text:
1,476 Possible Causes for Facial Redness, Lumbar and Sacral Arthritis, Ventral Hernia
This is a single case of a 65-year-old American woman who presented with substantial weight gain and insulin resistance (IR) post-Roux-en-Y gastric bypass (RYGB) surgery. Before RYGB, she had reached 340 lbs (155 kg) and a body mass index (BMI) of 56.6 kg/m2 The surgery resulted in a 70 lbs (32 kg) weight loss,[…][ncbi.nlm.nih.gov]
Morbid obesity is associated with liver pathology, most commonly non-alcoholic steatohepatitis (NASH) leading to cirrhosis. However, the morbid obesity impedes qualification for organ transplantation. We present a case report of a 56-year-old woman who underwent bariatric procedure followed by liver transplantation[…][ncbi.nlm.nih.gov]
Hemolytic Transfusion Reaction
We present the case of a 53-year-old woman with long-standing immune thrombocytopenia who underwent repair of a symptomatic ventral hernia.[ncbi.nlm.nih.gov] The patient presented for repair of her symptomatic ventral hernia (Fig. 3 ).[bmcsurg.biomedcentral.com] Laparoscopic view of a 4-cm ventral hernia before b and after c closure with Ventrio ST mesh.[bmcsurg.biomedcentral.com]
Missing: Lumbar and Sacral Arthritis
For subsequent ventral hernia repair, a perioperative management strategy was devised, which resulted in an uneventful perioperative course.[ncbi.nlm.nih.gov]
Physicians are often presented with patients complaining of facial redness and difficult to control rosacea.[ncbi.nlm.nih.gov] Typically, rosacea is characterized by facial redness and flushing.[news-medical.net] redness and erythematotelangiectatic rosacea.[ncbi.nlm.nih.gov]
Missing: Lumbar and Sacral Arthritis Ventral Hernia
A typical feature of facial non-pigmented AK is a composite pattern named "strawberry pattern", characterized by a background erythema/red pseudonetwork consisting of unfocused[ncbi.nlm.nih.gov] A typical feature of facial non‐pigmented AK is a composite pattern named "strawberry pattern", characterized by a background erythema/red pseudonetwork consisting of unfocused[doi.org] Common side effects include dryness, itching, redness, and rash at the site of application.[en.wikipedia.org]
Crescent Medical Journal. 2014; 16(6) 6 Facial sebum affects the development of acne, especially the distribution of inflammatory acne C.W.[doi.org] American Academy of Dermatology. 2014; 5 Comparing Nigella sativa Oil and Fish Oil in Treatment of Vitiligo Alireza Ghorbanibirgani,Ali Khalili,Darioush Rokhafrooz Iranian Red[doi.org]
Missing: Ventral Hernia
Ludwig Kürten and Uwe Schmidt of the University of Bonn have brought vampire bats into the lab and shown that they can detect the infra red radiation emitted from living human[scientificamerican.com] Many species of bat have a facial structure called a nose leaf, which is thought to aid in the echolocation of prey, but only vampire bats have a set of three nasal pits surrounding[scientificamerican.com]
Food allergy is an increasingly prevalent problem in westernized countries, and there is an unmet medical need for an effective form of therapy. A number of therapeutic strategies are under investigation targeting foods that most frequently provoke severe IgE-mediated anaphylactic reactions (peanut, tree nuts,[…][ncbi.nlm.nih.gov]
Chronic Alcoholism
Vascular effects of alcohol Facial redness One of the earliest signs of alcohol abuse is a persistently red face due to enlarged blood vessels ( telangiectasia ).[dermnetnz.org]
Differential diagnoses, possible causes and diseases for Facial Redness, Lumbar and Sacral Arthritis, Ventral Hernia listed by probability for chosen subpopulation according to the database at Symptoma®, the medical search engine for diseases.
Facial Redness & Lumbar and Sacral Arthritis & Ventral Hernia


Published 04/21/2019 01:08:17 pm at 04/21/2019 01:08:17 pm in Storage Bins For Kids.
storage bins for kids folding non woven fabric storage box closet cubes bins organizer kid toy storage bins offices toy storage ikea orange trofast tubes in a white storage unit.
toy storage storage organization the home depot espresso collection espresso and white kids toy storage organizer with plastic bins, ikea alternative affordable cool modern shelving and bins ikea alternative the cool new modern shelving and storage bins from sprout kids, new holiday bargains on mind reader toy storage organizer with mind reader toy storage organizer with storage bins and bookshelf kids storage for bedroom, amazing deals on mind reader toy storage organizer with storage mind reader toy storage organizer with storage bins kids storage for bedroom white, kids toy storage organizer with plastic bins natural kidsstorageorganizernatural , score big lastminute savings kids zoo storage bin set jungle kids zoo storage bin set jungle nursery jungle nursery decor fabric bin, how to organize every room of the house with storage bins just a plastic storage tubs used to organize kids toys in a playroom, childrens storage bin solidpartnerinfo childrens storage bin kid storage bin organizer storage bins kid storage bin organizer kids organizer m, d cartoon non woven kid toys storage bins animal embroidery d cartoon nonwoven kid toys storage bins animal embroidery foldable clothes storage boxs for, storage shelf with bins contemporary kids storage benches and storage shelf with bins, get the deal mind reader toy storage organizer with storage bins mind reader toy storage organizer with storage bins kids storage for bedroom.


text:
<?php

namespace Tests\Unit\Structure;

use Scraper\Structure\AnchorField;

class AnchorFieldTest extends StructureTest
{
    public function setUp()
    {
        parent::setUp();
        $configuration = $this->configurationManager->getConfiguration();
        $configuration->setFields(
            [
                new AnchorField(
                    [
                        'name'               => 'relativeUrl',
                        'xpath'              => './/a',
                        'convertRelativeUrl' => false,
                    ]
                ),
                new AnchorField(
                    [
                        'name'  => 'fullUrl',
                        'xpath' => './/a',
                    ]
                ),
            ]
        );
        $this->extractor->configuration = $configuration;
    }

    public function testExtractData()
    {
        $data = $this->extractor->extract();
        $this->assertCount(2, $data);
        $this->assertEquals('/first.com', $data[0]['relativeUrl']);
        $this->assertEquals('/second.com', $data[1]['relativeUrl']);

        $this->assertEquals(
            'http://localhost/first.com',
            $data[0]['fullUrl']
        );
        $this->assertEquals(
            'http://localhost/second.com',
            $data[1]['fullUrl']
        );
    }
}

redpajama_set_name: RedPajamaGithub


Antitactae (q. d. ἀντιτακταί, from ἀντιτάσσω, to resist), the Antinomian branch of the Gnostics. Gnosticism regarded matter as absolutely evil, and the body as the seat and source of evil. Gnostic morality, therefore, consisted in the mortification of the body. One class of Gnostic sects tried to attain this end by means of rigorous asceticism, SEE ENCRATITES, the other by wilfully abusing it for debauchery. The latter class bore the collective name Antitactae, as they considered the law as not obligatory for them, and intended to show their contempt of the law, and of the Demiurgos, the author of matter, and, consequently, of evil, by purposely transgressing the commandments of the law. To this class belong the Carpocratians, Basilidians, and others. Whether any particular sect ever bore the name Antitactae is still controverted.Neander, Ch. Hist. 1, 451. See GNOSTICISM.


Yes, please check individual product pages on the shop tab for a list of retailers. However, we are seeking retail partners worldwide. You may apply by clicking here.
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text:
Feasibility, efficacy and safety of exercise stress echocardiography during the COVID-19 pandemic
Health care delivery, economics and global health care
Reinette Hampson Department of Cardiology, Northwick Park Hospital, Harrow, UK PubMed articlesGoogle scholar articles
Christina Botrous Department of Cardiology, Northwick Park Hospital, Harrow, UK PubMed articlesGoogle scholar articles
Navtej Chahal Department of Cardiology, Northwick Park Hospital, Harrow, UK PubMed articlesGoogle scholar articles
Roxy Senior Department of Cardiology, Northwick Park Hospital, Harrow, UKCardiology, Royal Brompton Hospital, London, UKNational Heart and Lung Institute, Imperial College, London, UK PubMed articlesGoogle scholar articles
Correspondence to Professor Roxy Senior; r.senior{at}imperial.ac.uk
Hampson R, Botrous C, Chahal N, et al
Open Heart 2022;9:e001894. doi: 10.1136/openhrt-2021-001894
Received October 20, 2021
Accepted March 11, 2022
First published April 20, 2022.
© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

redpajama_set_name: RedPajamaCommonCrawl


Santa leads a fiery torchlight parade down the slopes followed by a gift giveaway for all the good girls and boys! No one is busier than Santa this time of year, but he still finds the time for the good boys and girls in Whitefish. What a guy!
Location: Torchlight Parade will be on Ed's Run, just outside Ed and Mully's Lounge.
Santa's Gift Giveaway will be in Ed and Mully's Lounge.
6:30pm – 8pm: Santa hands out gifts at Ed & Mully's Lounge.
Gifts: Anyone can bring ONE gift per child to be given by Santa and his Whitefish Elf.
Anyone can bring ONE gift per child to be given by Santa and his Whitefish Elf. Please leave more valuable gifts for Christmas morning.
You MUST include the Name Age Town listed on the package. Please write clearly legibly and in large print (Santa has bad eyes you know must be from all that soot). If you have more than one child, please wrap all gifts in the same type of paper.
Gift Drop off Locations– Base Lodge Information Center (2ND Floor) or Lodging Check-In (Kintla Lodge in Upper Village) anytime by 4pm 12/24.
Be at the bottom of Chair 2 at 5pm register. Load Chair 2 at 5:30. Torchlight Begins at 6pm.
You must be able to ski in very low light and icy conditions. All torch lighters are encouraged to wear warm but worthless clothing to avoid damage from torches.
Participants under 18 yrs of age must have a parent or guardian sign a liability waiver. No exceptions.
The Torchlight Parade takes place on Ed's Run in the Upper Village at Whitefish Mountain Resort.


