[Q957.Ebook] Fee Download The Ruby in the Smoke: A Sally Lockhart Mystery, by Philip Pullman

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“BEWARE THE SEVEN blessings . . . ” When she first utters these words, 16-year-old Sally Lockhart doesn’t know their meaning. But when an employee of her late father hears them, he dies of fear. Thus begins Sally’s terrifying journey into the seamy underworld of Victorian London, in search of clues to her father’s mysterious death.

• Sales Rank: #342141 in Books
• Brand: Knopf Books for Young Readers
• Published on: 2008-09-09
• Released on: 2008-09-09
• Original language: English
• Number of items: 1
• Dimensions: 8.10" h x .50" w x 5.21" l, .43 pounds
• Binding: Paperback
• 230 pages

Features

• Great product!

Most helpful customer reviews

2 of 2 people found the following review helpful.
Her name was Sally Lockhart; and within 15 minutes, she was going to kill a man
By R. King Meeker
In The Ruby in the Smoke, Phillip Pullman combines three of my favorite things: young adult fiction, a good mystery and a Victorian era setting.

Sixteen-year-old Sally Lockhart has recently lost her father in a shipwreck. After receiving a mysterious note warning her to "beware of the Seven Blessings", she visits her late father's shipping firm in the hope that someone there can make sense of the note. When she asks one of her father's employees about the Seven Blessings, the man is so terrified that he dies of a heart attack right in front of Sally. And so begins a chain of events that will have Sally questioning the circumstances of her father's death as well as her connection to a priceless Indian ruby. All the while Sally is pursued by a series of villains who are determined to kill her before she can learn the truth.

The Ruby in the Smoke is filled with colorful, vivid characters that seem ready to leap off the page. Sally is a strong female character, but she's not perfect by any means. Pullman avoided the pitfall of turning her into an unrealistic super heroine, while still highlighting her cleverness and charm. Even some of the villains are likeable while still being villainous; I was very amused by one soft-hearted thug who gives a temperance tract to a drunken man he's just beaten up.

With witty dialogue and twists and turns on nearly every page, The Ruby in the Smoke is a delightful and exciting read. I highly recommended it to any reader who loves a good mystery.

0 of 0 people found the following review helpful.
Her name was Sally Lockhart; and within 15 minutes, she was going to kill a man
By R. King Meeker
In The Ruby in the Smoke, Phillip Pullman combines three of my favorite things: young adult fiction, a good mystery and a Victorian era setting.

Sixteen-year-old Sally Lockhart has recently lost her father in a shipwreck. After receiving a mysterious note warning her to "beware of the Seven Blessings", she visits her late father's shipping firm in the hope that someone there can make sense of the note. When she asks one of her father's employees about the Seven Blessings, the man is so terrified that he dies of a heart attack right in front of Sally. And so begins a chain of events that will have Sally questioning the circumstances of her father's death as well as her connection to a priceless Indian ruby. All the while Sally is pursued by a series of villains who are determined to kill her before she can learn the truth.

The Ruby in the Smoke is filled with colorful, vivid characters that seem ready to leap off the page. Sally is a strong female character, but she's not perfect by any means. Pullman avoided the pitfall of turning her into an unrealistic super heroine, while still highlighting her cleverness and charm. Even some of the villains are likeable while still being villainous; I was very amused by one soft-hearted thug who gives a temperance tract to a drunken man he's just beaten up.

With witty dialogue and twists and turns on nearly every page, The Ruby in the Smoke is a delightful and exciting read. I highly recommended it to any reader who loves a good mystery.

5 of 5 people found the following review helpful.
Quality Mystery for Young Adults/Pre-teens
By JET
Pullman's 'Ruby in the Smoke' is an intriguing and gripping mystery for young adults or pre-teens. It is not quite as deep, tightly woven, or well-written as a few other books for this age group (notably, Harry Potter), but it still presents a quality read.

Sally Lockhart, a Victorian girl recently orphaned by a horrifying but mysterious accident, is the heroine of the book. She is a great character - strong and intelligent, but still believable for her age and era. Throughout the course of the book, Sally will attempt to find out how and why her father died, where the title ruby is, who is trying to cause her harm, and whom she can trust. The plot is very exciting, and pushes you to keep reading, and the characters are varied and believable.

