text:
Background and Objectives for the Systematic Review
Antipsychotic medications are used to treat a number of psychiatric disorders, including schizophrenia, bipolar mania, dementia, and psychotic depression. First generation antipsychotics were initially developed in the 1950s. Side effects vary among the various medications, but common side effects include dry mouth, sedation, extrapyramidal side effects (EPS; a cluster of symptoms consisting of akathisia, parkinsonism, and dystonias), and in severe cases, tardive dyskinesia or neuroleptic malignant syndrome. Second generation antipsychotics were first developed in the 1980s. They generally have lower risk of motor side effects, but are associated with significant weight gain, elevated lipids and prolactin levels, and have been associated with the development of type 2 diabetes.
Studies have shown that prescription patterns for psychotropics in children and youth have changed and use has increased over the last 20 years. This includes use of antipsychotic medications.1-5 Use of these medications in the pediatric population is controversial mainly because of limited high quality and longitudinal data on which to base conclusive clinical practice recommendations, especially with regard to safety. In children and youth, antipsychotic medications have both on-label and off-label indications depending on the medication, country, and psychiatric condition. For example, on-label indications are available for treatment of childhood schizophrenia and bipolar disorder in the United States. Off-label prescriptions are used in younger children for behavioral symptoms (e.g., irritability and aggression) that are related to diagnosable conditions (e.g., pervasive developmental disorder). In some instances, however, off-label use may be for behaviors that are also part of the child's normal developmental trajectory and/or may reflect an adaptive response to an environmental stressor (e.g., parental divorce). In general, the choice of medication in children and youth is often driven by side effect profiles that may affect normative growth and development, medication adherence and persistence, as well as other important domains such as educational performance and health-related quality of life (HRQOL).6 Therefore, close clinical monitoring is recommended.7
The objective of this comparative effectiveness review (CER) is to provide a comprehensive synthesis of the evidence examining the benefits and harms associated with first and second generation antipsychotics in the pediatric and young adult populations (24 years and younger). The CER is intended for a broad audience, including clinicians, policymakers and funding agencies, professional societies developing clinical practice guidelines, patients and their care providers, as well as researchers conducting studies on the use of antipsychotic medications in the pediatric and young adult populations.
For this CER, the Evidence-based Practice Center (EPC) was asked to study first and second generation antipsychotics (Table 1, Appendix A Tables A1 to A4) that are currently approved by the U.S. Food and Drug Administration (FDA). There is no consensus on the terminology to describe antipsychotic medications (e.g., first and second generation, typical and atypical). For the purposes of this review, the terms "first generation" and "second generation" antipsychotics will be used.
We were asked to study the use of these drugs for the following conditions: 1) pervasive developmental disorders,8 2) disruptive behavior disorders and ADHD,8 3) pediatric bipolar disorder,8 4) schizophrenia and schizophrenia-related psychoses,8 5) obsessive compulsive disorder, 6) post traumatic stress disorder, 7) anorexia nervosa, 8) Tourette's syndrome, and 9) behavioral issues, including aggression, agitation, anxiety, behavioral dyscontrol, irritability, mood lability, self-injurious behaviors, and sleep disorders.
Table 1. List of antipsychotics included in the CER
|First generation antipsychotics
Second generation antipsychotics
The Key Questions
The Key Questions (KQ) were posted for public comment on the Agency for Health Care Research and Quality (AHRQ) Effective Health Care Program website. Following review of the comments by members of the Technical Expert Panel, AHRQ and the EPC, the following changes were made to the original KQ:
- The terminology of "typical" and "atypical" antipsychotics has been changed to "first generation" and "second generation" antipsychotics in the topic title, and throughout the key questions and protocol.
- Wording has been changed to clarify that the CER will compare efficacy, effectiveness and safety across individual antipsychotics (not just at the "class" level). In addition to head-to-head first versus second generation comparisons, the CER will include head-to-head comparisons of first versus first generation and second versus second generation medications.
- Patients with schizoaffective disorder and substance-induced psychoses have been included within the diagnostic group "schizophrenia and schizophrenia-related psychoses."
- Patients with attention deficit hyperactivity disorder (ADHD) have been added alongside the diagnostic group "disruptive behavior disorders."
- Obsessive compulsive disorder, post traumatic stress disorder, Tourette's syndrome and anorexia nervosa have been added to the list of disorders examined in this review.
- The list of behavior issues eligible for inclusion in the review has been expanded to include: anxiety, irritability, mood lability and sleep disorders.
- The following outcomes were added: patient or parent/caregiver preferences, work-related functional outcomes, patient insight into illness. Elevated transaminases was added to the list of general adverse events.
- The following subgroups were added to KQ4: monotherapy versus co-treatment; first episode psychosis vs. treatment in context of history of prior episodes (related to schizophrenia); duration of illness; naïve vs. history of previous antipsychotic use.
The Key Questions to be investigated in this CER are presented below.
Question 1: What is the comparative efficacy or effectiveness of first and second generation antipsychotics for treating disorder/illness specific and nonspecific symptoms in children, youth and young adults (≤ 24 years) for the following disorders or illnesses?
- Pervasive developmental disorders (PDDs), including autistic disorder, Rett's disorder, childhood disintegrative disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified (NOS)
- Attention deficit hyperactivity disorder (ADHD) and disruptive behavior disorders (DBDs), including conduct disorder, oppositional defiant disorder, and disruptive behavior disorder NOS
- Pediatric bipolar disorder, including manic or depressive phases, rapid cycling, and mixed states
- Schizophrenia and schizophrenia-related psychoses, including schizoaffective disorder and drug-induced psychosis
- Obsessive compulsive disorder
- Post traumatic stress disorder
- Anorexia nervosa
- Tourette's syndrome
- Behavioral issues, including aggression, agitation, anxiety, behavioral dyscontrol, irritability, mood lability, self-injurious behaviors, and sleep disorders
Population: Children, youth, and young adults (≤ 24 years) with PDD, ADHD, DBD, pediatric bipolar disorder, schizophrenia / schizophrenia-related psychosis, obsessive compulsive disorder, post traumatic stress disorder, anorexia nervosa, Tourette's syndrome or behavioral issues
Interventions: Any FDA-approved first or second generation antipsychotic
Comparators: Any other FDA-approved first or second antipsychotic, placebo, or another dose of the same antipsychotic
Outcomes: Disorder/illness specific and nonspecific symptoms
The following symptoms are included for each disorder or illness:
- PDDs: qualitative impairment in social interactions, communication and restricted repetitive and stereotyped behaviors, interests, and activities
- ADHD and DBDs: negativistic, hostile and defiant behavior
- Bipolar disorder: mood disturbance, psychotic features
- Schizophrenia and related psychoses: positive and negative symptoms, disorganized behavior, impaired thought process, cognition and mood symptoms
- Obsessive compulisive disorder
- Post traumatic stress disorder
- Anorexia nervosa
- Tourette's syndrome
- Behavioral issues: aggression, agitation, anxiety, behavioral dyscontrol, irritability, mood lability, self-injurious behaviors, and sleep disorders
Timing: All time points
Settings: All settings, including inpatient hospitalization and outpatient treatment
Question 2: Do first and second generation antipsychotics differ in medication-associated adverse events when used in children, youth, and young adults (≤ 24 years)? This includes:
- Overall adverse events
- Specific adverse events
- Withdrawals/time to withdrawal due to adverse events
- Persistence and reversibility of adverse events
Population: See KQ1 above
Interventions: See KQ1 above
Comparators: See KQ1 above
Outcomes: Medication-associated adverse events, withdrawal due to adverse events, persistence and reversibility of adverse events.
- Major adverse events include:
- Mortality
- Cerebrovascular disease-related events
- Development of diabetes mellitus
- Diabetic ketoacidosis
- Neuroleptic malignant syndrome
- Seizures
- Tardive dyskinesia
- Cardiomyopathies
- Cardiac arrhythmias
- Agranulocytosis
- General adverse events include:
- Extrapyramidal effects
- Weight gain (e.g., using Body Mass Index (BMI) growth charts)
- Agitation
- Constipation
- Sedation
- Elevated cholesterol
- Elevated transaminases
- Adverse events related to prolactin elevations
- Galactorrhea/bloody galactorrhea
- Exercise intolerance
- Precocious puberty
Timing: See KQ1 above
Settings: See KQ1 above
Question 3: Do first and second generation antipsychotics differ in other short- and long-term outcomes when used in children, youth, and young adults (≤24 years)? Short-term is defined as outcomes occurring within 6 months; long-term is defined as outcomes occurring post-6 months.
