O'Connell struggle with an accent that isn't "chav".
The dialogue seems as though its been directly lifted from the graphic novel, to the extent that your brain almost tricks you into seeing the speech bubbles floating above the action, and yet it is delivered with such gravity and solidarity that not only do you not mind, but you might actually be roused by it. Morro throws everything at the screen — blood, baby oil, a dead body — as if to see what might stick, then throws it all again for good measure. At one point Xerxes stands on a platform to overlook his kingdom, a scene composition that works rather well in 3D, only to then do it again and again throughout the movie. It's incredible to watch; the sort of movie that seems designed not for a cinema but for a theme park, where in addition to stereoscopy customers can also enjoy D-Box, Aromascope and jets of ambiguous liquid to the face. I can only imagine it would smell as ripe as it sounds.
Though it might get few points for originality, then (in fact, original subtitle Battle of Artemisium was dropped for sounding "too exotic"), 300: Rise Of An Empire certainly gets points for effort. Run at normal speed Murro's film might only be eleven minutes long, but they're likely to be eleven of the loudest, dumbest and most gloriously over-the-top minutes you've spent in the cinema this year.

subset: commoncrawl


text:
Model Agreement
You can Download file here
[Name Partner University,
City, Country,]
And the
University of Haifa,
Haifa, Israel,
The [Name Partner University], represented by [TITLE & NAME(S)], who is (are) fully authorized to execute this agreement in his/her (/their respective) position(s) as [FILL IN POSITION(S)],
The University of Haifa, Israel, represented by Professor Aaron Ben-Ze'ev, Professor David Faraggi and Professor Michal Yerushalmy, who are fully authorized to execute this Agreement in their respective positions as President, Rector and Vice President & Dean of Research,
(hereinafter referred to collectively as the "Parties" or individually as the "Party"),
the Parties have decided to enter into this Framework of Academic Collaboration (the "Agreement") in order to promote, facilitate and consolidate international cooperation in education and research, based on the principles of reciprocity and mutual benefit.
Decide as follows:
Article 1. Areas of Cooperation
The areas of cooperation shall include, subject to mutual consent, any activity or program at either institution as considered feasible and desirable on either side in order to foster and develop the cooperative academic relationship between the two parties.
Article 2. Modes of Cooperation
The implementation of research and study programs determined in conformity with Article 1 may be carried out through the joint realization of research projects and teaching programs at the location of both Parties, according to the modalities specified in Article 4 of this Agreement.
More specifically, the Parties agree to the following modes of cooperation:
· Exchange of scholars
· Joint research projects
· Joint teaching and/or supervision of students
· Joint participation in workshops and/or conference days
· Student mobility and prospective exchange of students (as may be mutually agreed upon)
· Participation of students in Study Abroad programs hosted by each institution
Article 3. Liaison
The Parties will appoint a faculty member as coordinator of the activities entailed in this general framework agreement who will also be responsible for facilitating and maintaining communication with the other Party for that purpose.
Article 4. Specific Cooperation Agreements
Nothing in this Framework Agreement shall be construed as creating any legal or financial relationship or commitment between the two Parties.
The terms of collaboration and the necessary funding for each program and activity shall be mutually negotiated, discussed and agreed upon in writing by both Parties in separate specific cooperation agreements prior to the initiation of any particular program or activity. Each institution will designate a lead coordinator for the activities or programs of potential cooperation that may form the basis for specific cooperation agreements to be executed between the parties.
Besides implementation modalities specifying academic, organizational, technical and financial aspects, specific cooperation agreements shall contain terms relating to intellectual property rights and procedures for publication etc.
Article 5. Principles
All participants will be treated in the same non-discriminatory manner in carrying out the provisions of the agreement, subject to the provisions of the policies and requirements of each of the institutions.
Article 6. Terms of Cooperation
6.1 Duration
This Framework Agreement shall commence on the later of the two dates of signature of the parties, this being the date when both parties have duly accepted the conditions laid down in this Agreement. The Agreement shall be in force for five (5) years with automatic prolongation for the following five (5) years subject to the right of early termination for convenience pursuant to section 6.3 below.
6.2 Amendments
Any amendment and/or modification of the Framework Agreement will require written approval of both Parties and shall be appended hereto.
6.3 Termination for convenience
Either Party reserves the right to terminate this Agreement at any time, for any or no reason, subject to ninety (90) days prior written notice to the other party hereto. Any program or activity that has already commenced pursuant to specific cooperation agreements executed between the parties hereto, if executed, shall survive termination of this Agreement and be completed to the best of both parties' abilities pursuant and subject to the terms of the relevant specific cooperation agreement.
Date: ______________________
[Partner University]
[title and name signatory]
[title and name signatory]
[title and name signatory]
Date: ________________________
University of Haifa
Mr. Amos Shapira
Prof. David Faraggi
Prof. Michal Yerushalmy
Vice President & Dean of Research


