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Public Health Pratice • Rev. Saúde Pública 49 11 Aug 2015 • https://doi.org/10.1590/S0034-8910.2015049005447 copy
Budget impact from the incorporation of positron emission tomography – computed tomography for staging lung cancers
Aline Navega Biz
Programa de Pós-graduação em Saúde Coletiva. Instituto de Medicina Social. Universidade do Estado do Rio de Janeiro. Rio de Janeiro, RJ, Brasil
Rosângela Caetano
Departamento de Planejamento e Administração em Saúde. Instituto de Medicina Social. Universidade do Estado do Rio de Janeiro. Rio de Janeiro, RJ, Brasil
To estimate the budget impact from the incorporation of positron emission tomography (PET) in mediastinal and distant staging of non-small cell lung cancer.
The estimates were calculated by the epidemiological method for years 2014 to 2018. Nation-wide data were used about the incidence; data on distribution of the disease´s prevalence and on the technologies' accuracy were from the literature; data regarding involved costs were taken from a micro-costing study and from Brazilian Unified Health System (SUS) database. Two strategies for using PET were analyzed: the offer to all newly-diagnosed patients, and the restricted offer to the ones who had negative results in previous computed tomography (CT) exams. Univariate and extreme scenarios sensitivity analyses were conducted to evaluate the influence from sources of uncertainties in the parameters used.
The incorporation of PET-CT in SUS would imply the need for additional resources of 158.1 BRL (98.2 USD) million for the restricted offer and 202.7 BRL (125.9 USD) million for the inclusive offer in five years, with a difference of 44.6 BRL (27.7 USD) million between the two offer strategies within that period. In absolute terms, the total budget impact from its incorporation in SUS, in five years, would be 555 BRL (345 USD) and 600 BRL (372.8 USD) million, respectively. The costs from the PET-CT procedure were the most influential parameter in the results. In the most optimistic scenario, the additional budget impact would be reduced to 86.9 BRL (54 USD) and 103.8 BRL (64.5 USD) million, considering PET-CT for negative CT and PET-CT for all, respectively.
The incorporation of PET in the clinical staging of non-small cell lung cancer seems to be financially feasible considering the high budget of the Brazilian Ministry of Health. The potential reduction in the number of unnecessary surgeries may cause the available resources to be more efficiently allocated.
Positron-Emission Tomography, economics; Carcinoma, Non-Small-Cell Lung, therapy; Health Care Costs; Budgets; Unified Health System
Economic evaluation of diagnostic and therapeutic interventions is gaining importance to support decisions concerning the incorporation and dissemination of new health care technologies.2222 Vianna CMM, Caetano R. Avaliações econômicas como um instrumento no processo de incorporação tecnológica em saúde. Cad Saude Colet.2005;13(3):747-66. Those analyses, however, do not provide all necessary information for decision-making, as they do not assess the feasibility for the introduction of the best alternative considering available budgets.1111 Hilden J. Budget impact analysis and its rational basis. Med Decis Making. 2008;28(4):460-1. DOI:10.1177/0272989X08321903The further conduction of budget impact analyses to evaluate short and medium-term financial consequences regarding the incorporation, changed use, or withdrawal of a technology from the set of available interventions in the health care system is required.22 Brosa M, Gisbert R, Rodríguez JM, Soto, J. Principios, métodos y aplicaciones del análisis del impacto presupuestario en el sector sanitario.Pharmaco Econ Spa Res Art. 2005;2(2):64-78. DOI:10.1007/BF03320900,88 Ferreira-da-Silva AL, Ribeiro RA, Santos VCC, Elias FTS, d'Oliveira ALP, Polanczyk CA. Diretriz para análises de impacto orçamentário de tecnologias em saúde no Brasil. Cad Saude Publica. 2012;28(7):1223-38. DOI:10.1590/S0102-311X2012000700002
Brazil reports a high number of lung cancer cases: 27,330 new cases are estimated for 2014.aa Ministério da Saúde. Instituto Nacional de Câncer. Estimativa 2014: incidência de câncer no Brasil. Rio de Janeiro (RJ); 2014. Non-small cell lung carcinomas (NSCLC) account for 75.0%-85.0% of cases, which can be potentially cured with surgical resection in the localized disease.55 Devaraj A, Cook GJ, Hansell DM. PET/CT in non-small cell lung cancer staging-promises and problems. Clin Radiol. 2007;62(2):97-108. DOI:10.1016/j.crad.2006.09.015,bb Caetano R, Biz AN, Bastos CRG, Garay OU, Schluckebier L. Avaliação econômica: análise de custo-efetividade do uso da 18FDG-PET/TC no estadiamento do câncer pulmonar de células não pequenas: relatório preliminar de pesquisa. Rio de Janeiro (RJ): Instituto de Medicina Social da UERJ; 2013. Often, the diagnosis is achieved in advanced stages. Thus, due to the disease spread to mediastinal lymph nodes or distant metastases at the time of diagnosis, only 20.0% of patients are considered operable.cc National Collaborating Centre for Cancer. Lung cancer. The diagnosis and treatment of lung cancer. London: NICE; 2011 [cited 2012 Oct 10] (Nice Clinical Guidelines; 121). Available from: http://www.ncbi.nlm.nih.gov/books/NBK99021/
Evaluating the disease extension at the diagnosis is essential for defining therapies. That avoids improper procedures which can influence patients' survival and quality of life. The clinical staging is mainly conducted by means of computed tomography of the thorax and upper abdomen (CT of thorax), according to the clinical guidelines for the diagnosis and treatment of lung cancer, as disclosed by the Brazilian Ministry of Health (MH) in 2012.dd Ministério da Saúde. Portaria nº 600, de 26 de junho de 2012. Aprova as diretrizes diagnósticas e terapêuticas do câncer de pulmão. Diário Oficial União. 28 Jun 2012;Seção1:210. That exam is mainly based in morphological changes.
Positron emission tomography (PET) which is either combined to computed tomography (PET-CT) or not, is based on metabolic activity, rather than only on anatomical aspects. Both are more accurate than conventional imaging techniques in the evaluation of mediastinal and in distant areas involvement.55 Devaraj A, Cook GJ, Hansell DM. PET/CT in non-small cell lung cancer staging-promises and problems. Clin Radiol. 2007;62(2):97-108. DOI:10.1016/j.crad.2006.09.015 Its inclusion in the traditional diagnostic strategies may result in better management of cases, with reduced numbers of unnecessary surgeries2121 van Tinteren H, Hoekstra OS, Smit EF, van den Bergh JH, Schreurs AJ, Stallaert RA, et al. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet.2002;359(9315):1388-93. DOI:10.1016/S0140-6736(02)08352-6,2323 Viney RC, Boyer MJ, King MT, Kenny PM, Pollicino CA, McLean JM, et al. Randomized controlled trial of the role of positron emission tomography in the management of stage I and II non-small-cell lung cancer. J Clin Oncol. 2004;22(12):2357-62. DOI:10.1200/JCO.2004.04.126 and decreased morbidity and mortality. Another advantage would be staging the lung disease and distant metastases with a single exam.1414 Nguyen VH, Peloquin S, Lacasse Y. Cost-effectiveness of positron emission tomography for the management of potentially operable non-small cell lung cancer in Quebec. Can Respir J.2005;12(1):19-25.
PET is starting to be disseminated in Brazil, and it was included in the Brazilian Unified Health System (SUS) payrolls for procedures in April 2014.ee Ministério da Saúde. Portaria nº 7, de 22 de abril de 2014. Torna pública a decisão de incorporar o PET-CT no estadiamento clínico do câncer de pulmão de células não-pequenas potencialmente ressecável no Sistema Único de Saúde - SUS.Diário Oficial União. 23 Abr 2014;Seção1:78. The economic evaluation for the use of PET-CT in the staging of NSCLC, conducted for the MH in 2013, found that PET-CT is more cost-effective when compared to the currently offered management strategy, which is CT-based.bb Caetano R, Biz AN, Bastos CRG, Garay OU, Schluckebier L. Avaliação econômica: análise de custo-efetividade do uso da 18FDG-PET/TC no estadiamento do câncer pulmonar de células não pequenas: relatório preliminar de pesquisa. Rio de Janeiro (RJ): Instituto de Medicina Social da UERJ; 2013. The results confirm international findings,44 Cao JQ, Rodrigues GB, Louie AV, Zaric GS. Systematic review of the cost-effectiveness of Positron-Emission Tomography in staging of non-small-cell lung cancer and management of solitary pulmonary nodules. Clin Lung Cancer. 2012;13(3):161-70. DOI:10.1016/j.cllc.2011.09.002which show benefits in its inclusion for the staging of NSCLC patients, mainly for preventing unnecessary surgeries, that pay off for the additional costs for using of the new technology.
The study from 2013 did not evaluate the financial impacts from offering the procedure in Brazil's public health care service network. Budget impact analyses are scarce in Brazil, especially concerning diagnostic imaging. In a health care system which is set to offer universal and comprehensive care, the concern with using resources is shown to be important considering the dichotomic relationship among budget availability, extension of care, and continuous advancements in technology.
This study aimed to estimate the budget impact of the inclusion of PET-CT in the mediastinal and distant staging of non-small cell lung cancer.
The budget impact estimation has adopted SUS's perspective as a financing agent of health care services, as indicated by the Brazilian guideline.ff Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Diretrizes metodológicas: análise de impacto orçamentário: manual para o Sistema de Saúde do Brasil. Brasília (DF); 2012.
The chosen horizon was a five-year one (2014 to 2018), considering the possible morosity in the reallocation of government budgets and restrictions in the availability and access to PET-CT.
The projected use of PET-CT was conducted under the epidemiological method. Eligible patients correspond to all newly-diagnosed cases. Thus, estimates for numbers of lung cancer cases for 2006 to 2014 were used, as disclosed by the Brazilian National Cancer Institute (INCA) (Table 1), with 85.0% of total cases assigned to NSCLC histological type.55 Devaraj A, Cook GJ, Hansell DM. PET/CT in non-small cell lung cancer staging-promises and problems. Clin Radiol. 2007;62(2):97-108. DOI:10.1016/j.crad.2006.09.015 The number of new cases were estimated by admitting a 75.0% coverage for the SUS-supported patient population.gg Agência Nacional de Saúde Suplementar. Caderno de informação da Saúde Suplementar: beneficiários, operadoras e planos. Rio de Janeiro (RJ); 2013.
Cases of lung cancer and NSCLC, from 2006 to 2014, and the projected number of new NSCLC cases, from 2006 to 2014, and the ones handled by the Brazilian Unified Health System, from 2014 to 2018.
Three analysis scenarios were defined: reference (strategies of management that are widely used, based on CT of thorax for all patients); alternative 1 (use of PET-CT restricted to patients with previous negative CT results, allowing for coverage of situations with more limited access to PET-CT); alternative 2 (use of CT and PET-CT for all cases, with further clinical management being defined by the combined results of the two exams – only patients with both negative images would directly proceed to pulmonary resection). This last strategy yielded a higher reduction in the number of unnecessary surgeries in the cost-effective study used as basis,bb Caetano R, Biz AN, Bastos CRG, Garay OU, Schluckebier L. Avaliação econômica: análise de custo-efetividade do uso da 18FDG-PET/TC no estadiamento do câncer pulmonar de células não pequenas: relatório preliminar de pesquisa. Rio de Janeiro (RJ): Instituto de Medicina Social da UERJ; 2013. with small differences in the incremental cost-effectiveness ratio between the two usage methods for PET-CT in the conducted sensitivity analyses.
Only direct costs of procedures involved in the staging and therapies of patients were considered (Table 2). As the PET-CT procedure was not included in SUS payrolls when the analyses were conducted, we used values as estimated by micro-costing.33 Caetano R, Schluckebier L, Bastos CRG, Silva RM, Carneiro MP, Silva JWE, et al. Análise dos custos do procedimento PET-TC com 18F-FDG na perspectiva do SUS provedor: estudo em uma unidade pública de saúde do Rio de Janeiro, Brasil. Cad Saude Publica. 2014;30(2):379-392 DOI:10.1590/0102-311X00016413 The values were calculated again to have a 30.0% reduction in the F18-fluoro-2-deoxy-D-glucose costs (18FDG),hh Ministério da Ciência, Tecnologia e Inovação. Comissão Nacional de Energia Nuclear (CNEN). Relatório de Gestão do Exercício de 2011. Rio de Janeiro (RJ); 2012. to consider the recent increase in the number of private input producers which took place when the Federal Government lost its monopoly for radiopharmaceuticals in 2006. For all procedures figuring in SUS payroll charts, values regarding November 2013 were used, which were listed in SUS Management System for the Chart of Procedures, Medications, and Orthoses, Prosthetics, and Special Materials.iiMinistério da Saúde. Departamento de Informática do SUS (DATASUS). Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS (SIGTAP). Brasília (DF); 2013 [cited 2013 Nov 25]. Available from: http://sigtap.datasus.gov.br/tabela-unificada/app/sec/inicio.jsp
Cost parameters (in PPP-adjusted US$, as per 2013 rates)*, accuracy, and epidemiological data that were used in the budget impact analysis and data source.
For the budget impact estimates, the same decision trees and parameters that were used in the cost-effectiveness study, conducted for MH in 2013, were used again here.bb Caetano R, Biz AN, Bastos CRG, Garay OU, Schluckebier L. Avaliação econômica: análise de custo-efetividade do uso da 18FDG-PET/TC no estadiamento do câncer pulmonar de células não pequenas: relatório preliminar de pesquisa. Rio de Janeiro (RJ): Instituto de Medicina Social da UERJ; 2013. The new cases projected for each year and the costs of procedures fed the trees related to each analysis scenario, which generated estimates for quantities of conducted procedures and total costs associated to that target population. The yearly budget impacts and the budgets for the period between 2014 and 2018 were calculated for each scenario. No discounts rates or values regarding adjust for inflation were introduced, in compliance to international11 Alzahouri K, Lejeune C, Woronoff-Lemsi MC, Arveux P, Guillemin F. Cost-effectiveness analysis of strategies introducing FDG-PET into the mediastinal staging of non-small-cell lung cancer from the French healthcare system perspective. Clin Radiol. 2005;60(4):479-92. DOI:10.1016/j.crad.2004.10.01022 Brosa M, Gisbert R, Rodríguez JM, Soto, J. Principios, métodos y aplicaciones del análisis del impacto presupuestario en el sector sanitario.Pharmaco Econ Spa Res Art. 2005;2(2):64-78. DOI:10.1007/BF03320900,1313 Mauskopf JA, Sullivan SD, Annemans L, Caro J, Mullins CD, Nuijten M, et al. Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices - budget impact analysis.Value Health. 2007;10(5):336-47. DOI:10.1111/j.1524-4733.2007.00187.x,1616 Orlewska E, Mierzejewski P. Proposal of Polish guidelines for conducting financial analysis and their comparison to existing guidance on budget impact in other countries. Value Health. 2004;7(1):1-10. DOI:10.1111/j.1524-4733.2004.71257.x and nationalff Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Diretrizes metodológicas: análise de impacto orçamentário: manual para o Sistema de Saúde do Brasil. Brasília (DF); 2012. guidelines for this type of study.
The incremental budget impact for each examined year was calculated by means of the difference between the total budget impacts for the alternative and reference scenarios. The incremental difference among the alternative strategies was evaluated, which enabled the analysis of a wider and more restricted offer of technology.