Population: See KQ1 above
Interventions: See KQ1 above
Comparators: See KQ1 above
Outcomes: Other short-term and long-term outcomes, including:
- Response rates with corresponding dose, duration of response, remission, relapse, speed of response, time to discontinuation of medication
- Growth and maturation
- Cognitive and emotional development
- Suicide-related behaviors or death by suicide
- Medication adherence and persistence
- School performance/attendance
- Work-related functional capacity
- Patient insight into illness
- Patient or parent/care provider reported outcomes, including levels of physical activity/inactivity, diet (i.e., caloric intake, food preferences)
- Health-related quality of life
- Legal/justice system interaction (i.e., arrests, detention)
- Health care system utilization (e.g., protective services, social services)
- 'Outcomes that matter' to children, youth and young adults, and their families. These functional outcomes may reflect a developmental perspective
Timing: See KQ1 above
Settings: See KQ1 above
Question 4: Do the effectiveness and risks of first and second generation antipsychotics vary in differing sub-populations including:
- Gender
- Age group (< 6 years, 6–12 years, 13–18 years, 19–24 years)
- Race
- Co-morbidities, including substance abuse, ADHD
- Co-treatment versus monotherapy
- First episode psychosis vs. treatment in context of history of prior episodes (related to schizophrenia)
- Duration of illness
- Treatment naïve versus history of previous antipsychotics use
Population: Demographic and clinical subgroups of children, youth, and young adults (≤ 24 years) with PDD, DBD, pediatric bipolar disorder, obsessive compulsive disorder, post traumatic stress disorder, anorexia nervosa, Tourette's syndrome, schizophrenia / schizophrenia-related psychosis or behavioral issues
Interventions: See KQ1 above
Comparators: See KQ1 above
Outcomes: Disorder specific and nonspecific symptoms (see KQ1 above); other short-term and long-term outcomes (see KQ3 above)
Timing: See KQ1 above
Settings: See KQ1 above
Analytic Framework
Figure 1. Analytic framework for evaluating the comparative effectiveness of FDA-approved first generation and second generation antipsychotics in the pediatric and young adult population diagnosed with pervasive developmental disorder (PDD), disruptive behavior disorder (DBD), bipolar disorder (BPD), schizophrenia or other psychotic illnesses (Sz), obsessive compulsive disorder (OCD), post traumatic stress disorder (PTSD), Tourette's syndrome (TS), anorexia nervosa (AN) and behavioral issues (BI)
The methodological approaches to this CER are described below. They follow the methods suggested in the Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews, Version 1.0 published by AHRQ (available at /sites/default/files/pdf/cer-methods-guide_research-2008.pdf).
A. Criteria for Inclusion/Exclusion of Studies in the Review
Study design
For efficacy, we will include randomized controlled trials (RCT). For effectiveness and adverse events, we will include RCTs, nonrandomized controlled trials (NRCT), and cohort studies (retrospective or prospective).
We will include studies that enroll children, youth and young adults (≤ 24 years) with one of the following conditions:
- PDD, including autistic disorder, Rett's disorder, childhood disintegrative disorder, Asperger's disorder, pervasive developmental disorder NOS (including atypical autism)
- ADHD and DBD, including conduct disorder, oppositional defiant disorder, disruptive behavior disorder NOS
- Bipolar disorder, including manic or depressive phases, rapid cycling, mixed states
- Schizophrenia and schizophrenia-related psychoses, including schizoaffective disorder and substance-induced psychoses
- Obsessive compulsive disorder
- Post traumatic stress disorder
- Anorexia nervosa
- Tourette's syndrome
- Behavioral issues, including aggression, agitation, anxiety, behavioral dyscontrol, irritability, mood lability, self-injurious behaviors and sleep disorders
Polypharmacy is common in these clinical populations; therefore, studies including patients taking other medications will be included providing these medications are monitored (dose) during the study.
Intervention drugs of interest
The intervention drug must be an FDA-approved first or second generation antipsychotic drug. These drugs include: aripiprazole, asenapine, clozapine, iloperidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone, chlorpromazine, flupenthixol, fluphenazine, haloperidol, loxapine, molindone, perphenazine, pimozide, prochlorperazine, thiothixene, thioridazine, and trifluoperazine. All formulations of drug delivery (e.g., tablet, liquid, injectable) and doses are eligible.
Comparison drugs of interest
The comparison drug must be any other FDA-approved first or second generation antipsychotic drug, placebo, or a different dose of the same antipsychotic drug. All formulations of drug delivery (e.g., tablet, liquid, injectable) and doses are eligible.
Outcomes of interest
Primary outcome:
- Symptom response (e.g., behavioral issues, core features of the disorder/illness).
Secondary outcomes:
- Response rates with corresponding dose, duration of response, remission, relapse, speed of response, time to discontinuation of medication
- Growth (using BMI growth charts) and maturation (Tanner stage)
- Cognitive and emotional development
- Suicide-related behaviors or death by suicide
- Medication adherence and persistence
- School performance/attendance
- Work-related functional capacity
- Patient insight into illness
- Patient or parent/care provider reported outcomes, including levels of physical activity/inactivity, diet (i.e., caloric intake, food preferences)
- Health-related quality of life
- Legal/justice system interaction (i.e., arrests, detention)
- Health care system utilization (e.g., protective services, social services, hospitalization)
- 'Outcomes that matter' to children, youth and young adults, and their families. These functional outcomes may reflect a developmental perspective
Adverse events include overall events, specific events, withdrawals due to adverse events, time to withdrawal due to adverse events, and persistence and reversibility of adverse events.
- Major adverse events: mortality, cerebrovascular disease-related events, development of diabetes mellitus, diabetic ketoacidosis, neuroleptic malignant syndrome, seizures, tardive dyskinesia, cardiomyopathies and cardiac arrhythmias, agranulocytosis
- General adverse events: extrapyramidal effects, weight gain (e.g., using BMI growth charts), agitation, constipation, sedation, elevated cholesterol; adverse events related to prolactin elevations, galactorrhea/bloody galactorrhea, exercise intolerance, precocious puberty
Publication characteristics
In order to coincide with the DSM-III-R diagnostic codes, only studies published after 1986 will be included. Given the substantial diagnostic changes that occurred in the 1987 revision, earlier research may not accurately reflect the conditions or patient symptom domains examined by research conducted following the publication of DSM-III-R.
Only studies published in the English language will be included. There are no restrictions on sample size. Conference abstracts will be included. Where applicable, we will contact study authors for clarification and additional data.
B. Searching for the Evidence: Literature Search Strategies for Identification of Relevant Studies to Answer the Key Questions.
The research librarian, in collaboration with the investigative team, will develop and implement search strategies designed to identify evidence relevant to questions of efficacy, effectiveness and safety.
For the questions on efficacy and effectiveness, we will conduct comprehensive searches in the following electronic databases: Ovid's MEDLINE®, EMBASE, PsycINFO, International Pharmaceutical Abstracts (IPA), Ebscohost CINAHL, ProQuest® Dissertations and Theses - Full Text, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus™. All searches will be restricted to English language studies published since 1987. Using a combination of controlled vocabulary and keywords, study design restrictions for RCTs, NRCTs, and cohort studies will be applied to the search results retrieved from the above listed databases. We will also conduct a forward search of the Scopus™ Citation Tracker for relevant studies. Following submission of the draft report to AHRQ, searches will be re-run in PubMed, EMBASE, PsycINFO, and CENTRAL to identify any new publications.
Appendix B outlines the MEDLINE search terms and strategy. This will serve as a guide when designing and implementing search strategies in the remaining databases in order to capture the unique controlled vocabulary and search language of each database.
For questions on adverse effects, in addition to the databases mentioned above, we will search the U.S. National Library of Medicine's TOXLINE® and MedEffectTM Canada Adverse Drug Reaction Database. The same date, language and study design restrictions will be applied.
Reference lists of relevant systematic reviews, guidelines, and included studies will be screened to identify potentially relevant studies. We will handsearch the conference proceedings of the following key scientific meetings for the last 3 years to identify potentially relevant studies: American Academy of Child and Adolescent Psychiatry, International College of Neuropsychopharmacology, and International Society for Bipolar Disorders. Drug manufacturers and authors of included studies will be contacted to obtain information and/or data from unpublished or ongoing studies that we have identified as potentially relevant. Documents from government and professional associations (e.g., National Institute of Mental Health), theses and dissertations, as well as unpublished studies or studies in progress will also be searched in order to identify potentially relevant studies. We will also search online trial registries (e.g., World Health Organization, ClinicalTrials.gov, ISRCTN) in order to identify unpublished as well as ongoing trials.
Results from the literature searches will be entered into a Thomson Reuters Reference Manager 11.0.1® bibliographic management database.
C. Study Selection
A two-step process will be used for study selection. First, two reviewers will independently screen the titles and abstracts (when available) of search results to determine if a study meets the general inclusion criteria of an English language study involving a pediatric or young adult population with one of the disorders and interventions of interest. Each report will be rated as: include, exclude, or unclear. The full text of all reports classified as "include" or "unclear" will be retrieved for formal review. Next, two reviewers will independently assess the full text of each report using a standard form that outlines the pre-determined inclusion and exclusion criteria. Disagreements will be resolved by discussion between the two reviewers or third party adjudication, as needed.
D. Data Abstraction and Data Management
Data will be extracted using a standardized form and entered into a Microsoft Excel™ database (Microsoft Corp., Redmond, WA). Data will be extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Reviewers will resolve discrepancies by consensus or in consultation with a third party, as needed. The following data will be extracted from each study: author identification, year of publication, source of study funding, study design characteristics and methodological quality criteria (see below), study population (including study inclusion and exclusion criteria, run-in period, study withdrawals, length of study, duration of patient followup), patient baseline characteristics (diagnosis and age at diagnosis, age, sex, race, weight, height, body mass index, co-morbidities, use of concurrent standard medical therapies), details of the intervention and comparator (drugs utilized, dose, route of administration), and results reported for the outcomes of interest, including adverse events.
Adverse events will be recorded for each intervention group including the description of the adverse event, the number of patients in each group, and the number of patients affected. Each event will be counted as if it represents a unique individual. Because a single individual might experience more than one event, this assumption may overestimate the number of people having an adverse event. If a study mentions an adverse event in the discussion but does not report data on that adverse event, we will not include that study in the analysis. We will not assume an adverse event occurred unless a specific number of events are reported. By taking this approach, we may underestimate the number of patients for whom a particular adverse event is observed. After abstracting data for adverse events, we will identify mutually exclusive groups of similar events, based on clinical expertise. For example, events that affect the head, ear, eye, nose, or throat will be grouped together as HEENT. A group may contain subgroups; for example, decreased salivation, increased salivation, and eye irritation are subgroups of HEENT, with their own analyses.9 For each adverse event subgroup, we will report the number of studies that provide data for any event in the subgroup. We will also report summary totals of the number of individuals in the medication groups who are observed to have experienced the event and the total number of patients in the medication groups in relevant trials. The dose of each medication that is associated with an adverse event will be recorded to facilitate a dose-adverse event analysis.