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text:
7 Minute Read
In the classic Christmas movie Home Alone, Kevin McCallister made a blueprint for how he was going to tackle the intruders in his house. He knew all he needed to outsmart the Wet Bandits was a plan of attack. A little glue here, some glass ornaments there—and a couple of swinging paint cans for good measure.
What's our point? Well, just like Kevin McCallister, you need a plan. The budget is your plan. It will lead you to success, but only if you follow it! Speaking of your budget . . . have you downloaded the EveryDollar app yet? Sign up now and you'll be ready to start setting up your Christmas budget.
What Is a Zero-Based Budget?
The concept of a zero-based budget is simple: Income minus outgo equals zero. If you earn $3,000 a month, you want every dollar you spend, save, give, or invest to all add up to $3,000. That way you know where every one of your dollars is going. Not knowing where their money is going is what kills a lot of people's money situations. They just look up one day and find they have no money—and no clue about where it went.
Here's How to Make a Zero-Based Budget for Christmas:
1. Write down your monthly income.
Open up our free budgeting app EveryDollar and begin listing your income. This should include paychecks, small-business income, side jobs, residual income, child support, and so on. If it's money and comes into your household's bank account, write it down and add it up.
2. Write down your monthly expenses.
Before the month begins, write down every expense. Things like rent, food, cable, phones, and everything in between should be added to the list. But be sure to start your budget with the four walls—food, clothing, shelter and utilities, and transportation. After those essentials are covered, continue listing your monthly expenses. Your needs will vary from month to month, so you should make a new spending plan each month. And since we're gearing up for Christmas, think about gifts, wrapping paper, decorations, and all the ingredients you need for your delicious Christmas dishes.
3. Write down your other expenses.
Think through the calendar year—what expenses will you have coming up? You know Christmas is in December every year, so there's no reason to act like it suddenly snuck up on you. Start stashing away money for Christmas now! Go ahead and plan for the special occasions that happen throughout the year, every year. Birthdays, anniversaries and holidays are set dates that shouldn't surprise you or your budget.
Next, think about irregular expenses that pop up. Plan for those too! Things like car tag renewal fees, property taxes, and even your insurance premiums can be budgeted for. If you set aside a little bit each month, you won't feel the strain of an expense "blindsiding" you all at once.
4. Subtract your income from your expenses to equal zero.
Ideally, this number should be zero, but it might take some practice. Don't be shocked or worried if they don't balance each other out. This just means you need to do something to bring one of the numbers up, the other down, or both. But whatever you do, don't spend anything that's not accounted for. If you budget $100 for eating out and you're already at $95, shop on the dollar menu. Don't break your plan!
If you're spending more than you make, you need to make some cuts so your income and outgo are equal. To reduce expenses, try buying generic at the grocery store, using coupons or the store's app, making coffee instead of buying it, or catching a carpool to work. If you need to generate more money, start a side hustle or sell some things.
Here's the deal with a zero-based budget: Every dollar must have a name! That means you must have zero dollars left to budget. If you fill out every item in your budget and come out $100 ahead (meaning you have nothing for that $100 to do), you haven't finished your budget. You must assign that remaining $100 to something. Whatever you decide is up to you. But if you don't give it a name, it will be spent carelessly, and you'll end up scratching your head over that missing $100 you thought you had.
What If You Have an Irregular Income?
If you have an irregular income—don't sweat it. You can still use zero-based budgeting! It is just as easy to make a plan for an irregular income as it is for a regular one. When you budget, base your income on the lowest earning month from the previous year. Then list your expenses in order of importance. Make sure you cover the four walls first (food, clothing, shelter and utilities, and transportation).
When you do get paid, take that amount and spread it out over the items in your budget. If your paycheck doesn't cover everything listed on the budget, that's okay. Cover what you can. If you get an additional check during the month, pick up where the last check left off.
Set Up a Christmas Fund
It's easy to create your Christmas budget! Simply log in to EveryDollar from a desktop computer and click the "make this a fund" feature.
Take a look at how much you spent on Christmas gifts last year. Where did you overspend? Where can you cut back this year? Make a gift-giving goal amount and stick to it! You'll be amazed at how quickly you can pile up a stash of cash when you just make a point to save.
Once you've determined the total you want to spend on Christmas gifts, divide it by three (the number of months left until Christmas). For example, if your budget is $1,000, save $500 a month for two months. Or around $330 from each paycheck for the next three months. EveryDollar will track how much you're saving and how much more you need to save to meet your goal. In December, your Christmas savings will be fully funded and you can enjoy the season instead of feeling pinched for extra money.
Start Tracking Your Expenses
Tracking expenses through EveryDollar is easy! Just enter in the date and the amount you spent for the transaction. Then assign it to the category it falls into and EveryDollar with deduct it from your budget. And with EveryDollar Plus, you don't have to do any manual entry since it's already linked to your bank account. All you have to do is drag and drop the transactions! That's it!
Does This Work?
Yes! Having a budget (your detailed spending plan) is the quickest way to make your money goals a reality! Saving for Christmas? You need a budget! Trying to get out of debt? You need a budget. Saving for retirement? You need a budget. Already a millionaire? Guess what—you still need a budget.
Remember, you're the boss of your own budget. You get to tell every single dollar exactly where it will go each month. And don't think of it as confining. Having a budget actually gives you the freedom to spend money! Who doesn't love that? Especially during the holly, jolly Christmas season.
Did you know you can get transactions from your bank account linked directly to EveryDollar? Sign up today for EveryDollar Plus and start using the easiest online budgeting app on the planet.
Local experts you can trust.Find an ELP


text:
AMSTERDAM (Reuters) - The head of a United Nations Human Rights Commission inquiry into last summer's conflict between Israel and Gaza said he would resign following Israeli allegations of bias due to consultancy work he did for the Palestine Liberation Organisation.
Canadian academic William Schabas was appointed last August by the head of the U.N. Human Rights Council to lead a three-member group looking into alleged war crimes during Israel's military offensive in Gaza.
In a letter to the commission, a copy of which was seen by Reuters on Monday, Schabas said he will resign immediately to prevent the issue from overshadowing the preparation of the report and its findings, which are due to be published in March.
(Reporting by Thomas Escritt; Editing By Anthony Deutsch/Hugh Lawson)


text:
Hosted by: Sacred Heart
Young Adults in the Eastside Deanery are invited to join together the 1st Thursday of the month in order to sing songs of praise, participate in small groups, and engage in fellowship with one another. We will have child care for the children of our young families. *Musicians interested in working with the band can contact Jeff Kress, Pastoral Assistant for Youth and Young Adult Ministry, (425-450-3911).
*Region 2