It should be noted that this is not a book for young children, as the plot often delves into the seedy side of London in the Victorian era, and many adult themes are present, including murder, greed, and drug use (opium), although NOTHING immoral is glorified in any respect.

I am eager to read the next book in the series and find out what happens to Sally and her companions! I highly recommend this for anyone who enjoyed Harry Potter or the Series of Unfortunate Events books. I also look forward to reading other Pullman books.

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[J896.Ebook] Download Ebook CDC Health Information for International Travel 2016, by Centers for Disease Control and Prevention Centers for Disease Control and Preven

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Amid recent changes in global health, the public interest in travelers' safety has never been greater. For both international travelers and the health professionals who care for them, CDC Health Information for International Travel (more commonly known as The Yellow Book) is the definitive resource for preventing illness and injury in a globalized world.

This 2016 edition offers the US government's most current health recommendations for travelers to international destinations, including disease risk maps, country-specific guidelines, and vaccine requirements and recommendations. The book also offers updated guidance for specific types of travel and travelers, including:

· Precautions for immunocompromised travelers and disabled travelers
· Guidance for the pregnant, last-minute, or resource-limited traveler
· Health considerations for newly arrived adoptees, immigrants, and refugees
· Advice for air crews, humanitarian aid workers, and health care workers traveling to provide care overseas

Written by a team of experts at CDC on the forefront of travel medicine, The Yellow Book provides a user-friendly, vital resource for those in the business of keeping travelers healthy abroad.

• Sales Rank: #61202 in Books
• Published on: 2015-06-01
• Original language: English
• Number of items: 1
• Dimensions: 6.90" h x 1.40" w x 9.90" l, .0 pounds
• Binding: Paperback
• 688 pages

Review

"All clinicians who give travel advice should be familiar with "The Yellow Book."
This is the preeminent book for travel recommendations and the most up-to-date resource in print. Travel clinics should either have this book on hand or have access to the website. The fact that a new edition is available every two years reflects the necessity of staying current in this dynamic field.
Weighted Numerical Score: 98 - 5 Stars!" -- John M Horne, Doody's

About the Author

The Centers for Disease Control and Prevention (CDC) is a United States federal agency under the Department of Health and Human Services headquartered in Atlanta, Georgia.

Gary W. Brunette, MD, MS, is Chief of the Travelers' Health Branch, Centers for Disease Control and Prevention.

Editor in Chief
Gary W. Brunette, MD, MS

Chief Medical Editor
Phyllis E. Kozarsky, MD

Medical Editors
Nicole J. Cohen, MD, MS
Mark D. Gershman, MD
Alan J. Magill, MD
Stephen M. Ostroff, MD
Edward T. Ryan, MD
David R. Shlim, MD
Michelle Weinberg, MD, MPH
Mary Elizabeth Wilson, MD

Managing Editor
Megan Crawley O'Sullivan, MPH

Technical Editor
Ronnie Henry

Most helpful customer reviews

1 of 1 people found the following review helpful.
Intrepid Wanderers: You Need This Book!
By Charles E. Alexander
This is the most useful version of this essential manual yet! Much more user friendly than before, it should be consulted by anyone planning a trip abroad, preferably starting at the introduction through to the section on travelers with special needs, omitting only diseases not expected on the itinerary. It is essential in every travel medicine clinic and desirable at most travel agencies and public health agencies. Infectious disease specialists and primary care physicians dealing with frequent travelers would find it useful to keep at hand. And, compared to most medical textbooks, it's a downright steal at fifty bucks.

1 of 1 people found the following review helpful.
This edition is definitely an upgrade as the maps are more useful and the information presentation is better than in previous ..
By Michele in NOLA
I am a travel medicine specialist and this is our "bible". I buy one for every office every two years. This edition is definitely an upgrade as the maps are more useful and the information presentation is better than in previous versions. It is always nice to provide client's with a good "visual" as to why we make certain recommendations.

1 of 1 people found the following review helpful.
The standard health reference for foreign travel
By Bobbzz
This book pretty much has all the necessary information regarding health risks to travelers abroad. It is a reference book, not a novel, so it's great for looking things up but not exactly a page burner. Plan on using this a few months before departure, since some immunizations require a second dose. It's also available on Kindle, handy while traveling.