E. Assessment of Methodological Quality of Individual Studies
The internal validity of RCTs and NRCTs will be assessed using the Cochrane Collaboration Risk of Bias tool.10 This tool consists of six domains (sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and "other" sources of bias) and a categorization of the overall risk of bias. Each separate domain is rated "yes," "unclear," or "no." Blinding and incomplete outcome data will be assessed separately for subjective outcomes (e.g., quality of life or function scales) and objective clinical outcomes (e.g., weight gain, glucose tolerance test). The overall assessment is based on the responses to individual domains. If one or more individual domains are assessed as having a high risk of bias, the overall score will be rated as high risk of bias. The overall risk of bias will be considered low only if all components are rated as having a low risk of bias. The risk of bias for all other studies will be rated as unclear. In addition, information will be collected for each study on the source of funding.11
Cohort studies will be assessed using the cohort Newcastle-Ottawa Scale (NOS).12 The NOS includes seven items assessing sample selection, comparability of cohorts, and the assessment of outcomes. One star is allotted for each item that is adequately addressed in the study, with the exception of the comparability of cohorts, for which a maximum of two stars can be given. The overall score is calculated by tallying the stars, with a total possible score of eight stars. In addition, information regarding the source of funding will be collected.11
Two reviewers will independently assess the methodological quality of included studies. Each assessment form will be pilot tested on a sample of studies. Decision rules regarding application of the tools will be developed a priori through discussions with content and methodology experts. Discrepancies in quality assessment will be resolved through consensus or third-party adjudication.
F. Data Synthesis
For each study, we will analyze comparisons between dichotomous outcomes using risk ratios (RR) and between continuous outcomes using mean differences. We will compute the 95% confidence intervals (CI) for all estimates.
Where populations, interventions and outcomes are sufficiently clinically homogenous, results will be statistically pooled using a DerSimonian-Laird random effects model. This will be done using the Mantel-Haenszel method for RR and the inverse variance method for pooling mean differences. In cases where the outcomes are measured in different scales, a standardized mean difference (SMD) will be used to pool results, rather than a weighted mean difference (WMD). Heterogeneity among studies will be measured using the I2 statistic. In cases of substantial heterogeneity, subgroup and meta-regression analyses will be performed if the number of studies is sufficient to warrant these analyses.13 A priori subgroups have been identified in KQ4. Sensitivity analyses will be conducted to assess the robustness of the findings across study quality, parallel vs. crossover trial designs, and random effects vs. fixed effects analyses.
Where possible, we will also analyze publication bias both visually using the funnel plot and quantitatively using Begg's14 and Egger's15 tests. Review Manager version 5.0.22 (The Cochrane Collaboration, Copenhagen, Denmark) and Stata version 7.0 (Stata Corp., College Station, TX) will be used for all these analyses. In the event that studies cannot be pooled, evidence tables will be produced and a narrative summary of the results will be presented.
If in any disease/condition and outcome, we have comparative studies across several different interventions we will attempt to do a network meta-analysis in a Bayesian framework.16 Non-informative prior distributions will be selected and sensitivity analyses will be performed to determine the influence of the prior distribution on final results. Markov chain Monte Carlo simulation using WinBugs version 1.4 (Imperial College and MRC, London, UK) software will be used to perform all computations.
G. Grading the Evidence
The strength of evidence for the primary outcome for KQ1—symptom response for each disorder/illness—will be assessed using the EPC approach to grading the strength of a body of evidence.17 This approach assesses the evidence based on four domains: risk of bias, consistency, directness, and precision. We will classify the strength of evidence as high, moderate, low, or insufficient.
- Zito JM, Safer DJ, dosReis S, et al. Trends in the prescribing of psychotropic medications to preschoolers. JAMA 2000;283(8):1025-30.
- Zito JM, Safer DJ, dosReis S, et al. Psychotropic practice patterns for youth: a 10-year perspective. Arch Pediatr Adolesc Med 2003;157(1):17-25.
- Zito JM, Safer DJ, Berg LT, et al. A three-country comparison of psychotropic medication prevalence in youth. Child Adolesc Psychiatry Ment Health 2008;2(1):26.
- Zito JM, Safer DJ, Sai D, et al. Psychotropic medication patterns among youth in foster care. Pediatrics 2008;121(1):e157-e163.
- Pathak S, Arszman SP, Danielyan A, et al. Psychotropic utilization and psychiatric presentation of hospitalized very young children. J Child Adolesc Psychopharmacol 2004;14(3):433-42.
- Jensen PS, Buitelaar J, Pandina GJ, et al. Management of psychiatric disorders in children and adolescents with atypical antipsychotics: a systematic review of published clinical trials. Eur Child Adolesc Psychiatry 2007;16(2):104-20.
- Zito JM, Derivan AT, Kratochvil CJ, et al. Off-label psychopharmacologic prescribing for children: History supports close clinical monitoring. Child Adolesc Psychiatry Ment Health 2008;2(1):24.
- American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. ed. Washington, D.C.: American Psyciatric Association; 1994.
- Shekelle P, Maglione M, Bagley S, et al. Comparative effectiveness of off-label use of atypical antipsychotics. Comparative effectivenss review no. 6. Rockville, MD: Agency for Healthcare Research and Quality. 2007:1-77.
- Higgins JPT, Altman DG, eds. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions. Chichester, UK: John Wiley & Sons; 2008:187-241.
- Cho M, Bero L. The quality of drug studies published in symposium proceedings. Ann Int Med 1996;124:185-9.
- Wells G, Shea B, O'Connell B, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottawa: Dept of Epidemiology and Community Medicine, University of Ottawa. 2009. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm.
- Borenstein M, Hedges LV, Higgins JPT, et al. Introduction to meta-analysis. West Sussex, UK: John Wiley and Sons; 2009.
- Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994;50:1088-101.
- Egger M, Smith GD, Schneider M, et al. Bias in meta-analysis detected by a single graphical test. Br Med J 1997;315:629-34.
- Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment comparisons. Stat Med 2004;23:3105-24.
- Owens DK, Lohr KN, Atkins D, et al. Grading the strength of a body of evidence when comparing medical interventions. Agency for Healthcare Research and Quality. 2008.
Definition of Terms
Not applicable.
Summary of Protocol Amendments
Not applicable.
- Review of Key Questions
For Comparative Effectiveness reviews (CERs) the key questions were posted for public comment and finalized after review of the comments. For other systematic reviews, key questions submitted by partners are reviewed and refined as needed by the EPC and the Technical Expert Panel (TEP) to assure that the questions are specific and explicit about what information is being reviewed.
- Technical Expert Panel (TEP)
A TEP panel is selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicted opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore study questions, design and/or methodological approaches do not necessarily represent the views of individual technical and content experts. The TEP provides information to the EPC to identify literature search strategies, review the draft report and recommend approaches to specific issues as requested by the EPC. The TEP does not do analysis of any kind nor contribute to the writing of the report.
- Peer Review
Approximately five experts in the field will be asked to peer review the draft report and provide comments. The peer reviewer may represent stakeholder groups such as professional or advocacy organizations with knowledge of the topic. On some specific reports such as reports requested by the Office of Medical Applications of Research and National Institutes of Health there may be other rules that apply regarding participation in the peer review process. Peer review comments on the preliminary draft of the report are considered by the EPC in preparation of the final draft of the report. The synthesis of the scientific literature presented in the final report does not necessarily represent the views of individual reviewers. The dispositions of the peer review comments are documented and will, for CERs and Technical briefs, be published three months after the publication of the Evidence report.
It is our policy not to release the names of the Peer reviewers or TEP panel members until the report is published so that they can maintain their objectivity during the review process.
