It starts before Claude and Ray go to prison, when they stumble into a southern roadhouse, Claude asks for some coffee and pie. "You going to find out before me," says a wiser Ray.Īlthough Murphy gets the comical run of the yard, Lawrence gets his time too. "Why they call him Jangle Leg?" Claude wonders. Nun~ez Jr.) a mute baseball sensation called Can't Get Right (Bokeem Woodbine) and a strange, bulgy-eyed guy called Jangle Leg (the great Bernie Mac). Goldmouth is one of several ultimately engaging characters, including a bandanna-topped prison queen called Biscuit (Miguel A. For this display, Ray gets his first prison whupping, courtesy of Goldmouth.Īfter that, the atmosphere of the movie softens almost to a Roberto Benigni level, as our newest inmates adjust to the new life. Ray decides this is the time to talk tough and show everyone what he's made of. The first initiation involves getting to know their new cellmates, including a very big guy called Goldmouth (Michael "Bear" Taliferro), who demands to eat Claude's cornbread. With nothing but life before them, our two performers comically go to town. 4317, and their home is a Mississippi state prison, full of bullies and sissies, one ornery black guard called Hoppin' Bob (Brent Jennings) and an even meaner redneck prison boss (Nick Cassavetes). The judge issues them brand new numbers and a new, rural address. (Quick, someone stop me before I use the word "Bildungsroman" in the same review as "Martin Lawrence.") The prisoners are petty hustler Ray Gibson (Murphy) and aspiring bank teller Claude Banks (Lawrence), who start off as free men in Harlem, but who find themselves unceremoniously thrown together one fateful night when they can't pay their bar bills.įorced to do a moonshine run in Mississippi to make up the difference, they run into some serious trouble, southern style.Ĭaught near the body of a dead man, they get a bum rap for his murder by the redneck sheriff who did the deed. Let's just say the movie, which has some passing similarities with "The Shawshank Redemption," spans two lifetime sentences. "Life," written by Robert Ramsey and Matthew Stone, is a surprisingly well-textured, if sentimental narrative that starts in Harlem in the 1930s, runs through the war years and civil rights, then continues all the way to Afros and bell-bottoms and I'll stop there in the interest of preserving surprise. Instead of letting the exuberant headliners take a half-witted story line and overrun it with improvisational flair, director Ted Demme channels their performances into the flow of the story.Īnd a good story it is. Murphy and Lawrence to let a project go by without a few nasty licks.īut this movie is much more than a dirty dukeout between two of Richard Pryor's most prominent disciples. Oh, "Life" gets down and dirty, all right. When you saw ads for "Life," a comedy starring Eddie Murphy and Martin Lawrence, you were expecting a bad-boy raunchfest? You wanted some serious back and forthing between these two of the unprintable variety? Eddie Murphy, right, and Martin Lawrence are in it for the long haul in "Life."Ĭontains fisticuff violence, nudity and obscenity
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12/9/2023 0 Comments Sherlock seriesWhile Arthur Conan Doyle’s original Sherlock has long been a, shall we say, abrasive personality, the full extent of Sherlock’s sociopathy is fiercely debated. Meanwhile, the equally skilled Freeman, as a put-upon John Watson, never fails in that delicate balance of being way out of his depth and being the very source of gravity to pull in Sherlock and his dangerous antisocial tendencies. This was the role that shot Cumberbatch to fame and served as his unofficial audition for the similarly calculated Doctor Strange. ShutterstockĮlsewhere, Cumberbatch’s lauded portrayal as Sherlock Holmes still has teeth. In short, it’s good filmmaking.Ĭumberbatch and Freeman, in Sherlock. By maintaining the same font through every season and blanketing the text in white regardless of sender and receiver, Zhou notes that audience investment is increased. Tony Zhou, the film editor behind the film studies YouTube channel Every Frame a Painting, credited Sherlock in 2014 for its “definitive” and obsolescence-proof method. Comparatively more complicated, clunky, and time-consuming to accomplish, Sherlock borrowed an idea from South Korea, refined it, and now it’s everywhere. While Japanese anime and South Korean cinema have included cell phone texts onscreen since the early 2000s, Sherlock popularized the form in the 2010s for mainstream audiences as a solution over conventional insert shots of phones. Its elegant depiction of texting - plain, simple white text on screen - is perhaps what keeps the series from ever feeling or looking dated now. Though some of its episodes are now over ten years old, they remain as fresh as ever. Watch those scenes of Sherlock’s deductive “powers” at work and