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Oncology Massage is a very light and relaxing massage specifically tailored for people with cancer. It can be given at varying stages of your diagnosis including during chemotherapy, after radiation, pre and post-surgery, for those recovering from treatment or in remission and anyone at risk of lymphoedema. It is a safe form of massage that allows people to feel whole again and more positive about their body. Tumour or treatment sites will not be massaged to avoid discomfort or too much pressure on the affected area and underlying organs.
The massage will be tailored specifically for you:
- A detailed health history will be completed including the type of cancer you have (or had), your treatment (past, present, future), medical devices, lymph node involvement, medications, treating specialist
- Pressure will be modified to a very light, relaxing pressure and the length of time of the massage will be reduced while we find your "new normal"
- Positioning will be modified to accommodate surgical sites, radiation sites, medical devices and your comfort
- This massage is deeply relaxing and nurturing and will restore your sense of wellbeing
- It may consist of several different modalities including bone marrow support, lymphatic drainage and massage depending on your needs at the time of your booking. (If only Bone Marrow Support is required – the client remains fully clothed. It is a sequence of hand movements that improves and supports bone marrow production).
It is important for people who have cancer to let their medical care provider know they are receiving massage. Family members and other caregivers can be instructed in certain massage techniques and are encouraged to book their own little piece of "me time" as well. Several types of massage are available.
I've heard that massage can spread cancer
Massage DOES NOT cause cancer to spread.
Cancer may spread (metastasise) into the lymphatic system via the lymph nodes, or it may start in the lymphatic system itself. However, the circulation of lymph – from massage or other movement – does not cause cancer to spread. Researchers have shown that cancer develops and spreads because of changes to a cell's DNA (genetic mutations) and other processes in the body.
What if I am at risk of lymphoedema
As part of your oncology massage, we will assess you regarding your risk factors for lymphoedema and offer education on where you are at.
Another benefit of massage is reducing lymphoedema. Lymphoedema is the abnormal accumulation of protein-rich fluid accompanied by low-level chronic inflammation and reactive fibrosis. In short, it is swelling in the tissues caused by a build-up of fluid after surgery or radiotherapy to the lymph nodes. Once you develop lymphoedema, it never goes away but it can be reduced and managed. Manual Lymphatic Drainage (MLD) is done as part of Complex Decongestive Therapy (CDT) which is used to help in the reduction of lymphoedema after certain cancer surgeries. CDT also includes bandaging, compression garments, special exercises, skin care and activity modification. This treatment is usually done by lymphoedema specialists rather than general-practice massage therapists.
Can I bring someone with me?
Of course, you can. Your carer may wish to know what they can do to help relieve your symptoms and offer you comfort in between your visits to us. We will gladly go over some simple techniques that can be implemented at home.
I am in the middle of treatment and have a medical device
As long as you are up to leaving your home and have the all-clear from your medical team, you are not precluded from specialised massage. We are trained to work safely around your medical devices and surgical sites. You will be positioned on the massage table in a safe and comfortable way to allow you to reap the benefits of a nurturing massage.
Please tell us though where you are in your treatment regimen and what medications / infusions you are receiving so we, as the therapist, can safely massage you.
Key Benefits of Oncology Massage
Scientific studies have been done to show the effects of various body-based practices on people having cancer treatments such as chemotherapy and surgery. These studies have shown that massage may:
Improve sleep
Reduce fatigue, pain and anxiety, nausea and vomiting
Increase energy and appetite
Strengthen the immune system – stimulation of the immune system by increasing blood flow and improving circulation and increasing mobility
Aid in the repair of scar tissue
Provides a distraction
Gives some relief from constipation


text:
Although you may want to turn off your sound when viewing this video, this video contains many shots of the weapons system in action in the Leopard 2A4. This video consists of armored vehicles in the Finnish armed forces. I personally know the video creator who was a tank commander. He has shared many stories with me to say the least.
For example he has told me about his detailed adventures in simulation warfare and how has adapted tanks to modern day tactics by being in the field and experiencing everything upfront. You can see these things taking place in this video.
I will warn again however that the music is loud.


text:
Sign & Send
Personalize a handwritten Hallmark card
Be An Adventurous Couple Valentine's Day Card
Regular price $4.99
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Card Details
Keep it light-hearted and make your sweetheart laugh with this humorous card for couples.
- Includes envelope and Gold Crown seal. Envelope color may vary.
- 5.75" W x 8.25" H
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text:
|Message view
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|[jira] Closed: (GERONIMO-309) Review whether a more recent version of Castor should be used
|Mon, 20 Sep 2004 05:14:37 GMT
Message: The following issue has been closed. Resolver: David Blevins Date: Sun, 19 Sep 2004 10:14 PM OpenEJB 1 uses Castor 0.9.5.3. The related code in OpenEJB 2 isn't used by Geronimo and is in disrepair. When it is updated, the Castor version will be updated. --------------------------------------------------------------------- View the issue: http://issues.apache.org/jira/browse/GERONIMO-309 Here is an overview of the issue: --------------------------------------------------------------------- Key: GERONIMO-309 Summary: Review whether a more recent version of Castor should be used Type: Task Status: Closed Priority: Minor Resolution: FIXED Project: Apache Geronimo Components: buildsystem Versions: 1.0-M2 Assignee: David Blevins Reporter: John Sisson Created: Sun, 19 Sep 2004 4:14 AM Updated: Sun, 19 Sep 2004 10:14 PM Description: Geronimo currently uses Castor version 0.9.3.9, which is dated December 11, 2001. There have been many releases of castor since then.. http://www.castor.org/changelog.html --------------------------------------------------------------------- JIRA INFORMATION: This message is automatically generated by JIRA. If you think it was sent incorrectly contact one of the administrators: http://issues.apache.org/jira/secure/Administrators.jspa If you want more information on JIRA, or have a bug to report see: http://www.atlassian.com/software/jira
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Metal Roofing Installation Available to Residents of Denver, CO & Surrounding Areas
Metal roofing is a popular and aesthetically appealing choice among homeowners in Denver, Colorado, and all surrounding areas. If this interests you, turn to the experts at Northern Lights Exteriors. We have experience working with a large variety of different metal roofing products including Pro-Panel, stone-coated steel, and standing seam. Additionally, our entire installation team is factory-trained and -certified and receive regular, ongoing educational classes to remain up-to-date on all of the roofing products we offer.
Northern Lights Exteriors is a company that prides ourselves on working hard to bring our customers the best installations and customer service. We do this by beginning every project with a complimentary consultation and a free estimate. At this initial meeting, we will inspect your current roof and break down all of the advantages associated with switching to metal roofing. However, our dedication to customer service doesn't end there. Homeowners in Denver, CO, will also benefit from:
- A five-year workmanship warranty on all the labor we perform
- Impressive manufacturer warranties
- A proprietary web portal with up-to-date information including materials delivery dates, payment terms, due dates, and photos
- Convenient financing options available to all of those who qualify
- And more
To learn more about the metal roofing installation services that we can provide to homeowners in Denver, CO, and all surrounding areas, contact Northern Lights Exteriors today.