Appendix A: Summary tables of first and second generation antipsychotics included in the CER
|Generic name
|Trade names(s)
|Mode of administration
|Usual dose
|Chlorpromazine hydrochloride
Chlorpromazine hydrochloride
D/C: Intensol, Promapar, Sonazine, Thorazine
|Adult, 200-600 mg/day;
Children ≥6mo, 0.5 to 1mg/kg/dose
300-800 mg/day
|1-4 times
q4-6 hr
q4-6 hr
|Fluphenazine decanoate
Fluphenazine hydrochloride
D/C: Fluphenazine, Permitil, Prolixin, Prolixin decanoate, Prolixin enanthate
|2.5-10 mg/day
2.5-10 mg/dose
|3-4 times
Haloperidol decanoate
D/C: Haldol solutab, Haloperidol intensol, Haloperidol lactate
IM (as lactate)
|Adult, 4-12 mg/day
Children 3-12 yr, 0.5 to 0.15mg/kg/day
Adult, maximum 20mg/day
|1-2 times
2-3 times
Every hr if needed
Loxapine succinate
D/C: Loxitane, Loxitane C, Loxitane IM
|Adult, 60-100 mg/day;
Not recommended in children <16yr
|2-4 times
|50-100 mg/day
|3-4 times
D/C: Trilafon
|Oral (non-hospitalized)
Oral (hospitalized)
|12-18 mg/day;
16-64 mg/day
|3 times
2-4 times
|Adults, 7-10 mg/day;
Children initiate at 0.05 mg/kg once at bedtime; increase every third day to a maximum of 0.2 mg/kg not to exceed 10 mg/day
|1-3 times
Prochlorperazine edisylate
Prochlorperazine maleate
D/C: Compazine,
|15-40 mg/day
15-40 mg/day
7.5-40 mg/day
25-50 mg/day
|3-4 times
3-4 times
3-4 times
1-2 times
D/C: Thiothixene hydrochloride, Thiothixene hydrochloride intensol
|6-30 mg/day
|2-3 times
|Thioridazine hydrochloride
D/C: Thioridazine hydrochloride intensol, Mellaril, Mellaril-S
|150-300 mg/day
|2-3 times
|Trifluoperazine hydrochloride
D/C: Stelazine
|Oral (non-hospitalized)
Oral (hospitalized)
|Adult, 1-2 mg
Adult, 15-21 mg/day
Children (6-12 yrs), 1 mg
|2 times/day
2 times/day
1-2 times/day
|Generic name
|Brand names(s)
|Mode of administration
|Recommended dose
Orally disintegrating tablet
|Adult schizophrenia, 10-15mg/d;
Adolescent schizophrenia, 10mg/d;
Pediatric BD (mania), 10mg/d;
Pediatric irritability with autistic disorder, 5-10 mg/d
Max 30mg/d
≥2 hr between doses
|Orally disintegrating tablet
|Schizophrenia 5mg;
BD 10mg
|2 times/day
2 times/day
Orally disintegrating tablet
|300-450 mg/day
|1-3 times/day
|2 times/day
Zyprexa Zydis
Orally disintegrating tablet
IM injection
|Adult/Adolescent schizophrenia, 10mg/day;
Adult BD I 10-15mg/day;
Adolescent BD I 10mg/day
Invega sustenna
|Tablet extended release
|QD in the AM
|Quetiapine fumarate
Seroquel XR
Sustained release tablets (Safety and effectiveness have not been established for pediatric use)
|Adult schizophrenia, 150-750mg/day;
Adolescent schizophrenia, 400-800mg/day;
Adult BD (mania), 400-800mg/day;
Child/adolescent BD (mania), 400-600mg/day;
Adult BD (depression), 300mg/day;
Adult BD (maintenance), 400-800mg/
|2 times/day
2 times/day
2 times/day
2 times/day
QD at bedtime
2 times/day
Risperdal consta
Orally disintegrating tablet
IM injection
|Adult schizophrenia, 4-8mg/day;
Adolescent schizophrenia, 3mg/day;
Adult BD (mania), 1-6mg/day;
Child/adolescent BD (mania), 2.5mg/day;
Irritability childhood autism (≥ 5yrs), 0.5mg/day (<20kg); 1mg/day (≥ 20 kg)
|1-2 times/day
|Ziprasidone hydrochloride
IM injection
|Adult schizophrenia, up to 80mg;
BD (manic/mixed, maintenance), 40-80mg;
Agitation associated with schizophrenia (IM), up to max 40mg/day
|2 times/day
2 times/day
10mg may be injected q 2 hr
|FDA status
|Age group approved for
|Black box Warnings
|Approved 1974
BP (mania)
Uncontrolled hiccups, nausea and vomiting
Children (1-12 years)
|Patients with cardiovascular disease or hx of seizures
|Approved 1960
BD (mania)
Children >12yrs
Not recommended for use in children under 12 years
|Possible increased mortality in elderly with dementia-related psychosis
Not approved for the treatment of dementia-related behavior problems.
|Approved 1986
Tourette's Disorder
Safety and effectiveness in pediatric patients <18 years have not been established
|Increased mortality in elderly with dementia-related psychosis
|Approved 1975
Safety and effectiveness in pediatric patients <16 have not been established
|Increased mortality in elderly with dementia-related psychosis
|Approved 1974
Use in pediatric patients <12 years is not recommended because safe and effective conditions for its usage have not been established
|Increased mortality in elderly with dementia-related psychosis
|Approved 1965
Safety and effectiveness in pediatric patients have not been established
|Increased mortality in elderly with dementia-related psychosis
Children, adolescents, and young adults taking antidepressants are at increased risk of suicidal thinking
|Approved 1984
|Tourette's Disorder
|Children and adults 8-53 years. Limited evidence in children <12 years
Use and safety have not been evaluated in other childhood disorders, ORAP is not recommended for use in any condition other than Tourette's Disorder
|Use of pimozide in tx of Tourette's Disorder involves different risk/benefit considerations than tx of other conditions. A decision to use ORAP should take into consideration
Tardive Dyskinesia
Neuroleptic Malignant Syndrome (NMS)
Sudden, unexpected deaths in conditions other than Tourette's Disorder.
May have tumorigenic potential.
|Approved 1956
Severe nausea and vomiting
|Adults and children
Children >2 years and > 20 pounds
|May cause tardive dyskinesia
|Approved 1967
Safety and effectiveness in pediatric patients <12 years have not been established
|Increased mortality in elderly with dementia-related psychosis
|Approved 1962
|Adults and children
|Life-threatening pro-arrhythmic effect
|Approved 1959
|Adults and children (6-12 yrs)
|Increased mortality in elderly patients with dementia-related psychosis
|FDA status (year approved)
|Age group approved for
|Black box warnings
BD(L) (manic/mixed) monotherapy or adjunctive to lithium or valproate
Adjunctive tx of major depressive disorder
Autistic Disorder, Injection
|Adults & adolescents (13-17 yr)
Adults & pediatrics (10 -17 yr)
Children (6-17 yr)
Adults with agitation associated with schizophrenia or BD(L) (manic/mixed)
|Increased mortality in elderly with dementia-related psychosis
Children, adolescents, and young adults taking antidepressants are at increased risk of suicidal thinking & behaviour
Leukopenia, Neutropenia, Agranulocytosis
Not approved for behavior problems in older adults with dementia.
BD(L) (manic/mixed) monotherapy or adjunctive to lithium or valproate
Adjunctive tx of major depressive disorder
|Adults and adolescents (13-17 yr)
Adults and pediatrics (10-17 yr)
Adults with agitation associated with schizophrenia or BD(L) (manic/mixed)
|Increased mortality in elderly with dementia-related psychosis
Children, adolescents, and young adults taking antidepressants are at increased risk of suicidal thinking and behavior
Not approved for behavior problems in older adults with dementia.
|Acute schizophrenia
BD I (manic/mixed)
Pediatric use: safety & effectiveness not established in patients <18 yr
|Increased mortality in elderly with dementia-related psychosis
|Treatment resistant schizophrenia
Reduce the risk of suicidal behavior in younger schizophrenics.
Pediatric use: safety & effectiveness not established in patients <18 yr
|1. agranulocytosis
2. seizures
3. myocarditis
4. cardiovascular and respiratory effects, (respiratory and/or cardiac arrest).
5. increased mortality in elderly patients with dementia-related psychosis
|Acute schizophrenia
|Increased mortality in elderly with dementia-related psychosis
Not approved for patients with dementia-related psychosis.
2003: combined w fluoxetine
2009: combined w fluoxetine
|Schizophrenia &BD(L) (manic/mixed)
BD (depressive)
BD(L) long-term tx
Tx resistant depression
Adolescents (13-17 yr), schizophrenia & BD (manic/ mixed)
Pediatric use: safety & effectiveness not established in patients <13 yr
|Increased mortality in elderly with dementia-related psychosis
Not approved for patients with dementia-related psychosis.
Schizoaffective disorder
Pediatric use: safety & effectiveness not established in patients <18 yr
|Increased mortality in elderly with dementia-related psychosis
BD (acute manic)
BD (depression)
BD (maintenance)
|Adults & adolescents (13-17 yr)
Adults, children & adolescents (10-17 yr)
|Increased mortality in elderly with dementia-related psychosis
Increased risk of suicidal thinking and behavior
Not approved for patients with dementia-related psychosis
BD (manic/mixed)
Irritability associated with autism
|Adults & adolescents (13-17 yr)
Adults & adolescents (10-17 years)
Children (5-16 yr)
|Increased mortality in elderly with dementia-related psychosis
BD (manic/mixed)
BD (maintenance)
Pediatric use: safety & effectiveness not established in patients <18 yr
|Increased mortality in elderly with dementia-related psychosis
Appendix B: MEDLINE search terms and strategy
- Child Development Disorders, Pervasive/
- Asperger Syndrome/
- Autistic Disorder/
- Rett Syndrome/
- Schizophrenia, Childhood/
- Mental Retardation/
- Movement Disorders/
- "Attention Deficit and Disruptive Behavior Disorders"/
- Conduct Disorder/
- Childhood Disintegrative Disorder.tw.
- "Pervasive Developmental Disorder Not Otherwise Specified".tw.
- (atypical adj1 autism).tw.
- Oppositional Defiant Disorder.tw.
- "Disruptive Behavior Disorder Not Otherwise Specified".tw.
- Schizophrenia/
- Schizophrenia, Catatonic/
- Schizophrenia, Disorganized/
- Schizophrenia, Paranoid/
- Psychotic Disorders/
- first episode schizophrenia.tw.
- (prodrom$ and schizophren$).tw.
- Schizotypal Personality Disorder/
- Bipolar Disorder/
- "Depressive Disorder, Major"/ and (refractory or chronic or resistant).ti,ab.
- Depression/ and (refractory or chronic or resistant).ti,ab.
- Depressive Disorder/
- Obsessive-Compulsive Disorder/
- OCD.tw.
- exp anorexia nervosa/
- ((anorexia adj nervosa*) or anorexia*).tw.
- exp stress disorders, post-traumatic/
- ((chronic or acute or delayed onset) and (post-traumatic adj stress adj disorder*)).tw.
- ((posttraumatic or post-traumatic or post traumatic) adj (neuroses or disorder)).tw.
