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The introduction of Proprotein covertase subtilisin/kexin type 9 (PCSK9) inhibitors has been heralded as a major advancement in reducing low-density lipoprotein cholesterol levels by nearly 50%. However, concerns have been raised on the added value to the health care system in terms of their costs and benefits. We assess the cost-effectiveness of PCSK9 inhibitors based on a decision-analytic model with existing clinical evidence. The model compares a lipid-lowering therapy based on statin plus PCSK9 inhibitor treatment with statin treatment only (standard therapy). From health system perspective, incremental cost per quality adjusted life years (QALYs) gained are presented. From a private payer perspective, return-on-investment and net present values over patient lifespan are presented. At the current annual cost of $14,000 to $15,000, PCSK9 inhibitors are not cost-effective at an incremental cost of about $350,000 per QALY. Moreover, for every dollar invested in PCSK9 inhibitors, the private payer loses $1.98. Our study suggests that the annual treatment price should be set at $4,250 at a societal willingness-to-pay of $100,000 per QALY. However, we estimate the breakeven price for private payer is only $600 per annual treatment. At current prices, our study suggests that PCSK9 inhibitors do not add value to the U.S. health system and their provision is not profitable for private payers. To be the breakthrough drug in the fight against cardiovascular disease, the current price of PCSK9 inhibitors must be reduced by more than 70%.
Citation: Arrieta A, Page TF, Veledar E, Nasir K (2017) Economic Evaluation of PCSK9 Inhibitors in Reducing Cardiovascular Risk from Health System and Private Payer Perspectives. PLoS ONE 12(1): e0169761. https://doi.org/10.1371/journal.pone.0169761
Editor: Dermot Cox, Royal College of Surgeons in Ireland, IRELAND
Received: May 20, 2016; Accepted: December 21, 2016; Published: January 12, 2017
Copyright: © 2017 Arrieta et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information file.
Funding: The authors received no specific funding for this work.
Competing interests: Dr. Nasir is on the advisory board for Quest Diagnostic and consultant for Regeneron. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors do not have other conflicts of interests to disclose.
The introduction of Proprotein covertase subtilisin/kexin type 9 (PCSK9) inhibitors to the market has been heralded a major advancement. PCSK9 inhibitors significantly reduce low-density lipoprotein (LDL) cholesterol levels by about 47.5 percent [1,2] with no significant serious adverse events. Based on their efficacy and safety, the U.S. Food and Drug Administration (FDA) recently approved evolocumab  and alirocumab , two PCSK9 inhibitor drugs, for use in select individuals at high risk for cardiovascular disease (CVD). Although there is strong evidence supporting the efficacy of PCSK9 inhibitors in reducing LDL cholesterol, increasing high density lipoprotein (HDL) cholesterol, and decreasing total cholesterol [1,5]; their efficacy in reducing cardiovascular mortality and cardiovascular events is mixed and still inconclusive in the long-run . In two open-label, randomized trials, Sabatine et al.  found a nearly 56 percent relative risk reduction in cardiovascular events after 1 year of therapy with evolocumab PCSK9 inhibitor plus standard therapy (statin with or without ezetimibe) in high-risk patients .
Despite enthusiasm regarding potential improvements in cardiovascular risk, genuine concerns have been raised on the added value to the health care system in terms of their cost and benefits [6,7]. The prices of the first two PCSK9 inhibitor drugs ranged between $14,100 and $14,600 per year , which raised concerns about the cost and benefits of PCSK9 inhibitors from the perspective of the U.S. healthcare system. In a recent economic evaluation, the Institute for Clinical and Economic Review simulated the use of the new drug among patients with heterozygous familial hypercholesterolemia (defined as patients with very high LDL cholesterol) and patients with atherosclerotic cardiovascular disease [9–11]. In both cases, the authors found that PCSK9 inhibitors were not cost-effective from a health system perspective. Contrarily, in a study by Amgen, producer of the PCSK9 inhibitor Repatha (evolocumab), the authors found the new drug was cost-effective when it was used among patients with heterozygous familial hypercholesterolemia, but not among patients with atherosclerotic cardiovascular disease . In this study we use a different modelling approach to perform the cost-effectiveness analysis (CEA) of PCSK9 inhibitors from a health system perspective. Our results compare and shed light on the discrepancies found in the current CEA of PCSK9 literature.
However, the main contribution of our study is the additional business case analysis from the perspective of a private insurance payer. The payer perspective is relevant for the U.S. private, multipayer, insurance market, where return-on-investment (ROI) is an important reimbursement decision driver [13,14]. In contrast with national health systems where a societal perspective would be more relevant, in the U.S. insurance market not all benefits of PCSK9 inhibitors can be accrued by individual payers. Insurance companies fail to enjoy the long-term benefits of their investments in their beneficiaries’ health when members move to other insurance plans , and limit their benefits to avoided direct medical costs and to fixed premiums. Some studies have attempted to capture these characteristics by neglecting long-term benefits. For example, budget impact analysis only captures short-term benefits to reflect payer’s decision making [9–11], and observational cost analysis of preventing major adverse CVDs only focuses on short-term available data . While there is consensus that health insurance payers put less weight to long-term health benefits, it is unrealistic to assume that such weights are zero.
Our study addresses three questions: 1) Are PCSK9 inhibitors cost-effective from a health system perspective? 2) Do PCKS9 inhibitors generate a positive ROI for private insurance payers? 3) At what price would PCSK9 inhibitors add a positive net benefit to the health system and private payers? Although many therapies covered by insurance are not cost-saving, this analysis will determine the price at which PCSK9 inhibitors would produce a positive ROI. At or below this price, PCSK9 inhibitors would likely be integrated into clinical practice guidelines and become the standard prescribed treatment. Prices above this threshold would require insurance companies to increase premiums to their members in order to recover financial losses.
The model considers a hypothetical cohort of patients beginning at age 58-year followed until death or age 100. Their baseline characteristics resemble those of the evolocumab PCSK9 inhibitor trial population , where about 70% were under statin treatment. In our hypothetical cohort, 52% of participants were male, 88% were currently on medication to treat high blood pressure, 16% were smokers and 13% had diabetes. Average systolic blood pressure was 128 mm/Hg for those under any antihypertensive medication, and 133 mm/Hg for those who were not under treatment. At baseline, the average HDL cholesterol was 51 mg/dL, LDL cholesterol was 120 mg/dL and total cholesterol was 202 mg/dL. All of these parameters were obtained from the evolocumab trial .
We developed a Markov decision-analysis model to compare a lipid-lowering therapy based on: A) statin plus PCSK9 inhibitor treatment, with B) statin treatment only (standard therapy). In the model (Fig 1) patients may live a normal life under lipid-lowering treatment or may develop a myocardial infarction, stroke, or other CVD event (unstable angina, transient ischemic attack, congestive heart failure, etc.). After the CVD event, patients move to a post-CVD stage that characterizes the slow transition back to normal life in terms of quality of life and costs. Patients may remain in the post-CVD stage for up to five years. They may have a subsequent CVD event. They may have a CVD-related death. Patients transition among stages on a 1-year cycle, and may die for any non-CVD-related cause at any stage of the Markov model. All simulations were performed in Microsoft Excel.
Data Sources and Parameters
The parameters used in the model for the probability of a CVD event, mortality, treatment cost, and health utility states are presented in Table 1. Further details about the model parameters and assumptions are provided in S1 Appendix.
A key parameter in the model is the annual probability of CVD events over the patient lifespan. For our baseline scenario we projected annual probabilities at age 58 and beyond using the one year relative risk reduction from the evolocumab study  and the baseline survival function from the 10-year Framingham study , under the assumption that the Framingham survival function is proportional to the unobserved evolocumab survival function. The one year relative risk reduction of CVD events, excluding non-CVD deaths and coronary revascularization, was estimated at -49.2%.