try not to giggle. Cumberbatch and Freeman anchor Sherlock, even through some stylistic stumbles. Smart filmmaking and a killer score by David Arnold and Michael Price ( “The Game Is On” is so good it should be Sherlock Holmes’ theme across all media for the rest of time) enhance the series’ pair of charismatic, electric leads. And while the last season and 2016 special received mixed reviews, there is still power in that first batch of episodes. In true British TV fashion, the series is less than 15 episodes in all, each clocking in at a feature film’s length. Martin Freeman (left) and Benedict Cumberbatch (right) star in the BBC hit Sherlock, a modern interpretation of Arthur Conan Doyle’s classic fictional detective. "And Sherlock Holmes is already the most filmed character in all fiction, so there will always be more versions if you don't like ours." (Both Cumberbatch and Downey would later share the screen together in 2018’s Avengers: Infinity War.) “We are being precisely as reverential as Conan Doyle was," Gatiss quipped. Such an example was the 2009 Hollywood movie Sherlock Holmes, with the title role played by actor Robert Downey Jr. In a 2010 interview with The Guardianduring the show’s launch, Gatiss lamented that recent Sherlock adaptations were “too reverential and too slow,” almost all of them Victorian period pieces. But it wasn’t until producer Sue Vertue, Moffat’s wife, talked Moffat and Gatiss into actually making it, warning them other writers may steal the novel idea before them. The brainchild of Doctor Who writers Steven Moffat and Mark Gatiss, the two conceived the idea of Sherlock operating in the 21st century over commutes to the Doctor Who set in Cardiff. In an appropriate update on Watson’s role as Sherlock’s “biographer” in Arthur Conan Doyle’s books, Watson blogs about their cases, which goes viral and turns Sherlock into a reluctant celebrity. While Sherlock’s abrasive personality causes conflict between him, Watson, and the Metropolitan Police Service, Sherlock’s unmatched intellect, deduction, and observation make him an invaluable resource in solving crimes. Sherlock, which famously stars Benedict Cumberbatch as Arthur Conan Doyle’s iconic detective and Martin Freeman as John Watson (reimagined here as an RAMC veteran fresh from service in Afghanistan), takes place in modern-day London. 12/9/2023 0 Comments Parallels coherence linuxTo be honest, this feature took me by surprise. VMWare Fusion: Great Linux support for Unity view It didn’t even go all the way into booting up the Solaris image where I can then proceed to install the OS!Ģ. However, when I tried to boot Solaris Express 11 on Parallels Desktop 7, it just hung at the boot-up screen. VMware Fusion 4 would be on of your best choice in this area, especially so if you need to OSes other than just Windows, OS X or Linux.īut wait, what about Parallels Desktop 7 then? Well, if you just need to run Windows, the various popular Linux distributions (I’ve personally tested Ubuntu, Fedora, and Red Hat and they work fine) and OS X, the Parallels works well too. So, if being able to run a vast array of operating systems as the guest OS is important to you, then look no further. I mean, it even officially supports Novell NetWare! And on a personal basis, I do need to run a Solaris guest OS at times to run tests for work and only VMWare allowed me to run Solaris 11 Express without any issues.Īs you can see from the screen shot on the left, I was able to install Solaris perfectly. This is perhaps one of the main reason why you would want to run VMWare Fusion, instead of Parallels. VMware Fusion: Vast guest operating system support!įirst up, I believe one of VMware Fusion 4‘s best point (and well, VMware in general) is its supportability of many popular guest OS. So let’s start with VMWare Fusion 4 and where it excels.ġ. Instead, my assessment would be from the usability point of view, which IMHO just makes more sense. I would also not rely on synthetic benchmarks to compare the performance between the two. I would not however be listing down all the features and functionalities and then compare them side-by-side. And I’d also summarize to a few key decisions makers on which solution you would eventually choose. And in each of those strong points, I would also compare what the other has to offer. In writing this article, I would be looking for the strengths of both VMWare Fusion and Parallels Desktop. Now that it has finally been released, a fairer comparison can now be made between the two. Well, that’s before VMWare Fusion 4 was released. I’ve previously written an article here on why I thought Parallels Desktop 7 just beats the heck out of VMWare Fusion 3. It’s without a doubt that the very recent release of VMware Fusion 4 and Parallels Desktop 7 for Mac has invigorated the on-going comparisons between the two popular virtualization solutions for Mac users.