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[Y627.Ebook] PDF Ebook The Change Handbook: The Definitive Resource on Today's Best Methods for Engaging Whole Systems, by Peggy Holman, Tom Devane, Steven Cady,

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In 1999, the first edition of The Change Handbook provided a snapshot of a nascent field that broke barriers by engaging "whole systems" of people from organizations and communities in creating their own future. In the last seven years, the field has exploded. In this completely revised and updated second edition, lead authors Peggy Holman, Tom Devane, and Steven Cady profile sixty-one change methods--up from eighteen in the first edition. Nineteen of these methods are explored in depth, with case studies, answers to frequently asked questions, and details on the roles and responsibilities of the people involved, conditions for success, and more. This tremendously expanded second edition--400 pages longer, nearly twice the length of the first edition--will undoubtedly become the definitive resource in this rapidly expanding area.

• Sales Rank: #375158 in Books
• Brand: Brand: Berrett-Koehler Publishers
• Published on: 2007-01-04
• Original language: English
• Number of items: 1
• Dimensions: 9.18" h x 1.48" w x 8.10" l, 3.02 pounds
• Binding: Paperback
• 732 pages

Features

• Used Book in Good Condition

From the Publisher

Proven change strategies for tapping human potential in organizations and communities

This extensively updated new edition of the classic bestseller features profiles of sixty-one change methods by the originators and foremost practitioners of such high-leverage change methods as Appreciative Inquiry, the World Café, Six Sigma, Future Search, and Open Space Technology. Each author outlines distinctive aspects of their approach, answers frequently asked questions, and provides case studies and references to learn more. A one-stop comparative chart helps you determine which methods will work best for you, along with chapters on mixing and matching and sustaining results. This tremendously expanded second edition is the definitive resource in the exciting area of engaging "whole systems" of people to create their own future.

"What the Encyclopedia Britannica does for facts and the Oxford English Dictionary does for words, this book does for changing whole systems (both organizations and communities). A definite reference must for your organizational book shelf."
--Martin Rutte, coauthor of Chicken Soup for the Soul at Work

"Get ready to re-think your work and have it set in a larger perspective. This book is for those seeking a pragmatic blend of spirit and practice. It is the best book on large system change methods, bar none."
--Geoff Bellman, Consultant and author of The Consultant's Calling

"A treasure trove that, with disciplined application, can ignite a performance step change in an individual or organization. Its extremely practical tone brings distilled `What to do' insight and remarkable `How it works' clarity to each tool. This will be an invaluable contribution to even the best change agents in the world."
--Tony Singarayar, Senior Director, Business Models/Business Case, Advanced Technologies, Johnson & Johnson Consumer and Personal Products Worldwide

"The Change Handbook is what I turn to when I want to review a process I have run before or select to a new one. Invaluable for all facilitators who want to rise above the ordinary!"
--Gifford Pinchot III, President, The Bainbridge Graduate Institute, and author of Intrapreneuring

"A terrific resource. I highly recommend this book to change leaders who want to find and learn about methods for creating and sustaining change."
--Francis M. Duffy, PhD, Professor of Change Leadership in Education, Gallaudet University

About the Author
Peggy Holman brings generative processes to organizations and communities, increasing their capacity for achieving what is important to them. Her work encourages people to take responsibility for what they love.

Tom Devane is an internationally known consultant and speaker who helps companies plan and implement transformations that utilize highly participative methods to achieve sustainable change.

Steven Cady is a professor in the management department at Bowling Green State University. He is also the director of the institute for Organizational Effectiveness and former chief editor of The Organization Development Journal.

Most helpful customer reviews

5 of 5 people found the following review helpful.
Great Reference Guide for Systems Thinkers and Change Agents
By Marty Jacobs
This book is a must-have guide of over 60 techniques for anyone implementing systemic change. The first part of the book gives a detailed overview of how to select methods, mix and match methods, and create sustainable results. The next part is a detailed section describing each of the methods, broken down into the following categories: adaptable methods, planning methods, structuring methods, improving methods, and supportive methods. There is also a section that gives quick one-page summaries of each method, including the following key information: purpose, outcomes, when and when not to use, number and type of participants, typical duration, and a brief example.