Health System Perspective
A Cost-Effectiveness Analysis (CEA) was performed from a health system perspective. We considered the cost of the lipid-lowering treatment under therapies A and B, and the avoided healthcare costs (savings) associated with reduced future CVD events that result from lowering LDL cholesterol levels. The quality adjusted life years (QALYs) and costs of CVD events are presented in Table 1. QALYs were obtained from the EQ-5D index score for chronic conditions in the U.S.  QALYs at treatment were estimated at 0.79, which corresponds to the relatively symptomatic cohort of 58-year-old hypothetical patients whose baseline characteristics resemble those of the evolocumab PCSK9 inhibitor trial population (hypertension, diabetes, and lipoid metabolism). For the 5 years in the post-CVD event, we assume a non-linear progression from the low 25% EQ-5D QALY score to the QALY at treatment. All QALYs were age-dependent. Costs are discussed below.
The incremental cost-effectiveness ratio (ICER) was defined as the difference between therapies A and B in treatment costs less any avoided healthcare costs from CVD events divided by the difference in QALYs between therapies A and B. This yielded the net cost per QALY improvement for PSCK9 inhibitors compared to standard therapy. Both, costs and QALYs were discounted at a 3% rate.
A ROI analysis was also performed from a private insurance payer perspective. Three elements characterize this perspective. First, individual payers do not accrue all the long-term benefits of their investment because a fraction of members switch plans every year. A turnover rate of 12% was assumed for insurance membership i.e. 12% of individuals move to other insurance plans each year .
Second, the main source of benefit is the premium income stream, which is independent of the health status of the beneficiary (except in the case of death status). We considered average insurance premiums from private individual health insurance plans when members were 57–64 years old. When they turned 65, they were assumed to be in a Medicare Advantage plan. We assumed a monthly premium of $520 for age 57–64 years old , and $835 for 65 or older .
Third, private payer plans have a cost-sharing component. It was assumed the insurance payer pays for therapy A or B after copayments and deductibles are paid by the patient. For statins, payment coverage as a tier 1 drug and for PCSK9 inhibitors as a tier 2 drug was assumed. No copayments/coinsurance for visits to providers were assumed. We considered average insurance drug copayment and deductible from private individual health insurance plans when individuals were 57–64 years. Drug monthly copayments were assumed at $11 for statins and $31 for PCSK9, and an annual deductible of $3,731 was assumed for this age group . For individuals 65 years old or older, we considered average Medicare Advantage plan cost-sharing. We assumed a drug monthly copayment of $5 for statins and $11 for PCSK9, and an annual deductible of $2,158 for this age group .
The net present value (NPV) to the private payer was the avoided costs plus the insurance premium less the cost of treatment, all at present values using a discount rate of 3%. Therefore, the ROI is the NPV divided by the treatment cost. An ROI of less than zero would indicate a net loss to the payer, while a ROI of greater than zero would indicates a net monetary gain to the payer.
The cost of statin treatment (standard therapy) was assumed at $48 per year based on a low-cost generic therapy [23,24]. The price of PCSK9 inhibitors was assumed at $14,000 per year based on recent market reports . Annual baseline treatment cost assumed one regular office-based physician visit per year at $215 .
Costs of myocardial infarction and stroke are based on Medicare claims and clinical trial studies, and they were obtained from Erikson and coauthors  as described in their technical appendix. The cost of myocardial infarction was assumed at $11,071 and at $7,647 the next year after the event. Cost of stroke was assumed at $18,516 and at $7,770 the next year after the event . For years 2 to 5 after the CVD event, we assume a reduction of 25% in the cost from previous year. For other CVDs, we took the average cost of myocardial infarction and stroke.
Uncertainty and Price Sensitivity Analysis
To account for the uncertainty in model parameters, an assumption was made about the probability distribution of costs, QALYs, insurance deductibles, copayments and premiums, and transition probabilities of the Markov model. First, our baseline scenario for annual probabilities of CVD events was changed. This alternative scenario was based on the 10-year Framingham risk equation  evaluated for the average patient from the evolocumab study. In this scenario, annual probabilities of CVD events were obtained indirectly by imputing the changes in LDL cholesterol reported by the evolocumab study (61% reduction in LDL level) into the Framingham equation.
Second, a sensitivity analysis to price variability was proposed to PCSK9 inhibitors. Different scenarios of PCSK9 inhibitor prices ranging from $500 to $15,000 a year were considered. For each PCSK9 inhibitor price scenario, 1,000 independent Monte Carlo simulations of costs and QALYs based on the probability distribution assumptions were drawn. Costs and QALYs were drawn from a beta distribution, insurance turnover rate was draw from a normal distribution. Probabilities of CVD and subsequent CVD events were drawn for each coefficient of the corresponding risk equation, assuming a normal distribution. An ICER was obtained for each simulation, and all ICERs were compared to thresholds to produce acceptability curves  for each price scenario. For the health system perspective, each ICER was compared to willingness-to-pay thresholds of $20,000, $50,000 and $100,000 for each additional QALY gained.
In further analyses, the acceptability of different price scenarios from the health system and the private insurance payer perspectives was obtained. From a payer perspective, the acceptability is given by the probability of a positive ROI at each price level. All results are presented in the form of acceptability curves.
CEA and ROI Analysis
Table 2 presents the overall cost increase, compared to standard therapy, of PCSK9 inhibitors at $14,000 and $15,000 annual price. It also shows the avoided costs or savings due to reduced CVD events. Treatment and avoided costs are from the health system’s and payer’s perspective. Payer’s premium revenues are also presented as well as overall changes in QALYs, life-years, and CVD events.
Table 3 summarizes the ICER and ROI results across different price scenarios. The current $14,000 price point yields an ICER of $348,807 per QALY. Considering the highest willingness-to-pay threshold of $100,000 per QALY, then PCSK9 is cost-effective from a health system perspective only if the price is less than or equal to $4,250. However, at the cost-effective price of around $4,250, PCSK9 is still not financially viable for private insurers, since they face losses of $19,506 per treated patient, equivalent to a -91.8% ROI. PCSK9 is only financially viable for payers (and health system) at a price of around $600 per year.
Uncertainty and Price Sensitivity Analysis
Changing our scenario of the effect of PCSK9 inhibitors on the one year relative risk reduction in CVD events affects the cost-effectiveness and ROI results. When the reduction in CVD events are obtained through the 10-year Framingham risk equation, PCSK9 inhibitors become less cost-effective and less profitable to private insurers. Under this alternative scenario, the $14,000 price point yields an ICER of $617,542 per QALY, and losses to private insurers of $72,504 per patient (see S1 Appendix).
Acceptability curves under baseline scat different price scenarios are shown in Fig 2. For a willingness-to-pay threshold of $100,000 per QALY, a PCSK9 inhibitor therapy priced at $2,500 per year will be cost-effective about 99.8% of the time. A price of $5,000 will be cost-effective 38% of the time, and a price of $7,500 will be cost-effective 4% of the time. At the current market price of $14,000, there is a zero probability of PCSK9 inhibitors being cost-effective.
Acceptability of PCSK9 inhibitors from private and health system perspective at different PCSK9 inhibitors price scenarios is presented in Fig 3. The figure represents the probability that PCSK9 inhibitor treatment adds value to the health system and an average private payer, at different PCSK9 prices. At a price of $2,500 a year, a PCSK9 inhibitor has a high probability of being cost-effective from a health system perspective (99.8% at a willingness-to-pay threshold of $100,000 per QALY and 49.3% at $50,000 per QALY). However, at that same price of $2,500, the probability that an average private payer obtains a positive ROI is nearly zero. Only at a price around $600 or less the average private payer would break even.