text:
Sunday Times Editor Apologizes 'Unreservedly' for Timing of 'Blood Libel' Cartoon
The anti-Semitic cartoon including The Sunday Times masthead.
In a meeting with British Jewish Leaders earlier today, the Acting Editor of The Sunday Times Martin Ivens apologized "unreservedly" for running a cartoon on International Holocaust Memorial Day that was described by the Anti Defamation League as "a modern day evocation of the ancient 'blood libel' charge leveled at Jews."
The cartoon by Gerald Scarfe which depicts Israeli Prime Minister Benjamin Netanyahu building a wall with the bodies and blood of Palestinian Arabs caused an international outcry, prompting an apology yesterday from Sunday Times owner Rupert Murdoch, who described the cartoon as "grotesque."
After an initial defense of the cartoon from the paper, followed by a reserved statement attempting explanation from Ivens, the Editor finally issued the full apology saying, "on behalf of the paper I'd like to apologise unreservedly for the offence we clearly caused. This was a terrible mistake."
Ivens implied that his regret was specifically a product of the timing of the cartoon rather than for the content itself, saying, "The timing – on Holocaust Memorial Day – was inexcusable. The associations on this occasion were grotesque […]"
Mick Davis, Chair of The Jewish Leadership Council, a Jewish representative body, whose leaders attended the meeting, accepted the apology from Ivens. "I welcome the genuine apology from the Sunday Times. I appreciate the urgency and respect with which the Sunday Times have treated Jewish communal concerns and now look forward to constructively moving on from this affair," he said, according to a release.