Univariate and extreme scenarios sensitivity analyses were conducted to consider the uncertainties related to parameter values and premises used.1515 Nuijten MJC, Mittendorf T, Persson U. Practical issues in handling data input and uncertainty in a budget impact analysis. Eur J Health Econ. 2011;12(3):231-41. DOI:10.1007/s10198-010-0236-4 The evaluated parameters in the first ones were: the annual variation rate of lung cancer cases; costs of PET-CT procedure; prevalence of mediastinal and distant lesions; probability of conducting confirmatory mediastinoscopy; and CT and PET-CT sensitivity. The same ranges of values that were obtained in the literature and used in the study for the MH were used here.bb Caetano R, Biz AN, Bastos CRG, Garay OU, Schluckebier L. Avaliação econômica: análise de custo-efetividade do uso da 18FDG-PET/TC no estadiamento do câncer pulmonar de células não pequenas: relatório preliminar de pesquisa. Rio de Janeiro (RJ): Instituto de Medicina Social da UERJ; 2013.
The parameters were simultaneously modified in the extreme scenarios sensitivity analysis. The "best-case scenario" corresponded to minimizing the budget impact from PET incorporation for any alternative scenario adopted. The minimum values in the range that figures in Table 2 for the following parameter were employed: costs of PET-CT, annual variation rate for the number of new cases and CT sensitivity. Simultaneously, the following were employed considering their maximum values: biopsy sensitivity, share of patients having undergone mediastinoscopy procedure; and prevalence of metastases in mediastinal lymph nodes (N2/3) and distant metastases (M1). The "worst-case scenario" corresponded to the same parameters varying in the opposite direction to the one mentioned above.
Moreover, the influence from the rate by which the technology is disseminated at SUS was analyzed. It is possible that, even with it being included in SUS payrolls, delays may take place until it is fully offered, due to the current geographical availability of equipment and qualified staff for its operation. Sixty percent of patients were considered eligible for using PET-CT in 2014, with 10.0% increases with each year, until full access was achieved in 2018.
Written authorization was obtained from the Project (CNPq 564797/2010-3) coordinator, concerning the usage of data and model of the cost-effectiveness study.
The current diagnostic and therapeutic management model for NSCLC patients in Brazilian health care services, which is focused on CT use, would result in 397.5 BRL (246.9 USD) million in expendituresjj The conversion of all monetary amounts to the American dollar that is presented in the text, in the tables, and figure, was conducted based on the PPP conversion factor for Brazil, regarding the year of 2013, as disclosed by the World Bank. PPP conversion factor, GDP (LCU per international $). Washington (DC): World Bank; 2015 [cited 2015 May 2]. Available from: http://data.worldbank.org/indicator/PA.NUS.PPP in five years for SUS.
The introduction of PET-CT in NSCLC staging would imply an increase in total expenditures for SUS (Table 3) due to its complementary, non-replaceable nature, regardless of the strategy for its use. Its restricted use in patients with negative CT of thorax results would determine a total impact of 555.5 BRL (345.0 USD) million over the period (+39.8% as compared to the current management). Its use for all patients would cause an impact of 600.1 BRL (372.8 USD) million (+51.0%).
Total and incremental budget impact per year and for 2014 to 2018, regarding the studied analysis scenarios (in PPP-adjusted USD from 2013)a.
The financial impact from the more restricted PET-CT offer would imply an additional allocation of 158 BRL (98.2 USD) million in five years (Table 3). Extending the offer to all potential candidates would involve 202.7 BRL (125.9 USD) million in additional resources, with 44.6 BRL (27.7 USD) million being the difference between the strategies at the end of the period.
The cost of PET-CT procedure was the parameter with the biggest impact in the univariate sensitivity analyses (Figure) using the values from the range in Table 2. The reduction in the cost of the procedure to 1,637.87 BRL (1,017.31 USD) would cause a total five-year budget impact reduction of BRL 67.9 (42.2 USD) million in the restricted offer (-12.2%) and 90.6 BRL (56.3 USD) million in the most inclusive use (-15.1%). The difference from the two strategies would drop to 21.9 BRL (13.6 USD) million. An increase in the cost of the procedure to 2,927.19 BRL (1,818.13 USD) would result in relatively smaller increases in the total budget impact: 16.4 BRL (10.2 USD) million (+2.9%) in the restricted offer and 21.9 BRL (13.6 USD) million (+3.6%) in the inclusive offer.
Result from the total budget impact univariate sensitivity analysis (in PPP-adjusted dollars from 2013).a Evaluated scenarios, Brazil, 2014 to 2018.
The variation in the share of patients submitted to mediastinoscopy to confirm imaging exam results, between 0% and 100%, was shown to be important, given their costs to SUS. Non-performance of mediastinoscopy corresponded to a reduction in the total budget impact of 24.6 BRL (15.3 USD) million in the "PET-CT for CT-" scenario, and 20.3 BRL (12.6 USD) million in the use of "PET for all". Its conduction in all patients, on the other hand, would lead to increases in both scenarios of the same amounts mentioned above.
The use of the lower value of the range of the growth of staging-eligible NSCLC cases produced decreases in the budget impact regardless of the analyzed scenario: from 14 BRL (8.7 USD) million, in the "PET-CT for CT-" scenario, and 15.1 BRL (9.4 USD) million, with the offer of "PET-CT for all". Using the upper limit of that parameter resulted in increases of 3.7 BRL (2.3 USD) million and 4 BRL (2.5 USD) million, respectively.
The extreme scenarios sensitivity analyses (Table 4) showed significant reduction in total budget impact in the "best-case scenario": 90.3 BRL (56.1 USD) million in the inclusive use of PET-CT (-15.0%), and 62.5 BRL (38.8 USD) in the restricted offer (-11.3%). The incorporation would result in increased budget impacts of 25.9 BRL (16.1 USD) million in the "PET-CT for all" strategy (+4.3%), and 22.4 BRL (13.9 USD) million in the restricted use (+4.0%) in the "worst-case scenario".
Total and incremental budget impact analyses of staging strategies per projected year (in PPP-adjusted USD from 2013)a. Brazil, 2014 to 2018.
The total reduction in the budget impact would be of 31.6 BRL (19.6 USD) million (-5.7%) in the scenario with the restricted offer of the technology, and 44 BRL (27.4 USD) million with availability to all (-7.3%), considering a progressive dissemination – from 60.0% to 100% in five years – of PET-CT at SUS.
The incorporation of PET-CT in the staging of NSCLC, a highly relevant neoplasia in Brazil's nosological scenario, would imply total expenditures of 555.5 BRL (345.0 USD) million to SUS, in case its use is restricted to patients with previous negative results in computed tomography of thorax, and 600.1 BRL (372.8 USD) million, in the situation in which it is offered to all new cases that are diagnosed in the period. These values represent additional costs to the current expenditures with computed tomography-based staging, of around 158.1 BRL (98.2 USD) to 202.7 BRL (125.9 USD) million in five years, depending on its more restricted or inclusive use. In absolute or incremental terms, the estimated values reinforce the importance of properly planning and managing of budgets and governmental actions, including health care, in a way to optimize the use of available resources, which are scarce in our field.
The National Policy on Health Technologies Managementkk Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Política de Gestão de Tecnologias em saúde. Brasília (DF); 2011. and Law 12,401ll Brasil. Lei nº 12.401, de 28 de abril de 2011. Altera a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a assistência terapêutica e incorporação de tecnologias em saúde no âmbito do SUS. Diário Oficial União. 29 Abr 2011:Seção1:1-2. have recognized the role of complementary economic evaluation. The conduction of budget impact studies to support decisions regarding the incorporation of new technologies at SUS is explicitly recommended.
One of SUS's challenges lies in its compliance to the principle that health services should follow the principle of universality. Offering PET-CT to all candidates may not be feasible due to financial, infrastructural, or human resources limitations, among others. That acknowledgment, plus the fact that the literature and the study to the Ministry of Health point towards higher health benefits for the group with previous negative CT exams66 Dietlein M, Weber K, Gandjour A, Moka D, Theissen P, Lauterbach KW, et al. Cost-effectiveness of FDG-PET for the management of potentially operable non-small cell lung cancer: priority for a PET based strategy after nodal-negative CT results. Eur J Nucl Med.2000;27(11):1598-609. DOI:10.1007/s002590000376,bb Caetano R, Biz AN, Bastos CRG, Garay OU, Schluckebier L. Avaliação econômica: análise de custo-efetividade do uso da 18FDG-PET/TC no estadiamento do câncer pulmonar de células não pequenas: relatório preliminar de pesquisa. Rio de Janeiro (RJ): Instituto de Medicina Social da UERJ; 2013. led to the simulation of the restricted offer for the exam. However, extending the offer to all potential candidates would result in an increased total budget impact of only 44.6 BRL (27.7 USD) million at the end of the period.
The extent of the impacts which are associated with the incorporation of PET-CT would have significant financial implications, especially if the number of eligible patients were weighted in. That is so because, in 2013, the number of new lung cancer cases corresponded to only 0.01% of the Brazilian population.
The expenditures of the Ministry of Health, which figure in the Annual Budget Act for 2014,mm Senado Federal. Portal do Orçamento. Lei Orçamentária Anual 2014: Volume IV –Detalhamento das Ações – Órgão do Poder Executivo – Presidência da República e Ministérios (exceto MEC). 36000. Brasília (DF); 2014 [cited 2014 Jan 13]. Available from: http://www12.senado.gov.br/orcamento/loa?ano=2014&categoria=3.1.7&fase=elaboracao were looked after for better understanding of the meaning of the resources volumes which were estimated with the incorporation of PET-CT. The estimated amount needed to maintain SUS's current management of the disease corresponds to 0.075% of the 106,019,264,465.00 BRL (65,850,474,822.98 USD) that were predicted for 2014. In the alternative scenarios, the total budget impact estimated would correspond to 0.105% of the MH budget (restricted offer) or to 0.113% (inclusive offer).
Another way to examine how substantial the estimated impacts are would be to compare them to the sums which are spent by SUS with care of lung cancer patients, e.g., related to diagnostics and treatment in their various modalities. However, no consolidated information was found in the literature, nor was it in official documents about expenditures made for that condition. The expenditures from the Ministry of Health that are related to CT of thorax exams, conducted and approved by SUS, can be obtained from the Sistema de Informações Ambulatoriais(System of Ambulatorial Information).nn Ministério da Saúde. Departamento de Informática do SUS (DATASUS). Sistema de Informações Ambulatoriais do SUS (SIA/SUS). Brasília (DF); 2014. Available from:http://www2.datasus.gov.br/DATASUS/index.php?area=0202 But this information correspond to the use of the procedure in several clinical indications (neoplastic or non-neoplastic), and not only for lung cancer, which renders any comparison impossible. The expenditures with inpatient care from SUS related to lung cancer, which were obtained from theSistema de Informações Hospitalares (System of Hospital Information), added up to 23,405,185.25 BRL (14,537,382.14 USD) from January to November 2013.oo Ministério da Saúde. Departamento de Informática do SUS (DATASUS). Sistema de Informações Hospitalares do SUS (SIH/SUS). Brasília (DF); 2014 [cited 2014 Jan 15]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0202 That makes up for 29.5% of the 79.4 BRL (49.3 USD) million of the budget impact that was estimated in the reference scenario for 2014, but it does not include the remaining diagnostic and therapeutic components which are involved with handling the condition.
The dissemination of PET-CT into the clinical practice took place in a context in which concern with expenditures and impacts for health care systems was building up. Thus, the technology was the subject of several cost-effectiveness studies in several countries. Budget impact evaluations for its implementation are less frequent in the literature, and that is maybe so because they are conducted internally in the governmental environment which is involved with offering the technology. Nonetheless, directly comparing the results of those budget impact analyses with the ones herein is inappropriate. That is so because the management and organization of health care systems, structures of their models, epidemiological data, and especially the underlying cost structures greatly differ among studies.1717 Sculpher MJ, Pang FS, Manca A, Drummond MF, Golder S, Urdahl H, et al. Generalisability in economic evaluation studies in healthcare: a review and case studies. Health Technol Assess. 2004;8(49):iii-iv, 1-192. DOI:10.3310/hta8490
Comparing budget impact estimates that are conducted in our reality would be ideal. Even though the MH has internally simulated the budget impact from PET at SUS,pp Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. PET-TC no estadiamento de câncer pulmonar de células não-pequenas. Relatório de Recomendação da Comissão Nacional de Incorporação de Tecnologias no SUS – CONITEC-107. Brasília (DF); 2014. Available from: http://portalsaude.saude.gov.br/images/pdf/2014/abril/23/Relatorio-PET-EstadiamentoCancerPulmonar-FINAL.pdf its estimation methods and likelihood of bearing important methodological biases hinders comparisons with the results from this study. Besides that, according to the budget impact guidelines, estimates should not be restricted to comparing amounts and prices of technologies per se, but to the financial result from the set of clinical consequences and diagnostic, therapeutic procedures that relate to examined technologies, as this study aimed at.
Although employing PET does not show a significant increase in the survival of patients,44 Cao JQ, Rodrigues GB, Louie AV, Zaric GS. Systematic review of the cost-effectiveness of Positron-Emission Tomography in staging of non-small-cell lung cancer and management of solitary pulmonary nodules. Clin Lung Cancer. 2012;13(3):161-70. DOI:10.1016/j.cllc.2011.09.002 its use allows for better (financial, material, and human) resource distribution in the system, as it more accurately identifies the extension of disease and allows planning the therapeutic strategy that is the most adequate to each case. Such smoother method would prevent unnecessary surgical procedures, which is more relevant when there are famous problems with access to health care services in the country, especially regarding oncology, and significant regional discrepancies in its offer.1010 Gomes Jr SCS, Almeida RT. Modelo de simulação para estimar a infraestrutura necessária à assistência oncológica no Sistema Público de Saúde.Rev Panam Salud Publica. 2009;25(2):113-9. DOI:10.1590/S1020-49892009000200003,qq Tribunal de Contas da União. Política Nacional de Atenção Oncológica; Relator Ministro José Jorge. Brasília (DF); 2011.
Budget impact studies are scarce, and only more recently they have gained guidelines on good practices more established. This study followed the main available guidelines on budget impact analyses from Task Force on Good Research Practices from the International Society for Pharmacoeconomics and Outcomes Research1313 Mauskopf JA, Sullivan SD, Annemans L, Caro J, Mullins CD, Nuijten M, et al. Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices - budget impact analysis.Value Health. 2007;10(5):336-47. DOI:10.1111/j.1524-4733.2007.00187.x and the ones from the Ministry of Health, which were recently published.ff Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Diretrizes metodológicas: análise de impacto orçamentário: manual para o Sistema de Saúde do Brasil. Brasília (DF); 2012. Required adaptations were made, as they mainly focus on therapeutic procedures.