īoth has its own merits and depending on your expectations and needs from the virtualization solution, both choices will deliver what it promises to you. For now, you may want to check out my first impressions of Parallels Desktop 8 for Mac. So do check back soon for an update to this article in about a weeks time after I’ve had some time with both of them. Update (Aug 31): I’ve just gotten hold of both VMware Fusion 5 and Parallels Desktop 8 for Mac. Update (Sept 7): Check out the latest my usability and comparison report of VMware Fusion 5 and Parallels Desktop 8 for Mac here now! 12/9/2023 0 Comments Black and white nike bubble coatYou can always change your preference by visiting 'Cookie Settings' at the bottom of the page. Blocking some types of cookies may impact your experience of the site and the services we are able to offer. 99 Spire Mens Black Peak Bubble Quilted Hooded Down Puffer Coat Jacket Size M. Nike Duck Down Filled Red White Blue Hooded Puffer Jacket Bubble Coat Mens Large. Click on the different category headings to find out more and change our default settings. Get the best deals on Mens Bubble Jacket when you shop the largest online selection at. Buy mens hoodies, pullovers & sweatshirts from Nike, adidas, Under Armour & more. Because we respect your right to privacy, optional cookies are not set unless you enable them. Shop our mens hoodies & sweatshirts at rebel. We would like to set optional cookies to give you a better user experience and to assist us in understanding how visitors use our site. Add heat to your cold season fit with our selection of designer puffer jackets. We use Strictly Necessary cookies to make our website work. The information does not usually directly identify you, but it can give you a more personalized web experience. 1-48 of 77 results for 'nike bubble coat men' RESULTS Price and other details may vary based on product size and color. Nike Boy's Sportswear Synthetic Fill Jacket (Little Kids/Big Kids) 108 9000 List: 100. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. Mens Winter Coats at Footasylum - Shop mens coats & jackets from the biggest brands. 1-48 of 105 results for 'nike bubble jacket' Results Price and other details may vary based on product size and color. Please be aware that, due to licensing restrictions, we cannot ship Nike SB products to customers outside the UK and European Economic Area.When you visit any website, it may store or retrieve information on your browser, mostly in the form of cookies. Free shipping on many items Browse your favorite brands affordable prices. Related Content: Nike SB MLB Dunks - 'Bubble Gum' Pack Get the best deals on Mens Bubble Jacket when you shop the largest online selection at. Accompanied by a Nike SB Dunk capsule that features creative colourways inspired by the legacies of teams such as the Philadelphia Phillies, New York Mets and the LA Dodgers. ASOS DESIGN co-ord oversized varsity jersey bomber jacket in blue. Nike Basketball NBA LA Lakers unisex jacket in black and white. Our bomber jacket styles, such as leather, suede and baseball, will help you stand out. Nike SB x MLB Varsity Jacket in Black and White. Tommy Jeans TJM Archive Colorblock Puffer Jacket White/Multi-Coloured. Discover the latest mens bomber jackets with ASOS. Named after the endless amounts of gum chewed in baseball dugouts, Nike’s ‘Bubble Gum’ pack pays homage to Major League Baseball rivalry, World Series success and some of the most iconic teams of all time. Stussy Womens Graffiti Hood Puffer Jacket Black. Shop Womens Nike Black Size M Puffers at a discounted price at Poshmark. Finished with two welted front pockets, a right chest Swoosh logo and with an embroidered jock tag sewn above the hem. Styled with a water-repellent finish and inspired by classic on-pitch stylings, this Nike jacket features striped elasticated cuffs, a rib knit hemline and a full length snap-popper fastening that complements the classic bomber-style collar. Arriving as part of the brand’s ‘Bubble Gum’ pack, this Nike SB varsity jacket is tailored to a loose fit from 100% polyester. Nike SB x MLB Varsity Jacket in Black and White. 12/9/2023 0 Comments Europa universalis 3 steamunlockedIn response, Paradox pledged to conduct a "thorough audit" of its processes.Įuropa Universalis 4 will remain free to download and keep on the Epic Games Store until next Thursday, 7th October, whereupon PC Building Simulator becomes Epic's latest freebie. It would, of course be remiss not to mention that developer Paradox was recently accused of fostering a culture of bullying and gender discrimination after a union-led employee survey found almost half of the 133 staff who participated had experienced "mistreatment", with the issues said to be "worst for women". Just, you know, maybe steer clear of Leviathan. Europa Universalis 4 - Epic Games Store Trailer.Īnd if it does manage to get you in its grip, the good news (depending on your perspective) is there's an absolute mountain of additional DLC - currently totalling 17 expansions and a heap of smaller-scale stuff - to keep things fresh. It's a supremely complicated beast (I ended up watching ten hours of YouTube tutorials before I could even begin to fathom its depths and make sense of its interface), but the core game is a dazzlingly rich thing, full of enthralling strategic possibilities, if you manage to crack its shell. Released back in 2013 and still tottering along today (its most recent expansion, Leviathan, was so disastrous its director issued an apology), Europa Universalis 4 gives players control of a country somewhere between 1444 to 1821 and lets them shape it into global significance through trade, diplomacy, colonisation, and war.