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The problem with writing historical fiction is that it is easy to loose yourself in the facts. I learned that discouraging bit of news after sending the 83,000-word sequel to the Thirty-Ninth Man to my editor. Aaarrrggg! AND SHE IS RIGHT!
The basic plot I had in mind was to follow governmental misdeeds as the nation expands westward. The story was to end with the Wounded Knee Massacre. That is the plot. Bring the reader from the first organized governmental action against the Sioux Nation ending in the hangings at Mankato (the first novel), and carry the story through to the confrontation that ended the Sioux Indian Wars. The first novel covered about 60-years. The follow-up should be easy. No big deal–I thought. The sequel would only have to cover the time from 1862 to 1890, a period of 28-years. It should be a piece of cake —WRONG!
What I learned: 1) People get older and their physical capabilities decline with age. Your hero's abilities decline—except in a fantasy. 2) Research is guaranteed to uncover historical evidence revealing facts not made available to the general public. Choose carefully the evidence you choose your characters to reveal.
First Lesson: Stick to your story!
Don't loose the reader by changing POV (point of view) to include important historical facts supporting the final outcome. It will result in confusion and interrupt the story you are trying to tell. If you are writing a novel, the story MUST always come first. Include facts that are witnessed by one or more of your primary characters. Find a way to place them in direct contact with the event. Too much movement between events, locations, new characters, and first person accounts are guaranteed to cause interest to wane and drive your editor to drink. Best to forget including them.
My next entry will show you exactly what I mean by maintaining POV. Now, please excuse me. I have a lot of rewriting to do.
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Mar 3rd, 2016
Author: eric315
Category: Bodybuilding Food
Best Preworkout Foods
Are you the type of person that never eats before exercise? If so, do you often become tired and irritable half way into your workout? If you answered yes to these questions you should read on. Unfortunately, you are not alone! There are millions of athletes and casual exercisers who mistakenly believe that eating a meal prior to exercise has no benefit and could possibly hurt their performance. They are mistaken! In fact, eating a meal before working out serves three important function: help prevent low blood sugar which leads to symptoms such as light-headedness, fatique, blurred vision, and indecisiveness; helps settle stomach and absord gastric juice; and fuels your muscles with carbohydrates and protein, which is used for energy and muscle building. Know that the only time a pre work out meal can damage performance is when too much food is consumed too fast and/or the wrong types of foods are eaten.
So what exactly are you supposed to eat pre workout? I get asked this all the time!!! Not only am I going to tell you what to eat pre workout to help maximize performance, but also how much to eat in regards to protein, carbohydrates, fat, etc. I'm gearing this article on pre workout nutrtion to the casual exerciser and bodybuilder exercising for 60 minutes or less, not aerobic enduranace athletes. That will be something I cover later in my blog. Aerobic endurance athletes require a difference pre workout nutrition plan due to their high need of constantly supplied carbohydrates.
During high intensity exercise such as weight lifting, HIIT training, or circuit training the body's primary source of energy is carbohydrates. This is its fuel if you will. Think about an automobile, without gasoline the car starts to halt and putter, and it will eventually shut down all together. This is similar to what your body can do when it is in a state of starvation! Without the proper fuel to keep you going during high intensity exercise, your body is unable to process properly and although you may continue to move it is actually shutting down. High intensity exercise requires carbohydrates for energy and conversion purposes, as fat will simply not provide the energy required for maximum performance. On the other end, however, low intensity exercise or physical activity such as every day tasks or walking, fat is a suitable source of energy to provide fuel for the body. Keep this in mind should you switch up routines or if you will experience a long duration between high intensity exercise programs.
In most cases, consuming an adequate amount of carbohydrates pre workout is very achievable. For some, however this may be difficult at first, train your stomach to eat pre workout by starting out with very small amounts of food 1 hour pre workout, a few calories from fruit juice is a good start, then gradually increase the amount until you are able to eat the suggested grams of carbohydrates. For a 140 pound female, a yogurt and large banana, 1 cup of almonds and one cup of yogurt, or 1 bagel and 1 large apple would all be excellent choices for a pre workout meal 1 hour prior to strength training or other high intensity exercise last 60 minutes or less.
Protein also known as amino acids, are an extremely important part of the pre workout ritual. Many studies have shown that pre workout protein is beneficial to anyone looking to gain muscle and lose fat because the delivery of amino acids is much greater during a bout of exercise than after exercise. This concept directly opposes the premise protein after a workout is more important for gaining muscle which is mostly what is heard among fitness enthusiasts and professionals. Since these opposing views exist, I and most others prefer consuming protein both before and after working out. Consuming approximately 10 to 20 grams of protein 1 hout prior to training will fuel your body with plenty of amino acids to promote muscle building and the loss of stored fat. Additionally, a slow digesting protein, such as found in the form of casein or meat, is best to consume an hour before training since it is long lasting. If you are limited on time and need to eat closer to training time i suggest you choose whey protein instead as it is fast absorbing.
Examples of protein sources to consume pre workout:
Trail Mix
Peanut Butter
Lean Turkey
Lean Chicken
Whey Protein powder
Casein Protein powder
Just peel and eat. Plenty of potassium and no sticky pits! We all know I hate pits
Although highly debated and more of a nutritional supplement, caffeine has been and still is a popular pre exercise supplement, when taken before training and with your meal it will provide an additional benefit. Not only does caffeine provide energy, but it stimulates the brain leader to enhance concentration, which can ultimately benefit your training session. The majority of studies have revealed that caffeine does indeed enhance performance for longer lasting, endurance and short term, high intensity activities. Additionally, according to research caffeine does not lead to dehydration and is perfectly suitable for athletes when taken in moderation. Unfortunately, some people may be negatively affected by caffiene, thereby suffering from nausea or "coffee stomach." It is best to start with a small amount pre workout and testing how your body reacts. For those not sensitive to caffeine I suggest 1.5 milligrams per pound of body weight 45-30 minutes prior to training.
An adequate pre workout meal is extremely beneficial for anyone looking to build muscle and lose fat. Aim for a small or ight meal an hour prior to workout or a larger meal 4 hours before training. In both cases, an adequate amount of carbohydrates and protein should make up the bulk of the meal. This way, you can rest assured that your workout will be sufficiently fueled thereby maximizing performance benefits and post workout benefits. Many studies have proven that a pre workout meal, consisting of protein and carbohydrates, can maximize performance and enhance muscle growth and fat loss. Additionally, if taken in moderation, caffein can significantly enhace energy and concentration when included in the pre workout ritual.