Despite our using a nine-year time series (2006 to 2014) to estimate future lung cancer new cases, it was not possible to predict possible alterations arising from population changes or in the prevalence of some of its risk factors. Besides that, this study used parameter values from the cost-effectiveness study. Thus, the same limitations from before remain, as a gap in the national data regarding some epidemiological parameters, accuracy measurements for diagnostic technologies from international studies, and from the missing information about the share of patients who are submitted to mediastinoscopy within the country. The multiple sensitivity analyses conducted aimed at shedding some light on those uncertainties, and potentializing the knowledge regarding the extent of the impact they generate to SUS.
Trueman et al2020 Trueman P, Drummond M, Hutton J. Developing guidance for budget impact analysis. Pharmacoeconomics. 2001;19(6):609-21. DOI:10.2165/00019053-200119060-00001 discuss the incompatibility between the effort to maximize efficiency, which is the core target of economists, and the limits for the current budgets, which is commonly the main need from managers. Budget impact analyses do not show the best way to distribute available resources in the economy, whose most proper evidence come from comprehensive economic evaluation studies, such as the cost-effectiveness ones. Furthermore, the decisions to incorporate technologies in health care systems must take into account other factors, such as the availability of human and budget resources, political factors, and aspects regarding equal access to health care.
Data that is similar to the ones in this study, along with the evidence the technology is cost-effective in Brazil, may allow decisions taken to be properly backed up. Thus, the incorporation of PET in the clinical staging of potentially resectable NSCLC seems to be financially feasible considering the high total budget from Brazil's Ministry of Health and the potential reduction in the number of unnecessary surgeries better staged patients are submitted to. This may cause the available resources to be more efficiently distributed.
Alzahouri K, Lejeune C, Woronoff-Lemsi MC, Arveux P, Guillemin F. Cost-effectiveness analysis of strategies introducing FDG-PET into the mediastinal staging of non-small-cell lung cancer from the French healthcare system perspective. Clin Radiol. 2005;60(4):479-92. DOI:10.1016/j.crad.2004.10.010
Brosa M, Gisbert R, Rodríguez JM, Soto, J. Principios, métodos y aplicaciones del análisis del impacto presupuestario en el sector sanitario.Pharmaco Econ Spa Res Art. 2005;2(2):64-78. DOI:10.1007/BF03320900
Caetano R, Schluckebier L, Bastos CRG, Silva RM, Carneiro MP, Silva JWE, et al. Análise dos custos do procedimento PET-TC com 18F-FDG na perspectiva do SUS provedor: estudo em uma unidade pública de saúde do Rio de Janeiro, Brasil. Cad Saude Publica. 2014;30(2):379-392 DOI:10.1590/0102-311X00016413
Cao JQ, Rodrigues GB, Louie AV, Zaric GS. Systematic review of the cost-effectiveness of Positron-Emission Tomography in staging of non-small-cell lung cancer and management of solitary pulmonary nodules. Clin Lung Cancer. 2012;13(3):161-70. DOI:10.1016/j.cllc.2011.09.002
Devaraj A, Cook GJ, Hansell DM. PET/CT in non-small cell lung cancer staging-promises and problems. Clin Radiol. 2007;62(2):97-108. DOI:10.1016/j.crad.2006.09.015
Dietlein M, Weber K, Gandjour A, Moka D, Theissen P, Lauterbach KW, et al. Cost-effectiveness of FDG-PET for the management of potentially operable non-small cell lung cancer: priority for a PET based strategy after nodal-negative CT results. Eur J Nucl Med.2000;27(11):1598-609. DOI:10.1007/s002590000376
Dwamena BA, Sonnad SS, Angobaldo JO, Wahl RL. Metastases from non-small cell lung cancer: mediastinal staging in the 1990s-meta-analytic comparison of PET and CT. Radiology 1999;213(2):530-6. DOI:10.1148/radiology.213.2.r99nv46530
Ferreira-da-Silva AL, Ribeiro RA, Santos VCC, Elias FTS, d'Oliveira ALP, Polanczyk CA. Diretriz para análises de impacto orçamentário de tecnologias em saúde no Brasil. Cad Saude Publica. 2012;28(7):1223-38. DOI:10.1590/S0102-311X2012000700002
Gambhir SS, Hoh CK, Phelps ME, Madar I, Maddahi J. Decision tree sensitivity analysis for cost-effectiveness of FDG-PET in the staging and management of non-small-cell lung carcinoma. J Nucl Med.1996;37(9):1428-36.
Gomes Jr SCS, Almeida RT. Modelo de simulação para estimar a infraestrutura necessária à assistência oncológica no Sistema Público de Saúde.Rev Panam Salud Publica. 2009;25(2):113-9. DOI:10.1590/S1020-49892009000200003
Hilden J. Budget impact analysis and its rational basis. Med Decis Making. 2008;28(4):460-1. DOI:10.1177/0272989X08321903
Marshall DA, Douglas PR, Drummond MF, Torrance GW, Macleod S, Manti O, et al. Guidelines for conducting pharmaceutical budget impact analyses for submission to public drug plans in Canada. Pharmacoeconomics.2008;26(6):477-95. DOI:10.2165/00019053-200826060-00003
Mauskopf JA, Sullivan SD, Annemans L, Caro J, Mullins CD, Nuijten M, et al. Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices - budget impact analysis.Value Health. 2007;10(5):336-47. DOI:10.1111/j.1524-4733.2007.00187.x
Nguyen VH, Peloquin S, Lacasse Y. Cost-effectiveness of positron emission tomography for the management of potentially operable non-small cell lung cancer in Quebec. Can Respir J.2005;12(1):19-25.
Nuijten MJC, Mittendorf T, Persson U. Practical issues in handling data input and uncertainty in a budget impact analysis. Eur J Health Econ. 2011;12(3):231-41. DOI:10.1007/s10198-010-0236-4
Orlewska E, Mierzejewski P. Proposal of Polish guidelines for conducting financial analysis and their comparison to existing guidance on budget impact in other countries. Value Health. 2004;7(1):1-10. DOI:10.1111/j.1524-4733.2004.71257.x
Sculpher MJ, Pang FS, Manca A, Drummond MF, Golder S, Urdahl H, et al. Generalisability in economic evaluation studies in healthcare: a review and case studies. Health Technol Assess. 2004;8(49):iii-iv, 1-192. DOI:10.3310/hta8490
Silvestri GA, Gould MK, Margolis ML, Tanoue LT, McCrory D, Toloza E, et al. Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest 2007;132(3 Suppl):178-201. DOI:10.1378/chest.07-1360
Sloka JS, Hollett PD, Mathews M. Cost-effectiveness of positron emission tomography for non-small cell lung carcinoma in Canada. Med Sci Monit. 2004;10(5):MT73-80.
Trueman P, Drummond M, Hutton J. Developing guidance for budget impact analysis. Pharmacoeconomics. 2001;19(6):609-21. DOI:10.2165/00019053-200119060-00001
van Tinteren H, Hoekstra OS, Smit EF, van den Bergh JH, Schreurs AJ, Stallaert RA, et al. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet.2002;359(9315):1388-93. DOI:10.1016/S0140-6736(02)08352-6
Vianna CMM, Caetano R. Avaliações econômicas como um instrumento no processo de incorporação tecnológica em saúde. Cad Saude Colet.2005;13(3):747-66.
Viney RC, Boyer MJ, King MT, Kenny PM, Pollicino CA, McLean JM, et al. Randomized controlled trial of the role of positron emission tomography in the management of stage I and II non-small-cell lung cancer. J Clin Oncol. 2004;22(12):2357-62. DOI:10.1200/JCO.2004.04.126
This research was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes – Process 1083861 – master's scholarship).
Ministério da Saúde. Instituto Nacional de Câncer. Estimativa 2014: incidência de câncer no Brasil. Rio de Janeiro (RJ); 2014.
Caetano R, Biz AN, Bastos CRG, Garay OU, Schluckebier L. Avaliação econômica: análise de custo-efetividade do uso da 18FDG-PET/TC no estadiamento do câncer pulmonar de células não pequenas: relatório preliminar de pesquisa. Rio de Janeiro (RJ): Instituto de Medicina Social da UERJ; 2013.
National Collaborating Centre for Cancer. Lung cancer. The diagnosis and treatment of lung cancer. London: NICE; 2011 [cited 2012 Oct 10] (Nice Clinical Guidelines; 121). Available from: http://www.ncbi.nlm.nih.gov/books/NBK99021/
Ministério da Saúde. Portaria nº 600, de 26 de junho de 2012. Aprova as diretrizes diagnósticas e terapêuticas do câncer de pulmão. Diário Oficial União. 28 Jun 2012;Seção1:210.
Ministério da Saúde. Portaria nº 7, de 22 de abril de 2014. Torna pública a decisão de incorporar o PET-CT no estadiamento clínico do câncer de pulmão de células não-pequenas potencialmente ressecável no Sistema Único de Saúde - SUS.Diário Oficial União. 23 Abr 2014;Seção1:78.
Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Diretrizes metodológicas: análise de impacto orçamentário: manual para o Sistema de Saúde do Brasil. Brasília (DF); 2012.
Agência Nacional de Saúde Suplementar. Caderno de informação da Saúde Suplementar: beneficiários, operadoras e planos. Rio de Janeiro (RJ); 2013.
Ministério da Ciência, Tecnologia e Inovação. Comissão Nacional de Energia Nuclear (CNEN). Relatório de Gestão do Exercício de 2011. Rio de Janeiro (RJ); 2012.
Ministério da Saúde. Departamento de Informática do SUS (DATASUS). Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS (SIGTAP). Brasília (DF); 2013 [cited 2013 Nov 25]. Available from: http://sigtap.datasus.gov.br/tabela-unificada/app/sec/inicio.jsp
The conversion of all monetary amounts to the American dollar that is presented in the text, in the tables, and figure, was conducted based on the PPP conversion factor for Brazil, regarding the year of 2013, as disclosed by the World Bank. PPP conversion factor, GDP (LCU per international $). Washington (DC): World Bank; 2015 [cited 2015 May 2]. Available from: http://data.worldbank.org/indicator/PA.NUS.PPP
Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Política de Gestão de Tecnologias em saúde. Brasília (DF); 2011.
Brasil. Lei nº 12.401, de 28 de abril de 2011. Altera a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a assistência terapêutica e incorporação de tecnologias em saúde no âmbito do SUS. Diário Oficial União. 29 Abr 2011:Seção1:1-2.
Senado Federal. Portal do Orçamento. Lei Orçamentária Anual 2014: Volume IV –Detalhamento das Ações – Órgão do Poder Executivo – Presidência da República e Ministérios (exceto MEC). 36000. Brasília (DF); 2014 [cited 2014 Jan 13]. Available from: http://www12.senado.gov.br/orcamento/loa?ano=2014&categoria=3.1.7&fase=elaboracao
Ministério da Saúde. Departamento de Informática do SUS (DATASUS). Sistema de Informações Ambulatoriais do SUS (SIA/SUS). Brasília (DF); 2014. Available from:http://www2.datasus.gov.br/DATASUS/index.php?area=0202
Ministério da Saúde. Departamento de Informática do SUS (DATASUS). Sistema de Informações Hospitalares do SUS (SIH/SUS). Brasília (DF); 2014 [cited 2014 Jan 15]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0202
Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. PET-TC no estadiamento de câncer pulmonar de células não-pequenas. Relatório de Recomendação da Comissão Nacional de Incorporação de Tecnologias no SUS – CONITEC-107. Brasília (DF); 2014. Available from: http://portalsaude.saude.gov.br/images/pdf/2014/abril/23/Relatorio-PET-EstadiamentoCancerPulmonar-FINAL.pdf
Tribunal de Contas da União. Política Nacional de Atenção Oncológica; Relator Ministro José Jorge. Brasília (DF); 2011.
Based on the master's thesis by Aline Navega Biz, titled: "Impacto orçamentário da incorporação da tomografia de emissão de pósitrons (PETscan) no estadiamento do câncer de pulmão na perspectiva do Sistema Único de Saúde", which was presented to Instituto de Medicina Social of the Universidade do Estado do Rio de Janeiro in 2014.
: Aline Navega Biz. Rua São Francisco Xavier, 524 Pavilhão João Lyra Filho 7º andar Blocos D e E/ 6º andar Bloco E Maracanã 20550-013 Rio de Janeiro, RJ, Brasil. E-mail: alinebiz@gmail.com
Figure Result from the total budget impact univariate sensitivity analysis (in PPP-adjusted dollars from 2013).a Evaluated scenarios, Brazil, 2014 to 2018.
Table 1 Cases of lung cancer and NSCLC, from 2006 to 2014, and the projected number of new NSCLC cases, from 2006 to 2014, and the ones handled by the Brazilian Unified Health System, from 2014 to 2018.
New lung cancer cases
New NSCLC cases
New NSCLC cases handled by SUS
2006 27,170 23,095 –
2014a 27,330 23,231 17,423
2015b – 23,248 17,436
Source: Estimates from the data regarding number of cancer cases, as disclosed by the Brazilian National Cancer Institute in 2005, 2007, 2009, 2011, and 2014.
NSCLC: Non-small cell lung cancer; SUS: Sistema Único de Saúde (Brazilian Unified Health System)
The preliminary data from the following source were repeated: Ministério da Saúde. Instituto Nacional de Câncer. Estimativa 2014: incidência de câncer no Brasil. Rio de Janeiro (RJ); 2014.
Estimated from the variation regarding years 2006 to 2014.
Table 2 Cost parameters (in PPP-adjusted US$, as per 2013 rates)*, accuracy, and epidemiological data that were used in the budget impact analysis and data source.
Costs*
CT of thorax (US$) 84.73 – Sigtap/DataSUSi
Whole body PET-CT (US$) 1,662.58 1,017.31;1,818.13 Caetano3 (2014) + Premises
Mediastinoscopy (US$) 860.37 – Sigtap/DataSUSi
Biopsy (US$) 598.68 – Sigtap/DataSUSi
Surgery (US$) 2,687.32 – Sigtap/DataSUSi
Chemotherapy + Radiotherapy (US$) 2,416.15 – Sigtap/DataSUSi
Palliative care (US$) 683.23 – Sigtap/DataSUSi
Deaths from mediastinoscopy (US$) 1,687.77 – Sigtap/DataSUSi
CT of thorax sensitivity for mediastinal lymph nodes (%) 51 47;62 Dwamena7 (1999); Silvestri18 (2007)
Biopsy sensitivity for distant metastases (%) 100 80;100 Gambhir9 (1996); Sloka19(2004)
Epidemiological parameters
Variation rate of number of cases (%) 0.0754 -1.1983;0.4054 Estimates from INCA in 2005, 2007, 2009, 2011, and 2014
Prevalence of distant metastases (%) 20 12;25 NICE 2011c
Prevalence of metastases in mediastinal lymph nodes (%) 30 15;40 Dietlein6 (2000); NICE 2011c
Probability for conduction of mediastinoscopy (%) 50 0;100 Alzahouri1 (2005) refers to specialists
CT: Computed tomography; INCA: Brazilian National Cancer Institute; PET-CT: Positron emission tomography along with computed tomography
World Bank's PPP conversion rate for 2013 (PPP-adjusted USD): 1 USD = 1.61 BRL.
Table 3 Total and incremental budget impact per year and for 2014 to 2018, regarding the studied analysis scenarios (in PPP-adjusted USD from 2013)a.
Total budget impacta
Incremental budget impacta
PET-CT for CT-b
PET-CT for allc
PET-CT for CT-b regarding CT
PET-CT for allc regarding CT
PET-CT for allc regarding PET-CT for CT-b
2014 49,297,708.43 68,902,114.70 74,438,876.78 19,604,406.27 25,141,168.35 5,536,762.07
2014-2018 246,860,292.33 345,030,158.99 372,755,721.65 98,169,866.66 125,895,429.32 27,725,562.65
CT: Computed tomography; PET-CT: Positron emission tomography along with computed tomography
World Bank's PPP conversion rate for 2013 (PPP-adjusted USD for 2013): 1 USD = 1.61 BRL.
PET-CT for CT-: conduction of PET-CT only for patients with negative CT results.
PET-CT for all: conduction of PET-CT for all patients, considering both the results from PET and CT for resuming the clinical, therapeutic management.
Table 4 Total and incremental budget impact analyses of staging strategies per projected year (in PPP-adjusted USD from 2013)a. Brazil, 2014 to 2018.
PET for CT-b
PET for CT-b regarding CT
PET-CT for allc regarding PET for CT-b
Base case
Best-case scenariod
2014-2018 252,228,973.39 306,181,621.01 316,695,374.12 53,952,647.63 64,466,400.74 10,513,753.11
Worst-case scenarioe
2014-2018 238,402,366.32 358,911,536.71 388,862,025.90 120,509,170.40 150,459,659.58 29,950,489.18
Best-case scenario: variation for the lower limit of the parameter interval: cost of PET-CT, annual variation in number of cases, and CT sensitivity; and for maximum values of parameters: biopsy sensitivity, share of patients who were submitted to mediastinoscopy and prevalences of metastases in mediastinal lymph nodes (N2/3) and distant metastases (M1).
Worst-case scenario: variation for the upper limit of the parameter interval: cost of PET-CT, annual variation in number of cases, and CT sensitivity; and for minimum values of parameters: biopsy sensitivity, share of patients who were submitted to mediastinoscopy and prevalences of N2/3 and M1.