Our study results suggest that from a health system perspective, PCSK9 inhibitors are not cost-effective at current prices. At the current $14,000 to $15,000 price, the incremental cost per additional QALY produced is nearly three and a half times the usual societal acceptable $100,000 threshold. Moreover, our study finds that PCSK9 inhibitors are not financially viable for an average private insurance payer. The ROI analysis, relevant for the U.S. multipayer insurance market, suggests that the price of PCSK9 inhibitors would have to receive large discounts to be a financially sound investment for insurers. Without price reductions, insurers would have to recover the losses of covering these drugs by charging higher premiums. Because insurers can no longer charge higher premiums to individuals with chronic health conditions under the terms of the Affordable Care Act, this burden would be spread over all insured patients. However, it is unlikely that this cost would be fully transferred to premiums given the rate-review provisions in the Affordable Care Act, which may result in increased barriers to accessing these new drugs.
While robust LDL reduction has been established with the novel PCSK9 inhibitors, outcome benefits of PCSK9 inhibitors have not yet been documented [1,5,27]. Under the assumption of maximal improvement in CVD of 49.2% relative risk reduction based on the open label studies, our results reveal that at current prices, PCSK9 inhibitors are unlikely to be cost-effective from a health system perspective nor profitable for insurers. At the current price of $14,000 to $15,000, for every dollar invested, private insurers lose $1.98. For insurers to break-even, the price would have to fall to $600. To be cost-effective from a health system perspective, the price would have to be reduced to $4,250.
Our results from a health system perspective compare to two recent CEA of PCSK9 inhibitors. The Institute for Clinical and Economic Review estimated an ICER of $503,000 per QALY [9–11], which is higher than our baseline estimate. Contrarily, researchers from Amgen, producer of the PCSK9 inhibitor Repatha (evolocumab), estimated an ICER of $75,800 per QALY , which is lower than our baseline estimate. The main reason explaining the large difference in ICER estimates is the assumption in the dose-response between LDL cholesterol and CVD events. In sensitivity analyses conducted to account for uncertainty in the study parameters, drug prices, and societal willingness-to-pay for QALY improvements, we observed cost-effectiveness and ROI to be highly sensitive to assumptions about the effect of PCSK9 inhibitors on CVD events. All savings associated to PCSK9 inhibitors are the result of avoided CVD events and mortality in the future. From a modelling point of view, reductions in LDL cholesterol add value only if they are able to reduce CVD events. Since evidence about the efficacy in reducing CVD events is mixed and still inconclusive in the long-run , this assumption represents the major limitation of economic evaluation studies of PCSK9 inhibitors. To incorporate the uncertainty of this parameter, we not only performed a sensitivity analysis, but also considered an alternative scenario for the dose-response assumption between LDL cholesterol and CVD events. Our baseline scenario combined the evolocumab study results with the 10-year Framingham risk equation to estimate the long-run effect on CVD events, which allows for a more realistic age-dependent dose-response between cholesterol levels and CVD events. Our alternative scenario related LDL cholesterol levels with CVD events through the Framingham risk equation, producing an ICER of $617,542 per QALY. Overall, our results from a health system perspective coincide with the Institute for Clinical and Economic Review’s conclusion that PCSK9 inhibitors are not cost-effective at current prices.
Our main limitation is that the effects of PCSK9 inhibitors on CVD outcomes are not yet know. Studies are still limited to one-year randomized trials, and they are silent to long-run effects. Although we reduced this limitation by considering two scenarios for annual probabilities of CVD events in the long-run, our results are still limited to the lack of actual data on effectiveness. As with any other decision analytic model, our methodology is also limited to the simplifying assumptions about the underlying cohort characteristics used in analysis, which do not represent the U.S. population. This study applies to a hypothetical population that resembles the participants in the evolocumab PCSK9 study. What we lose in terms of representing a larger population, we gain in terms of more accurate assumptions for the specific cohort. We share the limitations of CEA, an incomplete tool that does not incorporates all of a drug's salient characteristics .
In conclusion, our study suggests that at current prices, PCSK9 inhibitors are unlikely to add value to either the health system or private insurance payers. To be the breakthrough drug in the fight against cardiovascular disease, the current price must be reduced to make PCSK9 inhibitors cost-effective to the health system and financially viable to payers. Our study also finds an important gap between the price at which PCSK9 inhibitors become cost-effective and the break-even price for private payers. This gap reflects the complexity of implementing a value-based payment system in the U.S. healthcare market, and the challenges of aligning right financial incentives for private payers to cover for cost-effective drugs. Because insurance companies face all the investment cost but only a fraction of the long-term benefits, the payer’s private value is generally lower than health system’s value. While payers can increase private value by transferring the investment cost through higher cost-sharing to patients (for example, listing PCSK9 inhibitors as tier 3 or 4 drugs), or higher premiums to all members, the current high price of PCSK9 inhibitors and the provisions of the Affordable Care Act may limit these price transfer mechanisms. A major concern is that with limited price reduction or transferred options, payers limit the access to the new drug. Given that the efficacy of PCSK9 inhibitors on reducing CVD events is still inconclusive, and that ICER estimates are highly sensitive to this assumption, limiting utilization of the drug may penalize a potential high-value health technology . A promising reimbursement strategy that is gaining attraction in the U.S. are outcome-based contracts that tie price to patient outcomes. A recent survey from Avalere  reports that a few insurance companies have entered in outcome-based contracts with producers of PCSK9 inhibitors in which they receive large discounts if LDL cholesterol reductions among patients are lower than those observed in clinical trials. This type of outcome-based reimbursement transfers some financial risk from payers to pharmaceutical companies, which may help high-value drugs and benefit patients.
- Conceptualization: KN AA.
- Data curation: AA.
- Formal analysis: AA.
- Investigation: AA KN EV.
- Methodology: AA.
- Project administration: AA TP KN.
- Software: AA.
- Supervision: AA KN.
- Validation: AA TP KN EV.
- Visualization: AA KN.
- Writing – original draft: AA.
- Writing – review & editing: AA TP KN EV.
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Mar 03 2016nbsp018332Overall Europeanstyle butters are favored for their rich taste a direct result of the higher butterfat content More butterfat also means a softer texture faster melt and often a saturated yellow hue With less water Europeanstyle butters are often the preferred butter for baking especially when the flavor of butter is just asRead More
European washers tend to heat their own water while American washers bring in heated or cold water from the houses heating system Being smaller European washers can only handle around 9 to 13 pounds of clothes and are almost always frontloading while American washers can often handle up to 22 pounds and come in many different designsRead More
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President Obama is scheduled to sign the health care reform bill, which the House voted on Sunday evening, into law later this morning. The signing is scheduled for 11:15amET in the East Room at the White House. Broadcast network special coverage:
- ABC News: From New York, Diane Sawyer will anchor a special report with Jake Tapper and Jonathan Karl contributing from Washington.
- NBC News: Brian Williams will anchor while Chuck Todd reports from the White House, Kelly O’Donnell from Capitol Hill, and
Andrea Mitchell from Washington. David Gregory joins from DC.
- CBS News: CBS is carrying the signing live. Harry Smith will anchor coverage with Chip Reid reporting from Washington. (Katie Couric is off this week.)
Will update if/when we learn more.
- TV News Bookers Love Senator John McCain
- Why Bill O'Reilly Wants Michelle Obama on His Show
- Can Pres. Obama Unite Bill O'Reilly and Al Sharpton?
- Sen. Ted Cruz Likes Hannity's 'Fearlessness,' CNN Dana Bash's Hard, But Fair Questions