text:
Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries
The ACTION Study Group
One of the biggest obstacles to developing policies in cancer care in Southeast Asia is lack of reliable data on disease burden and economic consequences. In 2012, we instigated a study of new cancer patients in the Association of Southeast Asian Nations (ASEAN) region – the Asean CosTs In ONcology (ACTION) study – to assess the economic impact of cancer.
The ACTION study is a prospective longitudinal study of 9,513 consecutively recruited adult patients with an initial diagnosis of cancer. Twelve months after diagnosis, we recorded death and household financial catastrophe (out-of-pocket medical costs exceeding 30 % of annual household income). We assessed the effect on these two outcomes of a range of socio-demographic, clinical, and economic predictors using a multinomial regression model.
The mean age of participants was 52 years; 64 % were women. A year after diagnosis, 29 % had died, 48 % experienced financial catastrophe, and just 23 % were alive with no financial catastrophe. The risk of dying from cancer and facing catastrophic payments was associated with clinical variables, such as a more advanced disease stage at diagnosis, and socioeconomic status pre-diagnosis. Participants in the low income category within each country had significantly higher odds of financial catastrophe (odds ratio, 5.86; 95 % confidence interval, 4.76–7.23) and death (5.52; 4.34–7.02) than participants with high income. Those without insurance were also more likely to experience financial catastrophe (1.27; 1.05–1.52) and die (1.51; 1.21–1.88) than participants with insurance.
A cancer diagnosis in Southeast Asia is potentially disastrous, with over 75 % of patients experiencing death or financial catastrophe within one year. This study adds compelling evidence to the argument for policies that improve access to care and provide adequate financial protection from the costs of illness.
The Association of Southeast Asian Nations (ASEAN) region consists of ten countries – Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam – and is home to over half a billion people. The burden of cancer is increasing in the ASEAN region, due to population ageing and growth and the adoption of cancer-associated lifestyle behaviours [1]. In 2012, there were estimated to be over 750,000 new cases of cancer, and incidence is expected to rise to 1.3 million per year by 2030 [2]. Survival rates for most cancers are poor and quality of life is greatly impaired [2–4]. In addition to this significant disease burden, cancer can have a profound economic effect on individuals and their households, especially among the poor and under-insured [5].
Most studies examining the economic burden of cancer have, however, been conducted in high-income settings. Little is known about its economic impact in low- and middle-income settings, where the financial implication of a cancer diagnosis may not be equitable because out-of-pocket (OOP) payments are the principal means of financing health care [6]. This not only relates to primary treatment, but may include long-term costs of adjuvant therapy and follow-up care [7–9]. Hence, a cancer diagnosis can quickly result in catastrophic payments for a household; that is, spending a disproportionate amount of household income on cancer treatment [10]. Furthermore, patients may be unable to continue working due to the burden of their symptoms, treatment, or side-effects, leading to poorer economic circumstances [11].
Health insurance is seen as an important means in offering households protection from catastrophic payments for illness. However, the extent of financial protection through insurance depends on which health services are covered and the level of subsidy offered. In the ASEAN region, while population coverage varies between 8 % (Laos) and 100 % (Malaysia), all countries – including those with universal health coverage – rely heavily on OOP financing [12, 13].
Despite the risk of a cancer epidemic overwhelming the region, governments have been slow to react to the health consequences of socioeconomic and demographic changes. Hence, in 2011, two regional initiatives were launched to increase cancer awareness and inform priority setting. First, a series of roundtable meetings of key stakeholders and experts were organised to generate knowledge and interest through engagement with the media [14, 15]. Second, a study of new cancer patients in eight countries in the ASEAN region (Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Thailand, and Vietnam) was instigated – the Asean CosTs In ONcology (ACTION) study – to assess the economic and health impact of cancer. This paper presents the main results.
Ethical approval
The ACTION study was approved by the University of Sydney's Human Research Ethics Committee. Approvals from local institutional ethics committees and other regional or national regulatory bodies were obtained prior to the initiation of the study in all centres (Additional file 1). Written informed consent, complying with local, regional, and national requirements, was obtained from all participants prior to entry into the study.
ACTION was a prospective longitudinal study; detailed methods have been published previously [16]. In brief, patients diagnosed with a first time cancer were consecutively recruited (within 12 weeks from initial date of diagnosis) from 47 sites, including public and private hospitals and cancer centres. Patients were aged 18 years and older, aware of their cancer diagnosis, and willing to participate in follow-up interviews. Participants were interviewed (face-to-face or by telephone) at baseline, 3, and 12 months after diagnosis. Questionnaires were translated into local languages.
Baseline measures and key outcomes
Data were collected on age, sex, marital status, country of residence, highest level of education attained, employment status, recent experience of economic hardship (whether in the previous 12 months they were unable to make any necessary household payments (for example, food, housing) or needed assistance to do so) [17], annual household income, and health insurance status. Clinical characteristics, cancer site, and cancer stage (TNM classification) were obtained from medical records. Health-related quality of life was assessed using the EuroQol (EQ-5D) [18]. Further details are given in the study protocol [16].
The primary outcome at 12 months was financial catastrophe (FC) following treatment for cancer, defined as OOP costs at 12 months equal to or exceeding 30 % of annual household income [19, 20]. OOP costs represented hospital and non-hospital health care costs which were directly incurred by patients at point of delivery and not reimbursed by insurance. Participants prospectively completed a cost diary for the duration of the study. The second key outcome was all-cause mortality. FC and death were recorded at both follow-up interviews.
Multinomial regression models were used to estimate odds ratios (ORs) and 95 % confidence intervals (CIs) for death and FC, relative to being alive without experiencing FC, thus allowing for death as a competing risk to FC. Baseline characteristics considered for association with these joint outcomes were socio-demographic (age, sex, and level of education), economic (household income grouped into low (0–75 % of mean national income), middle (75–125 %), and high income (>125 %), insurance status (yes or no), experience of economic hardship, and paid work status), and clinical (baseline health-related quality of life, cancer site – separately by sex – and cancer stage) [21]. Due to small numbers for some cancer sites, sites were grouped into body location or system: digestive/gastrointestinal; breast; gynaecological; head and neck; haematological/blood; respiratory/thoracic; and other cancers. Analyses were adjusted for age, sex, cancer stage, and geographic region, grouped as low (Cambodia, Myanmar), low-middle (Indonesia, Laos, Vietnam, the Philippines), and upper-middle income (Thailand, Malaysia). Participants who experienced FC at 3 months, but could not be contacted at 12 months, were coded as having experienced FC at 12 months. Primary analyses were conducted on participants with complete data on outcome status at 12 months. More extreme cut-offs for household income groups were tested in a sensitivity analysis: low (0–50 % of mean national income); middle (50–150 %); and high income (>150 %). Furthermore, multiple imputation (m = 5) using predictive mean matching was carried out to impute the missing data on the outcome variables. The imputation models included the outcome variables themselves, all socio-demographic, clinical, and economic predictors examined, and country [22]. Analyses were performed using STATA, version 12.0 (Stata, College Station, TX, USA), and R, version 2.15.3 (R Foundation for Statistical Computing, Vienna, Austria).
Between March 2012 and September 2013, after exclusions due to patient or doctor refusals, 9,513 patients were recruited into the study. The mean age was 52 years, 64 % were women, 61 % had attained at least secondary education, and 45 % had some form of health insurance. The most common cancer site recorded was breast (26 %); the greatest number was recruited in Indonesia (Table 1). For patients with available data on cancer stage (n = 5,159), 11 % presented with stage I, 31 % with stage II, 33 % with stage III, and 24 % with stage IV cancers. Haematological cancers were diagnosed in 825 patients (Additional file 2: Table S1).
Table 1 Demographic, socioeconomic, and clinical characteristics of the study population (n = 9,513)
The follow-up interviews at 3 and 12 months were completed by 7,245 (76 %) and 5,245 (55 %) participants, respectively. At 12 months, 1,993 (29 %) participants had died. Complete outcome data (data on FC and death) were available for 6,787 participants (71 %) (Fig. 1).
Participant flowchart
Participants with incomplete outcome data (n = 2,726) were slightly younger (51 versus 52 years), more likely to be male (38 versus 33 %), and less likely to have a high income (17 versus 38 %), compared to those with complete outcome data (all P values <0.001). There were no significant differences in other socio-demographic, clinical, or economic characteristics.
At 12 months, 3,248 participants (48 % of those with complete outcome data) experienced FC and 1,546 (23 %) were alive and did not experience FC. Survival without FC was most frequent in participants with haematological cancer (37 %), gynaecological cancer (27 %), and breast cancer (26 %) (Fig. 2).
Competing outcomes of death, financial catastrophe, and alive with no financial catastrophe at 12 months after diagnosis, by location of cancer in the body
After controlling for confounding variables, women had lower odds of death (OR, 0.62; 95 % CI, 0.51–0.75) than men, but sex was not significantly associated with FC, relative to the reference outcome (alive and no FC) (Table 2). Age of >65 years was associated with a higher odds of FC (1.51; 1.17–1.94) and death (2.64; 2.00–3.49), compared to age <45 years. Being unmarried was also associated with a higher odds of FC (1.09; 1.09–1.60) and death (1.42; 1.15–1.77), compared to participants who were married. Having completed primary education only, compared to tertiary education, was significantly associated with a higher odds of FC (1.45; 1.16–1.82) and death (2.50; 1.93–3.25).
Table 2 Odds ratios (and 95 % confidence intervals) for financial catastrophe and death, relative to no financial catastrophe (reference) in all participants with complete outcome data (n = 6,787), adjusted for age, sex, cancer stage, and geographic region
Participants in the low income category within each country had significantly higher odds of FC (5.86; 4.76–7.23) and death (5.52; 4.34–7.02) than participants with high income, relative to being alive and no FC. Using more extreme cut-offs for low and high household income (0–50 % of the mean national income for a low income and >150 % for a high income) resulted in higher odds of FC (9.16; 7.07–11.87) and death (9.30; 6.95–12.44) for the low income category. The country-region specific analysis showed that a low income is especially a factor in predicting FC in the upper-middle income countries (13.75; 10.21–18.51) and less so in lower-middle income countries (1.97; 1.38–2.82) (Additional file 2: Table S2a and S2b). Not having paid work also increased the odds of FC (1.32; 1.11–1.56) and death (1.60; 1.31–1.94). Having some form of health insurance provided protection from FC; those without insurance were more likely to experience FC than those with insurance (1.27; 1.05–1.52). Participants without health insurance were more likely to die (1.51; 1.21–1.88), relative to being alive and not experiencing FC; health insurance was inversely related to FC in upper-middle income countries only.
Cancer stage IV at diagnosis was significantly associated with a higher odds of FC (1.52; 1.12–2.05) and death (5.43; 3.76–7.82), compared to stage I. In terms of health-related quality of life, a decrement of 0.1 point as assessed on the EQ-5D was associated with higher odds of FC (1.11; 1.07–1.16) and death (1.24; 1.18–1.30).
In females, cancer site was not associated with FC. In males, cancer in the head and neck region (0.54; 0.36–0.80) and haematological cancers (0.56; 0.42–0.76) were associated with a lower odds of FC compared to digestive cancers (reference group).
Sensitivity analyses employing missing value imputation (Additional file 2: Table S3) did not change the inferences, except that the effect of health insurance on the odds of FC became non-significant at the conventional 5 % level.
To our knowledge, the ACTION study is the largest observational study of the household burden of cancer yet conducted in Asia. A year after diagnosis, almost a third of patients affected by cancer in the ASEAN region died and almost a half of their households faced catastrophic health care expenses. Patients with advanced stages of cancer at diagnosis and socioeconomically disadvantaged cancer patients, including those with primary education only, low income, and no health insurance, were more likely to experience FC or die within 12 months.
This research adds compelling evidence to the argument for effective cancer control policies and timely access to affordable treatment in low- and middle-income countries. Previously, evidence of significant household economic burden due to cancer has come from only a few, small cross-sectional studies [23, 24]. There has, however, been increasing attention given to the economic impact of non-communicable diseases in low- and middle-income settings, with two recent reviews highlighting the heavy financial burden that such diseases pose on affected households [25, 26]. In a review of studies that reported on expenditures on chronic diseases, mean expenditures ranged from 5 % to 59 % of household income, household total health expenditure, and household non-food expenditure, but results on catastrophic health expenditures were not reported [26]. A literature review on the costs imposed by non-communicable diseases in low- and middle-income settings included 19 studies that reported on OOP health expenditure as a percentage of capacity to pay or total household expenditure due to health shocks, and found that between 0 % and 34 % of the study population experienced FC, depending on the methods used [25]. Comparison of these findings with our results is difficult due to differences in defining catastrophic spending: some studies used a threshold OOP share of total household expenditure; others of household 'capacity to pay'; or of 'non-food expenditure'. In addition, the threshold used also varies, ranging from 10 % to 40 %. Furthermore, in the majority of the above-mentioned studies, OOP estimates were based on retrospective recall of health care utilisation in household surveys, while our study used a prospective cost diary. Studies have shown that OOP estimates depend heavily on the measures used and length of recall periods [27, 28]. Compared to prospective cost diaries, health care utilisation is generally under-reported in household surveys [27]. Nonetheless, results from this study, taken together with other studies, signal the potential for cancer to result in a significant economic burden.
Women were less likely to die in the year following a cancer diagnosis than men, but no significant association between the patient's sex and their household's odds of experiencing FC was found. Better survival rates for female cancers may be explained by the high proportion of breast cancer in this population, and its relatively good prognosis, while colorectal, mouth and lung cancers, with a generally poor prognosis [29], were most common in men. The risk of FC increases with age, perhaps due to increasing co-morbidities which result in greater complexity of the illness and treatment. As expected, age was significantly associated with the risk of death at 12 months. A more advanced cancer stage at diagnosis was associated with higher odds of FC and death.
We found that having a below average income, no health insurance, not having paid work, having experienced economic hardship prior to diagnosis, and having experienced no more than primary education, were all associated with a higher odds of experiencing FC. Household income showed the strongest association, with these patients having more than five times the odds of FC when an income <75 % of the mean national income was considered a low income, and even nine times the odds when an income <50 % was used as the threshold. That this gradient was found to be more pronounced in upper-middle compared to lower-middle income countries suggests that the risk of FC posed by having a low income is as much based on relative as opposed to absolute disadvantage.
The relationship between health insurance and FC found in the primary analyses of this study was not particularly strong, and was non-significant in the sensitivity analysis where missing data were imputed. Analyses by level of economic development provided some explanation to these inconclusive results: in upper-middle income countries (Malaysia and Thailand) health insurance did provide significant protection from FC; but in lower-middle income countries it did not. This may be explained by the limitations of benefit packages available through health insurance programs in some of the participating lower-middle income countries, which has been well-recognised as a problem in Vietnam and the Philippines [13]. Since health insurance status was assessed as a categorical variable it was not possible to take into account variations in level of coverage.
The findings in relation to the socioeconomic variables reinforce the well-founded conclusions that can be drawn from the social determinants literature – those at greater levels of disadvantage tend to have higher risks of financial hardship and poor health [30]. Reflecting this was the strong relationship of various socioeconomic indicators and death within 12 months. This, and the observed association between low quality of life and higher odds of FC, underscores the relationship between underlying economic disadvantage, health, and economic outcomes in cancer.
The study has a number of limitations. We did not recruit a random cross-section of people with incident cancer in the region due to a variety of reasons. First, as we could only identify cases once individuals presented to hospital, we potentially excluded individuals who did not seek hospital treatment due to geographical isolation, poverty, or socio-cultural barriers [31]. Second, clinicians responsible for enrolling patients into the study appear to have under-recruited those with the most virulent types of cancer, such as lung and liver cancers. Third, public awareness of some types of cancer, specifically breast cancer, was greater than for others, which is likely to have additionally motivated certain cancer patients, particularly women, to agree to participate in the study. Furthermore, patients treated in private hospitals were under-represented in the study (6 %) and it is unclear whether this has introduced a bias in our estimates of the level of FC. Although private hospitals have often been observed to generate the highest OOP expenses [25] they also tend to attract patients with a higher income. All these factors compromise the generalisability of some of our results, and probably means that we have underestimated the 12-month rate of death from all cancers, but is unlikely to invalidate the main conclusions. Another drawback is that 2,767 participants (29 %) lacked at least one component of data on death, household income, or OOP costs required to compute the study outcomes. The challenges of eliciting income and other socioeconomic data have been well-documented [32], and incomplete follow-up due to being unable to contact many subjects in rural areas, despite repeated telephone calls and field visits, is inevitable in the region studied. The findings from the sensitivity analysis, in which multiple imputation was used to impute the missing data, did not vary substantially from the non-imputed findings, and would not alter conclusions.
These drawbacks have to be considered in the light of the paucity of cancer statistics from the region sampled [2, 15, 33]. The study benefited from having a large sample of patients with various cancer sites and cancer stages from eight countries which have disparate health systems. Due to the large size of the study, it was possible to produce reliable estimates of the influence of a range of demographic, socioeconomic, and clinical predictors. In addition, the study's longitudinal approach improved on most previous economic studies which used cross-sectional surveys based on retrospective reporting of costs, as well as much smaller sample sizes, with subsequent jeopardy for both bias and sampling error. Furthermore, using a multinomial logistic regression model, we were able to adjust FC for the competing outcome of death. This is important as studies that have previously examined the burden to households associated with illnesses have generally focused exclusively on 'economic' outcomes in terms of OOP costs and FC [10, 25, 26], but have overlooked a crucial reason why patients may avoid, or not report incurring, high OOP costs, that is, they may die, and this is unlikely to be non-informative censoring.
This study provides the type of precise evidence that is required to develop effective policies and programs to address the overall burden of cancer care in the ASEAN region, with potential generalisation elsewhere in the developing world. The results show that a cancer diagnosis is disastrous, even within only 12 months, for over 75 % of new patients. Socioeconomically disadvantaged cancer patients and patients with advanced cancer stages at diagnosis were common and particularly vulnerable to adverse economic outcomes and poor survival. The need for more resources to aid early detection as well as policies that improve access to care, by removing financial barriers and providing adequate financial protection from the costs of illness, is clear.
Over 75 % of new cancer patients in Southeast Asia experience financial catastrophe or die within one year. An advanced stage at diagnosis and socioeconomic disadvantage are significant risk factors for these poor outcomes. There is an urgent need for more resources to aid early detection and policies aimed to provide adequate financial protection from the costs of cancer.
Asean CosTs In Oncology
ASEAN:
FC:
Financial catastrophe
OOP:
Out-of-pocket
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This work was supported by an unrestricted educational grant from the Roche Asia Pacific Regional Office. The funder of the study had no role in study design, data analysis, data interpretation, or writing of this paper. Roche supported the data collection through recruitment of hospital sites and facilitating site investigator meetings. The authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.
The authors wish to acknowledge the many patients and their family members who participated in this study, and physicians and other health personnel of participating sites. The Action Study Group comprises the writing committee, principal investigators and other contributors as detailed below.
Writing committee
Merel Kimman, Stephen Jan, Cheng Har Yip, Hasbullah Thabrany, Sanne A Peters, Nirmala Bhoo-Pathy, and Mark Woodward.
Phetsamone Arounlangsy, Soe Aung, Soledad L Balete, Nirmala Bhoo-Pathy, Bounthaphany Bounxouei, Dieu Bui, Jay Datukan, Agnes E Gorospe, Cheng Har Yip, Prasit Khopaibul, Thanut Khuayjarernpanishk, Thiravud Khuhaprema, Myo Khin, David Kingston, Tawin Klinwimol, Somkiet Lalitwongsa, Dhanoo Lawbundis, Conrado Lola, Leo Marbella, Khoa Mai Trong, Soe Oo Maung, Shu Mon, Win Pa Pa Naing, Corazon A Ngelangel, Htun Lwin Nyein, Annielyn Beryl Ong-Cornel, Khin May Oo, Irisyl Orolfo-Real, Dung Pham Xuan, Seang Pharin, Pujianto, Oudayvone Rattanavong, Kouy Samnang, Somphob Sangkittipaiboon, Suleeporn Sangrajrang, Cherelina Santiago-Ferreras, San Shwe, Eav Sokha, Thanadej Sinthusake, Darunee Suanplu, Jitraporn Tanabodee, Hasbullah Thabrany, Kitisak Thepsuwan, Yin Yin Tun, Heng Viroath, Le Le Win, Swe Swe Win, and Tin Moe Win.
Ami Ashariati, Djumhana Atmakusuma, I Made Bakta, Loan Dang Thi Kim, Phung Dang Thi Ngoc, Tuan Diep Bao, Ario Djatmiko, Andi Fachruddin, Johan Kurnianda, Helen Monaghan, Abdul Muthalib, Trang Ngo Thuy, Thao Nguyen Hoang, Nga Nguyen Thi Hoai, Sonar S Panigoro, Huy Phạm Quang, Goh Pik Pin, Khanh Quach Than, Prih Sarnianto, Dradjat R Suardi, Shridevi Subramaniam, Aru W Sudoyo, Khoa Tran Dang, Ha Tran Dinh, Catharina Suharti, and Suyatno.
The George Institute for Global Health, Level 10, King George V Building, 83–117 Missenden Road, Camperdown, NSW, 2050, Australia
The authors declare that they have no conflicts of interest, other than the source of funding for this study.
Principal investigators assisted with the design of the questionnaires and were responsible for patient recruitment and data collection at participating sites. Other contributors assisted with data collection, patient interviews, and data entry. Contributions of members of the writing committee: MK, SJ, and MW designed the study; NBP, CHY, and HT collected data; MK wrote the first draft; and NBP, SJ, SP, HT, MW, and CHY made critical revisions to the manuscript. SP conducted the statistical analysis. All members approved the final manuscript.
Merel Kimman1,2,*
Email: mkimman@georgeinstitute.org.au
Stephen Jan1
Cheng Har Yip3
Hasbullah Thabrany4
Sanne A Peters5
Nirmala Bhoo-Pathy6,7
Mark Woodward1,5,**
Phone: +61 2 99934514
Email: markw@georgeinstitute.org.au
1The George Institute for Global Health, University of Sydney, Level 10, King George V Building, 83–117 Missenden Road, Camperdown, NSW 2050, Australia
2Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
3Department of Surgery, University of Malaysia Medical Centre, Kuala Lumpur, Malaysia
4Center for Health Economics and Policy Studies, Universitas Indonesia, Jakarta, Indonesia
5The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
6National Clinical Research Centre, Ministry of Health, Kuala Lumpur, Malaysia
7Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
*Corresponding author. Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
**Corresponding author. The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
Phetsamone Arounlangsy (Lao Cancer Center, Department of Health Care, Ministry of Health, Laos), Soe Aung (Oncology Society, Myanmar Medical Association, Yangon, Myanmar), Soledad L Balete (Section of Medical Oncology, Jose R Reyes Memorial Medical Centre, Manila, Philippines), Nirmala Bhoo-Pathy (National Clinical Research Centre, Ministry of Health, Malaysia; Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia), Bounthaphany Bounxouei (Mahosot Hospital, Laos), Dieu Bui (K Hospital, Vietnam), Jay Datukan (Section of Medical Oncology, St Luke's Medical Centre, Quezon City, Metro Manila, Philippines), Agnes E Gorospe, (Section of Medical Oncology, St Luke's Medical Centre, Quezon City, Metro Manila, Philippines), Cheng Har Yip (University of Malaya, Kuala Lumpur, Malaysia), Prasit Khopaibul (Suratthani Cancer Centre, Suratthani, Thailand), Thanut Khuayjarernpanishk (Ubonratchathani Cancer Centre, Ubonratchathani, Thailand), Thiravud Khuhaprema (National Cancer Institute of Thailand, Bangkok, Thailand), Myo Khin (Department of Medical Research, Lower Myanmar, Myanmar), David Kingston, Tawin Klinwimol (Ubonratchathani Cancer Centre, Ubonratchathani, Thailand), Somkiet Lalitwongsa (Lampang Cancer Hospital, Lampang, Thailand), Dhanoo Lawbundis (Lopburi Cancer Hospital, Lopburi, Thailand), Conrado Lola (Section of Medical Oncology, National Kidney and Transplant Institute, Quezon City, Metro Manila, Philippines), Leo Marbella (Section of Medical Oncology, National Kidney and Transplant Institute, Quezon City, Metro Manila, Philippines), Khoa Mai Trong (Bach Mai Hospital, Vietnam), Soe Oo Maung (Department of Radiotherapy, Yangon General Hospital, Yangon, Myanmar), Shu Mon (Bahosi Hospital, Myanmar), Win Pa Pa Naing (Department of Medical Research, Lower Myanmar, Myanmar), Corazon A Ngelangel (Section of Medical Oncology, University of the Philippines – College of Medicine, Philippine General Hospital, Manila, Philippines), Htun Lwin Nyein (Haematology Department, Yangon General Hospital, Yangon, Myanmar), Annielyn Beryl Ong-Cornel (Veterans Memorial Medical Centre, Quezon City, Philippines), Khin May Oo (Department of Medical Research, Lower Myanmar, Myanmar), Irisyl Orolfo-Real (Section of Medical Oncology, University of the Philippines – College of Medicine, Philippine General Hospital, Manila, Philippines), Dung Pham Xuan (Oncology Hospital, Ho Chi Minh city, Vietnam), Seang Pharin (Department of Onco-Hematology, Calmette Hospital, Cambodia), Pujianto (Department of Health Policy and Administration, School of Public Health, Universitas Indonesia, Indonesia), Oudayvone Rattanavong (Mahosot Hospital, Laos), Kouy Samnang (Department of Oncology, Khmer-Soviet Friendship Hospital, Cambodia), Somphob Sangkittipaiboon (Lopburi Cancer Hospital, Lopburi, Thailand), Suleeporn Sangrajrang, (National Cancer Institute of Thailand, Bangkok, Thailand), Cherelina Santiago-Ferreras (Section of Medical Oncology, Veterans Memorial Medical Centre, Quezon City, Metro Manila, Philippines), San Shwe (Department of Medical Research, Lower Myanmar, Myanmar), Eav Sokha (National Cancer Centre, Calmette Hospital, Cambodia), Thanadej Sinthusake (Mahavajiralongkorn Thanyaburi Hospital, Pathumthani, Thailand), Darunee Suanplu (Suratthani Cancer Hospital, Suratthani, Thailand), Jitraporn Tanabodee (Chonburi Cancer Hospital, Chonburi, Thailand), Hasbullah Thabrany (Center for Health Economics and Policy Studies, Universitas Indonesia, Indonesia), Kitisak Thepsuwan (Chonburi Cancer Hospital, Chonburi, Thailand), Yin Yin Tun (Department of Medicine, No 2 Military Hospital, Myanmar), Heng Viroath (Department of Oncology, Khmer-Soviet Friendship Hospital, Cambodia), Le Le Win (Department of Medical Research, Lower Myanmar), Swe Swe Win (Department of Oral Medicine, University of Dental Medicine, Yangon, Myanmar), and Tin Moe Win (Mandalay General Hospital, Myanmar).
Ami Ashariati (Soetomo Hospital, Indonesia), Djumhana Atmakusuma (Cipto Mangunkusumo Hospital, Indonesia), I Made Bakta (Sanglah Hospital, Indonesia), Loan Dang Thi Kim (Oncology Hospital Ho Chi Minh city, Vietnam), Phung Dang Thi Ngoc (Oncology Hospital Ho Chi Minh city, Vietnam), Tuan Diep Bao (Oncology Hospital Ho Chi Minh city, Vietnam), Ario Djatmiko (Surabaya Oncology Hospital, Indonesia), Andi Fachruddin (Wahidin Hospital, Indonesia), Johan Kurnianda (Sardjito Hospital, Indonesia), Helen Monaghan (The George Institute for Global Health, Australia), Abdul Muthalib (Medistra Hospital, Indonesia), Trang Ngo Thuy (Bach Mai Hospital, Vietnam), Thao Nguyen Hoang, (K Hospital, Vietnam), Nga Nguyen Thi Hoai (K Hospital, Vietnam), Sonar S Panigoro (Dharmais Cancer Center Hospital, Indonesia), Huy Phạm Quang (K Hospital, Vietnam), Goh Pik Pin (National Clinical Research Centre, Malaysia), Khanh Quach Thanh (Oncology Hospital Ho Chi Minh city, Vietnam), Prih Sarnianto (Universitas Indonesia, Indonesia), Dradjat R Suardi (Hasan Sadikin Hospital, Indonesia), Shridevi Subramaniam (National Clinical Research Centre, Malaysia), Aru W Sudoyo (MRCCC Siloam Hospital, Indonesia), Khoa Tran Dang (Ha Noi Oncology Hospital, Vietnam), Ha Tran Dinh (Bach Mai Hospital, Vietnam), Catharina Suharti (Karyadi Hospital, Indonesia), and Suyatno (Adam Malik Hospital, Indonesia).
CAMBODIA: Calmette Hospital (Phnom Penh) and Khmer-Soviet Friendship Hospital (Phnom Penh). INDONESIA: Adam Malik Hospital (Medan), Cipto Mangunkusumo Hospital (Jakarta), Dharmais Cancer Center Hospital (Jakarta), Hasan Sadikin Hospital (Bandung), Karyadi Hospital (Semarang), Sanglah Hospital (Denpasar), Sardjito Hospital (Yogyakarta), Soetomo Hospital (Surabaya), Wahidin Sudirohusodo Hospital (Makassar), and Surabaya Oncology Hospital (Surabaya). LAOS: Mahosot Hospital (Vientiane). MALAYSIA: Hospital Ampang (Ampang), Hospital Kuala Lumpur (Kuala Lumpur), Hospital Melaka (Melaka), Hospital Queen Elizabeth I (Kota Kinabalu), Hospital Raja Perempuan Zainab II (Kota Baru), Hospital Seri Manjung (Seri Manjung), Hospital Sibu (Sibu), Hospital Sultanah Aminah (Johor Bahru), Hospital Sungai Buloh (Sungai Buloh), Hospital Tengku Ampuan Rahimah (Klang), Hospital Tuanku Fauziah (Kangar), Hospital Wanita dan Kanak-Kanak Sabah (Likas), Sime Darby Medical Centre (Subang Jaya), National Clinical Research Centre (Kuala Lumpur), University Malaya Medical Centre (Kuala Lumpur), and University Malaya Specialist Centre (Kuala Lumpur). MYANMAR: Bahosi Hospital (Yangon), Mandalay General Hospital (Mandalay), No 2 Military Hospital (Yangon), University of Dental Medicine (Yangon), and Yangon General Hospital (Yangon). PHILIPPINES: Jose R Reyes Memorial Medical Centre (Manila), University of the Philippines – College of Medicine Philippine General Hospital (Manila), National Kidney and Transplant Institute (Quezon City), St Luke's Medical Centre (Quezon City), and Veterans Memorial Medical Centre (Quezon City). THAILAND: Chonburi Cancer Hospital (Chonburi), Lampang Cancer Hospital (Lampang), National Cancer Institute of Thailand (Bangkok), Lopburi Cancer Hospital (Lopburi), Mahavajiralongkorn Thanyaburi Hospital (Pathumthani), Suratthani Cancer Centre (Suratthani), and Ubonratchathani Cancer Hospital (Ubonratchathani) VIETNAM: Bach Mai Hospital (Hanoi), K Hospital (Hanoi), and Oncology Hospital Ho Chi Minh city.
Nirmala Bhoo-Pathy, Bounthaphany Bounxouei, Gloria Cristal-Luna, Nguyen Chan Hung, Myo Khin, Thiravud Khuhaprema, Merel Kimman, David Kingston, Stephen Jan, Eav Sokha, Hasbullah Thabrany, and Mark Woodward.
Helen Monaghan, Merel Kimman, Stephen Jan, and Mark Woodward.
Additional file 1:
Overview approvals local ethics boards ACTION Study. (DOCX 14 kb)
Additional file 2: Table S1.
Cancer stage by cancer site (n = 5,984). Cancer stage was not available for 3,529 participants. Table S2a. Odds ratios (and 95 % confidence intervals) for financial catastrophe and death, relative to no financial catastrophe (reference) in participants from lower-middle income countries, adjusted for age, sex, cancer stage, and geographic region. Table S2b. Odds ratios (and 95 % confidence intervals) for financial catastrophe and death, relative to no financial catastrophe (reference) in participants from upper-middle income countries, adjusted for age, sex, cancer stage, and geographic region. Table S3. Odds ratios (and 95 % confidence intervals) for financial catastrophe and death, relative to no financial catastrophe (reference) in all participants (n = 9,513), using missing value imputation and adjusted for age, sex, cancer stage, and geographic region. (DOCX 36 kb)
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries. BMC Med 13, 190 (2015) doi:10.1186/s12916-015-0433-1
High Odds
Catastrophic Health Expenditure
Total Household Expenditure
Catastrophic Payment
Big Risks: the challenges and opportunities in addressing the biggest global causes of premature mortality