- ptsd.tw.
- exp tourette syndrome/
- ($tourette* adj (syndrome or disorder or disease)).tw.
- (tic adj disorder).tw.
- (multiple adj motor adj vocal adj tic adj disorder).tw.
- or/1-38
- Antipsychotic Agents/
- Tranquilizing Agents/
- chlorpromazine/
- fluphenazine/
- haloperidol/
- loxapine/
- molindone/
- perphenazine/
- thiothixene/
- trifluoperazine/
- thioridazine/
- methotrimeprazine/
- Phenothiazines/ad, to, tu, ct, po, ae [Administration & Dosage, Toxicity, Therapeutic Use, Contraindications, Poisoning, Adverse Effects]
- Butyrophenones/ad, to, tu, ct, po, ae
- Thioxanthenes/ad, to, tu, ct, po, ae
- Dibenzoxazepines/ad, to, tu, ct, po, ae
- Indoles/ad, to, tu, ct, po, ae
- or/40-56
- atypical antipsychotic$.tw.
- clozapine/
- risperidone/
- olanzapine.tw.
- quetiapine.tw.
- ziprasidone.tw.
- aripiprazole.tw.
- paliperidone.tw.
- Isoxazoles/ad, to, tu, ct, po, ae
- Dibenzazepines/ad, to, tu, ct, po, ae
- Pyrimidinones/ad, to, tu, ct, po, ae
- Piperidines/ad, to, tu, ct, po, ae
- Dibenzothiazepines/ct, ad, to, tu, ae, po
- Piperazines/ad, tu, to, ct, po, ae
- Pirenzepine/tu, ad, to, ct, po, ae
- Thiazoles/ad, th, ct, po, to, ae
- Quinolones/to, po, ct, ad, tu, ae
- or/40-41,58-74
- or/57,75
- and/39,76
- randomized controlled trial.pt.
- controlled clinical trial.pt.
- randomi?ed.ab.
- placebo.ab.
- drug therapy.fs.
- randomly.ab.
- trial.ab.
- groups.ab.
- or/78-85
- (editorial or letter or comment).pt. or case reports/
- (animals not (humans and animals)).sh,hw.
- 86 not 87
- 89 not 88
- cohort studies/
- follow-up studies/
- longitudinal studies/
- prospective studies/
- Retrospective Studies/
- Case-Control Studies/
- (cohort$ or longitudinal or retrospective or prospective or follow-up or case-control).tw.
- or/91-97
- 98 not 87
- 99 not 88
- exp infant/
- exp child/
- exp adolescent/
- exp pediatrics/
- ($child$ or adolescen$ or p*ediatric$).tw.
- or/101-105
- and/77,90,106
- and/77,100,106
- 77 and 90
- 77 and 100
- 109 or 110
- limit 111 to "all child (0 to 18 years)"
- 107 or 108
- 112 or 113
- limit 114 to english language
- limit 115 to yr="1987 -Current"
- limit 111 to "young adult (19 to 24 years)"
- limit 117 to english language
- limit 118 to yr="1987 -Current"
- 119 not 116
- exp Young Adult/
- (young adj adult*).tw.
- ((college or university) adj2 (age or student*)).tw.
- students/
- or/121-124
- and/77,90,125
- and/77,100,125
- or/126-127
- limit 128 to (english language and yr="1987 -Current")
- 129 not 116
- 120 or 130


text:
Sharing and building Solution Focused practice in organisations
Dedicated to SF Teambuilding concepts, ideas, formats and suggestions for helping teams and groups achieve their goals the SF way.
Members: 60
Latest Activity: Nov 22, 2018
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subset: commoncrawl


text:
Subtitle: (St. Entropy has an app for that…)
'Twas the night before Christmas in the Museum's big hall,
And all through the building soft echoes did fall.
Not a creature was stirring, from microbe to 'gator—
Not mice, and not people, not one stray curator.
The museum was peaceful from tail tip to snout,
'Cause most of the staff jobs had been parceled out.
The stockings were hung by the chimney with care
By Millennials learning that "real" jobs are rare.
The curators were nestled, as was their sad habit,
But they all were gig workers assigned by TaskRabbit®.
And all of the creatures that had been in the cases
Were leased to retailers and other such places.
[Want a real live (dead) polar bear at your reception?
You can have it, no questions–for cash, no exception.
Deer, 'possums, frogs, each exquisitely posed,
For a nominal fee make great party tableaux.]
I was hunched at my desk with Jingle Bells blaring
Counting receipts for the loot from this "sharing"
When out on the lawn there arose such a clatter,
I quaked in my boots, my teeth started to chatter.
Away to the guard booth I flew just to see
What images appeared on the CCTV.
There, decked with a giant pink mustache (quite spiff)
Came a miniature sleigh, arranged via Lyft®.
With a jolly old driver, now drawing so near
I could see that his steeds were from Rent-A-Reindeer.
More rapid than updates his curses now came
As he whistled and shouted out dating app's names,
I just want this iPhone to quit making me stupid."
And then, in a twinkling, as I turned around,
Down the chimney Saint Nicholas came with a bound.
His eyes, how they glistened; his hair, what a mess.
I knew in a moment he had the wrong address.
"What's this?" said Santa, waving our master key.
"This can't be the museum I leased through Airbnb®!
It was supposed to have specimens! Curators! Cases!
Instead it's impoverished, and lacking all graces.
You had dioramas. You had stories to tell.
You had magic and logic and that rare old book smell."
"Oh, well," he said, "Your lesson is learned,
"What was given away was worth more than was earned."
Then he pulled from his bag all the stuff we were missing:
Dinosaurs, preparators, even two interns, kissing.
From the dregs of the sack he fished out our director
(Who long had been absent, leased to a collector).
As the poor woman, dazed, looked around her in awe,
Santa leapt on his sleigh and let loose a guffaw,
And, putting his finger aside of his nose
(Not inside, thank goodness), through the ductwork he rose.
And I heard him exclaim, as he rose through the night,
"Take back what you own, and take care of it right!"
–Elizabeth Merritt, Sally Shelton, and John Simmons have never been leased out to anyone, though John did attempt to sell Sally once.Skip over related stories to continue reading article


text:
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Design upgrades & comments:
Upgrades from FW18: Wider midfoot.
Midfoot stud.


text:
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Developer Blogs
Quality of Life Improvements in Game Update 1.4
On top of the major features that we work on and deliver to the fans, we also try to work in smaller features to improve the overall quality of life for our players. Game update 1.4 has several of these features, and it's worth calling these out.
Group Finder Teleport Back – The top complaint about the Group Finder when we shipped it was that it did not send you back to where you were originally adventuring when you completed the content.
After much discussion, design came up with a compromise that we think will work pretty well. Starting in Game update 1.4, when you leave the Flashpoint by any means, you will be offered a teleport back to your adventuring location IF you have killed at least one boss in that Flashpoint (or in some cases, hit a significant checkpoint). This will be presented in a menu – players can choose instead to jump to the entry of the Flashpoint (in case you want to just jump to the Fleet to repair, for example).
Delayed Binding – Ever accidentally roll greed by mistake? Ever spend your commendations on the wrong item at the token vendor? In Game Update 1.4, players will be able to address this issue. Bind on Pickup and Bind on Legacy items will now have a 2 hour limit in which they can be exchanged. If they were a loot item, you can freely give the item to any party member who was in on the kill and therefore eligible to loot the item. Similarly, if you buy something from a commendation vendor, you will have 2 hours to return the item to any vendor and get a full refund of commendations.
There are limitations. This does not apply to stackable items or mission items. Adding or removing mods and augment slots will permanently bind the item (prematurely ending the timer), as will opening a lockbox. If the item is a Bind on Equip item you get from a vendor, then mailing, trading, listing the item on the GTN, or placing in the guild bank will also prematurely end the timer.
Moods – Here's something fun: in Game Update 1.4, you can set your character's mood – i.e. his facial expression. As an example of this, try typing /alarmed or /cheery. This will set your character's facial expression permanently (although it will be overwritten in conversations when the dialogue calls for a specific animation there). The full list of moods you can choose will appear in the emote browser attached to your chat window.
Companion Customization Improvements – Finally, starting in Game Update 1.4 players will be able to hide the helmet, or unify colors to chest, for their companion's gear (see the screenshot at the top of this article). No more mismatched, silly outfits (unless you like them that way)!
These are, of course, small improvements, but in these cases, a little bit of programming and design work go a long way towards making players happy and improving quality of life. We're always on the lookout for small wins like these, and there will be more of them in the future.
Damion Schubert, Principle Lead Systems Designer


text:
Test Drive: Ferrari Racing Legends Sports class brings the best Italy has to offerMon, 02 Apr 2012
The first Test Drive video game was released back in 1987. The franchise was then owned by Accolade, and it featured the Lamborghini Countach, the Ferrari
Testarossa, the Lotus Esprit Turbo, the Porsche
911 Turbo and the C4 Chevrolet Corvette. Though small, that's not a bad selection of cars for a title when video games we're just hitting their awkward adolescent phase.
Fast-forward 25 years. Video games have come of age, and the Test Drive franchise--now owned by Atari--will release its 16th title, Ferrari Racing Legends for Xbox and PlayStation 3 this summer. We gave you the overview in February, but now its time for specifics.
Ferrari Racing Legends will feature 36 tracks and nearly 50 cars under three main umbrellas: Sport, GT and Monoposto. Today, we have an exclusive preview of the cars in the Sport class.