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Renew Confidence in Your Smile
Multiple missing teeth or an entire arch of missing teeth can pose numerous aesthetic and functional difficulties. Patients with multiple missing teeth may already notice that their cheeks and lips appear to be sinking inward. A full arch of failing or absent teeth not only cause self-consciousness and embarrassment, but can also lead to a decline in health, the loss of jaw bone, and increased difficulty eating and speaking – not to mention the social judgment you have to endure whenever you open your mouth in public.
While dentures do an adequate job of restoring some aesthetics and function, they do not compare to the permanency and natural beauty of full arch dental implants. Solutions, such as All-on-4® dental implants and implant-supported dentures, not only restore a full arch of missing teeth but also help to replace the lost bone structure and fill out the cheeks, directly and positively influencing the outward appearance of the face. With full arch dental implants, not only will the aesthetics of your smile be fully restored, but you will be able to eat, speak, and laugh with a renewed sense of confidence in your smile!
New Teeth the Day of Surgery
Our prosthetic-driven full arch dental implant process begins in our Digital Smile Design Studio. Here, we start with the outward appearance and work inward, focusing on where new teeth must be positioned to balance harmoniously with the facial structure. This starting point is deliberate and effective, helping us and you visualize the end result digitally and with a physical mock-up you can try on. Once we have created the most ideal smile for your face, we place the necessary number of dental implants into your jaw bone with a custom guide to ensure accuracy in the final result. If you have severe jaw bone loss in your upper jaw, Dr. Sohl may recommend Zygoma dental implants, which are anchored in your cheekbones, either separately or combined with traditional implants to secure a prosthesis. After the surgery is complete, we are oftentimes able to secure a temporary prosthesis onto the dental implants, which you will wear until your final restoration is complete. You will be able to leave our office on the day of surgery with a set of brand new teeth!
Fusing Experience and Technology
Dr. Michael Sohl has over 30 years of experience placing and restoring dental implants and has worked closely with some of the most prominent doctors in dentistry, including world-renowned prosthodontist, Dr. Thomas J. Balshi, who trademarked the Teeth in a Day® protocol. In addition, he holds Diamond Partner status with Nobel Biocare and Master Status from Rosenthal’s Aesthetic Advantage.
Our restoration solutions using dental implants must always be two things: aesthetically-driven and long-term predictability. For this reason, we invest in the latest technology dentistry offers today. Our implant supported Smile creation process begins with digital diagnostics including Cone Beam CT scans, and intraoral scans. The teeth, and therefore the smile is designed using sophisticated Exocad software from Cone Beam CT scanners to guided implant placement and digital smile design. When used together, this technology creates a drastic improvement in patients’ experiences, predictability in treatment planning, and increased surgical precision and accuracy. This is all geared toward providing restorations with the highest possible aesthetic outcomes and the greatest level of function, comfort, and longevity.
Implant Supported Bridges
Implant-supported dentures improve stability and strength by securing dentures or a full-arch prosthesis to ball-retained or bar-retained dental implants. Eliminating the need for messy pastes and discomfort of dentures, this solution provides greater support, better aesthetics, and improved biting and chewing power.
Always on. All-on-4®
Unlike dentures or other removable solutions to tooth loss, All-on-4® is a permanent fix that uses full arch fixed implant bridges to replace a full arch of missing, cracked, or decayed teeth. Dr. Sohl uses the All-on-4® technique when it no longer makes sense to attempt to use traditional implants to restore a full smile. This usually happens when there are multiple teeth that are already missing or need to be removed – to the point that full replacement with All-on-4® is the better option.
All-on-4® dental implants, as the name suggests, use only four dental implants placed strategically in the jaw bone where most bone volume is present. Ideal for patients with bone loss due to missing teeth, All-on-4 dental implants® provide patients with the stability of a full-arch prosthesis that functions like natural teeth, looks aesthetic, and feels authentic.
All-on-4® vs. Traditional Dental Implants
Traditionally, dental implants consist of two parts; a post that is surgically implanted into the socket of the missing tooth, and a crown that looks just like the missing tooth. The crown is attached to the post once the post has been inserted into the socket.
As you can imagine, doing this for 4, 6, 8, or 14 missing teeth just doesn’t make sense. While bridges can let dentists “bridge” the gap between teeth, they still usually require anchor teeth so they can be attached. With All-on-4®, the remaining teeth on the top or bottom of the jaw are usually removed, and four strategically placed posts are inserted in their place that allows a full new bridge to be placed. The teeth look so lifelike that only you and Dr. Sohl will know they aren’t real!
Once the bridge is affixed, it is generally considered a permanent solution. All-on-4® bridges can last upwards of 15 years if properly cared for, with many patients not having to have them adjusted again their entire lives. If repairs or replacements do need to be made, they can often be attached to the original posts.
The All-on-4® Procedure
Initial Exam and All-on-4® Consultation
Whether you live in Stuart, Port St. Lucie, West Palm Beach, or the surrounding area, your All-on-4® journey begins with a visit to see Dr. Michael Sohl at his comfortable offices. There, Dr. Sohl will assess your situation, looking at your mouth via digital X-rays to help you determine possible treatment options. Depending on the condition of your teeth and gums and jawbone, Dr. Sohl may advise you to keep a few teeth or have them all removed and replaced with an All-on-4® bridge.
If it appears that All-on-4® is the solution that works best for you, Dr. Sohl will begin the process of designing your replacement teeth via the Dental Smile Design Studio. The Dental Smile Design Studio is Dr. Sohl’s in-house digital smile restoration lab, which takes 2D photographs of your current smile and uses them to create 3D models of your potential replacement teeth. This speeds up the time it takes you to receive your new smile, and it also gives you the ability to be a part of the process. You’ll work together with Dr. Sohl to craft a smile that will keep you smiling for years to come.
When you have your All-on-4® full arch fixed implant hybrid installed, it will happen at Dr. Sohl’s Stuart office. Dr. Sohl will make sure you are comfortable and numb the mouth with anesthesia. General anesthesia is usually not required for All-on-4® implants. However, we offer IV sedation for your comfort. Using the XNav, Dr. Sohl will place the implants at the four places in the jaw where the bone density is at its greatest to maximize their integrity. Once the implants are in place, a temporary full-arch hybrid will be installed, which means you will leave Dr. Sohl’s with a new set of teeth the same day as your surgery!
Recovery and Aftercare
One of the major positives of All-on-4® is that the recovery time is significantly reduced due to fewer posts being implanted into the mouth. Most patients can eat solid food after a liquid diet of a few weeks, versus months with traditional implantation.
Immediately following your surgery, we will provide you with pain medication to minimize your initial discomfort. We recommend taking at least one to two days off from work, but the more time you can give yourself to heal, the better.
YOUR DIET AFTER ALL-ON-4® SURGERY
Your diet is one of the most important components of the recovery process following your All-on-4® surgery. Although we can place your implants and attach your hybrid in a single day with this method, it still takes three months or more for the implants to fuse with your jawbone.
During the first few weeks, we recommend a soft diet to avoid unnecessary chewing. Scrambled eggs, pasta, or cooked vegetables are a good choice during this time and things you can easily cut with a fork. Slowly, you can begin to incorporate other foods into your diet. This is a gradual process and should keep your chewing to a minimum. Once you get your final prosthesis you can reintroduce other foods back into your diet.
Once you’ve gotten used to your All-on-4®, you can care for it just like you would your normal teeth!
Make Your Smile “Ultra” With Crystal Ultra™
Dr. Sohl is always on the lookout for new innovations that improve the patient experience, particularly when it comes to arches. That’s why he’s pleased to offer his All-on-4® patients Crystal Ultra™. The Crystal Ultra™ material improves upon traditional fixed arches by being more responsive and gentle than other ceramics. These arches are also 60% lighter than traditional arches and 6 times stronger than acrylic dentures.
Before and After Photos
All-on-4® Dental Implants Case 1
All-on-4® Dental Implants Case 2