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text:
HARRY SHEARER's "Number One Son," Sixth Song In Donald Trump Series, Out Now
Under : HARRY SHEARER, Press Releases
FROM: MARCEE RONDAN
"THE SIMPSONS" AND "SPINAL TAP" STAR
HARRY SHEARER
Releases Sixth Song in Donald Trump Series
NUMBER ONE SON
A high quality person
I barely know him
They tell me he's my
My Number One Son
#DonaldTrumpSong
Today (September 4) HARRY SHEARER releases "NUMBER ONE SON" as the sixth track as Donald Trump in a series which runs with a song a week leading up the November election. Over the summer, the star of "The Simpsons" and "Spinal Tap" has been exploring, through song, the dark and often comical recesses of the president's mind during his time in office.
"NUMBER ONE SON" proves, in SHEARER's words, that,
"The apple doesn't fall far from the refrigerator."
With more to follow, "NUMBER ONE SON"is Donald Sr.'s paean to his eldest child Donald Jr. The song depicts the current incumbent of The Oval Office singing an "electric chop suey" tribute to his favorite first born. Charting all the qualities he holds dear in his eldest son, from his penchant for hunting to his conversations with Russians, SHEARER's president reveals his new found love for the boy who serves him well.
The new track follows the old-school R&B anthem to Jared Kushner "SON IN LAW"; the disco/plaintive folk number celebrating Trump's consistent inconsistency in his approach to the pandemic "COVID-180"; VERY STABLE GENIUS" a low-power power-ballad, in which the leader of the free world vaunts his self-proclaimed intellectual prowess combined with his calm and balanced disposition; "STORMY DANIELS," a romantic ballad of passion, power and pay off; and last week's "ALABAMA," a southern rock style tribute to the state that holds such a special place in Trump's "heart."
With music and lyrics by SHEARER, "NUMBER ONE SON" also has "The Simpsons" star on vocals as Donald Trump. He is joined by Sharlotte Gibson and CJ Vanston on backing vocals, Marc Bonilla on guitars, Toss Panos on drums and CJ Vantson on keyboard and other instruments. It is mastered by Peter Doell at Aftermaster and released by Twanky Records.
HARRY SHEARER has vocally portrayed every U.S. president of his lifetime. Donald Trump is the third he has portrayed physically, having previously played Richard Nixon and Ronald Reagan on screen.
HARRY SHEARER says of the series of Trump-themed songs, which will be released on a weekly basis over the next seven weeks:
"My Donald Trump is almost as eager for continued public attention as the'real' Trump."
For more about Harry Shearer, click here.
Here's a link to the HARRY SHEARER's series of Trump themed songs.