-- 1947 Ferrari 125 S
-- 1951 Ferrari 212 Export Vignale Spyder
-- 1957 Ferrari 250 Testa Rossa
-- 1962 Ferrari 250 GTO
-- 1967 Ferrari 330 P4
-- 1989 Ferrari F40 LM
-- 1994 Ferrari 333 SP
-- 1995 Ferrari F355 Challenge
-- 1997 Ferrari F50 GT
-- 2005 Ferrari FXX
-- 2006 Ferrari F430 Challenge
-- 2009 Ferrari F458 Italia
Each Prancing Horse model is rendered with a fully detailed cockpit. A first-person driver model will interact realistically with the controls. For example, if a player switches gears in the game, the virtual driver's hand will reach down and move the shifter.
Additionally, publisher Slightly Mad Studios made sure the game works with multiple driving wheel controllers, exhibiting the proper force feedback and responsiveness.
Test Drive: Ferrari Racing Legends will be available before the end of spring, and autoweek.com will have a full review before it hits store shelves. We might even have a few copies to give away.
By Jake Lingeman


text:
Hope you have a great weekend. I am one of those looking forward to the Royal Wedding which is only hours away. I am about to head home to immerse myself in the coverage! I can't wait to see her dress! See you next week...
Friday, 29 April 2011
Thursday, 28 April 2011
New Things
We've had another influx of new things at Black & Spiro this week. The new blue and white inlay chest of drawers which we have placed in our front window with the butterfly fabric is very beautiful. We also have new pale pink cockatoo lamps which we've had custom made for our store, lots of new cushions in fabrics I bought when we were overseas earlier this year, a pair of antique armchairs and yet another delivery of our special blue and white ginger jars.
It certainly has been a busy week getting all of our new things into the shop. Here are a couple of photos I thought you might like to see. The colourful, mismatched and at times very wild style we seem to be known for is very noticeable in these pictures.
I can't believe it's Friday tomorrow already and another long weekend. I don't know about you but I'm finding it hard to fit everything I need to do into these short weeks!!
Posted by Anna Spiro at 17:33 46 comments
Labels: Black + Spiro, Shop
Saturday, 23 April 2011
Happy Easter
The anticipation is building in our household for the Easter Bunny's arrival tonight and for what he might bring. Today Harry made this large, colourful card for the Easter Bunny which we will leave out tonight along with some carrots and some milk. It is so fun watching the innocence of young children at times like these. I am looking forward to our annual Easter Egg hunt in the garden tomorrow morning which I have been preparing for over the last few days. I hope everyone is enjoying special times with family and friends. Happy Easter!!
Posted by Anna Spiro at 15:46 22 comments
Labels: A Family Tradition, Easter, Family
Thursday, 14 April 2011
Back Soon
These flowers have been sitting on the fireplace mantel in our bedroom for 2 weeks now. I am surprised they have lasted so long. At $3.00 a bunch at the markets they were a good investment. I have enjoyed looking at them every morning when I wake up.
I am taking off early this week for a few days away. I am so tired. See you soon.
Posted by Anna Spiro at 17:13 31 comments
Wednesday, 13 April 2011
Good Old Blue & White
I have posted this bedroom before but I thought I would post it again today as I still love it and it reminded me that blue and white can look so beautiful in a bedroom. I also love the black iron bed and the mix of furniture styles in this room. {image - country living magazine}
Here are a couple of new blue and white fabrics which hit our fabric library this week. I'm sure the die hard blue and white fans will be excited to know that we have had a very big influx of beautiful blue and white fabrics over the last few months into our library.
PS. It seems that the fresh flower post I wrote yesterday has created a bit of stir amongst readers from areas where it is hard to grow and buy fresh flowers/produce. I am very lucky to live in a sub-tropical climate where flowers/foliage/fruit & vegetables are accessible and easy to grow. I apologise if I have offended anybody with my post. That certainly wasn't my intention. I was purely stating my own personal preference and in my haste I didn't consider the circumstances of readers in remote/barren areas.
Posted by Anna Spiro at 20:10 34 comments
Labels: bedrooms, Blue, Blue and White, fabrics
Tuesday, 12 April 2011
Fresh is Best
The other day we had a lady in the store ask us for some fake flowers. I had to bite my lip and very kindly advise her that we only use fresh flowers. I don't go for anything fake. I'm a real or nothing girl in all aspects of my life. If I can't have real flowers then I would prefer to go without. Today I brought into the shop some of the succulent pots I have been potting up at home which I placed onto a tray on one of the coffee tables. They look great mixed with the fresh lemons in the clam shell. It just goes to show that fresh really is best.
Posted by Anna Spiro at 21:31 44 comments
Labels: Black + Spiro, Flowers, Shop Display, Vignettes
Monday, 11 April 2011
Great Issue
I think this month's issue of Ivy & Piper is excellent. They've certainly highlighted some lovely things. In particular I loved their feature on Fenton and Fenton...one of my favourite furniture and homewares stores in Melbourne.
I also thoroughly enjoyed their interview with my friend Stuart Membery. He really is such a talent and his home, which I have had the pleasure of visiting, is seriously beautiful and so stylish.
And last but definitely not least, I loved seeing our friend Paul Hunt featured. He too is so talented and creative. I am always inspired after he has dropped into B&S for a visit.
Overall a great issue I think!! Our online Australian magazines are just getting better and better. I can't wait to see what Adore magazine and Ivy & Piper magazine come up with next.
Posted by Anna Spiro at 20:27 11 comments
Sunday, 10 April 2011
Natural Cane
We spent lots of time with my family on the weekend as it was my brother's birthday and birthdays in our family tend to be celebrated over a few days.
Whilst at my parent's house this afternoon, I couldn't help noticing how beautiful the Stuart Membery cane chairs look with the older pieces of cane on their deck. This is one of the chairs from Stuart's Home Collection above which we sell at Black & Spiro and when you look at it mixed with mum's old cane chairs as below, it looks like it has been part of her furniture collection for years.
I have been collecting a few of these old cane chairs {like mum's above} for our house which I have also mixed with Stuart's chairs on our verandahs. I really love the look of this natural cane and I think it looks particularly nice mixed with Antique furniture and blue and white fabrics and china.
photos by me at mum & dad's house
Posted by Anna Spiro at 21:14 15 comments
Labels: Black + Spiro, Blue, Blue and White, cane furniture, Stuart Membery
Thursday, 7 April 2011
A Perfect Flower Stall
When I was a little girl I was as obsessed with flowers as I am these days.
I think I might have been around 8 years old when we lived in an old Queenslander at Wellington Point with a beautiful garden which my mother absolutely loved. I would collaborate with my neighbour Angela who was about a year younger than I was. We would pick flowers {mostly the daisies} out of mum's very large garden and we would set up a flower stall in front of my parent's house and sell the flowers on the roadside.
I would never let my children do that these days but back then it was different. When I spotted these little stalls by Mouta over on Poppy Talk earlier this week memories of these fun times came flooding back. I wish I had one of these back then. I think if I did it might have improved sales!!
Posted by Anna Spiro at 20:42 20 comments
Labels: Flowers, Me, memories, My Childhood, My Life
Wednesday, 6 April 2011
Ned Turns 2
I can't believe our beautiful Ned turned 2 the other day. It feels like it was yesterday that I picked him up from the airport. He has been such a wonderful addition to our family and we just love him so much. Golden Retrievers are the BEST family dogs!
This week whilst Brad and Harry are away at Brad's family farm in NSW Ned has spent a lot of time on our bed. He isn't usually allowed on our bed but I let him when Brad isn't around....just down on the end of the bed. He loves it and secretly so do I. I feel safe with him there as I can be a bit of a scaredy cat when when I am home alone.
Oh and just in time for Ned's Birthday this week Max {our 11 month old} started saying woof woof...exciting times in our household!! Happy Birthday Ned.
Posted by Anna Spiro at 22:08 43 comments
Tuesday, 5 April 2011
I think these lilies which we have in the shop at the moment are the prettiest lilies I have ever seen.
I am smitten with our new hot pink {well it's actually fluoro/neon pink} love heart fabric which just arrived onto my desk this morning.
This vintage rug in my office keeps me smiling all day. I love it.
And these new baskets in the shop are calling out to me - "take me home".....
Posted by Anna Spiro at 14:22 36 comments
Labels: Black + Spiro, Fabric, Flowers, Shop
Monday, 4 April 2011
Cosmo Fun Fearless Female
To my complete surprise I have been nominated with 9 other wonderful Australian female bloggers in this years Cosmopolitan Magazine Fun Fearless Female Competition in the Bloggers category. I actually haven't ever won anything in my life and I'm not so sure that this will change however, if you do enjoy visiting my blog and if you do enjoy my posts and if you would like to vote for me then I would love that. Click HERE to vote. It only takes a few minutes. I think it would be wonderful to be one of the 3 finalists however, I am just so thrilled to have been nominated in the first place.
Thank you for your continued interest in my blog. I feel a bit funny asking you to vote...it's not really my thing to ask for votes....but if you decide to then thank you so much!!xx
Posted by Anna Spiro at 23:15 29 comments
Labels: blogging, Competitions, Fun Fearless Female Competition, Me
Flowers, Vases, Baskets, Fabric, Plates & Pots
I've had a busy few days fossicking around the garden, the markets and local Antique shops.
In my travels I stumbled across these vintage vases which I couldn't resist. They now sit on our chest of drawers in our entry hallway. The vibrant orange of the larger vase makes me happy every time I see it and I just love the quirky bird clinging to the other vase/jug....it certainly is something you either love or hate.
I fell in-love with these little yellow flowers at the markets but I can't remember the name of them so please do tell if you know.
I also picked up one of these baskets which I have been coveting along with this piece of fabric which I am thinking of making into table napkins for an upcoming event I have planned.