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As the doom and gloom of the financial crisis begins to subside for consumers, banks continue to live their own personal nightmares, bracing themselves against the onslaught of regulatory scrutiny and record-high fines.
Bank CEOs wake up every morning wondering what issues continue to lurk within the depths of the economy. With financial markets invariably in a transition state, the most definitive thing we can say is that different markets are going to be impacted in unpredictable ways.
Another thing I can say with certainty: the amount of debt out there at current interest rates is unsustainable. Furthermore, as the global economy improves, monetary policy is going to tighten.
This nightmare could begin to get even scarier.
Cue the entrance of zombie companies, businesses that can sustain themselves on low interest rates alone and are able to pay back minimum interest payments but are in no position to repay the actual debt itself.
Zombie companies, especially prevalent in the hospitality and retail industries, have survived on the loose monetary policy of the past few years, designed to help at-risk businesses stay afloat and keep people employed in the wake of the financial crisis.
In the U.S., the resurgence of covenant-lite leveraged loans has the Federal Reserve worried. In 2013, the volume of leveraged loans usually rated subprime and often handed out to indebted companies to refinance their debt exceeded pre-crisis levels.
According to R3, a U.K.-based insolvency association, there are over 100,000 zombie companiesemploying at least half a million peoplelurking in the U.K.
Couple these two developments with an inevitable drop in consumer spending as interest rates rise, and the industry has got a problem brewing.
So what's to be done? How should banks deal with a bubble that has yet to burst?
First, banks need to begin scrutinizing their debt portfolio and conducting data analysis to figure out which companies pose the most risk. Sector and jurisdictional analyses are in order, and models need to be built to assess financial viability and buoyancy at different levels of increase in interest rates.
Banks need to divide customers into different groups. Which sectors are prone to this lapse in debt? Who are their at-risk customers? Who has officially entered zombie territory?
The immediate impulse may be to proactively "pop the bubble" and take extraordinary measures to reclaim at-risk capital from those on the razor's edge. Considering the current regulatory environment, however, that may be the wrong thing to do and it could be seen as pushing clients into insolvency.
A balanced approach, however, is essential to keeping capital safe.
Banks should develop programs to coach their customers through what is bound to be a difficult time. Work with clients to more closely monitor and track debt. Devise mutually satisfactory and proactive ways to restructure debt. Invest in debt and capital management programs to help counsel customers back to health and to strong capital positions. Bring them to a point where default is not the default.
And, if default does occur, try to be the first to capture your debt, not the last. Implement a rigorous but fair process to ensure minimal damage to customers and clients.
Like in any zombie apocalypse, players need to keep resources safe and sound and stored in the right place. Banks are going to need to move quickly to transfer capital to high areas of growth.
Banks need to ask themselves: Which sectors are going to see high growth? What analyses are needed to figure out which enterprises are worth injecting capital into?
In short: have a debt recovery plan so that you're not the last claimant in a line of debtors. This is one zombie party you can't afford to be late to.
Brandon Daniels is the president of Clutch Group, a global provider of litigation, investigation, compliance and other legal services for Fortune 500 companies.


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Editor, Elle SA
Jackie Burger is the editor of Elle magazine in South Africa. Her background includes having been a brand manager at Foschini, associate fashion editor for Fair Lady as well as a brand consultant for Lever Ponds. Jackie has also been a finalist in the fashion category of the 2001 and 2003 Mondi Paper Magazine Awards, and subsequently won this award in 2002. She is also a winner of the Most Innovative Style category, of the 2003 SA Style Awards.


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gouin miller roll WM. Able
Does anyone have info on this William Able on the Gouin Miller rolls? Since it cost $17.50 to get a copy of the application, we ought to be able to get a peek to see if it is one we are seeking!
Our family located a ggreatgrandfather by sending for one, even though the name was only similar.
Thank you


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Description: This metal Keyring has one a photo of Wollongong Harbour. It's a quality Wollongong made keyring which comes in a black box as seen in the photo above.
Price: $13.00 each
Postage: FREE Australian Postage. Standard International Postage rates apply.
All of my products are 100% Made, Designed and Printed in Australia.
Custom Photo: Want to pick your own photo for this Key Ring? Note down any Chilby Photography photo from the open edition galleries and include the product code in an email to firstname.lastname@example.com
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Wollongong Harbour Keyring
Product Code: CPKR2
Price: AU$12.00
Ex Tax: AU$12.00


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Qld man guilty of horrifying assault on two-year-old son
A CAIRNS man who assaulted his toddler son, causing a life-threatening head injury, initially said he would plead guilty to the charge but changed his mind more than a year later.
A Cairns District Court jury took just over two hours yesterday to find the 33-year-old from Cairns North, who cannot be named for legal reasons, guilty of the 2015 grievous bodily harm of his son when he was just 2½.
During the trial the court heard the boy had to undergo major surgery after suffering bleeding on the brain caused by blunt force trauma to his head.
At the time, the man shared custody with the boy's mother and was living with another partner, their infant daughter and her three other children.
His sentencing has been adjourned until November as the prosecution awaits a medical report about the long-term affects of the injuries to the boy who is now aged four.


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Original and iconic; your bold style statement. The versatile watch for every occasion; let our obsession with detail be your personal trademark.
A discerning nod to neo-classic style. Where classic meets contemporary, this timepiece is engineered for those who want the best of both without compromise.
A homage to vintage watch design; angular inspiration with a modern touch. The perfect addition to this season's wardrobe; carry this style boldly.
With a focus on versatility, the Jura Collection features a small-seconds subdial and pops of colour. Inspired by some of the greatest vintage dress watches of the last 50 years the Jura pays tribute to our commitment for refined design. The texture detailing on the subdials of the Jura Collection delicately reflect the light to create a shimmered sunray effect. The entire collection is available in a variety of both classic and contemporary colour variations. A true homage to sophisticated design..
Inspired by the textures and architecture of the British Museum. The ultimate in refined luxury.
The ultimate in delicate horology, the Bernadotte collection showcases the true beauty of natural iridescence. A dedication to timeless elegance.
An Obsidian inspired nod to our iconic style, the Jette collection features bold, clean designs. Elegant modernity to the very last detail.
With a focus on the art of variety the Solaris collection boasts a dynamic and colourful range of sunray dial pieces. Versatility for every occasion.