redpajama_set_name: RedPajamaCommonCrawl


Sri Lanka's army disbanded the mostly ineffective "safe zone" it had established in the war-wracked north and set up a new refuge Thursday for the tens of thousands of civilians still trapped. Military spokesman Brig. Udaya Nanayakkara said the government set up a new haven because the Tamil Tiger rebels forced most of the civilians seeking shelter from the fighting out of the original one. The two sides have been fighting heavy battles since government troops overran the rebels' de facto state in the north and boxed them into a tiny strip of land along the northeast coast. The military says it has pushed the insurgents to the brink of defeat and hopes to soon end the 25-year-old civil war.


BECKLEY, WV (WOAY) – There is a measles outbreak in the Northwest and doctors are advising people who have not been vaccinated to get their immunization.
Measles, a viral infection that usually starts out with a high fever around 105. Exhibiting visible symptoms such as white spots in the mouth, runny nose, cough, pink eye and a typical looking rash.
Your contagious from four days before the rash appears until 4 days after it breaks out. Nine out of Ten people who have not been immunized against it will get sick from it.
A local pediatrician tells us the best way to prevent catching the measles.
Measles have been eradicated in the United States through the aggressive and highly effective immunization program.
The best way to protect yourself and your child and prevent catching the measles, is to get the immunization.


Kakinada, Apr 1: Prime Minister Narendra Modi has launched a scathing attack on Andhra Pradesh Chief Minister N Chandrababu Naidu by blaming him of dragging the Polavaram project for long for the sake of swindling money by escalating the project expenditure from time to time. Addressing a well attended public meeting at Rajahmundry on Monday evening, Mr Modi described the Polavaram project as an ATM for allegedly drawing money whenever required by Chandrababu Naidu and the ruling Telugu Desam government.
Alleging that either the present TDP government or the past regimes during last four decades are not serious of completing the Polavaram project, Mr Modi has claimed that the BJP-led NDA government soon after came to power had accorded National project status to Polavaram and released Rs.7,000 Crore to the state for its early execution.
But instead of speedy execution, he said , the TDP government has chosen to adopt delay tactics and escalating the project cost leaps and bounds only to benefit Mr Naidu personally and also his friends. Describing the Polavaram project as lifeline to Andhra Pradesh people especially the farmers, the Prime Minister said that BJP was committed for its early completion and also for the comprehensive development of the state and welfare of the people.
Stating that the people of Andhra Pradesh are known for their great heritage and culture and are in the forefront in country's development, Mr Modi has ridiculed Chandrababu Naidu for always bestowing his attention on development of his Heritage dairy industry at the cost of the peoples interests. Andhra Pradesh people consider India as their first priority but Chandrababu's aim was contrary. His family interests are utmost to him rather than the state. 'he remarked.
The Prime Minister also praised the Andhra People as honest and patriotic contrary to Chandrababu Naidu who is known for his betrayal. He described Chandrababu as U-turn babu and Sticker Babu who used to claim all the central schemes as of his own by putting his stickers on each and every scheme. Further, he blamed Chandrababu Naidu of indulging in cyber crimes by stealing the personal data of people using his Seva Mithra APP.
Mr Modi warned the people of facing the worst situation in the hands of Chandrababu Naidu if he was allowed to continue in power and advised them to defeat him in the general election. The Prime Minister also alleged that when our armed forces through surgical strikes annihilated the Terrorists camps, Chandrababu Naidu and his friends (political leaders) through their irresponsible talks have strengthened the Pakistan rulers.
He further alleged that Chandrababu Naidu joined hands with opportunistic elements and playing the role of the Villany king Bhallaladeva in the recent movie Bahubali and advised the people to give a fitting lesson in the election. During his half an hour speech, the Prime Minister has explained how the NDA government was keen on Andhra Pradesh development and the vital central institutions and projects sanctioned during its rule including the Kakinada petro chemical complex, Logistic park, Sagaramala project , Girijan university, expansion of Airports of Rajahmundry , Visakhapatnam and Vijayawada and development of inland waterways projects.
He also spoke about the 10 percent reservations given to the economically poorer sections, creation of separate ministry for fishermen community welfare and enhancing the income tax limit to Rs.5 lakh that comes into effect from today onwards.