12/9/2023 0 Comments Show database sqlite 3The above procedure will end with SQLite installation on your Mac OS X machine. Step 1 − Go to SQLite download page, and download sqlite-autoconf-*.tar.gz from source code section. Though the latest version of Mac OS X comes pre-installed with SQLite but if you do not have installation available then just follow these following steps − The above command will end with SQLite installation on your Linux machine. Step 1 − Go to SQLite download page and download sqlite-autoconf-*.tar.gz from source code section. Following are the following steps to install SQLite − If you do not see the above result, then it means you do not have SQLite installed on your Linux machine. So you just issue the following command to check if you already have SQLite installed on your machine. Today, almost all the flavours of Linux OS are being shipped with SQLite. Step 4 − Add C:\>sqlite in your PATH environment variable and finally go to the command prompt and issue sqlite3 command, which should display the following result.Įnter SQL statements terminated with a " " Step 3 − Create a folder C:\>sqlite and unzip above two zipped files in this folder, which will give you f, sqlite3.dll and sqlite3.exe files. Step 2 − Download sqlite-shell-win32-*.zip and sqlite-dll-win32-*.zip zipped files. Step 1 − Go to SQLite download page, and download precompiled binaries from Windows section. This chapter will take you through the process of setting up SQLite on Windows, Linux and Mac OS X. SQLite is famous for its great feature zero-configuration, which means no complex setup or administration is needed. Retrieves certain records from one or more tables Modifies an existing database object, such as a table.ĭeletes an entire table, a view of a table or other object in the database. These commands can be classified into groups based on their operational nature − DDL - Data Definition Language Sr.No.Ĭreates a new table, a view of a table, or other object in database. They are CREATE, SELECT, INSERT, UPDATE, DELETE and DROP. The standard SQLite commands to interact with relational databases are similar to SQL. The only access permissions that can be applied are the normal file access permissions of the underlying operating system. You may not execute a DELETE, INSERT, or UPDATE statement on a view. The DROP COLUMN, ALTER COLUMN, ADD CONSTRAINT are not supported.įOR EACH ROW triggers are supported but not FOR EACH STATEMENT triggers. The RENAME TABLE and ADD COLUMN variants of the ALTER TABLE command are supported. There are few unsupported features of SQL92 in SQLite which are listed in the following table. Richard Hipp designed SQLite for the purpose of no administration required for operating a program.Ģ000 - In August, SQLite 1.0 released with GNU Database Manager.Ģ011 - Hipp announced to add UNQl interface to SQLite DB and to develop UNQLite (Document oriented database). SQLite is available on UNIX (Linux, Mac OS-X, Android, iOS) and Windows (Win32, WinCE, WinRT).Ģ000 - D. SQLite is written in ANSI-C and provides simple and easy-to-use API. SQLite supports most of the query language features found in SQL92 (SQL2) standard. SQLite transactions are fully ACID-compliant, allowing safe access from multiple processes or threads. SQLite is self-contained, which means no external dependencies. SQLite is very small and light weight, less than 400KiB fully configured or less than 250KiB with optional features omitted. SQLite comes with zero-configuration, which means no setup or administration needed.Ī complete SQLite database is stored in a single cross-platform disk file. SQLite does not require a separate server process or system to operate (serverless). SQLite accesses its storage files directly. SQLite engine is not a standalone process like other databases, you can link it statically or dynamically as per your requirement with your application. It is a database, which is zero-configured, which means like other databases you do not need to configure it in your system. SQLite is an in-process library that implements a self-contained, serverless, zero-configuration, transactional SQL database engine. The source code for SQLite is in the public domain. SQLite is one of the fastest-growing database engines around, but that's growth in terms of popularity, not anything to do with its size. SQLite is a software library that implements a self-contained, serverless, zero-configuration, transactional SQL database engine. This chapter helps you understand what is SQLite, how it differs from SQL, why it is needed and the way in which it handles the applications Database. 