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Penn State hockey outside of the club level was but a pipe dream for the longest time. That all changed with PSU alumnus Terry Pegula though.
The billionaire invested a good chunk of change and made a once interesting club hockey team a full-fledged NCAA program starting in the 2012-13 season. It was an ambitious ask, going from pure club to D1 hockey overnight.
Many wondered if Penn State would be anything but a doormat for the rest of the D1 programs out there, as even the best of the ACHA club programs are nowhere near the level needed to compete at the D1 level.
Penn State was literally asking to create a D1 hockey program out of whole cloth.
It not only had to find players capable of playing at the highest level, but willing to start from the ground floor. There was a new arena to be built, 6,000 seats to try and pack and a fervor for hockey to establish in the Penn State community.
However, as Penn State looks forward to its fifth season of D1 hockey and fourth as a full member of the Big Ten it is hard not to notice the crazy ride Penn State has had towards the top of the college hockey world already.
After two seasons of losing hockey, Penn State put together its first winning season in 2014-15 by finishing 18-15-4 overall and 10-9-1 in B1G hockey play. It followed that season up with a 21-13-4 season in 2015-16 and again finished with a 10-9-1 record in conference play.
For a program just forming, having half of its life as a D1 hockey program on the positive side of the ledger is certainly impressive, it also indicates that Pegula's big investment in the sport in State College, Pa. has paid off in spades.
Now the march to a first-ever NCAA hockey tournament appearance is the next hurdle, as is proving that head coach Guy Gadawosky can be a hit on the recruiting trail as well. After all, those players who started this program from scratch are all gone by now.
The only remaining question is if Penn State can become a long-term player in college hockey. If so, the Big Ten goes from a questionable league to one of the strongest in college hockey with four out of six programs drawing attention in the college hockey world.
Add in Notre Dame in 2017 and you have a lot of firepower for the league as whole. The addition of Penn State could hardly have gone better for the Big Ten conference, who added the sport in direct relation to PSU adding the game as well.
What was a once crazy idea has become a thing of dreams come true for Pegula and for plenty of those hockey crazy Penn Staters who have packed Pegula Ice Arena the last four seasons.
talking10 Podcast
More in PSU Hockey
2017 NCAA Hockey Tournament: A Big Ten Primer
Can the Big Ten represent well after a great regular season showing for the...


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Fast reliable travel Visa applications to the public and trade since 1970. A fast, flexible, cheap and reliable visa and passport service. Every effort is taken to ensure our website is accurate and up to date, however visa requirements are continually changing therefore Benmar offer no guarantee for absolute accuracy of cost and time for authorisation and delivery. E&OE. If in doubt, please call us for the latest information.
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Forecasters who listed Maine South fourth behind New Trier, Glenbrook North and Evanston in the Central Suburban League South Division soccer race this season are beginning to check their crystal balls for cracks.
The Hawks, who lost 1-0 to Gordon Tech and tied Oak Park 1-1 in their first two outings, held visiting Glenbrook South without a shot-on-goal during a 1-0 decision Tuesday. It was Maine`s fourth straight victory.


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Courses I - L
882: Legal Research and Writing II
Credit Hours
This course is required for international students in the LL.M. and U.S. Law or the LL.M. in International Law.
During the fall semester, students take Legal Research and Writing I and are introduced to legal research methods and the fundamentals of legal writing. Students read and analyze legal authority and learn how to apply the legal authorities to particular fact situations. Through a series of legal memoranda and exam writing assignments, students develop their analytical and writing skills. Students are taught legal research methods through written exercises, research memos, and lectures. During the spring semester, students take Legal Research and Writing II which builds on the basic writing, analysis, and research skills learned in the first semester. In the spring semester, students are also introduced to persuasive writing and learn how to present an oral argument to the court. Computerized research techniques are included in the course.
Instructor approval (Brendel/Becker) required.


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In last Mentee founded, we hit few obstacles and got off the track. How did we solve everything and how did we get back to the original idea? Everything is in today's episode. Read on.
Our creative and innovative nature wasn't happy with creating just an improved copy of us-based portal. We wanted to create something new, something innovative and with bigger potential than just portal for teachers. In short, we wanted Mentee.
This need emerged soon as we stood on an emergency staircase of our office building – our favorite place to discuss pretty much everything with a cup of coffee in our hands. We were there with Peter and Lukas and we started discussing why we had put Mentee on ice.
After this brief debate, we've decided to rethink our move and focus on Mentee again. We spent some time looking for an answer to the question that deviated us from the track. We came up with two ways to overcome this problem:
- Change the main message and how we think about Mentee: Instead of using Mentee to learn new skill completely, you get a friend who'll help you with the basics of the skill – for example, when you want to learn to play guitar, you can ask for help with choosing the right guitar or for the best place where you can find lyrics. This means that the beginnings will be easier and there is a lower chance of quitting, since you have a companion and help on your journey to learn the skill.
- Test the app's principle: You can spent a year coming up with various scenarios, but unless you test it with the real users, it's all just presumptions. We decided to utilize Google Forms to simulate the login and skill picking process of the app, we matched the users manually and we used Google Hangouts to suplement the in-app chat.
Being us, we went on and did both. We changed and improved main message and we conducted a simple test.
Our second project – teacher's portal, was sent to ice. But it wasn't in vain. We used a lot of gained experience later, when we worked on Mentee.
It took us almost a month, but we got back to our first project – Mentee. We put our second project on the side and reused as much from it as we could for Mentee.
Overcoming all these obstacles gave us confidence in our project and reassurance that we are doing a good thing and are on a right path.
In the next Mentee Founded, we'll let you see the testing process and we'll show the results.
See you in a week and thanks for being with us.
Jakub & Zdeněk
PS: Do you like Mentee? Support us with a few clicks! 🙂


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Our Advanced Field Trip class takes you and your dog out and about to work on leash manners, reactivity, and recall.
We practice self-control and focus in everyday situations, and teach you to keep your pooch calm, cool, and under control.
This is a class for dogs who have completed our Intermediate class or an equivalent class elsewhere.
Since this is an outdoor class, FIDO offers Advanced Field Trip during the Spring, Summer, and Fall months only.