Where to dine in Sydney / NSW for NYE has come and gone, but you can still dine at these great restaurants. Visit us next year to view a new restaurant list for Where to dine in Sydney / NSW for NYE. In the meantime, check out our other 9 Sydney / NSW restaurants on the OpenTable network.
Only a minutes'' walk from Sydney''s iconic fireworks, Croft Restaurant level one, is the perfect spot to enjoy a special dinner with family and friends before welcoming in the New Year!
At the moment, there's no online availability within 2.5 hours of 22:00. Have another time in mind?
Enjoy lunch in The Squire's Landing's stunning restaurant which overlooks Circular Quay. Views span 270 degrees from Sydney Harbour Bridge around to Sydney Opera House.


text:
Three Enchantingly Painted Houses in the Lost City of Pompeii Are Finally Open to the Public After a 40-Year Restoration Project
A $113 million conservation effort rescued the ruins from, well, ruin.
Taylor Dafoe, February 19, 2020
Massimo Osanna, director of the Pompeii Archaeological Park, at the unveiling of one of the painted houses at Pompeii. Courtesy of the Italian Ministry of Culture and Tourism.
Three archaeological marvels at Pompeii, the ancient Roman city razed by the eruption of Mount Vesuvius in 79 AD, have reopened to the public following a 40-year conservation effort.
Calling it a "story of rebirth and redemption," the Italian Ministry of Culture and Tourism unveiled a trio of newly restored buildings this week, each adorned with vibrant frescoes that provide fascinating insights into the daily lives of the ancient Romans.
The site is "a place where research and new archaeological excavations are back thanks to the long and silent work of the many professionals of cultural heritage that have contributed to the extraordinary results that are there for all to see," said Dario Franceschini, Italy's minister for cultural heritage and activities, in a statement. They are "a source of pride for Italy," he added.
Courtesy of the Italian Ministry of Culture and Tourism.
The unveiling signaled the completion of the €105 million ($113 million) Great Pompeii Project, which the EU launched in 2014. Prior to that, rampant tourism, ecological disasters, and a lack of proper conservation resources had left the site in a state of ruin—even for a ruin. In 2010, less than 15 percent of Pompeii's 110 acres, and just 10 of its 60-some buildings, were open to visitors, according to National Geographic.
Since the advent of the EU's project, the status of the site has increased dramatically, and tourists have taken notice. The number of visitors to Pompeii annually has grown by 47 percent since 2014, topping at almost 4 million last year, according to The Sunday Times. Roughly 70 percent of the ancient city, including 30 buildings, is now accessible to the public.
Researchers are still working on the site, said Franceschini, and the state has allocated another €50 million ($54 million) to allow work to continue. "Pompeii will always require maintenance and research," the minister added.
The newly reopened buildings are the House of the Orchard, the House of Lovers, and the House of the Ship Europa. The best known of them, the House of Lovers, is named after a graffito scrawled above an interior fresco that reads Amantes, ut apes, vitam melitam exigunt, or "Lovers lead, like bees, a life as sweet as honey." The building, which symbolized the lost city, was uncovered in 1933, but an earthquake in 1980 rendered it too dangerous to enter.
The House of the Orchard, which is covered in verdant frescoes of fruit trees and animals, was partially excavated in 1913 before being fully uncovered in 1951. The House of the Ship Europa was excavated over the course of more than two decades, from 1951 to 1975. A painting on the building depicts a large cargo ship called Europe, alongside other boats.
See more images of the newly restored buildings below.
In Pictures: A New Show Explores Ancient Pompeii Dining Rituals, From Vermin Delicacies to Bone Toothpicks
By Sarah Cascone , Jul 8, 2021
Does This Look Like Princess Diana to You? The Internet Is Melting Down Over the Absurd Wax Figures in a Brazilian Museum
By Caroline Goldstein , Jan 13, 2021
Did the Ancient Pompeiians Invent Recycling? New Research Suggests They Used Trash to Build City Walls (and Much More)
France Charges Dissident Artist Pyotr Pavlensky With Invasion of Privacy for Leaking a Paris Politician's Sex Tape
By , Feb 19, 2020
A New Armory Show Prize Will Award $10,000 to an Outstanding Female Artist With a Solo Booth at the Fair


I had dinner that night with the woman whom I saw ___ swimming in the morning.
The woman whom he saw ___ and ran away from ___ later became his wife.
Usage books don't, as far as I know, discuss the coordinate structure constraint. That's because sentences like this are fairly obviously wrong on an intuitive level, and so little comment is required. Could it be that the writer of the article was so focused on the case of whom that he or she lost sight of the more fundamental grammatical flaw?


text:
God's People Harlot or Bride?
Parable of the Vineyard (Part 2) Matthew 20:1-16
In Scripture, God talks about His people as both a harlot and a bride. But what makes His people a bride versus a harlot?
Several years ago, I rolled over and gazed into the face of my new bride. The day before, we'd entered into a covenant. That night, we celebrated the sacrament of that covenant as we communed—body and blood, in the sanctuary of our covenant love. I had given her myself and all my things with me. She opened her eyes, gazed into my face, and said, "Now… what do I get?! I serve you; I cook and clean. I have sex with you…Now, what do I get?" It absolutely broke my heart. And I began to bleed, and bleed, and bleed, and bleed. The blood flowed off the bed, out the door, and covered the whole land to the depths of a horse's bridle. Now, of course, that didn't really happen… to me. What bride would ever say such a thing to her groom?
In Matthew 19:30 – 20:16, Jesus tells the story of a landowner who hired laborers to work in his vineyard early in the morning. He agrees to pay them a denarius for a day's work. He then went out later and hired some others and said, "Whatever is right I will give you." When evening came, he paid the laborers. When those who were hired later were paid, they each received a denarius. But when those first hired came, they thought they'd receive more, but they too each received a denarius. Then they complained…
Also, in Matthew 19, Jesus crossed the Jordan to redeem His whoring bride–Israel, and He talks about receiving the kingdom as a child. Little children receive everything by grace, not works. They work, but we call it play because they don't work for a wage. No matter how they work, their Father still provides for their daily need. They work freely, out of love. So work is its own reward.
In this passage, the early workers are offended at the Master's grace and they're jealous of those that haven't been doing His will (the will of Love). They don't have compassion for sinners. They're jealous of sinners because they don't have to work the vineyard. The early workers hate working in the vineyard. They hate the Master's will.
Well, what is it, "to work in a vineyard?"
And why would someone want to work there, if not for a wage?
If you're a student of Scripture, you may remember that a vineyard is mentioned in Song of Solomon, and Song of Solomon is a love story. In that story, "the beloved" was a servant or slave girl (one of "the last." She's made to work in the vineyard by her brothers – probably Solomon's vineyard.) Yet, she herself is a vineyard, and she's fallen in love with Solomon and gives him the fruit of her vineyard (Song of Solomon 7:8-12).
At the end of that passage, she sings: "Solomon had a vineyard in Baal Hamon; he let out his vineyard to tenants. Each was to bring for its fruit a thousand shekels of silver. But my own vineyard is mine to give; the thousand shekels are for you, O Solomon." In other words, this fruit is free.
As you know, Solomon is the "son of David," and a picture of Christ. And then this is a picture of the Bride of Christ – one servant girl, The Church.
Isaiah 5: 1‐6 I will sing for the one I love a song about his vineyard: My loved one had a vineyard on a fertile hillside. He dug it up and cleared it of stones and planted it with the choicest vines. He built a watchtower in it and cut out a winepress as well.
Isaiah prophesies amazing things about this winepress.
Isaiah 5:7 The vineyard of the LORD Almighty is the house of Israel, and the men of Judah are the garden of His delight (NIV).
So Israel is a vineyard, and we are the Israel of God, the Church, the Kingdom is a vineyard, and the Lord calls us to come work in it. To do His work is to obey His commandments, keep the law, but there are different ways of keeping the law. If you work for a wage, then you are A tenant, an employee, a servant girl, a maid, or a harlot. But, if you work for another reason, another logos, you're something else. It's the same work, but an entirely different reality.
It's much like the stories of Cinderella, or the maid in Manhattan or even Pretty Woman. When Cinderella becomes a bride, she stops working for a wage, but she'll still work, she'll still serve – not as a slave, but a princess. The maid in Manhattan will still cook and clean for the very same guy. She'll do the same work, but not for a wage. She's no longer a maid – but a bride. And Pretty Woman will no longer have sex for a wage. She'll no longer roll over and say, "What do I get?" Do you see? It's the same work – but not as a harlot, but a bride.
See . . . I don't think God wants employees, but sons.
He doesn't want mercenaries, but children.
He doesn't want slave girls, maids, and harlots; He wants a bride.
I don't think He wants a business; He wants a family.
What do you want? A wage?
Is that why you work the vineyard?
If so, maybe you're not really even working the vineyard.
Do you know what the vineyard is producing? This vineyard bears fruit. The fruit is grapes. I think they are like grapes of wrath, for the grapes are placed in a winepress and trampled. The grapes are crushed, they bleed, and that blood turns to wine. That wine must be mercy. Jesus said, "I desire mercy . . . for I came not to call the righteous, but sinners." He's quoting Hosea. Remember Hosea was commanded to marry a harlot, and then shower her with mercy that she might be redeemed, for that was what God was doing with Israel – His vineyard. The fruit of this vineyard is mercy, hesed–covenant love.
If the workers serve the vineyard, they will serve its produce. They will do the work of servant girls, maids, and harlots, but full of hesed–covenant love. They will be married, they will be brides–like law filled with love, they will be workers filled with mercy–the very blood of the Landlord; they will be sons.
The vineyard is producing children, brides, sons, – a family filled with the wine of the covenant–forgiven people full of Grace, the very life-blood that flows from the broken heart of the Father hanging on a tree. The vineyard is producing mankind in the image and likeness of God.
And who is God? God is Love – Love that won't quit, Love that won't fail, Love that bears all things, believes all things, hopes all things, endures all things, on a cross, on a hill that is a vineyard.
Bride of Christ, Your Beloved wants you!
Do you believe it or do you feel like you have to earn it?
This devotional was prepared by Peter's assistant, Kimberly Weynen. To dig into these things further, click on the link to read the whole transcript and/or watch the sermon: The Vineyard (10 Years Later)
Kimberly Weynen October 4, 2015


text:
Niagara Central Dorothy Rungeling Airport or Welland/Niagara Central Dorothy Rungeling Aerodrome, , is a registered aerodrome located in Pelham,  west of Welland, Ontario, Canada. Niagara Central accommodates a flight school, skydivers, aerial photographers, itinerant light aircraft and an automatic weather station. It was built in 1940 by the Royal Canadian Air Force as part of the British Commonwealth Air Training Plan and served as the relief airfield for the No. 6 Service Flying Training School in nearby Dunnville.