12/8/2023 0 Comments Olivia newton john greaseGrease was released in the United States on June 16, 1978, by Paramount Pictures. She was 73 years old and is survived by her husband, John Easterling, daughter, Chloe Lattanzi among other relations. The film depicts the lives of greaser Danny Zuko (John Travolta) and Australian transfer student Sandy Olsson (Olivia Newton-John), who develop an attraction for each other during a summer romance. As part of Newton-Johns contract for Grease, she would get to. Here are the most 15 essential tracks from the iconic singer. Newton-John won 4 Grammy Awards among a host of other prestigious awards. Olivia Newton-John was the queen of soft rock in the 70s and 80s. Dundee (2020), an Australian comedy where she played the role of Olivia. Newton-John's last movie appearance before her death was in The Very Excellent Mr. Her obituary called for donations to be made to the foundation to preserve Newton-John's legacy. Newton-John revealed in her 2019 memoir, Dont Stop Believin, that Grease costume designer Albert Wolsky wanted to stay as accurate to the 1950s as possible. Olivia Newton-John: el emotivo mensaje de despedida de John Travolta a su compañera en 'Grease' La actriz murió este lunes a los 73 años de edad en su casa de California. Newton-John shared her cancer experience with the public and started the Olivia Newton-John Foundation Fund, a non-profit aimed at researching the use of plant medicine including cannabis to treat cancer. She doggedly fought off the disease on two occasions but unfortunately, the cancer returned in 2017 progressing to stage IV. While the cause of death was not revealed in the statement, Newton-John was known to have batted breast cancer beginning in her forties. “Dame Olivia Newton-John (73) passed away peacefully at her Ranch in Southern California this morning, surrounded by family and friends,” the post read. Newton-John’s death was confirmed by her husband, John Easterling, who shared the news of her passing on Facebook Monday. Olivia Newton-John's death was revealed in a Facebook post via her verified account. Grease star Dame Olivia Newton-John has died. RELATED: Character Actor Clu Gulager Dead at 93 12/8/2023 0 Comments I2c digital isolatorThe isolated side includes ☑2.5V and 5V nominal power supplies, each capable of providing more than 20mA of load current. A logic supply pin allows easy interfacing with different logic levels from 1.62V to 5.5V, independent of the main supply.Īvailable options are compliant with SPI and I 2C (master mode only) specifications. A single 3.3V or 5V supply powers both sides of the interface through an integrated, isolated DC/DC converter. Simplify current and voltage monitoring with isolated SPI and I2C in your BMSĭesigning an Isolated I2C Bus interface by using digital isolators (Rev.The LTM2883 is a complete galvanic 6-channel digital μModule ® (micromodule) isolator. Top 6 design questions about I2C isolators Why are Digital Isolators Certified to Meet Electrical Equipment Standards?ĭistance Through Insulation: How Digital Isolators Meet Certification Requiremen How Do Isolated I2C Buffers with Hot-Swap Capability and IEC ESD Improve. UL Certificate of Compliance File E181974 Vol 4 Sec 3 VDE Certificate for Basic Isolation for DIN EN IEC 60747-17 (Rev. F)ĬQC Certificate for ISO154xD, ISO742xD, ISO71xxDBQ (Rev. ISO154x Low-Power Bidirectional I2C Isolators datasheet (Rev. Isolated bidirectional communication is accomplished within these devices by offsetting the low-level output voltage on side 1 to a value greater than the high-level input voltage on side 1, thus preventing an internal logic latch that otherwise would occur with standard digital isolators. For applications where clock stretching by the target is possible, the ISO1540 device should be used. The ISO1541 is useful in applications that have a single controller while the ISO1540 is suitable for multi-controller applications. The ISO1540 has two isolated bidirectional channels for clock and data lines while the ISO1541 has a bidirectional data and a unidirectional clock channel. The ISO1540 and ISO1541 devices enable a complete isolated I 2C interface to be implemented within a small form factor. This isolation technology provides for function, performance, size, and power consumption advantages when compared to optocouplers. When used with isolated power supplies, these devices block high voltages, isolate grounds, and prevent noise currents from entering the local ground and interfering with or damaging sensitive circuitry. These devices have logic input and output buffers that are separated by Texas Instruments Capacitive Isolation technology using a silicon dioxide (SiO 2) barrier. The ISO1540 and ISO1541 devices are low-power, bidirectional isolators that are compatible with I 2C interfaces. CSA approval per IEC 62368-1 end equipment standard.2500-V RMS isolation for 1 minute per UL 1577.HBM ESD protection of 4 kV on all pins 8 kV on bus pins.