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Roller derby has seen a resurgence in popularity in the last 10 years, and Hollywood movies have taken note. What Hollywood has left out in its movies, however, is the fact that the sheer physicality of the sport may result in injuries. For players, some may worry about being subjected to legal liability, and wonder what to expect in a personal injury lawsuit.
Roller derby hits hard in West Virginia
West Virginia man injured in summer traffic pile-up
Summer, or as some call it, "towing season," has arrived. May West Virginia drivers are out pulling boats, campers and trailers down the highways in their adventures across the state. However, those vehicles may require additional precautions.
Motorcyclists ride through West Virginia to raise support for TBI
You probably were aware that bike helmets may save lives and minimize traumatic brain injuries. However, you may not have known that for children in West Virginia under the age of 14, it is also the law.
West Virginia man sues employer for on-the-job brain injury
Imagine going to work and getting injured. Do you know what you would do next? Many people who sustain mining injuries in West Virginia know that an attorney can provide them with insight on how to bring a case for workplace accidents.


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A Back to School Fun Day Extravaganza!
Sunday, August 31st
Teens (7th-12th grade), get ready for basketball, bowling, video games, and Old Skool (adults) vs. New Skool (teens) competitive games!
The fun is from 10:00am - 11:30a.m @ The Bridge
NOTE: Teens, if playing basketball, please wear rubber sole tennis shoes or you will not be allowed to play.


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This week's prompts:
MORE PLEASE - Need I say more (pun intended)?
DIRTY - Even the dirt is dirty here where my volunteer tomato is growing.
I'M READING THIS - Menu. Very good lunch BTW.
MY VICE - I thought about red wine, or coffee, or chocolate. But, then I decided there are health benefits to those. So, I went with fabric. I have lots and lots of fabric and yet I still buy more for my stash.
SOMETHING I LEARNED - To let sleeping dogs lie.
GOOD - Morning world!
MONEY - I often wished our money was more colorful like in other countries. Must be the quilter in me.
Have a great week and
Quilt happy,


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Becoming an Expert Coach of Fencing
- By Norris Karl
- Published December 17, 2008
- Fencing , Coaching
- Unrated
Norris Karl
View all articles by Norris Karl
Fencing is a sport that involves two skilled contestants who use foils to strike at each other's body. The clubs and teams at college level playing fencing require a coach to teach players the virtues of fencing. Before you start coaching athletes, it is essential for you to understand the sound techniques and history of the game. Here are some tips that will definitely make you a better coach:
Following these tips will surely make you become an expert coach and in building a successful team.
- Consult some fencing coaches by coaching clinics. These clinics have equipment vendors and seminars on fencing technique that will allow you to share information about the game with other professionals.
- Score every practice duel by using a buzz box. These boxes record number of body hits on each fencing participant and hence helps in assessing the fighter's skills. This raw data will help in making new practice techniques later.
- Focus more on every player's attention on their defensive part during the practice session that will ensure success in competition. Tell players to stay on the balls of their feet and pose their foil to protect body and head. Repeated practice of this position will generate some good points for you during match.
- You can also use a dummy equipped with buzz box in order to demonstrate dueling techniques. Being an experience fighter and outstanding coach, you should know how to parry and thrust to avoid physical harm.
- Do not tell the team about the team captain. A team captain is an experienced fighter who has intimate knowledge of the game. Talk with your team captain to increase the morale of the team.
- Find out different methods to maintain foils when the season start in order to keep your team availed with best equipment. Replacing the sockets and guards regularly ensures the safety of each player.
Following these tips will surely make you become an expert coach and in building a successful team.