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Caroline Ouellette Collects 300th Point in Les Canadiennes' 5-3 loss to the Inferno
Calgary And Montreal Split Historic Weekend Series
SportsJordan Stoopler — Published December 12, 2016
Les Canadiennes' Caroline Ouellette picked up her 300th point Sunday afternoon in a 5-3 loss. Courtesy Louis-Charles Dumais / CWHL
Scoring her 300th career point at the Bell Centre would have been special for Canadiennes forward Caroline Ouellette. She grew up idolizing the Montreal Canadiens and dreamed of one day playing a professional hockey game on that ice. However, hitting her milestone on a rink named for her in the borough where she grew up wasn't bad either.
"It was very unique and special," said Ouellette after her team's 5-3 loss to the Calgary Inferno on Sunday afternoon on the Caroline Ouellette rink in Centre Etienne-Desmarteau. "I'm glad that I got it here and that I got it over with. It doesn't weigh any more on the team. It's special to share it with all my teammates."
"We actually wanted to get her to 300 yesterday," said Les Canadiennes' Ann-Sophie Bettez. "It's a great honour to have that happen on her own ice. I'm really thrilled for her."
The pivotal point came halfway through the first period. Already down a goal to Calgary's Bailey Bram, Les Canadiennes responded on a five-on-three power play. Ouellette, playing the point, fed the puck cross-ice to Marie-Philip Poulin. She passed down low to Bettez, whose shot managed to trickle past Inferno goaltender Genevieve Lacasse. Poulin was quick to retrieve the puck for her friend and teammate. The puck was taped up and on it was inscribed: "the first to reach 300."
Ouellette was happy that her parents were there to witness the historic point because she knows the end of her illustrious career is near.
"It's been a great journey," said Ouellette. "I've loved every moment of it, inside and out. I still do. It's hard to be getting old and getting to the point where you start to think about transitioning out but it's going to be coming soon, unfortunately."
Despite Ouellette's exploits, there was still a game to be played. Blayre Turnbull gave the visitors the lead before the first frame would come to a close.
The second period fell largely in favour of the Inferno. Montreal did tie the game with a clean point shot by Lauriane Rougeau on a delayed penalty, while goaltender Charline Labonté was pulled for an extra attacker. However, celebrations were short-lived.
Bram scored her second of the afternoon at 13:15 of the second period, followed by a point shot goal by defender Brigette Lacquette.
"Unfortunately, today we had some really bad breakdowns," said Ouellette. "I think it was a little bit of turnovers and mental mistakes that led to goals. They have so much talent that they are going to capitalize if you give them too much."
Despite an early goal by Calgary's Sarah Davis just 1:14 into the third period, Les Canadiennes did not back down. Karell Emard scored just over two minutes later to make the score 5-3. From there, Montreal squandered high-quality scoring chances and spent long stretches in the opposing end—all for naught.
"We battled so hard in the third," said Ouellette. "We never gave up. We created so many chances. I had the puck on my stick a couple times and if I put it away, it could be a different game."
The game was also marked by physical play between the rival teams. The Inferno's Hayleigh Cudmore and Montreal's Sarah Lefort were each given 12 minutes of penalties for head contact midway through the second period.
Montreal's Kim Deschênes was also on the receiving end of a hard hit from Lacquette just as the second period was coming to an end. Les Canadiennes had no problem with the rough play.
"We have to expect that against teams like this, where most of the players are playing in the national team," said Bettez. "That's what they want over there. As long as it's clean, it's fair game. You have to keep your head up and be able to step up for that."
"It wasn't dirty, it was physical," said Ouellette. "We went hard after one another. That made for two good hockey games."
Thanks to the weekend split, Montreal remain atop the Canadian Women's Hockey League standings with 21 points, to Calgary's 20. The Inferno have two more games to play than Montreal, giving them an advantage. Four games remain between the two clubs before the regular season ends, two in Montreal and two in Calgary. The Inferno understand how important they will be.
"They are going to be crucial, especially if we wind up being tied for first," said Inferno head coach Scott Reid. "Every game in this league is important. We have some history now with Montreal. We have to be able to bring our A game or we aren't going to win."
Les Canadiennes now have three weeks off in their schedule before returning to action on Jan. 7 against the Blades in Boston.
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active 18 mins ago
Full name: Valdis Čeičs
Destinations: Lithuania, Latvia, Estonia
Lives in: Riga, Latvia
Company: Baltic Nature Travel
Specialties: Adventure tourism, walking and biking tours
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Valdis Čeičs
Riga is my home in the Baltic States (Latvia, Lithuania and Estonia). Backpacking in different parts of the world, I discovered that I like to talk about my city and the region's history, culture and nature. Guiding people and showing them the local culture, traditions and sights makes me happy and I like that I get to show people around this incredible undiscovered jewel – the Baltic States.
What places and activities do you specialize in?
"I specialize in planning culture and adventure tours. Do you want to learn about the traditional cooking like smoking fishes, ride bicycle through the country side, visit a local farm and taste home-made food? We know how it's to be a traveler and to make the travel itinerary so you have the best experience."
How did you get involved in travel?
"It all started in childhood going on family trips and skiing tours with my father. After graduating from the high school I chose tourism as my study field and committed to be a professional tour guide. In year 2012 started to organize and guide "Riga Free tour" but soon I started do city tours, bicycle tours and escort travels in the neighboring countries like Lithuania and Estonia, . But I always wanted to go for long walks, bike rides in wilderness and to show the local culture and nature. So with a group of friends came an idea to establish Baltic Nature Travel and to brings the guests behind the curtain and the off the beaten track. We can organize for you accommodation in small villages and country side where only few international guests arrive due to the language barrier and lack of information. Our travel escorts and tour guides are educated and experienced and with love will present you the sights and local culture."
Valdis is part of the following groups: Lithuania Travel Agents, Latvia Travel Agents, Estonia Travel Agents
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Riga and the Midsummer Festival - 5 Days
Experience local culture and traditions in Riga by enjoying its annual Midsummer Festival, starting with a walking tour of the historic city center and its renowned architecture. Then participate in traditional songs, dances, and sauna rituals with locals at the festival, sleeping in the tranquility of Gauja National Park. Learn about Baltic culture and traditions with an herbal workshop, a carpentry workshop, and a visit to the open-air ethnographic museum.
Bike Estonia's Cities and Countryside - 5 Days
This cycling tour takes you through cities and countryside, starting in Estonia's capital of Tallinn, where you'll discover its preserved medieval Old Town and 18th-century Kadriorg Park. Then cycle through Laheema National Park's bogland, plus ride along the shores of Lake Peipsi, visit the city of Tartu, and bike on Saaremaa Island, Estonia's largest island with a beautiful windmill park. End the tour with visits to the towns of Kuressaare, Haapsalu, and Nõva, plus one last cycle through the scenic Noatootsi Peninsula.
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On this quick, three-day tour of Lithuania anchored in Vilnius, you'll explore cultural sites, along with plenty of brewery tours and tastings along the way. You'll also attend a basketball game featuring the decorated BC Žalgiris team, visit a castle in Kaunas, and take a trip to the Biržai region, complete with its historical beer museum.
Nature & History in the Baltics - 9 Days
This 9-day tour provides the ultimate off-the-beaten-path adventure in Europe. Starting in Lithuania's historic capital, you'll travel west to the Baltic coast to bike and relax on sand dunes and pretty beaches. Then, continue to Latvia's capital where you'll explore medieval buildings and exquisite Art Nouveau architecture. Finish with some day-trips to impressive palaces and castles—as well as a gorgeous national park—before returning to cobblestoned Riga for a range of restaurants and cafes.
Tallinn Song and Dance Festival (July 2019) - 5 Days
Take part as Tallinn becomes the world capital of song and dance from July 4–7, 2019, when they host the XXVII Song and XX Dance Celebrations. This festival takes place every five years and has become a symbol of Estonian culture and identity, with thousands of singers and dancers participating. Pair it with visits to Tallinn's historic Old Town, museums, and culinary hotspots for a five-day cultural excursion you won't forget.
Highlights of the Baltic Capital Cities - 8 Days
Discover the capital cities of Lithuania, Latvia, and Estonia on this whirlwind 8-day trip through the Baltic states. As you travel north from Vilnius to Riga to Tallinn, you'll learn about each city's rich cultural, historic, and culinary traditions. Visit churches in Vilnius, indulge in a food tour in Riga, and explore the creative hub of Tallinn on this Northern European adventure.
Recent trip reviews for Valdis
Latvia, Estonia, Lithuania · Latvia - Jul 20 - Jul 29, 2019
Traveler: Annette P. - Local specialist: Valdis Čeičs
Overall we had a good trip. The private guides were all amazing! At times things felt a bit disjointed but our trip coordinator Ieva made herself available via WhatsApp so we could coordinate.