12/8/2023 0 Comments Microsoft edge clear cache cookiesTo delete all data, simply set the time range to All time.Ĭheck each box that you wish to delete data for. Use the dropdown menu under Time range to set how far back the browser should delete cache, cookies, and history from. Scroll down to the Clear browsing data section and click the blue Choose what to clear button. In Microsoft Edge, click the 3 dots in the upper right corner and select Settings.Ĭlick Privacy, search, and services in the menu on the left. How to Clear Cache, Cookies, & Other Browsing Data in Microsoft Edge Desktop (Chromium Edge) These issues are why you might consider clearing cookies and cache in your browser. A similar issue can arise with cookies if the data stored in them is corrupt or incorrect. You won’t see the new content until the cache is cleared, or it expires. In some cases, your browser might load something from the cache when new content has been published. While cache and cookies usually make for a better browsing experience, they are not immune to occasional issues. For example, a website that uses a checkout / cart system might use a cookie to keep track of which items are in your cart. Loading this content from the local cache is much faster than requesting it from the server, making the page load faster in general.Ĭookies are small data files that some websites use to store user preferences or help the site function. This allows the browser to load this content from the local cache, rather than requesting the data from the web server every time. Simply put, Cache is a local storage that browsers use to “remember” parts of webpages through a process called caching. What is Cache, What are Cookies, and Why Clear Them? Without getting into too much detail, we’ll try to explain what cache and cookies, are and then show you how to clear them in Microsoft Edge. With the exception of browsing history these terms, and what they do, are still a mystery to many people. While clearing cookies will not significantly improve the overall speed of your computer, it can help improve the performance and privacy of your web browser.Microsoft Edge, like many browsers, stores data in cache, cookies, and history to create a better browsing experience for the user. Before you use another device to surf the Internet, clear the cookies first. When you are switching to other devices.If a website is experiencing issues, clearing its cookies can sometimes resolve the problem. When you have trouble opening websites.Always delete cookies after logging out from any website. It is best to delete cookies first before making online purchases. Make it a monthly habit for a smoother online experience. Just like tidying up your physical space, regularly clearing your cookies helps keep your digital life organized and streamlined. It also enhances your overall experience. Cookies can become outdated or invalid, which can cause browser errors or unexpected behavior when trying to access the stored information.Ĭlearing your cookies regularly helps maintain the privacy and security of your personal information online. Cookies can be vulnerable to attacks that put the security of your data at risk. Getting these information can lead to identity theft or financial fraud. Malicious actors with their advanced hacking tools uses data stored in cookies to get your login credentials or personal data. Like anything that saves your personal information, it could enhance your browsing experience, but it could also lead to issues like: Tick Cookies and saved website and Cached data and files, and then click Clear. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.Physically remove the hazard – eliminate potential exposure risk Ceftriaxone is preferred for pregnant women. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. Patients with pneumococcal or viral meningitis do not require isolation.ħ. Negative pressure ventilation is not required. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4Ħ. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.ĥ. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.Ĥ. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.ģ. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. The cause-and-effect relationship of herniation and LP has also been questioned.Ģ. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.ġ. Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. |
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