On Saturday I potted up 12 little pots with Succulents for my brother as he was having a lunch at his house over the weekend and needed something wonderful to place down the centre of his dining table. I kept a few for myself to add to my growing collection of pot plants. {Correction to my post last week the little pots sell for approx. $1.20 at Bunnings and the succulents came from there too}.
It seems I wasn't the only one playing with flowers on the weekend. Mum just sent me this picture of the fresh Banksias she collected from the trees on their property at the beach. I am hoping she might deliver some over to me this week.
And finally I added 18 mismatched vintage dinner plates to my blue and white collection. We never have enough plates when we have the family here for lunch or dinner so now we will. NB. Mismatched vintage is so much less expensive than heading out to buy a complete set and so much more interesting I think and the best thing is that I can keep on adding to them as I see them.
And finally I added 18 mismatched vintage dinner plates to my blue and white collection. We never have enough plates when we have the family here for lunch or dinner so now we will. NB. Mismatched vintage is so much less expensive than heading out to buy a complete set and so much more interesting I think and the best thing is that I can keep on adding to them as I see them.
Posted by Anna Spiro at 10:42 30 comments
Sunday, 3 April 2011
When I think about the month of April I think of Easter. I have fond memories of partaking in the Easter Bonnet Parade when I was a little girl and our family's annual Garden Easter Egg Hunt. This month I'm sure there's lots of children getting excited about such things. It's also a month to embrace home cooked treats, hot cross buns, pretty yellow and white flowers, chocolate Easter eggs and time with family. This month I hope to share some ideas for Easter giving and cooking. I am also looking forward to seeing what the talented bloggers on my blogroll come up with for Easter too. Happy April.
vintage basket and vintage rabbit vase from southside antique centre, alphabet stamp set from coming up roses @ bulimba, flowers from chandler markets
photos by me
Posted by Anna Spiro at 14:43 5 comments
Labels: Calendar, Calendar Vignette
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text:
FinCEN's New Beneficial Ownership Regulations
03 December 2019 09:46
- Risk & Compliance
- Risk Management
- Governance
- Anti-Bribery
- Corruption
- Human Rights
- PEP Risk
- Due Diligence
- Sanctions & Watchlists
- Ultimate Beneficial Ownership
Regulatory Risk in the U.S.: What Companies Need to Know
Since its introduction of the Foreign Corrupt Practices Act (FCPA) in 1977, the United States has led the world in efforts to counter bribery and corruption in corporate business that traverses national borders. Now it has gone a full step further with permanent adoption and expansion of its Corporate Enforcement Policy pilot program that incentivized voluntary disclosure of potential FCPA violations.
At the same time, new regulations under the U.S. Department of the Treasury's Financial Crimes Enforcement Network (FinCEN) become effective on May 11. They will require that "covered financial institutions", including banks, step up their due diligence practices when opening accounts for legal entity customers and amend their anti-money laundering programs accordingly.
With the ever-increasing complexity of global supply chains and third-party networks, these changes further emphasize the need for companies to examine their compliance programs to ensure they have robust auditing systems and internal anti-corruption controls. They need to be kept up to date with the latest regulatory requirements, and in the case of breaches—be they intentional or incidental— maximize the potential for recourse to mitigating circumstances.
FCPA Corporate Enforcement Policy revisions
Deputy Attorney General Rod Rosenstein announced the permanency and expansion of the FCPA's Corporate Enforcement Policy last November in a speech marking the 40th anniversary of Congress enacting the FCPA.
With the revisions now formally added to the U.S. Attorneys' Manual, U.S. companies, and other companies doing business with U.S. companies, face new challenges in understanding and navigating how the Department of Justice (DOJ) will interpret and apply them in exercising its prosecutorial discretion.
The revisions do not create a statutory right. Rather, as Rosenstein stated, they are designed "to provide guidance and greater certainty for companies struggling with the question of whether to make voluntary disclosures of wrongdoing". They also serve to guide the DOJ in exercising its discretion, and thereby "combat the perception that prosecutors act in an arbitrary manner".
Unlike practice under the 2016-17 pilot program, DOJ policy on FCPA matters now include a "presumption", but not a guarantee, in favor of reduced criminal charges "in the hope that more companies would choose to self-disclose corrupt business practices and work responsibly, in cooperation with the DOJ, to investigate, respond to and prevent this type of criminal behaviour". In short, companies are required to make voluntary disclosure of suspected FCPA violations to the DOJ, in a timely manner (promptly upon their discovery, and before investigation or prosecution is imminent). They must also fully cooperate with the DOJ throughout the investigation and make appropriate remedial efforts to mitigate the risk of similar conduct reoccurring.
Having met the requirements to the DOJ's satisfaction, a company could receive up to a 50% reduction off the low end of the Sentencing Guidelines fine range. Even without voluntary disclosure a company could receive a 25% fine reduction, based on subsequent full cooperation and appropriate remediation efforts within the company.
Rosenstein highlighted factors whereby offenders might lose eligibility for consideration: "Aggravating circumstances related to the nature and seriousness of the offense, or if the offender is a criminal recidivist" and "involvement by executive management of the company in the misconduct; a significant profit to the company from the misconduct; [and] pervasiveness of the misconduct within the company".
Companies should not take this policy revision as a signal that the DOJ is relaxing its stance on antibribery and corruption compliance. Notably, while there were fewer enforcement actions in 2017 than in 2016, the average fine size per company in 2017 was double that of the previous year. Also, multinational actions are on the rise due to stricter anti-corruption laws in many countries and regions with a U.S. business presence, including Eastern Europe, France, Mexico, Brazil, South Korea, and Saudi Arabia.
A fuller understanding of how the DOJ will exercise its prosecutorial discretion under its newly formalized policy will be crucial to sound and wise corporate governance. The means to achieving this will come in two forms: the department's announcements delivered through memoranda and policy statements; and its requirements and considerations as illustrated in its statements in regard to specific prosecutions.
New FinCEN regulations
The new FinCEN regulations, which become effective on May 11, will require that the covered financial institutions:
● Enhance their due diligence practices when opening new accounts for legal entity customers by obtaining and maintaining information identifying the individuals who are the customers' beneficial owners or controllers.
● Amend their anti-money laundering programs in relation to collecting, monitoring and maintaining this information.
The regulations are aimed at preventing financial crimes conducted through accounts created and operated anonymously through 'straw men' or nominees.
The covered financial institutions include banks, federally-insured credit unions, savings associations, corporations involved in international or foreign banking or financial operations, federally registered trust banks or trust companies that are subject to anti-money laundering requirements, mutual funds, and brokers or dealers in securities.
Legal entity customers are defined as corporations, limited liability companies, general partnerships and any other entity created by filing a public document with the secretary of state or similar office. This includes similar business interests formed in a foreign country.
Other U.S. anti-corruption laws
Where FCPA offences are not present, other U.S. laws covering corruption offences include anti-money laundering statutes, the Travel Act, tax laws, and mail and wire fraud statutes.
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text:
Post TigerLan Meeting SUNDAY at 2 at the Burger King!What the title says foo!
Published: Oct 20, 2011 - 07:55 PM
Articles: NO CLUB MEETING ON 10/7/2011Due to us setting up for TigerLan on Friday, there will be no club meeting that day. You are more than welcome to come help out though.
Published: Oct 05, 2011 - 04:12 PM
Read more about NO CLUB MEETING ON 10/7/2011 (27 more word(s))
Articles: TigerLan 21 Voting is Now Up! Go Check It Out!You heard me! Now head over to the TigerLan forums and start voting! Use this url if you can't find it: http://augamers.org/PNphpBB2-viewtopic-t-1362.html
Published: Aug 31, 2011 - 03:53 PM
Read more about TigerLan 21 Voting is Now Up! Go Check It Out! (8 more word(s))
Website: TigerLAN 20 polls are now up!It kinda makes me sad to see that 19's voting was 2 news messages ago...people should post more. Anyway...
Voting ends March 30!
Published: Mar 08, 2011 - 01:33 PM
Website: PMing IssuesThe PM button in the forums isn't working correctly for the time being. In order to send a message, you'll have to use the "My Messages" link in the left menu. We'll let you know when this hitch is fixed.
Published: Jan 16, 2011 - 02:42 PM


text:
The Latest Chat App for iPhone Needs No Internet Connection
Mobile app stores are stuffed with messaging apps from WhatsApp to Tango and their many imitators. But FireChat, released last week for the iPhone, stands out. It's the only one that can be used without cell-phone reception.
FireChat makes use of a feature Apple introduced in the latest version of its iOS mobile software, iOS7, called multipeer connectivity. This feature allows phones to connect to one another directly using Bluetooth or Wi-Fi as an alternative to the Internet. If you're using FireChat, its "nearby" chat room lets you exchange messages with other users within 100 feet without sending data via your cellular provider.
Micha Benoliel, CEO and cofounder of startup Open Garden, which made FireChat, says the app shows how smartphones can be set free from cellular networks. He hopes to enable many more Internet-optional apps with the upcoming release of software tools that will help developers build FireChat-style apps for iPhone, or for Android, Mac, and Windows devices. "This approach is very interesting for multiplayer gaming and all kinds of communication apps," says Benoliel.
Anthony DiPasquale, a developer with consultancy Thoughtbot, says FireChat is the only app he's aware of that's been built to make use of multipeer connectivity, perhaps because the feature remains unfamiliar to most Apple developers. "I hope more people start to use it soon," he says. "It's an awesome framework with a lot of potential. There is probably a great use for multipeer connectivity in every situation where there are people grouped together wanting to share some sort of information." DiPasquale has dabbled in using multipeer connectivity himself, creating an experimental app that streams music from one device to several others nearby.