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The Chin Progressive Party (CPP) and the Chin National Party (CNP), two of the main political entities in the western Myanmar state, are to merge into one party which will be called the Chin National Progressive Party (CNPP), according to a report by Khonumthung, a Chin news group.
The report quoted Salai Ceu Bik Thawng, the CNP General Secretary, as saying that documents relating to the merger will be completed by July for submission to Myanmar's Election Commission (EC).
The decision to merge the two parties was reportedly taken at a meeting in April; however the announcement was delayed because of bureaucratic requirements set down by the EC.
The CPP and CNP won seats in the 2010 general elections in Chin State, and the coalition plans to contest the general election state-wide in 2015, Khonumthung said.
Another major Chin news agency, Chinland Guardian, made no mention of the merger.
Related articles:
The UN's Humanitarian Coordinator, Ashok Nigam, has confirmed that a UN-led convoy has been allowed to deliver humanitarian assistance to people displaced in areas beyond Myanmar armed forces' control in Kachin State for the first time in almost a year.
Nigam acknowledged the cooperation of the Myanmar government and the Kachin Independence Organization in permitting the 10-truck aid convoy which departed Bhamo on June 12 June for Maija Yang, carrying food, household kits, and hygiene and sanitation supplies.
In a statement on Friday, the UN said the relief supplies should reach about 5,100 people displaced in multiple camps along the route before it returns to Bhamo by June 16.
"The cross-line convoy represents a positive step forward by the Government to help all people in need across Kachin State. It is crucial for this convoy to be the first of many, and that regular and unimpeded access to all people displaced in Kachin State is sustained," said Nigam, who also expressed hope that this will be "an encouraging sign of positive progress in Kachin State, following closely in the footsteps of recent peace talks held in Myitkyina in late May."
Since June 2011, fighting between the Kachin Independence Organization and the Myanmar army has forced an estimated 100,000 people from their homes.
For more background:
Representatives of the Restoration Council of Shan State/ Shan State Army (RCSS/SSA) and the Shan Nationalities League for Democracy (SNLD) plan to meet in Yangon within the next few days to discuss solutions to their political differences and seek a common approach to constitutional reform.
"Our purpose is to work out how we can cooperate on solving political issues," said RCSS/ SSA central committee member Sai Hla.
Speaking to Mizzima, he said that reformation of the 2008 constitution will be discussed extensively.
Sai Nyunt Lwin, the general secretary of the SNLD, confirmed that the meeting would go ahead, but said that no date or venue had yet been fixed.
Sai Hla said that the RCSS/ SSA, formerly known as the Shan State Army- South, would raise the issue of a "Panglong Conference", a summit aimed at reinforcing ethnic parties' wishes to adopt a federal system in Myanmar.
Related articles:
Myanmar President met with representatives of the Restoration Council of Shan State/ Shan State Army (RCSS/SSA) including its chairman, Lt-Gen Ywet Sit, on Monday in Naypyitaw where they discussed the resettlement of Shan refugees from third countries, said Sai Hla, an RCSS/SSA central committee member.
"The president said he will enact rehabilitations gradually," said Sai Hla. "He also said that he would hold further dialogue on the issue, including the issue of creating identity cards for those migrants who return."
He said no fixed date has been made for the next round of talks.
As a consequence of years of war in southern Shan state, some 500,000 Shan have sought work abroad, the vast majority in neighboring Thailand, while more than 10,000 people from Shan State are internally displaced persons or IDPs.
The spokesman of the RCSS/ SSA, previously known as the Shan Sate Army- South, said that Monday's negotiations were aimed at building mutual trust, allowing the RCSS/SSA to conduct business, and cooperation in antidrug efforts. They also spoke about forming monitoring groups as part of the process of bringing peace back to the eastern state, he said.
Sai Hla said the Shan group urged the president to revoke the outlaw status that has been imposed on the RCSS/ SSA, to which Thein Sein responded that it would be discussed only when every armed group in the country had signed ceasefire agreements.
Also present at the meeting were minister Aung Min of the government's Peace-working Committee and some
deputy ministers. The RCSS/ SSA were represented by Lt-Gen Ywet Sit, consultant Hkun Sai, Brig-Gen. Aung Htwe of the Peace Implementation Committee, and some central committee members.
Both sides signed a ceasefire agreement on December 2, 2011. Sai Hla said that more than 70 battles have occurred in southern Shan state since the ceasefire. This is the seventh time the Shan army has met with the president for talks since 2011.
Related articles:
Despite the signing of a seven-point preliminary peace agreement between the Kachin Independence Organization (KIO) and the Myanmar government last month, many children in refugee camps in the strife-stricken state are unable to attend school, according to the Kachin Peace Network (KPN).
At an event in Yangon on Sunday to mark the second anniversary of the Myanmar army's attack on the KIO, Khon Ja of the KPN told Mizzima that about 40,000 children had not received school education since fighting broke out.
"This year, children in refugee camps in Maija Yang area [in Kachin State] could not have formal education. Last year, Pan-ye-lan, a charity group, provided school books and support, so the conditions were better," said Khon Ja.
The camps are suffering from a lack of teachers and proper school buildings, said Aung Min Naing, a Kachin peace activist. Currently, children have to study at makeshift schools, he said.
Related articles:
Two assistants of US Ambassador to Myanmar Derek Mitchell traveled to Kachin State capital Myitkyina this week to meet leaders of Kachin civic groups following peace talks between the Myanmar government and the Kachin Independence Organisation (KIO).
Mang Seng Tu, a member of the Kachin Lawyer's Group which participated in last weeks' negotiations in the state capital, said that the American envoys' visit indicates "they are still watching over the peace negotiations even though they did not participate at the meeting, and that they will always be in it [the process]."
PCG Representative San Aung said the US envoys met with the Kachin Consultative Assembly, the Kachin Baptist Convention, the Peace-talk Creation Group (PCG) and Shan social organizations.
US Embassy spokesman Mike Quinlan confirmed to Mizzima on Friday that the meetings had taken place and said that the parties discussed a full range of issues including the ongoing government-KIO peace talks.
News agencies have reported that the US, the UK and the UN were excluded from the talks at the insistence of China, a claim the Chinese Embassy in Yangon has refuted.
For more background:


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S/S Redfish on Fly T-Shirt Charcoal
S/S Redfish on Fly T-Shirt Charcoal
There's nothing like sight casting for a redfish during a seasonal flood tide. The smell of a boat motor cranking up to leave the dock in the wee hours of a cool spring morning, the salt spray flickering off your line as you cast the lure in hopes of bagging a big bull red, and the moment you feel the bump in your line as your heart begins to race. This shirt is one that takes you back to a simpler moment in time: when the only uphill battle is you and the fish. Just like a reel made ages ago, by hand using premium materials and outstanding craftsmanship, this shirt is made of the highest quality cotton grown here in the U.S.A. We spend the extra time to make sure our shirts resonate a simpler time when things were made by hand and tested rigorously in the wild, not on a computer screen. This shirt is sure to last countless fishing trips, and stand the test of time.
• 100% American grown and sewn supima cotton
• Pre-shrunk True to size fit
• Lycra Neck for superior fit, comfort, and durability
• Front Pocket adorned with Custom Over Under design


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Oral steroids cycle is no different from taking these drugs in injectable form. It is important to pay special attention to how to take them. Oral anabolics are used in the same dosage, and injectable form, but they are worth sharing on multiple techniques, as they adversely affect the liver. Typically, oral steroids for sale used 2-3 times a day before or after a meal. It anabolics in pills form is very difficult to detect during inspection at the competition, and therefore resorted to them not only for inexperienced beginners but also athletes who are already professionally engaged in bodybuilding, heavy or athletics.
* These products are not intended to diagnose, treat, cure or prevent any disease. These statements have not been evaluated by the Food and Drug Administration (FDA). This website and the associated domain names "roid-" are representative of ingredients which may enhance blood levels of hormones in the body. This site is offering this extremely strong alternative to the highly toxic drug listed on the top of the page. These products are not drugs. Our products are not to be used by anyone under 18 years of age. The information provided on this site is not intended as a substitute for advice from your physician or other health care professional or any information contained on or in any product label or packaging. You should consult with a healthcare professional before starting any diet, exercise or supplementation program, before taking any medication, or if you have or suspect you might have a health problem.
Testosterone, like many anabolic steroids, was classified as a controlled substance in 1991. Testosterone is administered parenterally in normal and delayed-release (depot) forms. In September 1995, the FDA approved testosterone transdermal patches (Androderm), and many transdermal forms and brands are now available including implants, gels, and topical solutions. A testosterone buccal system, Striant, was FDA-approved in July 2003; Striant is a mucoadhesive product that adheres to the buccal mucosa and provides a controlled and sustained release of testosterone. In May 2014, the FDA approved an intranasal gel formulation of testosterone (Natesto). A transdermal patch (Intrinsa) for hormone replacement in women is under investigation; the daily dosages used in women are much lower than for products used in males. The FDA refused approval for Intrinsa in 2004 stating that more data regarding safety, especially in relation to cardiovascular and breast health, were required.