1 of 1 people found the following review helpful.
Good for the value and a keeper for the office
By Amazon Customer
Favorites in the book were Appreciative inquiry and Soar Methods of change initiatives. The book is large in volume but the reason is there are an abundant amounts of templates to use for organizational change. Almost any situation could be place into one of the modules. This is a twice through read.

1 of 1 people found the following review helpful.
Def. a "must add" to the change practitioner's library
By Katherine Parramore
It will be a long time before I run out of either tools that I've used -- and this book gives me additional validation to my use of same -- and also twists on new processes. A wonderful tool and I recommend it highly to both new and experienced OE/OD practitioners

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Following on from The Entertainment Industry: An Introduction, Entertainment Management takes the next step in the development of entertainment as a practice and as an academic subject. Aimed at higher level undergraduates, the book discusses best practices in the entertainment industry, profiling a different discipline per chapter, each one a branch of entertainment that offers employment opportunities within the sector. Fields include marketing, P.R., the media, live events, artist management, arts and culture, consultancy and visitor attractions. The book aims to reflect the knowledge students will need for real world of entertainment management such as technical standards, business management, people management, economic aspects and legal issues. Each chapter discusses the background of the discipline, best practice management principles, issues in the wider environment, case studies of real organisations and future trends.

• Sales Rank: #1679226 in eBooks
• Published on: 2014-06-06
• Released on: 2014-06-06
• Format: Kindle eBook

About the Author
Stuart Moss

Ben Walmsley

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[Z359.Ebook] PDF Download Subterranean, by James Rollins

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Beneath the ice at the bottom of the Earth is a magnificent subterranean labyrinth, a place of breathtaking wonders--and terrors beyond imagining. A team of specialists led by archaeologist Ashley Carter has been hand-picked to explore this secret place and to uncover the riches it holds. But they are not the first to venture here--and those they follow did not return. There are mysteries here older than time, and revelations that could change the world. But there are also things that should not be disturbed--and a devastating truth that could doom Ashley and the expedition: they are not alone.

Eleven years after it was initially published, James Rollins's debut novel Subterranean is now available in hardcover for the very first time.

• Sales Rank: #272526 in Books
• Published on: 2010-03-09
• Released on: 2010-03-09
• Original language: English
• Number of items: 1
• Dimensions: 9.00" h x 1.33" w x 6.00" l, 1.25 pounds
• Binding: Hardcover
• 432 pages

Review
"A gripping deep Earth adventure." -- New York Times bestselling author Charles Pellegrino

"Kept me turning the pages well into the night!" - John Saul

From the Author
About James Rollins

JAMES ROLLINS is a #1 New York Times bestselling author of international thrillers that have been translated into more than forty languages. Known for unveiling unseen worlds, scientific breakthroughs, and historical secrets, Rollins' knack for breakneck pacing and stunning originality has been hailed by critics and embraced by scores of millions of readers around the world.

The Critics Rave

The New York Times says that his "roguish charm comes from his efforts to persuade readers the story is credible [through] real-life sources for his novel's science, history and geography." Rollins' rare blend of action, suspense, and knowledge was also mentioned by the Huffington Post, which stated that "After Crichton passed away in 2008 he clearly passed the baton to James Rollins, who like Crichton, is a renaissance man."

NPR calls his work "adventurous and enormously engrossing..." and the New York Journal of Books had this to say: "If you're a fan of smart, entertaining adventure fiction, this is your summer beach read writ large....All the science, all the history, and all the locations are masterfully intertwined. The characters are multi-dimensional. And the story is, well, a corker."

The Story Teller's Story

As a boy immersed in the scientific adventures of Doc Savage, the wonders of Jules Verne and H.G. Wells, and pulps such as The Shadow, The Spider, and The Avenger, James Rollins decided he wanted to be a writer. He honed his storytelling skills early, spinning elaborate tales that were often at the heart of pranks played on his brothers and sisters.

Before he would set heroes and villains on harrowing adventures, Rollins embarked on a career in veterinary medicine, graduating from the University of Missouri and establishing a successful veterinary practice. This hands-on knowledge of medicine and science helps shape the research and scientific speculation that set James Rollins books apart.