The new feature of iOS7 currently only supports data moving directly from one device to another, and from one device to several others. However, Open Garden's forthcoming software will extend the feature so that data can hop between two iPhones out of range of one another via intermediary devices. That approach, known as mesh networking, is at the heart of several existing projects to create disaster-proof or community-controlled communications networks (see "Build Your Own Internet with Mobile Mesh Networking").
Apps built to exploit such device-to-device schemes can offer security and privacy benefits over those that rely on the Internet. For example, messages sent using FireChat to nearby devices don't pass through any systems operated by either Open Garden or a wireless carrier (although they are broadcast to all FireChat users nearby).
That means the content of a message and metadata could not be harvested from a central communications hub by an attacker or government agency. "This method of communication is immune to firewalls like the ones installed in China and North Korea," says Mattt Thompson, a software engineer who writes the iOS and Mac development blog NSHipster. Recent revelations about large-scale surveillance of online services and the constant litany of data breaches make this a good time for apps that don't rely on central servers, he says. "As users become more mindful of the security and privacy implications of technologies they rely on, moving in the direction of local, ad-hoc networking makes a lot of sense."
However, peer-to-peer and mesh networking apps also come with their own risks, since an eavesdropper could gain access to local traffic just by using a device within range.
Open Garden's main product is an app that allows Android devices to share their Internet connections (see "Could You Spare Some Internet Access?"). However, Benoliel says that won't be coming to the iPhone anytime soon because the feature that FireChat relies on cannot be used to share data connectivity.
Peer-to-peer mobile communications and mesh networks could prove especially important in countries with minimal communications infrastructure. "You can see Google spending billions on fiber and balloons, but this is not going to solve the problem of ubiquitous mobile connectivity," Benoliel says. He argues that the spread of cheap Android phones across the world will make mesh networking feasible. "We need to create small Internets that can function on their own and [then] connect them to the big Internet."
Deep Dive
What's next for the world's fastest supercomputers
Scientists have begun running experiments on Frontier, the world's first official exascale machine, while facilities worldwide build other machines to join the ranks.
The future of open source is still very much in flux
Free and open software have transformed the tech industry. But we still have a lot to work out to make them healthy, equitable enterprises.
The beautiful complexity of the US radio spectrum
The United States Frequency Allocation Chart shows how the nation's precious radio frequencies are carefully shared.
How ubiquitous keyboard software puts hundreds of millions of Chinese users at risk
Third-party keyboard apps make typing in Chinese more efficient, but they can also be a privacy nightmare.
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Nicolas Cage turns in his most pallid and unhinged performance since Leaving Las Vegas or, especially, Vampire's Kiss (he ate a cockroach, remember?) as Frank Pierce, an Emergency Medical Service paramedic whose soul is battered nightly on the graveyard shift. Hell's Kitchen (set a few years ago, before Giuliani began polishing the Big Apple) is awash with carnage, and as Frank repeatedly attempts to quit, Captain Barney (Arthur Nascarella) cajoles: "Go and help the people of New York for me go and mop them up." As Frank becomes increasingly strung out, Barney's kind offer to fire him "tomorrow" becomes less motivating. Drowning in the morbidity and bleak humor of his profession, the guy desperately seeks a rest.
Three nights and two days with Frank and his partners illustrate just why his seams are unraveling. For starters, he is deeply haunted by the face of Rose (Cynthia Roman), a young woman he failed to save. Add in the widespread circulation of a lethal heroin mix called Red Death, raging gang wars, a crumbling state of general health, a hospital filled far beyond its capacity, and reality and nightmare become indistinguishable. Dante Ferretti's design here makes Calcutta look like Bel Air, and, unlike Patrick Swayze's doctor in City of Joy, Frank isn't parlaying philanthropy into a new lease on life. Occasionally, he manages to save someone. More often, he doesn't. Thus, the title.
While Cage gets to spout some darkly hilarious lines with his trademarked wide-eyed goofiness ("Why is everything a cardiac arrest? Come on, people!"), he's most engaging when paired with any of the movie's several excellent co-leads. Ving Rhames steals the show as fellow EMS technician Marcus, flashing loads of humanity through a holy roller/Barry White hybrid that would otherwise collapse into caricature. (It's worth the price of admission to watch him "heal" a smack-addled Goth punk by leading all the other bat-cavers in a prayer circle.) John Goodman (reteamed with Cage for the first time since Raising Arizona) is detached and wary as partner Larry, lending contrast to Frank's psychological spiral. Tom Sizemore brings in a disturbing element of racist violence as Tom, a paramedic who has lost the line between medicine and mauling.
Endlessly cruising through scum and filth, Frank is reminiscent of Robert De Niro's Travis Bickle from Taxi Driver a quarter-century ago, but it's satisfying to note that the comparison is fleeting. Frank is not the violent misanthrope dreamed up by Scorsese and scribe Paul Schrader (who adapts Joe Connelly's first novel here), but, rather, a man struggling frequently in vain to bring peace and life to a realm of insanity and death. His sensitivity (or craving for it) is further explored through his tentative relationship with Mary Burke (Patricia Arquette), a mousy former skank whose father was revived by Frank (a miracle via Sinatra) only to hover in a coma throughout the movie. Arquette fills Mary with so much sucker-punched hope that, when Frank lets down his fake cheer and admits, "It's been bad lately . . . but it's always been bad," we feel it, too. Their chemistry is deceptively simple and one of the most satisfying elements here.
Several other superb players flesh out the ensemble. Not that we need another ER, but a successful TV series could be built around Mary Beth Hurt's Nurse Constance alone. Weary and overburdened yet razor sharp, Constance (with Afemo Omilani's steadfastly self-aware security guard, Griss) holds Mercy Hospital together in the face of utter despair. She's like a robust, female Wilbur Larch from The Cider House Rules, chopping up pathos with curt admonishment. ("Correct me if I am mistaken, but did we sell you the cocaine? Did we shove it up your nose?")
On the other side of the convalescent path is Cy Coates (Cliff Curtis), a minor drug czar whose good intentions (he runs a little pad he calls "Oasis") get stomped on just like everybody else's. Curtis, proving himself indispensable as an ethnic character actor (Three Kings, Insider), once again works wonders with a small role. It's a shame that his hussy, Kanita (Sonja Sohn), is also denied a larger part. (Their agents probably wouldn't mind the money.) Singer-actor Marc Anthony also pushes buttons as Noel, a dreadlocked (and frequently bloodied) childhood friend of Mary's who single-handedly symbolizes the wretched state of the neighborhood.
Amazingly, these complex turns barely hint at the wealth of material and characterization littered throughout Bringing Out the Dead, so it should be scintillating entertainment, right? Well . . . sort of. Try schizophrenic. Despite moments of gritty greatness that rival Scorsese's best, the movie is severely hampered by please-everyone-syndrome, especially in the
editing and choice of music. Rather than running with just Elmer Bernstein's score (schmaltzy echoes of '60s cop shows), the producers have decided to bombard us with a ludicrous stream of poorly juxtaposed rock songs. Yes, it is indeed stimulating to hear the Clash's "Janie Jones" and "I'm So Bored With the U.S.A." blasting nonsensically through ambulance montages, but the nonstop parade of hits (the Who, Stevie Wonder, R.E.M., Natalie Merchant, UB40, to name a few) quickly becomes distracting, an invitation to either plug the ears or close the eyes. The pace of the movie is ruined by this fervid, multigenerational marketing scheme. Why not just cut out the dull, redundant bits?
Excluding a strange and utterly unnecessary racial slur hurled at a turbaned taxi
driver, Bringing Out the Dead is composed of some profoundly compassionate ideas and scenes (note Frank's hallucinations and the guilt theme). It would be nice to gush poetically over it, to say things like "Graffiti and derelicts hover like a beckoning penance" or "This rumination upon mortality reawakens the soul" or (every payola critic's standby) "A shattering triumph!" But it's much more accurate to state that, this time around, Marty's New York is simply a pretty cool mess. Plenty of soulful blood is splattered, but only about half of it congeals.


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Chinese Zodiac Chopsticks — Dragon
Product Reference: A6AHB141XXPU
Chinese Zodiac Chopsticks — Dragon
Product Reference: A6AHB141XXPU
Unique utensils for dinner parties, a meaningful keepsake, a beautiful gift. Each pair of chopsticks from this collection is topped with brass statuettes of one of the Chinese zodiac animals — select yours based on your birth year. The sticks are crafted from quality wood and given a sleek matte finish in Shanghai Tang's signature vivid colours. Birth years of the Dragon: 1928, 1940, 1952, 1964, 1976, 1988, 2000, 2012, 2024 • Matte finished wood • Brass Chinese zodiac animal statuette • Brass chopstick rest included
Colour: Purple
Colour: Purple
• Length: 24.5cm • Width: 0.8cm
Wood, brass
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text: The visionary, groundbreaking cupcake ATM outside Sprinkles in Beverly Hills has streamlined the cupcake acquiring process. Now, customers don't have to deal with eyebrow-raising employees when they start eating their dozen red velvet cupcakes that were for a "birthday" on the way out the door — they can simply stride confidently up to the machine and let its senseless, nonjudgmental face process their order. Despite Japan's proclivity for all manner of vending machines, Sprinkles' ATM is, according to CBS, "the first of its kind in the world," dispensing cupcakes 24/7 even as it devours American confection jobs. If a cupcake ATM sounds good to you, I'm sure it won't be long until the trend spreads to all 50 states, but by then cupcake ATMs will be so over — baby sloth ATMs will be the next big innovation.