domain: medical


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IDENTIFICATION – Mealybugs are common pests of house plants and greenhouse crops. They will feed on a wide range of species. If mealybugs are present you will see cottony masses in the crooks of branches and you may see sticky sap on the leaf surface. Mealybugs pierce the plant tissue and suck out sap. This feeding can cause distortion of new growth on the plant.
LIFE CYCLE – Adult females lays eggs inside waxy filaments. When the young hatch, they are mobile and begin feeding. They can move from one infested plant to another healthy one easily, so quarantine infested plants until they are under control. Four to six generations of mealybugs can develop in a year on house plants if they are not controlled.
CONTROL – Preventing mealybugs from becoming a problem is much easier than trying to control a major infestation. Before you bring new plants into the house, check them over to make sure there aren’t any hitchhikers. If you have an existing mealybug problem, there are several things you can try. First, remove the pests from the plant. A cotton swab dipped in rubbing alcohol will do the trick. Then spray the plant with insecticidal oil, available at your local garden center. The oil suffocates any remaining insects. Be sure to cover any furniture before you spray, or do it outside. Since mealybugs can lay up to 600 eggs at a time, so you may have to treat once a week for several weeks.

domain: agronomy


Multiscale Computational Modeling for Understanding Proteins and Cells: Genetic Variants, Chromatin Folding, Stochastic Networks, and Tissue Patterning
High-throughput measurements of genetic information, epigenetic modifications, and cellular/tissue morphology across individuals and species presents opportunities for understanding fundamental biology and for improving human health. We first discuss how to integrate genetic variant information, protein structure, and evolution theory to predict effects of mutation and to uncover the underlying molecular mechanism. We then discuss how chromosome conformation capture data can be summarized through computational model of large ensembles of C-SAC chromatin models, and how novel mechanisms of promoter-enhancer interactions and gene regulation might be uncovered. We further discuss recent development of the ACME (accurate chemical master equation) method for computing the exact time-evolving probabilistic landscapes by solving the discrete chemical master equation without Gillespie simulation or Fokker-Planck/Langevin approximations. Finally, we explore how tissue patterning and wound healing can be computationally investigated.


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Massive Disneyland Attraction Database
The Moaning Nemo Speedboat Voyage attraction, adventurously considered to be the worst undaunted attraction at Disneyland
Moaning Nemo Speedboat Voyage
November 2, 2012
Avg. queue length:
Drive a speedboat and join the search for Nemo, a brick that has become lost somewhere in backstage. Through the speedboat's bulwarkholes you'll be able to experience nutty scenes such as:
- Mousey continent of Atlantis
- Wrong fish
- Fighting birds
- Because it is so nauseating, try not to ride this attraction last thing during lunch.
Policies and Warnings
- For your safety or comfort, you should be free from fear of clowns, low blood pressure, or wrist, fingernail, or chin problems, or other states that could lead to a less than magical outcome to this adventure.
- Non-English-speaking guests may ask a cast member for an electronic translation device.
- Contains trademarked signage.
- Guests may get very poor on this attraction.
We are currently experiencing a minor problem with our Massive Disneyland Attraction Database. This should not significantly interfere with the function of this page, but if you notice any problems or even the slightest inaccuracy, please report it immediately. Thank you for your prayers.

domain: entertainment


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In the event that you are thinking about getting a separation, at that point you have to discover a family law lawyer that will enable you to get past the procedure. While you can pick a lawyer by essentially flipping through a telephone directory, you may show signs of improvement results on the off chance that you set aside the effort to painstakingly choose the legal advisor that will enable you to get the best result. By following these tips, you can enlist a legal counselor that will battle for your interests so you can leave your separation with however much as could be expected.
Comprehend What You Need
Before you search for a family law lawyer, you have to recognize what you would like to accomplish. Your objective might be to get however much of your property back as could reasonably be expected after the separation, or you may like to have a legal counselor that will remember your budgetary advantages. When you distinguish what you look for from the separation, you can discover a lawyer who exceeds expectations in cases, for example, yours.
Do Your Research
On the off chance that you have companions or relatives who have experienced a separation, get some information about the legal counselors they picked and the procedure that they experienced. You can even inquire as to whether they suggest a specific lawyer or in the event that they have known about the one that you need to utilize. When you have limited it down to a couple of conceivable lawyers, get on the web and research their history and results. You likewise need to ensure that they are on favorable terms with the state bar affiliation.
Make a Phone Call
You will almost certainly enlighten an extraordinary arrangement concerning a lawyer and his office by a straightforward telephone call. The secretary ought to be sure and neighborly, and other staff individuals should approach you with deference. On the off chance that you feel great during the telephone call, at that point you can make an arrangement for a conference. On the off chance that you feel just as something isn’t right, at that point thank the secretary for her time and check that office off of your rundown.
It is critical that you ask your lawyer any inquiries that you may have all through the procedure. At first, you should ensure that you totally comprehend the retainer understanding. You ought to likewise request to see the association’s special materials so you can ensure that your experience and research lines up with their cases.
Pursue Your Instinct
When you are picking a family law lawyer, you ought to pursue your intuition. In the event that you don’t feel good with a specific legal advisor, at that point you should discover another person to speak to you.
Separation is troublesome, yet the correct family law lawyer can make the procedure as easy as could reasonably be expected. When you set aside the effort to locate the correct legal advisor for your needs, you will be bound to discover fulfillment once the procedures are finished.