Explosive Page-Turning Adventures

The exotic locales of James Rollins novels have emerged as a hybrid between imagination, research, and his extensive travels throughout the United States and Europe, as well as New Zealand, the South Pacific, China, Southeast Asia, Africa, Australia, and South America. Recent jaunts include book tours and stops across the country and several European nations to give talks, seminars, and media interviews.In recent years, much of James' travel has involved meeting readers in small and large groups, at writing and fan conferences, and even aboard seagoing "seminars." James' mentoring and coaching skills have made him a sought after writing instructor and guest speaker for workshops, symposia, conventions, and other forums throughout the country.

James Rollins is the author of nine thrillers in the bestselling Sigma Force series (Sandstorm, Map of Bones, Black Order, The Judas Strain, The Last Oracle, The Doomsday Key, The Devil Colony, Bloodline, and The Eye of God); six individual adventure thrillers; and the Jake Ransom middle grade series (Jake Ransom and the Skull King's Shadow, Jake Ransom and the Howling Sphinx.)

From the Inside Flap
Beneath the ice at the bottom of the Earth is a magnificent subterranean labyrinth, a place of breathtaking wonders - and terrors beyond imagining. A team of specialists led by archaeologist Ashley Carter has been hand-picked to explore this secret place and to uncover the riches it holds.

But they are not the first to venture here - and those they follow did not return. There are mysteries here older than time, and revelations that could change the world. But there are also things that should not be disturbed - and a devastating truth that could doom Ashley and the expedition: they are not alone.

With all the trademark elements that have made James Rollins a bestselling author around the world-pulse-pounding adventure, scientific intrigue, nail-biting suspense-Subeterranean deserves a place in every thriller lover's collection. Even if you've read it before, you won't want to put this classic Rollins down.

Most helpful customer reviews

0 of 0 people found the following review helpful.
rollin' with rollins
By Amazon Customer
This was a good book. Good, believable story line. As with all of Rollins's books he puts his heart and soul in his stories.

4 of 6 people found the following review helpful.
Journey to the Center of the Earth meets The Time Machine
By Kindle Customer
A scientifically well-thought out concept. In the tradition of Verne and Wells with some factual scientific mumbo-jumbo, in the style of Crichton and Kerr, thrown in to show the reader that the writer has a college education. Although "Subterranean" has all those geological and anthropological terms that most normal people would stare at and skip to the next word, it also has a quality that makes you use your imagination. It helps to expand your mind as well as your creativity. Detailed descriptions of the inside of a cavern transports you inside that cavern with the characters. Fast-paced action with snappy dialogue kept this reader up well past his bedtime. And it's sure to cause some long and sleepless night, but the journey is well worth it. I would tell you more about the plot and characters and suplots but that would just leave you wondering why you bought the book in the first place. Just believe me when I say the less you know the more you will enjoy it. Your friendly neighborhood bookworm.

0 of 0 people found the following review helpful.
A good read
By Gretchen Armato
Rollin's books are all spooky but realistic at the same time. A good read!

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[U829.Ebook] Free Ebook Oxford Beginner's Japanese DictionaryFrom Bunt, Jonathan (EDT)/ Hall, Gillian (EDT)

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Each Oxford Beginner's Bilingual Dictionary is designed to offer English speaking adult learners a comprehensive, straightforward introduction to foreign languages, covering all the vocabulary needed for the first years of study, along with notes on grammar and usage and guidance on the culture where the language is spoken.

These easy-to-use references break from standard dictionary design. Clear entries with examples showing how the language works in context make it quick and simple to find the translation you're looking for, and the bold, color layout makes the dictionary easy to navigate, allowing you to get to grips with the language fast. All main translations are preceded by an equals sign so that they are instantly identifiable, and all parts of the entry are spelled out in full, avoiding confusing jargon and abbreviations. Grammar and usage notes throughout the text warn of possible translation pitfalls, and thousands of example phrases show how the language is used in real life.