Makes ya wonder about how many volts are at the starter solenoid trigger wire for sure.
Oh and YES! snow down to sea level here in N Ca, and over 6 inches here at 1,500 feet!
Fellas, sorry for the long delay in response to this thread. As I mentioned last week, my daughter was sick and she was kind enough to share it with me. I was feeling like hell and I actually decided to stay home this morning, but as the day wore on I started feeling better and got bored. So out to the Jeep I went. I started by testing the voltage to my solenoid (0v), then starter relay wire-by-wire, as I was just *certain* that I had burned out a fusible link somewhere, well, apparently I hadn't.
, and it was from this video that I realized that my DAMN NEUTRAL SAFETY SWITCH was causing all my problems. Yes, I'll admit it, I was stupid and ruled out the NSS earlier in this thread. Well, I was wrong.
Ok, so seeing the 5v at ignition terminal is what tells us that we are having a problem - we shouldn't be seeing any voltage there, but because we are, we know the NSS is the problem.
So I won't go into the removal, cleaning, and rebuilding of the NSS because it's been done a lot elsewhere, and better than I could anyway, but suffice it to say, after I cleaned it and reinstalled it, the damn thing started right up upon the turn of the key. I do need to go back under there and readjust it some - my shifter is very tight, but that should be easy enough.
Moral of the story is; even if you think it's not your NSS, check it anyway.
Last edited by MayerMR; 02-11-2019 at 07:53 PM.
That was some good detective work. Congrats!! Glad you got it running and working like it should. You'll really appreciate it now that she's reliable again. I give you major kudos for persevering and thanks for sharing the image. I'm going to print it out for future reference.
I was planning on driving Ole Jeepie to work this morning and she cranked up perfectly - very satisfyingly, I might add. The shifter action was still hard, as I had expected, but I didn't *think* that it would have any affect on how the it drove. Well, I puttered down my alley like normal and as turned out onto the main street and began my trip to work. As I hit about 25-35 mph I started getting a shuddering and like, a clicking noise coming from the transmission. Best way I can describe the sound like like when you hear a relay opening and closing..."click click click click" while shuddering and not wanting to accelerate. Well I was running late already so I turned around and limped her home.
So - does this issue have to do with my poorly adjusted NSS or do I now have another problem??
BTW guys, I recently had a strange no-start situation (out of the blue). Turn key, not even a click. I know the batt is good, and other things had been looked at in the past.
What it took was a few taps on the starter with a long pry bar. Starter was stuck. It might be near the end of it's life. The point is, it's another trick that works on a lot of starters when they don't 'go'. Especially GMs. The best approach is to get under the vehicle and tap with a hammer handle (not the head). But I was lazy at that moment!
Flintstone/Cruiser - Thank you both for tag-teaming to get me the response. I wonder what is going on with DF's account? I looked around and it doesn't appear there is any way I (or anyone as far as I can tell) would be able to block him from this thread.
That said, I really appreciate the feedback and assistance!
Perhaps he has his tin foil hat on while posting????
Did you get a chance to solve this yet?
I did, yes. A couple of posts above explains my dumbassery.
Ok everyone, final update! I went out today and re-adjusted my NSS and we're back in business. The bucking in the transmission was definitely caused by the overly tight NSS nut. After loosening and readjusting then we were good to go!
A big THANK YOU to all of you for your assistance with my issue and helping me get back on the street!
Fellas, I need some input.
hey fellas, lookin to downsize from ur 37s with decent tread?