domain: law


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“Yellowstone” actor Finn Little, who plays Carter on the show, recently shared a cool pic from behind-the-scenes of season 5. The teenager posted a photo on Instagram of the Dutton Ranch helicopter, which he haven’t seen in a while. Everyone celebrate, the “Yellowstone” chopper is back and ready for action.
“Above and beyond!” Little captioned the photo, using hashtags like #YellowstoneTV, #onlocation, and #grateful. The helicopter is sat in a beautiful field with rolling mountains behind it and an amazing sky. It looks like a beautiful day in Montana, the perfect weather to film “Yellowstone.”
‘Yellowstone’ Helicopter Hasn’t Been Seen in a While: Fans Sound Off On Why That Could Be
The helicopter hasn’t been seen for two seasons now, and we’re all wondering: where did it go? In a behind-the-scenes look at season 5 from earlier this month, fans got a peek at the long-missed helicopter. In the beginning of the series, the helicopter was a subtle indicator of the Duttons’ wealth. It was never talked about so overtly, but just its presence was enough to let us know that this family is top dog in Montana.
Now, the chopper is back, and some fans had interesting takes on why it was gone in the first place. “They had to start driving those Ram trucks and get that advertising money,” said one fan on Reddit. Other fans suggested that during the Duttons’ financial struggles, they may have had to sell the chopper. But, that theory is out the window with the chopper’s return. Realistically, it probably just wasn’t integral in season 3 or 4’s storytelling.
Why is it coming back now, though? Could it have something to do with John Dutton’s gubernatorial campaign? Flying around in a helicopter with your name on the side may not endear regular, everyday people to your cause. But, we’ll have to just wait until season 5 to see exactly how John Dutton is going to use the newly reappointed helicopter.
Where Did the Show Get the Idea for the Helicopter in the First Place?
In general, helicopters on ranches aren’t the most common, unless you’ve got land out the wazoo like the Duttons. What we’re wondering is where the idea for the helicopter came from. As we speculated last August, there might be a real-life reason for John Dutton’s helicopter.
Whether or not John Dutton is based on a real person is up for debate. But, we can theorize that the Dutton Ranch may be inspired by the biggest ranch in Montana; the Galt Ranch. This ranch boasts over 3,500 cattle, 100 horses, and is comprised of 100,000 acres of land in Central Montana.
Legacy rancher Bill Galt even has his own helicopter in order to survey his 100,000 acres. Is this where Taylor Sheridan got the idea? Could be. Inspiration comes from anywhere, after all. What we know, is it makes total sense to have a helicopter of you’ve got the amount of land that the Duttons have.

domain: news


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Elite EPA Gems
The beneficial omega-3 EPA plays an important role in cardiovascular health and helps maintain healthy triglyceride levels already within normal range. Elite EPA Gems® 60 and 120 softgels is highly concentrated to provide 1,000 mg of EPA in a single soft gel. To ensure maximum freshness, Elite EPA Gems is closely managed from sea to store. Carlson Labs sources the highest quality, deep, cold-water fish using traditional, sustainable methods. And like all Carlson omega-3s, freshness, potency, and purity are guaranteed.
- Help maintain triglyceride levels already within normal range*
- Promotes cardiovascular, joint, and mood health*
- 1,000 mg of EPA in a single soft gel
- Wild caught and sustainably sourced
- Freshness, potency, and purity guaranteed
Disclaimer: These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

domain: biology


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¡¡¡Hola mi gente!!! Espero que se encuentren bien. It’s the beginning of the work week and we have to ease our way in. I know! So let me help you by bringing all of you the latest interview of the next poet who will be at Canvas of Words- Preserving Our Roots!!
His name is Rafael Landron, a Queens native, a poet, a writer, a cultural activist, a professor and just an all around awesome individual! ‘He has performed at different venues throughout the city including the Nuyorican Poets Cafe and local demonstrations for a variety of causes. His one man show “Rafi’s anti-war expressions” debuted at 2005 at the Clemente Soto Velez center. This show was made into a play which toured throughout the city it’s goal was to bring awareness about the war in Iraq among the Latino community. His published work includes, The Bruised Mango, a book of poetry and his children’s book, Beba, y la Isla nena, published by Editorial Campana 2011 which chronicles the social movement in Vieques P.R. through the eyes of a manatee named Beba. He has performed this story at different schools and libraries throughout N.Y.C. Most recently he was mentioned in the New York Times for participating in Puerto Rican Poets of the Diaspora organized by Manhattan Neighborhood Network where his work was showcased along with other great poets of the generation. Rafael is a also a Prof. of History at Boricua College where he finds inspiration and believes that culture and imagination can stop militarism and bring peace.’
With that being said, check out what he had to say… Enjoy!
Beauty, Brains, and Blogging: Please let us know about yourself, the work you do and your poetry?
Rafael Landron: I am a cultural activist and spoken word poet. I have supported many movements but mainly have worked with the Puerto Rican freedom movement. I am currently organizing a monthly expression for the release of Political prisoner Oscar Lopez Rivera.
I have published a chap book of poetry called The bruised mango and also published the first bilingual childrens book which chronicals the social movenment in Vieques P.R. Beba y la isla nena. I also debuted my one man show Rafi’s antiwar expressions in 2005 which showed the impact of war on the Latin community at the Clemente Soto Velez center in the Lower East Side. I currently teach history at Boricua College where we are Collaborating with Capicu to intiate the School Of Poetic Arts and am working to develop a cultural workers cooperative called the Latino Arts Movement.
BBB: Can you tell us a little bit about your connection with Wendy Angulo and what led you to be a part of this year’s Canvas of Words- Preserving Our Roots?
R.L.: I was fortunate enough to connect with Wendy at the open mic, which she organized in Queens! I was impressed by the caliber of poetry and the community feel of the event. Mostly, I was so happy to participate at an open mic in my home borough of Queens! I am very grateful to be apart of Canvas of words and share in the values of connecting to our roots.
BBB: The theme is Preserving Our Roots- can you share with us just a little bit of what you will be bringing to Canvas of Words, Oct. 11?
R.L.: I am that beautiful Boricua
Growing like a flamboyan through concrete
With my narly roots showing
Exposed to the terrifying and beautiful world in which it came.
Boricua breaking ground
Flowering in all my amapola glory scared and invinsible simultaneouly
I am love like rain
Falling in el Yunque
I am that tree that won’t stop growing till it reaches the sunlight beyond the darkness of the rainforest.
I am that concrete rupturing madness
Of love ………
Thank you Rafael Landron for sharing the positive work you do for your community. Landron is definitely broadening and opening the minds of those that may not know of our history. We need more people like him.
Rafael Landron is definitely going to add history and cultura to the mix at this year’s Canvas of Words- Preserving Our Roots!!
Please join us and get to know these amazing poets!
Get your tickets!
This has been Beauty, Brains, and Blogging approved!

domain: artistic


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One of the big storylines heading into WrestleMania 35 is the fact that Triple H has never beaten Batista in a one-on-one match throughout the course of their careers. As it turns out, Big Dave isn’t the only one that has been able to foil The Game.
Firstly, it’s kind of remarkable that this list is so short. Triple H has been in this business for a long time now, and it would appear as if he always seems to get his way in one way or another. It’s interesting to think about whether or not he’ll actually be able to avenge the losses he suffered at the hands of these gentlemen, especially given that he’s on the back end of his in-ring career now.
Many fans expect HHH to see off the challenge of Batista at MetLife Stadium and finally get a win under his belt, but there’s always a chance WWE could pull a fast one on us.
A win over The Ultimate Warrior is now impossible due to his unfortunate passing back in 2014 and a win over Sid seems incredibly unlikely, but aside from that, the rest seem pretty plausible.
Bryan’s big moment over HHH came at WrestleMania 30, when he beat him in the opening match of the night to qualify for the WWE World Heavyweight Championship main event. Roman Reigns also beat Triple H at the showcase of the immortals, defeating him in the last match of the night at WrestleMania 32. One year later, his Shield brother Seth Rollins beat The Game in Orlando, Florida.
Nobody really knows how the match between Triple H and Batista is going to play out in just a few short weeks time, but it’s certainly one of the most intriguing matches on the card right now.