At the center of each dictionary is a section devoted to useful information on the country, countries, or regions where the language is spoken. This includes background on lifestyles and culture, tips on etiquette and interaction, and a phrasefinder that provides handy phrases for use when traveling abroad. The dictionary also includes a section on core vocabulary--all the words you absolutely must know at a beginner's level, whether you are a student, traveler, or business person.

The Oxford Beginner's Bilingual Dictionary is the perfect tool for adult language learners who need basic vocabulary at their fingertips fast.

• Sales Rank: #71425 in Books
• Brand: Bunt, Jonathan (EDT)/ Hall, Gillian (EDT)
• Published on: 2006-10-16
• Original language: English, Japanese
• Number of items: 1
• Dimensions: 5.00" h x .80" w x 7.70" l, 1.07 pounds
• Binding: Paperback
• 480 pages

Most helpful customer reviews

38 of 39 people found the following review helpful.
Excellent beginner's dictionary
By Ray McDonald
I have looked for an easy-to-use bi-directional Japanese-English dictionary for a long time and this is one of the best I have found. The dictionary is easy to use and packed full of informative commentary to help a beginner Japanese student who has a functioning knowledge of hiragana. Some people might criticize the book for being lacking in vocabulary, but as far as beginners go, I believe it to be a very useful and easy-to-use book.

Some pros:
1. Dictionary is bi-direction (has a J-E and E-J)
2. The Japanese stands out from the English with a very easy to see blue hiragana text, with the kanji characters next to them as well.
3. Easy to understand break-down of different types of Japanese verbs.
4. Dictionary entries have useful commentary for sayings, idiomatic expressions, etc. as they come up.
5. An excellent "Learning and Lifestyle" kit in the back of the dictionary gives a whole array of tools to help beginners (and anyone who is learning Japanese) a wide array of need-to-know words, cultural hints, kana charts, phrases, etc.
6. Dictionary is small and compact, but extensive. It fits nicely inside a backpack with the rest of your college books!

0 of 0 people found the following review helpful.
this is a great dictionary! i bought it because it includes really ...
By Natalie B.
this is a great dictionary! i bought it because it includes really useful guides for traveling and quick phases - but also more importantly, because it doesn't include ANY romaji (yay), and it includes BOTH the hiragana/katakana + kanji versions of each word. it's really great for learning. the blue color coding is also nice on the eyes, and includes blue tips on the side for easily navigating through the alphabet. it's a dictionary + travel guide in one, and i can't stress enough how amazing it is that it doesn't JUST include the kanji (this helps with learning pronounciation via hiragana/katakana).

0 of 0 people found the following review helpful.
This was my favorite book back in the day
By Amy
This was my favorite book back in the day, really helpful for learning Japanese. Has sentences and phrase along with complete dictionary. Really really thick book!!!

See all 54 customer reviews...

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[J874.Ebook] Fee Download Drug Prescribing in Renal Failure: Dosing Guidelines for Adults, Fifth EditionFrom Brand: American College of Physicians

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Here is the classic pocket guide to drug-dosing for patients with impaired renal function in a revised and updated New Edition! Easy-to-read tables put the information physicians need when determining dosages for more than 450 drugs at their fingertips. Plus, this New Edition features brand-new guidance on pediatric dosing, making it the most complete resource of its kind.

• Sales Rank: #168380 in Books
• Brand: Brand: American College of Physicians
• Published on: 2007-06-06
• Original language: English
• Number of items: 1
• Dimensions: 8.25" h x .69" w x 4.94" l, .74 pounds
• Binding: Paperback
• 272 pages

Features

• Used Book in Good Condition

Most helpful customer reviews

8 of 8 people found the following review helpful.
Update Much Appreciated. Loses some efficiency as a pocket reference.
By Quadradox
Several features in Edition 5 are welcomed, these were on my wish list.

1. Expanded information about metabolism and excretion. Numerous entries do include limited details on P450 enzyme systems and the bibliography at the end gives references which could provide more specific data.
2. Percent plasma binding & volume of distribution are still given, these do help with predicting dialyzability of meds or anticipating difficulties in patients with large BSAs.
3. More supplementation guidelines are provided for intermittent hemodialysis, CRRT and PD when known.
4. There is, in fact, a mobile version for Palm, Blackberry, PocketPC, Tablet PC, Laptops and Desktops available through [...] and called RFDrugs which I have not yet explored.
5. Also I appreciate the consistent and concise categorization of CrCl (>50, 10-50 and 6. Where specific side-effects are more likely in renal patients, these are frequently highlighted as well.
7. A new pediatric section. In my training, this would have been useful though I have less practical need for it now.