Follow Me Down by Tanya Byrne.
Tanya was my favourite debut author last year. Her debut Heart-Shaped Bruise was definitely my favourite UKYA. So I can't wait to read her second novel which is published by Headline in May.
This book does sound awesome! Great pick Viv!
Gorgeous cover :) I think it looks fabulous!


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To find out about current properties available to rent, please contact us or call 0141 944 6544.


text:
From the Industrial Revolution to World War I, C. 1850–1914
What is Impressionism?
Impressionism is an artistic style that developed first in France in the latter half of the nineteenth century and is known for a somewhat unfinished quality, as well as a focus on leisure and café scenes, landscapes, cityscapes, and genre scenes. Like the Realists, the Impressionists were interested in capturing visual reality, but they were particularly interested in the properties of light, both natural and artificial. Artists such as Claude Monet studied changes in the colors of the atmosphere as the sun moved through the sky. Recent rainfall intrigued artists like Gustave Caillebotte and Camille Pissarro, who both painted natural light and light from gas lamps that reflected off the rain-soaked streets of Paris. Most Impressionists came from middle or upper class French families, but because their work was initially unpopular, they often lived in poor neighborhoods in Paris, frequently gathering at the Café Guerbois in the Montmartre district. The popularity of leisure and café scenes is a tribute to the lifestyle of the Impressionists.
The Impressionists had a difficult time being accepted by both art critics and the art-viewing public, and were regularly rejected from exhibitions at the Palais de Beaux Arts (Palace of Fine Arts). Instead, they held their own shows between 1874 and 1886, and ended up having an enormous influence on modern art. Today, impressionism continues to be one of the most popular styles of painting and sculpture and impressionist shows attract thousands of visitors to museums and galleries around the world.
This is a web preview of the "The Handy Art History Answer Book" app. Many features only work on your mobile device. If you like what you see, we hope you will consider buying. Get the App