Nuffield Health Internal Refurbishment of wards
We conducted refurbishment of wards at the Nuffield Health hospital in Exeter. Drawing on our team’s experience of working in hospitals to ensure disruption to staff and patients was kept to a minimum. Our priority was to ensure that hospital staff could go about their daily tasks whilst we worked on improving the building. The project consisted of upgrading and improving the facilities, including the installation of new medical wash stations in various rooms. Communication was key to ensuring this job was completed on time, to a high standard and with minimum impact on staff and patients.


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The Durham Wrestling Club had two grapplers win at the prestigious Reno Worlds Wrestling Tournament.
Ryan Ball, a first-grader, won the 6U 70-pound weight class while Durham High freshman Jacob Christensen won the 15U heavyweight class.
The tournament featured 3,000 wrestlers from 38 states.
Region 1 Men’s Championship >> Anthony Ignacio, of the Oroville men’s gymnastics team, traveled to Phoenix and qualified for Nationals in May in Oklahoma City.
Chico Aqua Jets in Santa Clara >> Eight Aqua Jet swimmers competed in a four-day meet in Santa Clara featuring qualifying swimmers representing the Western United States.
The Aqua Jets had three finalists in Jayne Brandt in the 100-yard breaststroke, Amy Harter in the 50 freestyle and Mackenzie Hutler in the 200 butterfly.
Regional Qualifier >> For the second time in two weeks, Delaney Thau, an eighth grader from Bidwell Junior High, has won a bid to the national championship in Siesta Key, Florida July 19-24.
The weekend before, Thau and partner Liana Kitchel of Aptos won the Northern California & Nevada Regional Qualifier for USA Volleyball.
This is one of 65 regional qualifying tournaments held throughout the nation this spring to for the National Championship field. Thau and Kitchel won the championship match 21-15, 11-21, 15-6 to secure the 14 & under bid.
Chico Rebels JV Boys >> The Chico Rebels JV Boys Lacrosse lost a pair of games over the weekend. The Rebels fell to Gold Country Stampede 11-9. Gray Osgood had three goals, Ethan Alexander had two.
Segan Chambers had three saves in the goal.
On Sunday, the Rebels lost to Folsom 6-4. Alexander had three goals and Chambers had 12 saves.
Chico Flight at Sac Area Sports Tournament >> The Chico Flight freshman boys basketball team finished 3-0 at the Sac Area Sports Tournament this past weekend winning its second tournament of the AAU season.
The Flight first defeated the Explosive Huskies, another Chico AAU team, 47-40.
Quentin Thomas led with nine points. Jasten Del Carlo, Phoenix Driscoll and Mason Walker each added eight points. Brandon Brott grabbed eight rebounds.
The Flight next beat Team Blackout from Sacramento 55-48. Thomas had a game-high 22 points while Stephen Schaefer had 10 points and eight rebounds.
In the final game of the round robin tournament, the Flight topped the Hurricanes from Sacramento 57-42. Thomas and Schaefer had 12 points each while Driscoll added 11.
Chico Flight at Sac Area Sports Tournament >> The Chico Flight seventh-grade girls basketball team moved up a level to play in the eighth-grade division and went 2-1 for a second-place finish at the Sac Area Sports Tournament.
The Flight lost in the opener 40-24 against the Sutter Lady Huskies. Campbell Vieg led with 13 points.
The Flight bounced back in the second game, winning 43-18 against the Hot Shots Elite out of Rocklin. Vieg led with 20 points while Halle Thomas added 11 points and dished out five assists.
In the final game, the Flight defeated the Eastside Cougars from Redding, 44-19. Vieg had 14 points and Thomas had nine points and seven rebounds.
Items for the community sports roundup must be typed and turned in by 5 p.m. on the Monday after the event. Include first and last names, scores, and/or times. Email them to firstname.lastname@example.org. No phone calls, late submissions or hand-written items.


The FlexLogger configuration -based data-logging software for validation test was launched at NIWeek in Austin by National Instruments. With intuitive workflows and integrated data management, FlexLogger helps automotive test departments quickly capture accurate, well-documented data to verify system functionality in real-world conditions and comply with strict government regulations.
Technology innovations in areas like active safety, electrification and
Vehicle-to-everything V2X communication are disrupting how the automotive industry designs, tests and produces vehicles.
Rapidly evolving components and systems including sensor fusion, high-capacity batteries and deep learning demand a higher volume of testing with accurate, traceable results to exceed safety-critical expectations for quality and reliability. These trends are pulling automotive test departments in different directions, intensifying challenges to build increasingly complex, mixed-measurement test
systems under compressed timelines, while managing the explosive growth of collected data.
Engineers can use FlexLogger to help simplify test configurations and extract key insights with sensor-specific workflows to acquire and log synchronised, mixed measurements - no programming required.
They can quickly integrate analogue sensors, digital pulse frequencies, CAN signals and calculated channels that are all logged to the universal Technical Data Management Streaming (TDMS) file format so that data can be correlated and analysed to accurately characterise an entire system. These capabilities address similar challenges faced in other industries including heavy equipment, aerospace, appliances and academic research.
For example, heavy equipment manufactures like CNH Industrial design and produce different vehicles like agricultural machines, construction plant, trucks
and buses. Each system has unique specifications for functionality and performance, which means every test has different requirements to integrate new sensors and industrial protocols.
“Characterising a combine harvester drivetrain requires a mix of different measurements including pressure, temperature, and current, CAN and shaft speed,” said Andy Tarman, lab test engineer at CNH Industrial.
“Flex Logger makes it easier to troubleshoot and verify that the raw data from different sensors are correct before I start my test. This helps shorten test development by saving time typically wasted on redoing configurations.”
These configuration-based workflows are the cornerstone that now empower technicians to streamline test development, integrate new measurements and manage data using NI’s flexible software platform and modular hardware
For example, leveraging NI’s data management expertise, FlexLogger automatically logs descriptive metadata about the test configuration including sensor and hardware
acquisition settings for easier traceability.
Test departments can improve access to data and effectively communicate results to the organisation using DIAdem data management software to find, analyse and report on FlexLogger data.


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Thirty-six Classic Stories ( hd )
- App Store Info
Description" Thirty-six classic story" a good preservation of the original thirty-six meter, the other hand, from the perspective of a new interpretation of the thirty-six meter in the modern sense, from content to form, are unique, innovative. The book every meter in addition to questions, comments and notes, and handed down the allusions, used the kit, used the examples. Handed down allusions is the way to communicate the initial reading, ancient and modern, explains. ,
What's New in Version 12.0+Support iOS9
+Correct some words.

domain: library


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Released by Film Score Monthly
The Man From U.N.C.L.E., Volume 3
Producer / Liner notes
Once again, Volume 2 sold so well that we decided to do one final volume, featuring not only the remaining great Man From U.N.C.L.E. scores but also the best of The Girl From U.N.C.L.E., the single-season spinoff (1966-67), and MGM’s own stereo re-recordings of the best of the original three Jerry Goldsmith scores. It is unfortunately out of print and now quite pricey — but worth every penny, as indicated by this wonderful review.