SKEPTICISMS:

Unfortunately several years of experience do not bear out for me the range of dosages listed for persons with renal insufficiency for nonsteroidal drugs nor for the narcotics. I am not sure why these continue to be listed so generously -- pharmacologic clearance studies separated from the whole person might lead to these predictions and should not be trusted readily. Caution, close observation, starting with low doses and titrating to least effective dose, and supplementing with other nonpharmacologic practices such as temperature, physical manipulation and therapy, acupuncture, etc are long standing principles for these particular drugs that still have major merit in renal patients. My experience is that patients with renal insufficiency frequently also have other co-morbidities such has diabetic gastroparesis, autonomic neuropathy, sleep apnea, liver compromise, interactions amount many entities on their very long med lists, and cerebral and renal vascular disease, etc. which result in relatively poor tolerance or no tolerance of any NSAIDS except 81 mg of aspirin per day, and a very limited therapeutic window for narcotics. I strongly suspect that the clearance studies were obtained in controlled setting in which the subjects were likely to only be on the study drug or a limited number of non-interfering drugs -- unfortunately not simulating the profound and sometimes necessary polypharmacy occurring in chronic renal patients. Thus, I would not leave these potentially life-threatening issues to pharmaceutical industry/manufacturer's claims in their product data sheets or to any textbook/reference alone. Rescuing hyperkalemia, apneic breathing, profound constipation/bowel obstruction/perforation and blood pressure too low to maintain adequate renal perfusion in someone wishing to not be on dialysis -- these seem a bit higher priority than is addressed here. I do understand and obviously have seen that people with normal kidneys and livers seem to be able to develop tolerance to massive amount of narcotics -- my reality is that this tolerance at times is much slower, much less impressive and sometimes never develops in my renal patients.

There may be other pharmaceutical categories that likewise should be started at lower doses than indicated here, as well. I unfortunately don't see a discrimination between potential initiation doses and chronic doses which might have been more helpful. For example, the first initiation dose for a narcotic in a patient presenting with acute pain who has renal insufficiency may be appropriately given a higher dose -- as no accumulation has yet occurred. The issue is the prolonged action, not all of which is predicted by drug clearance of the major metabolite -- there are minor metabolites, depletion of metabolic enzymes, changes in organ level function which may not bounce back as readily as the metabolite is claimed to clear, progressive hypoventilation in patients iwht sleep apnea, etc. Obviously the practitioner needs to make direct observation and take the safety of their patient very seriously regardless of the fact that higher doses might be "authorized" in this reference.

WISHES FOR THE NEXT UPDATE:
In order to keep the book small, concise and better for the coat pockets, I would reccommend the authors provide a website where corrections, updates, additions between formal revisions and specific drug-related commentary regarding issues noted in practice by the users of the book can be viewed by authorized purchasers. This would be an appropriate place to list the very extensive bibliography which currently takes up 30% of the pages of the book, even though it contains straightforward reference citations without annotations. Many college textbook companies now provide websites for supplemental information such as this and the ACP could probably do so very easily as well.

Fellows, hospitalists, nephrology offices and dialysis units would all be benefitted by having this reference readily available.

1 of 1 people found the following review helpful.
LMWH and bisphosphonates
By K. Stille
Certainly a very useful book and I am glad that it is available!
I would like to mention two points though that have disappointed me.
- Bisphosphonates, useful in some areas of nephrology, are not mentioned at all.
- The guidance on low-molecular-weight heparins (LMWH) is too short. The article listed in the bibliography section does not support the recommendations in the book. There are differences in the use of LMWH in renal impairment amongst the different preparations available. This is not noted at all.

1 of 3 people found the following review helpful.
dosing drugs in CKD
By Matias E. Abuchanab
Complete and specific information about drug prescribing in renal failure. Dosing for adults and pediatrics. A source of information to trust. The information includes supplementation for dialysis. All in pocket size.

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