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text:
class BoxStartupDescription < ActiveRecord::Migration
  def up
    add_column "boxes", "startup_description", :text
    Box.reset_column_information

    [
      ["customer_segments", "List your target customers and users"],
      ["value_propositions", "A concise statement that describes why customers will fall in love with your product"],
      ["channels", "The ways you will reach your customers"],
      ["customer_relationships", "What do you have that your competitors don't?"],
      ["revenue_stream", "List your sources of revenue"],
      ["key_resources", "List the metrics that will tell you the health of your business"],
      ["key_activities", "List a solution for each problem"],
      ["key_partners", "List the problems that you are trying to solve"],
      ["cost_structure", "List all of the costs associated with your business"],
    ].each do |name, description|
      Box.find_by_name(name).update_attributes!(:startup_description => description)
    end
  end

  def down
  end
end


text:
Real Estate Property Services Innovator Lessen Closes $35 Million Series A Funding Round
Marketplace Platform Receives Investment From Top VCs, Delivering Automation and Scale to Property Services Sector
SCOTTSDALE, Ariz.--(BUSINESS WIRE)--Lessen, the marketplace platform that unites property owners and service professionals to deliver property services better, faster and cheaper than ever before, today announced that it has closed a $35 million Series A funding round.
The Series A is being led by Fifth Wall, the largest venture capital firm focused on technologies for the global real estate industry. Seed-round investors in Lessen, including Khosla Ventures, General Catalyst and Navitas Capital, also participated in the company's Series A, bringing total capital invested in Lessen to $44 million. Proceeds from the current investment will be used to fund new technology products, support new field operations teams, and facilitate market expansion. Dan Wenhold, a partner at Fifth Wall, will join Lessen's Board of Directors.
Lessen modernizes the real estate industry with technology that delivers a comprehensive, end-to-end solution for property services. Lessen saves all parties time and money by replacing outdated manual processes and spreadsheets with centralized project and work order management, as well as integrated dashboards, billing and analytics.
Lessen's platform is flexible, efficient and service professional-friendly. It provides a well-defined and consistent job flow for service pros, incorporating fast and guaranteed payments for completed work, as well as tools that providers can use to quickly grow their businesses.
The platform currently has more than 1,000 service providers, across 26 markets, which have completed more than 2,000 jobs for institutional investors of single-family residential, multifamily residential, and short-term rental properties.
"We're ecstatic about partnering with a team of world-class investors to build and grow the future of real estate property services," said Jay McKee, Founder and CEO of Lessen. "The industry is poised for a revolution in the way that property services are performed, delivered and managed at scale."
He continued, "Lessen is excited about building a platform that will enable service professionals to increase earnings and reduce stress, while allowing property owners to lower their costs and completely outsource property management concerns."
"The pandemic has supercharged growth in the single-family rental market, with no sign of slowing down, yet landlords lack the technology needed to effectively manage maintenance across their portfolios at scale," said Dan Wenhold of Fifth Wall. "Lessen stands alone in its approach, offering a streamlined solution to the entire property services lifecycle. We believe the opportunity for Lessen is massive, and we're thrilled to support the company through this next phase of its evolution and beyond."
"Khosla Ventures backs great teams in large markets, and we found both with Lessen," commented David Weiden, Managing Director at Khosla Ventures. "Jay brings a rare combination of deep industry experience and a vision for how it can transform. Lessen brings a similar set of on-demand marketplace services to residential real estate we see in other investments in our portfolio such as DoorDash and Stripe."
"Lessen is creating agility and opportunity for property owners, reliable and smoother work for professionals, and better experiences for tenants," said Quentin Clark of General Catalyst. "We are thrilled to continue partnering with Jay and the entire Lessen team as they scale the solutions they are building to empower owners, managers and employees."
"Demand for the services solutions Lessen brings is large, growing and clear to real estate operators, but finding a team with the industry knowledge and technical skill to deliver is rare," said Louis Schotsky, Managing Partner at Navitas Capital. "The combination instantly stood out to us as a compelling investment."
About Lessen
Lessen is the marketplace platform that unites property owners and service professionals to deliver property services better, faster and cheaper than ever before. The Lessen platform provides complete job workflow and outsourcing of property service projects, automating the management of the entire property services lifecycle. It seamlessly connects property owners to a nationwide network of vetted professionals for renovation, maintenance, cleaning, and turn services, efficiently delivering property services at scale. Lessen is a venture-backed, privately held company based in Scottsdale, Arizona, with offices in Seattle and Miami. To learn more, please visit lessen.com.
Joe Casados
Joe@bospar.com
Lessen today announced that it has closed a $35 million Series A funding round.
#venturecapital
#proptech
#serviceprovider
#SeriesA


text:
Cacosternum nanum és una espècie de granota que viu a Sud-àfrica, Swazilàndia i, possiblement també, Lesotho i Moçambic.

Referències
 Channing, A., Minter, L. & Scott, E. 2004. Cacosternum nanum. Llista Vermella d'Espècies Amenaçades de la UICN 2006. Consulta: 7 d'abril del 2008.

Nanum

redpajama_set_name: RedPajamaWikipedia


Jerry's Service Center provides Ball Joint Replacement services to Norfolk, NE, Madison, NE, Battle Creek, NE, and other surrounding areas.
Why Should You Have Ball Joint Replacement Services Performed at Jerry's Service Center?
We proudly service the Ball Joint Replacement needs of customers in Norfolk, NE, Madison, NE, Battle Creek, NE, and surrounding areas.


WHILL, Inc. (WHILL) is excited to announce that we're taking our vision for comfortable and intelligent personal mobility to CES 2017. Our latest initiative, WHILL Rental, launches in partnership with Scootaround as a new service category for the 150,000+ conference attendees. Our mission is to transform the CES experience by making our next-gen fleet of personal electric vehicles readily available and easy for anyone to drive.
Attendees can stop by our booth outside FedEx in the North/Central Hall from January 5th through 8th to rent a WHILL Model A personal mobility device. Featuring an innovative and award-winning design, Model A is compact and agile for busy event spaces that require nimble movement. Our unique omni-wheel technology also makes Model A versatile for transitions to the outdoors and sidewalk/road terrain.
We're proud to debut this new program alongside Scootaround, one of North America's top personal mobility solution companies. Scootaround has been focused on developing solutions for travelers requiring personal mobility equipment since 1997. For a quick overview of the program, please see our booth information below.
Available at CES 2017, which runs Jan. 5-8, 2017, in Las Vegas, Nevada.