The airport is the home of the 87th Eagle Squadron of the Royal Canadian Air Cadets who have training and administration space in the airport's former meeting place of Welland Fire Company Number 1. The Southern Ontario Gliding Centre (SOGC) of the Royal Canadian Air Cadets also use the airport for spring and fall familiarization flights for the cadets.

In 1995, various members of Fonthill Branch 613 of the Royal Canadian Legion lobbied to have the airport renamed "Bud Kerr Welland Airport" in recognition of a local World War II Spitfire fighter pilot, but were unsuccessful. In 2015 the airport was renamed Niagara Central Dorothy Rungeling Airport, in honour of the legendary Canadian pilot Dorothy Rungeling, CM.

See also
 St. Catharines/Niagara District Airport
 Niagara Falls/Niagara South Airport

References

External links
 Page about this airport on COPA's Places to Fly airport directory
 Official website, see About Us for history
 Niagara Skydive, major tenant
 St. Catharines Flying Club, major tenant

Registered aerodromes in Ontario
Transport in Welland
Royal Canadian Air Force stations
Military airbases in Ontario
Airports of the British Commonwealth Air Training Plan
Military history of Ontario
1940 establishments in Ontario

redpajama_set_name: RedPajamaWikipedia


text:
#ifndef HL_CNN_STUB_H_
#define HL_CNN_STUB_H_

#include "hl_cnn.h"

inline void hl_shrink_col2feature(
    const real * dataCol, size_t channels,
    size_t height, size_t width,
    size_t blockH, size_t blockW,
    size_t strideH, size_t strideW,
    size_t paddingH, size_t paddingW,
    size_t outputH, size_t outputW,
    real* dataIm,
    real alpha, real beta) {}

inline void hl_expand_feature2col(
    const real* dataIm, size_t channels,
    size_t height, size_t width,
    size_t blockH, size_t blockW,
    size_t strideH, size_t strideW,
    size_t paddingH, size_t paddingW,
    size_t outputH, size_t outputW,
    real* dataCol) {}

inline void hl_maxpool_forward(
    int frameCnt, const real* inputData, int channels,
    int height, int width, int pooledH, int pooledW,
    int sizeX, int stride, int start, real* tgtData) {}

inline void hl_maxpool_backward(
    int frameCnt, const real* inputData,
    const real* outData, const real* outGrad,
    int channels, int height, int width,
    int pooledH, int pooledW, int sizeX,
    int stride, int start, real* targetGrad,
    real scaleA, real scaleB) {}

inline void hl_avgpool_forward(
    int frameCnt, const real* inputData, int channels,
    int height, int width, int pooledH, int pooledW,
    int sizeX, int stride, int start, real* tgtData) {}

inline void hl_avgpool_backward(
    int frameCnt, const real* outGrad,
    int channels, int height, int width,
    int pooledH, int pooledW, int sizeX,
    int stride, int start, real* backGrad,
    real scaleA, real scaleB) {}

inline void hl_CMRNorm_forward(
    size_t frameCnt, const real* in, real* scale, real* out,
    size_t channels, size_t height, size_t width, size_t sizeX,
    real alpha, real beta) {}

inline void hl_CMRNorm_backward(
    size_t frameCnt, const real* inV, const real* scale,
    const real* outV, const real* outDiff, real *inDiff,
    size_t channels, size_t height, size_t width, size_t sizeX,
    real alpha, real beta) {}

#endif  // HL_CNN_STUB_H_

redpajama_set_name: RedPajamaGithub


IMAG0063.jpg, originally uploaded by f_a_h.
The cooler weather has inspired me to knit more. I'm currently working on this scarf and already have a second one that I want to start. I'm trying to finish old projects before I start new ones though.


Dog Rocks are a proud supporter of Earth Day, which takes place each April, and this year we are encouraging you to recycle your used rocks!
There are now over 1 million Dog Rocks users worldwide who rely on these all natural rocks to help keep their grass green, and we want to make all pet owners aware of how they can responsibly recycle their used rocks.
Placed in the dog's water bowl, these natural rocks remove nitrate from the water and stop pet urine burn marks on grass. After 2 months the rocks should be be replaced, leaving you unsure as to what to do with them.
The great news is that they are 100% natural so the ideas as to what to do with them after use are endless!
If you're a Dog Rocks user and have found a fun, new, creative way to recycle the rocks after they've been used, we'd love to hear! Get in touch through our Facebook page and share it with the world!


text:
Q: x509 certificate signed issue in terraform planing terraform throws the following error in logs in debug mode when planing terraform. I use aws cli 2.0 on a windows machine. The error comes up only for aws west region deployment. the east is working fine. I tried updating the certificate chain in the python folder path C:\Program Files (x86)\Microsoft Visual Studio\Shared\Python37_64\Lib\site-packages\certifi.
still getting error. no luck
2021/06/07 19:30:58 [DEBUG] [aws-sdk-go] DEBUG: Send Request ec2/DescribeAccountAttributes failed, attempt 8/25, error RequestError: send request failed
2021-06-07T19:30:58.801+0530 [DEBUG] plugin.terraform-provider-aws_v2.70.0_x4.exe: caused by: Post https://ec2.us-west-2.amazonaws.com/: x509: certificate signed by unknown authority

A: Terraform providers are written in go and it should grab CA certificates from the default OS trust store.
There are a couple of things that can cause given error:
1. AWS CA update
During the last couple of years AWS was migrating to their own Certificate Authority, so this might be related. You can see their announcement blogs here.
For Windows installing latest OS updates should be enough to pull new CA certs.
You can also check AWS docs on how to install their CAs manually here
2. Outdated terraform provider
From provided logs looks like you are using aws provider version 2.70.0. It was build with older version of go that since had some fixes related to certificate validation on Windows. Try updating your provider to latest version

redpajama_set_name: RedPajamaStackExchange


text:
Q: Celery + RabbitMQ + "A socket error ocurred" I'm using Celery within Django with RabbitMQ as the broker on Heroku. My RabbitMQ service is CloudAMQP Tough on Heroku.  If relevant, we've been having somewhat frequent memory leaks that I've been trying to plug, but generally service isn't degraded when it happens.
When the site is heavily trafficked (like today), I start getting occasional errors like the following:
Couldn't log in: a socket error occurred

The task is completely thrown out and not registered anywhere.  This is obviously a business-critical problem.  My celery settings are below:
BROKER_URL = os.getenv('CLOUDAMQP_URL', DEFAULT_AMQP)
CELERY_TASK_SERIALIZER = 'pickle'
CELERY_RESULT_SERIALIZER = 'json'
CELERY_ACCEPT_CONTENT = ['pickle', 'json']
CELERY_ENABLE_UTC = True
# CELERY_RESULT_BACKEND = 'djcelery.backends.database:DatabaseBackend']
CELERY_STORE_ERRORS_EVEN_IF_IGNORED = True
CELERY_SEND_TASK_ERROR_EMAILS = True
CELERY_RESULT_BACKEND = False
CELERY_IMPORTS = ('business.admin', 'mainsite.views', 'utils.crons', 'mainsite.forms', )
BROKER_POOL_LIMIT = 5

# trying to clean up this memory leak
CELERYD_MAX_TASKS_PER_CHILD = 5
CELERYD_TASK_TIME_LIMIT = 60*60

I'm a bit new to celery so I'm happy to provide as follow-up whatever logs/etc will be helpful, but I'm not even sure what to provide at this point.  Is there anything obvious in my settings or environment that seems like it could be causing this problem when heavily trafficked?

A: Socket error might be due to RabbitMQ or Heroku being killed by Linux Out-of-Memory Killer. When server runs out of memory due to not utilized memory allocation of some processes, Linux kernel tries to find the cause and kills the associated process. Using too much memory by RabbitMQ might result in being killed.
You can find out if Linux OOM killed a particular process using grep -i kill /var/log/messages*
Use following links for more details & learning about Linux OOM configuration:
How to Configure the Linux Out-of-Memory Killer
Do you use supervisord?
Supervisord is a nifty daemon for running and monitoring processes. Using this one you can make sure all long running processes such as RabbitMQ would be always up & running, even if the process is killed.
There are two possible reason for memory leaks:

*

*If settings.DEBUG is True, this could result in memory leaks. Make sure that settings.DEBUG if is set to False in your worker configuration.

*You should consume the task results if you plan to keep them. If you do not consume them, you'll be facing memory leak problems. To solve the issue you may change your settings using these lines:
# Just ignore the results, in case you're not consuming results.
CELERY_IGNORE_RESULT = True
CELERY_STORE_ERRORS_EVEN_IF_IGNORED = False


This show almost didn't happen – it was the last thing I was able to do before re-imaging my Mac and going into a recovery cycle. Thankfully, I was able to restore almost all my data, so I suspect this week's show will go on as scheduled.
Thanks for listening, and I hope you enjoyed it!
As usual, my thanks to Dark Mother Media for hosting the show. And be sure to check out Spider Lilies and Razor Skyline on the web – they both do some awesome stuff.


text:
Appearances of Jesus // Jesus Appears to the Disciples(Thomas is Absent)
Images by Alyssa Marie Francis
When I was a kid, one of my favorite books was The Lion, The Witch, and The Wardrobe. My favorite part of that book was when the Stone Table broke. The sound terrified Susan and Lucy, and the next thing they knew, Aslan was with them again. He wasn't a ghost. Instead, he revealed that there was a Deeper Magic that the witch was unaware of:
"If she could have looked a little further back, into the stillness and the darkness before Time dawned, she would have read there a different incantation. She would have known that when a willing victim who had committed no treachery was killed in a traitor's stead, the Table would crack and Death itself would start working backwards."
Aslan's resurrection is an allegory of how Jesus appears to the apostles in today's passage. Like Aslan, Jesus revealed the deeper meaning behind what the Scriptures said about His death and resurrection. Jesus also foreshadows the coming of the Holy Spirit and how the apostles will spread the good news throughout the world. You can only imagine the shock, surprise, and relief the apostles felt as they watched their formerly dead rabbi eat amongst them again, and help them understand what just happened.
There's only one question, though: Why is Thomas absent? Nobody really knows for certain, but back when I was in college, I wrote a play that proposed a theory. In my play, some of the disciples, including Thomas, were in the Upper Room, figuring out what to do after Jesus's death, since the play takes place on Good Friday and the day after. Some of the apostles weren't around because they ran off to find other places to hide. Thomas, however, leaves the safety of his friends because he wanted to be alone. He was consumed by anger as a way to cope with losing Jesus.
Most of us know that Thomas is famous for being a doubter. When I wrote my play, I interpreted that doubt as a form of anger, denial, and despair. He might have been the kind of person who could only understand what's right in front of him, the things that he sees and hears and touches. And it's hard to cope with death when all you have is the material. There are many people out there like that who only believe in the material world and cling to disbelief out of some form of anger, denial, or despair. Please pray for these people.
Reflect: Why do you think Thomas wasn't there? How do you think you would've coped with Jesus's death if you weren't certain about him coming back?
Act: Pray for the conversions of atheists and agnostics.
Source: https://heartofmarywf.squarespace.com/blog/2017/4/21/appearances-of-jesus-jesus-appears-to-the-disciplesthomas-is-absent
Soul Saturday // Movie Review
Appearances of Jesus // Road to Emmaus