Medeama SC striker Prince Opoku Agyemang has stated that his target for theÂ ongoing 2019/20 Ghana Premier League is to emerge the top scorer.
The forward who joined the Tarkwa-based club recently on a three-year deal from Division One League side New Edubiase is on 11 goals following his brace in yesterday's win over Legon Cities and a goal shy of top scorer Victorien Adebayor.
In a post-match interview after the win against the Royals, striker Prince Opoku Agyemang revealed that he is keen on winning the Ghana Premier League golden boot.Â
â€œItâ€™s my target because every striker wants to score, so itâ€™s my mission that I have to score in every game that we are playing so itâ€™s my target that I want to win the goal king award."
He revelled his outfit victory at the Accra Sports Stadium that at seen them consolidate their lead at the top of the Ghana Premier League.
â€œThe feeling is so good, so great because itâ€™s not easy coming to away to score two goals, so the feeling is so great to meâ€.
Opoku was in devastating form as he aided the Mauve and Yellows to a win over Legon Cities in matchday 15 of the Ghana Premier League.Â
The former New Edubiase attacker two first-half goals was enough for the visitors to ran away with the 3 points at the Accra Sports Stadium.
Medeama next host Berekum Chelsea at the Akoon Park, Tarkwa.


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The one and only, Isaiah The 3rd is back. Today the wordsmith returns with a brand new album, unleashing a solid new project called Return Of The 3rd. The new project finds Isaiah The 3rd giving us something contagious, providing 13 new tracks in the process. The Brooklyn native not only shows off his lyrical prowess but also shows off his growth along the way.
The new album serves as a follow-up to last year’s Sad Boi mixtape with Isaiah effortlessly doing his thing in the process. This is not something we would suggest sleeping on. Check out the new album in the stream below and give us your thoughts in the comments below. Stay tuned for much more from Isaiah The 3rd coming soon and give us your thoughts in the comments.


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Discussion in 'Economy' started by Annie, Jun 14, 2006.
Frankly this is OLD news. WSJ and the Economist have been talking about this subject for almost two years.
Okay, that was enlightening.
Anything I can do to help.
I have been posting on financial markets for three years and I usually get harassed for suggesting that anything that GW is involved in is anything other than gold.
GW is now in charge of the global financial markets? Cool.
Well he is the leader of the strongest economy in the world and he does have jurisdiction over the largest trading system in the world. So that does make him in charge
Separate names with a comma.

domain: finance


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Evaluation With Power provides that support and guidance. Building on INDEPENDENT SECTOR?S ongoing research on evaluation, it is a practical, comprehensive handbook for transforming the organization, its management, programs, process, and organizational evaluation into a positive learning experience that connects performance to mission. The book focuses on the needs of the nonprofit and reveals the sort of evaluation that is most appropriate to and helpful for nonprofits. Sandra Trice Gray has brought together leading experts from a wide range of fields to show how to use the power of evaluation in key organizational areas, including program design, human resource management, information systems, volunteers, fund raising and more.
Evaluation With Power shows that true evaluation is a process of asking good questions, gathering information to answer them, and making decisions based on those answers
Evaluation With Power provides members of nonprofit sector organizations at all levels with the information and guidance they need to make evaluation work. It explains how evaluation relates to board and staff concerns and shows how it can help create an environment for learning and renewal. It provides the "how" of an ongoing process of evaluation and will help organizations make the most of limited resources and ensure its viability and health in a changing environment.
Ongoing Evaluation: A New Approach.
Empowering Staff for Evaluation.
The Board′s Role in Evaluation.
How Volunteers Can Contribute to Evaluation.
Using Client Feedback to Improve Programs and Services.
USING ONGOING EVALUATION TO IMPROVE PROGRAMS AND SERVICES.
Organizational Behavior and Policy (A. Merget & E. Weaver).
Program Effectiveness and Outcomes (J. Seeley).
Human Resource Management (D. Young & H. Doerman).
Information Management (R. Millett & M. Lelle).
Resource Development (P. McE. Buchanan & T. Hurwitz).
Ethics and Accountability (J. Belk & M. Daignault).
Adapting the Evaluation Process to the Organizational Culture (R. Adamson & E. Weaver).
Using Outside Evaluatorsv (P. Patrizi & J. Sanders).


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Hop on this historic uphill trolley to get to the top of Mount Washington. The perfect vantage point to take in the sight of the city right above where the three rivers collide. On clear days the view allows you to take excellent photos of Pittsburgh and if you wait out the crowds and take the ride at night you will be rewarded by the sight of the illuminated city below. Apart from the view, you will find a small museum, gift shop, and a few small restaurants near the top station as well.
Visiting the zoo and aquarium makes for a fun-filled family program. There are a lot of activities for kids including the petting zoo in Kids Kingdom and the stingray tanks where you can watch these magnificent creatures gliding around. The more than 400 different animals are grouped by their original living environments. There is an African Savanna, an Asian Forest as well as the Water’s Edge and the PPG Aquarium. Visitors are usually impressed by the variety of animals and most people suggest this as an excellent program in if the weather is nice.
Located just a short distance from two universities these magnificent gardens provide a popular background for weddings. Visitors can explore a great collection of flowers and other plants arranged by geographic regions. The greenhouses feature a wide variety of gardens from bonsai and tropical forests to butterfly houses. A cafe and a shop provide a place for visitors to relax and play areas for children offer a little break for parents if needed. Tickets cost $15 for adults and $11 for children aged between 2 and 18.
Home of the Pittsburgh Pirates. Catch a Major League baseball game and enjoy local hot dogs and craft beers and you are guaranteed to have a great time. Apart from the game, visitors say the whole atmosphere of the stadium is the real attraction, complete with stunning views of the skyline. The whole area comes alive on a game day and you can enjoy the riverfront with its eclectic collection of cafes, bars, beer trucks and street entertainment. Apparently, there is not a bad seat in the stadium, the food is great and the crowd is wild so you can buy your tickets with confidence.
This stunning, modern stadium doubles as the home of the Pittsburgh Steelers and as a great concert venue. The river provides a unique backdrop and if you are not lucky enough to catch a game, you can still take an informative guided tour between April and October. Tickets for the 90 min stadium tour costs $8 for adults and $7 for kids. You can take excellent photos of the family and friends in this iconic location. If you are coming for a game, easy accessibility, lots of nearby parking opportunities, friendly local fans and fantastic atmosphere will ensure you have a great time.
Make sure to read these top posts as well!

domain: geography


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Elegant Hotel Danang
Address: 22A Bach Dang St., Danang City
Phone: (84-511) 892893
Fax: (84-511) 835179
Location: Da Nang
|Efficient business hotel on the riverfront which lives up to its name. Both decor and standards are a cut above the competition at this price range.|
Note : The above rates are net inclusive of 10% tax, 5% service charge and breakfast.
- Elegant Hotel is situated close to the Business and Tourist Center of the Danang City Only 10 minutes away from the airport, and 10 minutes to the Cham Museum, with such a choice of location, both business and leisure travelers can only expect convenient accessibility within the city.
- Danang City is located in Central Vietnam; it is surrounded by Thua Thien Hue along the northern border and Quang Nam on the southern border. The main ethnic groups living in this area are the Kinh, Xo Dang, Co Tu, Co, and Gie Trieng.
- The tropical monsoon climate is divided into two seasons: the rainy and dry seasons. The average temperature is 25.6?C.
- Ngu Hanh Son Marble Mountains as well as the Linh Ung Pagoda, the Cham Museum, and Non Nuoc Beach are interesting attractions to visit.
- Room with A.C, minibar TV,
Facilities & Service :
- 32 various classes of room.
- Laudry services
- Air-con , fan, satellite , IDD phone and privated bathroom with hot shower, hair - dryers
- Mini bar and 24-hour room services.
- Spacious and safe parking place.
- Special discount for long-term, regular guests & group.