CINCINNATI, March 18, 2019 /PRNewswire/ -- Workhorse Group Inc. (NASDAQ:WKHS) ("Workhorse" or "the Company"), an American technology company focused on providing sustainable and cost-effective electric-mobility solutions to the transportation sector, today reported financial results for the fourth quarter and full year ended December 31, 2018.
December 2018: Secured $35 million financing from Marathon Asset Management.
November 2018: Announced strategic partnership with Duke Energy Corporation. Duke intends to explore further development of eFleet solutions to Workhorse customers which may include single-point management and financing of all the Behind The Meter (BTM) infrastructure necessary to support depot-wide electrification, vehicle and battery leasing and distributed energy resources. Duke and Workhorse believe a seamless, integrated solution will help reduce the overall costs of converting fleets to electric power, enabling faster adoption of electric vehicles into commercial fleets.
October 2018: Initiated build of N-GEN 1000 prototype test vehicles.
October 2018: Secured purchase order from DHL.
October 2018: Backlog of N-GEN vehicles grew to more than 1,100 units.
April 2018: Deployed N-GEN-450 manufacturer test vehicles on real-world, live delivery routes in San Francisco, CA and Cincinnati, OH.
February 2018: W.B. Mason deployed a Workhorse electric delivery vehicle at Princeton University, marking the first delivery ever made to campus by an all-electric truck.
December 2018: Performed live HorseFly package deliveries in Detroit, MI with partner StockX.
May 2018: Workhorse, the Federal Aviation Administration (FAA), and city of Loveland, OH, began a pilot HorseFly package delivery program.
April 2018: Workhorse announced that the United States Patent and Trademark Office (USPTO) had issued a patent for the HorseFly Truck Launched Drone Package Delivery System.
"While the fourth quarter and 2018 as a whole were a challenging time for our business, we've entered the new year with a different attitude and focus on improving our operational capabilities," said Workhorse CEO Duane Hughes. "At the end of 2018, we secured a $35 million revolving loan facility, which has allowed us to repay all previously outstanding debt obligations and also provides funding towards building and delivering vehicles to customers in this calendar year. More specifically, this facility allows us to shift away from our historical method of using equity funding to buy parts and further enables us to reduce our dependence on equity sourcing and its dilutive nature. Looking ahead, our primary goal is the profitable manufacturing and delivery of the electric vehicles we currently have in our significant backlog."
Sales for the fourth quarter of 2018 were recorded at $21,000, down from $5.2 million in the fourth quarter of 2017. The decrease in sales was primarily due to a decrease in volume of trucks delivered.
Selling, general and administrative expenses increased 80% to $2.7 million from $1.5 million in the same period last year. Expenses in the fourth quarter of 2017 were favorably impacted by the reversal of pre-Q4 2017 accruals. Excluding the benefit in 2017 related to the reversals, SG&A expenses in the fourth quarter of 2018 remained consistent compared to the same period last year.
Research and development expenses decreased 52% to $1.7 million from $3.6 million in the fourth quarter of 2017. The decrease in research and development expenses was due primarily to lower spending related to the US Postal Service (USPS) Next Generation Delivery Vehicle (NGDV) and SureFly.
Total operating expenses decreased 13% to $4.4 million from $5.1 million in the same period last year. The decrease in total operating expenses was due to lower R&D spending related to the initiatives previously mentioned.
Net loss was $17.7 million, compared with a net loss of $11.7 million in the fourth quarter of 2017. The change in net loss was due primarily to an increase in warranty reserve.
As of December 31, 2018, the company had cash, cash equivalents and short-term investments of $1.5 million compared to $4.1 million as of December 31, 2017.
Sales for the full year 2018 were $763,000, compared to $10.0 million in 2017. The decrease in sales was primarily due to a decrease in volume of trucks delivered.
Selling, general and administrative expenses for the full year 2018 increased 30% to $11.5 million from $8.8 million in the same period last year. The increase in selling, general and administrative expenses was due primarily to the reversal of accrued expenses in 2017 that were accrued in prior years and higher spending in 2018 for advertising, investment banking fees, and legal settlement.
Research and development expenses for the full year 2018 decreased 58% to $7.4 million from $17.7 million in 2017. The decrease in research and development expenses was due primarily to lower spending related to the USPS NGDV and SureFly.
Total operating expense for the full year 2018 decreased 29% to $18.9 million from $26.6 million in the same period last year. The decrease in total operating expenses was due to lower R&D spending related to the initiatives previously mentioned.
Net loss for the full year 2018 was $36.5 million, compared with a net loss in 2017 of $41.2 million. The improvement in net loss was due primarily to a decrease in R&D spending.
Workhorse management will hold a conference call today (March 18, 2019) at 10:00 a.m. Eastern time (7:00 a.m. Pacific time) to discuss these results.
Workhorse management will host the presentation, followed by a question and answer period.
The conference call will be broadcast live and available for replay here and via the Investor Relations section of Workhorse's website.
A replay of the conference call will be available after 4:00 p.m. Eastern time on the same day through March 25, 2019.
Workhorse is a technology company focused on providing electric mobility solutions to the transportation sector. As an American original equipment manufacturer, we design and build high performance battery-electric vehicles including trucks and aircraft. Workhorse also develops cloud-based, real-time telematics performance monitoring systems that are fully integrated with our vehicles and enable fleet operators to optimize energy and route efficiency. All Workhorse vehicles are designed to make the movement of people and goods more efficient and less harmful to the environment. For additional information visit workhorse.com.
This press release includes forward-looking statements. These statements are made under the "safe harbor" provisions of the U.S. Private Securities Litigation Reform Act of 1995. These statements may be identified by words such as "believes," "expects," "anticipates," "estimates," "projects," "intends," "should," "seeks," "future," "continue," or the negative of such terms, or other comparable terminology. Forward-looking statements are statements that are not historical facts. Such forward-looking statements are subject to risks and uncertainties, which could cause actual results to differ materially from the forward-looking statements contained herein. Factors that could cause actual results to differ materially include, but are not limited to: our limited operations and need to expand in the near future to fulfill product orders; risks associated with obtaining orders and executing upon such orders; the ability to protect our intellectual property; the potential lack of market acceptance of our products; potential competition; our inability to retain key members of our management team; our inability to raise additional capital to fund our operations and business plan; our inability to satisfy covenants in our financing agreements; our inability to maintain our listing of our securities on the Nasdaq Capital Market; our inability to satisfy our customer warranty claims; our ability to continue as a going concern; our liquidity and other risks and uncertainties and other factors discussed from time to time in our filings with the Securities and Exchange Commission ("SEC"), including our annual report on Form 10-K filed with the SEC. Workhorse expressly disclaims any obligation to publicly update any forward-looking statements contained herein, whether as a result of new information, future events or otherwise, except as required by law.


As cool autumnal air sweeps across the northern hemisphere, so begins Morocco's most enchanting season – balmy yet relieved of summer's heavy heat, with snow-capped mountains lining the horizon and a russet rainbow dressing the trees. It remains remarkably good-value, too, with affordable flights and many a homely riad in which to lay your hat.
Those who've done Marrakech and yearn to see a more authentic side of urban Morocco will love the city's quieter older sibling. Fes is the country's oldest imperial city, and home to some of North Africa's finest mosques and medersas (Islamic schools). It also has Morocco's largest intact medina, where 10,000 labyrinthine alleys hold countless curiosities (and Christmas shopping opportunities!).
According to Skyscanner, flights from London Stansted to Fes start from just £33 in November and £31 in December. Once you arrive, most riads can provide transfers for a reasonable rate (much easier than attempting to drive or take public transport into the city).
Fes is rich in affordable yet ornately decorated riads, many displaying spellbinding tadelakt tiling and intricate carvings. One such offering is Dar Roumana, which has a prime position in the northern medina and whose rooms start from just £76 in November. The roof terrace is a lovely space for post-souk relaxation, with sheltered seating and a raised crow's nest – dinner under the stars is not to be missed.
The famous Bab Bou Jeloud ('Blue Gate') marks the entrance to the warren-like medina. From here, the only permitted modes of transport are mules and horses. There's a sense of stepping back in time as you wander the little craft shops, unexpectedly intricate townhouses, abandoned palaces and still-vibrant medersas. While exploring, try to find your way to the Place an-Nejjarine to visit the Museum of Arts and Crafts and one of the city's most ancient funduqs (caravansaries).
If the medina starts to feel a bit claustrophobic, head just outside the walls to the Jardin Jnan Sbil. The manicured garden displays exemplary Moroccan symmetry with water features, palms and birds, and is a wonderful haven of calm.
If relaxation is on your mind, experience the delights of Riad Laaroussa's fabulous hammam. It's one of the city's best, and we can personally recommend the savon noir scrub followed by an essential-oil massage. Heavenly.
See our Insider's Guide for more local recommendations and browse our collection of boutique hotels in Fes.


text:
Rustlers Leads The Way As Kepak Unveils Plans To Double Sales
Kepak Convenience Foods has announced a £multi million investment to double sales in the convenience channel in the next three years.
The UK's leading supplier of micro snacks, and the driving force behind the fast-growing hot, quick & tasty category, has targeted annual sales in convenience of £66 million by 2018.
The move follows the launch last year of Rustlers Super 6 – a range of Rustlers top-selling SKUs all price-marked at £1.99 which already accounts for more than 40% of all sales within the micro-snacking market of 60 SKUs.
In addition to TV advertising (for the 14th successive year), innovative NPD, a new look for Rustlers and major on-pack activity this year, Kepak is increasing the size of its convenience sales force and stepping-up its face-to-face contact with wholesalers and retailers.
Rustlers, the UK's best-selling micro snack, will benefit from a major overhaul this year, including the introduction of a refreshed logo and new packaging to reflect the brand's growing male and female consumer base.
"Young lads can no longer make an exclusive claim on Rustlers," says John Armstrong, Kepak's Marketing Director.
Rustlers has evolved and has attracted lots of new consumers, so much so that 40% of Rustlers consumers are female and the age profile of Rustlers' consumers now stretches from 16 to 34-year-olds.
"This is really good news for retailers. With more consumers than ever before buying Rustlers, there's never been a better time to stock the brand, particularly as we're now embarking on an accelerated growth programme."
Kepak is starting from a position of real strength as 23 per cent of the company's sales are in the convenience channel (excluding Co-ops and major mults) vs. a grocery average of 7.7 per cent.
"The even better news is that currently only one in four of our core target market buys micro snacks regularly, so the potential is huge. However, we must plug the distribution gaps and work with more retailers to show the sales uplift they can achieve by selling micro-snacks and merchandising them effectively," adds Armstrong.
"Micro snacks are already amongst the top-performing SKUs in the chiller cabinet, but there's still an education job to be done.
"Our core target market of 16 to 34-year-olds are true convenience channel shoppers. They plan less, shop more frequently and are of course heavily into snacking, whether it's young adults buying for themselves or parents buying for older children still living at home."
"The combination of increased resource and focus on the convenience channel, major TV advertising, on-pack promotional activity, a new-look and innovative NPD will drive demand for Rustlers to new heights this year, ensuring that we're well on track to double our sales in convenience in the next three years," adds Armstrong.
"It's an exciting time for Rustlers and we want as many retailers as possible to join us as we double the brand size and reinforce Rustlers role as a true champion of chilled FMCG."
Hot Quick & Tasty, Rustlers
← A Merry Rustlers Christmas!
Kepak Turns up The Heat With Launch of New Limited Edition Hot & Kicking Range →


In the final installment of my Epic National Park Roadtrips series, I am going to focus on a road trip that highlights some of the best national parklands that the state of California has to offer. Not only is the state of California one of America's biggest states, but it is also one of the country's most beautiful. For that reason, it should come as no surprise that California is tied with the state of Alaska for the most national parks in the United States with eight.
In this fourth part of my Epic National Parks Road Trips series, I am going to walk you thru a road trip itinerary that takes you thru some of America's most stunning national parklands. The Pacific Northwest is renown for its wildness and its beauty and the national parks that are found in the Pacific Northwest of the United States are no different. They are wild and they are beautiful.
In this third installment of my Epic National Parks Road Trips series, I will be talking to you about an itinerary that takes you thru some of the most remarkable desert mountains and caves in the Southern United States. As you make your way thru the states of Texas, New Mexico, and Arizona, you will see one of the largest cave systems in the world, one of the biggest cactus species in the world, and beautiful mountains and rivers that have shaped the American Southwest.
The next epic road trip in my five-part series is an amazing trip thru the American Southwest. The Southwest is one of the most unique and beautiful areas of the United States, and undoubtedly my favorite part of the country. With breathtaking canyons, beautiful forests, and stunning desert landscapes, the canyon region of Southern Utah and Northern Arizona is an absolute must-see for any outdoor enthusiast. In this epic road trip, you will get to see the best that this region of the United States has to offer.
The first epic national parks road trip in my series covers some of the most well-known and popular national parks and monuments in the United States. After flying into Rapid City, South Dakota and renting a car, you will start exploring almost immediately. With the Badlands National Park and Mount Rushmore in the Rapid City area, you will get your first taste of America's national parks and monuments right at the start.