The binocular is arguably the most used tool in the hunter's toolbox. Whether still-hunting whitetails in Tennessee, stalking antelope throughout the grasslands of Wyoming, pursuing mule deer in the badlands of the Dakotas, looking for that trophy bull elk in the mountains of Nevada, or searching for the distinguished African gemsbock, more time is spent peering through a binocular than time spent on the rifle itself. For this reason alone, investment in a very nice binocular should be at the top of every hunter's priority. Enter Kahles optics direct from Austria.
Although the Kahles brand isn't widely known throughout the United States, it is one of the world's oldest optics manufacturers, being 116 years in existence. Kahles was founded in 1898 by Karl Robert Kahles in Vienna Austria and is one of the few optics manufacturers that builds everything under one roof. The company headquarters were located in Vienna until 2012 when they relocated to Guntramsdorf, Austria. Kahles manufactures a wide range of riflescopes along with three models of binocular, all of which are the roof prism design. The 10X42 model binocular is the subject of this review.
The 10X42 model Kahles binocular measures 5.6 x 4.9 x 1.9 inches and weighs 20.5 ounces according to my measurements. A rubber coating protects the magnesium frame and helps to absorb minor bumps to the binocular as well as provide a secure hold and noise dampening. Twist out eye cups are easy to operate and provide the correct distance for non-eyeglass wearers.
Phase correction coatings are applied to the internal prisms to provide the contrast while Kahles' proprietary AMV lens coatings are applied to the lenses for enhanced light transmission. Other details of the binocular include a tripod adapter, close focus distance of 8.2 feet, and the binocular is fully waterproof.
These specifications aren't much different from most any other 10X42 binocular, so what sets the Kahles brand apart from the rest of the pack? The answer to that question isn't easily answered through a cursory review of the specifications, but with a detailed analysis of every aspect of the binocular. The refinements in the rubber armor, the feel and operation of the eye cups and focus wheel, and optical characteristics place this binocular among the best in the business.


text:
<?xml version="1.0" encoding="utf-8" standalone="no"?>
<resources xmlns:xliff="urn:oasis:names:tc:xliff:document:1.2">
  <string formatted="false" name="value_volume_100_percent">Дауыстың дыбыс деңгейіне сәйкес</string>
  <string formatted="false" name="value_volume_75_percent">Дауыстың дыбыс деңгейінен 75%</string>
  <string formatted="false" name="value_volume_50_percent">Дауыстың дыбыс деңгейінен 50%</string>
  <string formatted="false" name="value_volume_25_percent">Дауыстың дыбыс деңгейінен 25%</string>
</resources>


When your business target private sale, your website need equipping with functions that weren't supported by Magento default. For example, you have some items that only sell to wholesalers with discounted price. The customers can't see the price of products until they log in their wholesale account or they have to submit a contact form to request prices of products if buying in bulk. Magento 2 Hide Price Call For Price extension offers you the optimal solution to do all of the actions above.
Many extensions are developed with just one function: Call For Price or Hide Price only, but Magento 2 Hide Price Call For Price extension by BSSCommerce combines these two functions into just one extension.
Firstly, let's make it clear. What is Call For Price? What is Hide Price?
Call For Price function allows admin to display a contact form to obtain customers' request on product price. The price of products and the Add to Cart button is disabled while a Call For Price button is displayed.
While you need to install two different extensions to have all of those features, BSSCommerce Hide Price Call For Price extension provides both functions in easy-to-use Magento 2 extension.
Send price request with Call For Price form.
Disable Add to Cart button and show a custom message.
Hide prices of products for not-logged-in customers and other customer groups.
Hide product price on all position of any page: Product page, Category page, Wishlist page, Comparison page, Related, Up-Sell, Cross-sell block.
Disable product price for specific categories or each product.
Change the Call For Price form as wish (text, field, types of fields).
Compatible with all product types, products with custom options (text field, text area, date, drop down, time) and products with special price or tier price.
Magento 2 Hide Price Call For Price extension is the perfect extension for Wholesale / B2B websites. It helps you conduct private sales to target the wholesale customers better while still operate your site for regular customers. Here are three remarkable reasons to prove that that Hide Price Call For Price extension by BSSCommerce is best for your website.
Without having to disable the product, you can keep the appearance of product on site while still hide the price of that item. This feature is useful when your site has special products with price that requires updating or verifying, price that changes depending on circumstances, or price of customization services.
The Call For Price function allows you to create a Call For Price form for customers to directly exchange wholesale price for bulk buying. This contact form appears as a pop-up when customers click the Call For Price button. The form includes customer name, contact number, and request of product price. You can customize the content and design of the Call For Price contact form as wish.
You can disable the price of several products or the whole category for the unregistered customer groups. Not-logged-in customers can only see the message "Please log in to see price" and can't add the product to cart or know the product price until logging in your website.
This function helps restricting untargeted customers to know your product's price and even avoid unwanted competition from the rivals.
Let's get a tour around backend configuration of Magento 2 Hide Price Call For Price extension by BSSCommerce.
The module configuration has two main parts: Customer Inquiry List and Configuration.
Customer Inquiry List presents all customer requests which sent via the Call For Price Form.
In here, you can know detailed information about customers' inquiries and decide to send email announcing product price with a simple click.
Here is an example of the email that customers receive.
The General Config permits you to enable or disable the extension and set up email sender as well as email templates for both admin notification email and customer reply email.
As indicated by the name, this section allows you to prioritize the Call For Price function or Hide Price function.
In this section, you can set up the design for the Call For Price Form. You can add more or remove fields on the form, change the field type, set the field as required, enable or disable the chosen field, and add the reCaptcha test to the Call For Price form.
Call For Price Global Config let you set up Call For Price function, including entering text for the Call For Price button, and applying Call For Price for categories or customer groups.
In this section, you can configure the Hide Price function, such as decide text for the Hide Price custom message and apply Hide Price for categories or customer groups.
How to Apply Hide Price Call For Price for Each Product?
When you enter the Edit Product Page in the backend, you can see the additional config to fully set up Hide Price function or Call For Price function for each product, choose the text and apply the function for customer groups.
You can experience BSSCommerce Hide Price Call For Price extension for Magento 2 by visiting the frontend demo.
The Call For Price form appears after you click the Call For Price button.
Magento 2 Hide Price Call For Price extension provides full functions with both Hide Price function and Call For Price function. This extension is excellent for any Wholesale/B2B website to satisfy all of your price hiding requests. With the reasonable price of $79.00, you can get this extension with free installation services, free update, and free 1-year support.


We are here to help you transport your boat or yacht over land or overseas. We provide shrink wrapping and preparation of your vessel, we provide custom cradles, storage as well as other transportation services. Once you are ready we will help you prepare to meet your unique pre-transportation preparation needs.
We want to earn your business and your trust, by providing you with our unique services. We are your best source for all your transportation needs. Regardless of your yacht or boat size, our experience and professional staff will strive to provide the services that are relevant to helping you achieve your expectations quickly and efficiently. We appreciate the opportunity to offer you our unique transportation services, designed exclusively to meet your needs.
Express Boat Transport is a family run boat, yacht and equipment logistics and transport business. Our crew of experts has over 20 years experience transporting boats, yachts and heavy equipment. We are wide load national and international transport and hauling specialists. We are well versed in transporting power boats, sailboats, and multiple loads throughout the nation and abroad. We specialize in transporting of all types of loads — no job is too small or too large.
Express Boat Transport is highly qualified to transport, ship, and assist you with your boat, yacht and heavy equipment transportation needs.
Are you ready to move? To get started simply ask for your FREE QUOTE NOW to enjoy a hassle-free experience.
While we are processing your FREE QUOTE it's a good time to prepare for the move. Here are some instructions to prepare your boat or yacht for the move.
Proper boat preparation is an important part of getting your boat ready for hauling.
Make certain that all loose items in your vessel such as plates, galley utensils, personal items or any other non-secured items have been secured or removed from the vessel.
Empty all fuel and water from the vessel.
Remove any device or fixture that extends beyond the hull of the vessel such as antennas, radar, compasses or depth sounders. These devices should be secured inside the vessel for shipping.
Remove the plug from the craft.
You will need to store and secure plastic and plexiglass windshields below.
If you are moving the boat during the winter months, then you need to winterize the engine, toilets, the water systems or any other weather sensitive device on the vessel.
Shrink wrap is an excellent way to protect your boat during transport. However, a poor shrink wrap may tear due to the high winds generated by road travel. If this happens, the vessel could suffer damage from the shrink wrap beating, chaffing and scratching the vessel. Express Boat Transport cannot accept responsibility for damages caused by improper shrink wrap.
If your larger boat needs to be loaded transom forward, then the craft needs to be shrink wrapped or we cannot accept liability for damage that may occur to the windshield during transport.
When moving a sailboat, you must remove all standing rigging, lights, spreaders, wind indicators and all other types of mast rigging prior to transport. Otherwise, Express Boat Transport cannot assume liability for damage such as scratches or abrasions that may occur on the mast or damaged rigging or lights left on the mast during transport.
HOW DO I CONTACT EXPRESS BOAT TRANSPORT?
You can reach one of our customer service representatives by calling our Nationwide Toll Free Number 800-350-2488 during normal business hours, from Monday to Friday 9:00am - 6:00pm EST (Eastern Standard Time).
WHERE DO I SEND PAPERWORK AND PAYMENTS?


text:
Kearton is a hamlet in the Yorkshire Dales, North Yorkshire, England.

Notable people with the surname Kearton include:
Ada Cherry Kearton (1877–1966), South African soprano, spouse of Cherry Kearton
Frank Kearton, Baron Kearton (1911–1992), British scientist and industrialist
Jason Kearton (born 1969), Australian association football goalkeeper
Richard and Cherry Kearton (1862–1928), late 19th/early 20th-century wildlife photographers and naturalists

First name
Kearton Coates (1820–1893), English-born member of the Wisconsin State Assembly