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Free web-based bug tracking system written on PHP. Some of the main features are: fully custom templates, advanced filters, LDAP support, email notifications, subscriptions, reminders, flexible permissions management, graphical project metrics, etc.1 weekly downloads
Poweradmin is a web-based DNS administration tool for PowerDNS server. The interface has full support for most of the features of PowerDNS. It has full support for all zone types, for supermasters, full support for IPv6 and multi-language support.242 weekly downloads
pH7 Social Dating CMS - pH7CMS
Professional Social Dating Builder Software (pH7CMS basic version)230 weekly downloads
PHP iAddressBook
Feature complete address book written in PHP for your personal website8 weekly downloads
IXThemes is an implementation of innovative methods in the development of qualitative universality modules and themes for the PHP based content management systems such as XOOPS, ImpressCMS, EXM System, and others.1 weekly downloads
Online collaboration and productivity tools for the office. Manages organization information, projects, documents, e-mail, social network, etc. All in a centralized and integrated environment.
forma.lms is a Learning Management System (LMS), opensource lms304 weekly downloads
XOOPS Web Application System
The world's leading content management systems (CMS) written in PHP533 weekly downloads
My Image Gallery
Mig is designed to be a simple but flexible program that enables users to manage online photo galleries.22 weekly downloads
MODx PHP Application Framework and CMS
MODx is a XHTML, CSS and Ajax Content Management Framework (CMF). More than just a simple CMS, MODx makes building XHTML/CSS designs that leverage "Web 2.0" technologies straightforward, and provides a customizable platform on which to build SEO effort
Mambo Old Versions
All version's of Mambo Here!1 weekly downloads
GRA4 Social Network (Micro)
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WikyBlog : Wiki / Blog CMS
WikyBlog is a CMS/Groupware application written in PHP/MySQL that fuses collaborative editing features of wikis with user friendly publishing characteristics of blogs. MediaWiki derived wiki syntax, AJAX enhanced, UTF8 and extendable (google maps).2 weekly downloads
squid front
just like mysql front, squid front is used to manage the squid tasks running on servers and monitor system status of each server, it also help you configure your ruels, users as well as other informations.1 weekly downloads
Redaxscript is a free, PHP and MySQL driven content management system for small business and private websites. It's extremely lightweight, simple and customizable. Explore demo.redaxscript.com for a live preview.1 weekly downloads
DISCUSS is so-called "chat" module for XOOPS, that supports your group to make rapid decisions. It offers rich user experience with IM-like interface powered by Ajax technology.1 weekly downloads
Y.O.D.A. - Yaro`s Oracle Data Admin
Web-based tool for developers and administrators to access into Oracle. Written in PHP to allow view,manage and export Oracle objects (tables, view,index,package, procedure, trigger..) over WWW (like phpMyAdmin, phpOraAdmin or funkctions like TOAD)1 weekly downloads
Allcode for SuperWikia- Mass Codebase
SuperWikia Alpha Allcode is a directory server application for all SuperWikia Alpha compatible programming languages and SDK/API/IDE applications. The Allcode uses SuperWikia Alpha to compile the mass codebase and its accessible directory system.
Kuggaa is a (A)gpl open source cloud computing project. Kuggaa enables remote applications and rich media experiences. Kuggaa enables most web based devices the ability to create, manage, and share files on most devices.3 weekly downloads
Simple Page Flow Controller Library (like Finit State Machine) in MVC Web Application Model.1 weekly downloads
Full featured photo collection PHP script - Light, fast and easy to install.5 weekly downloads
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PHP Screw
PHP Screw is a PHP script encryption tool. When you are developing a commercial package using PHP, the script can be distributed as encrypted up until just before execution, preserving your intellectual property.50 weekly downloads
PHP Locale
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Product Reviews
"HOW I MET YOUR MOTHER"-Season 7
If you love "How I Met Your Mother"; you'll want to add Season Seven to complete your set. It is another great season of laughs. Great acting AND writing. FIVE*****(very enthusiastic)*****STARS!
- How did the image on site compare with the actual product? the same
- How accurate was the on site description of the product? adequate
- Please tell us about the quality of the product. great
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This is sort of a general web development question that I need some experts' advice on. This is probably quite a no brainer for some of you, but I am having trouble getting this to display properly.
I have a database table set up where each entry has 5 text fields, and one image. What I want to do is use the repeater to display the text on the left hand side of the div, and the image on the right hand side of the div (basically aligned with the center of the text).
Company Name
Description3 Image goes about here.
I have the repeater all configured properly and ready to go, it's displaying the text just fine in a well formatted way. However, I'm having trouble getting that image to display properly. Do I need to use text wrapping here to accomplish this? I'm pretty stuck and don't know where to proceed. I can post my ASP.net code here if desired.
Thank you so much in advance. Very helpful site for new programmers.


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...Unfortunately because of two incidents now in which I have spent near an hour and near two hours researching and going over some difficult math problems to attest to my competency after which the student did not choose me for a session, I must take this measure. Any time (I will alert the studen...
43 Subjects: including Latin, English, Spanish, GRE
Dallas, TX
...I have an M.A.T. in Classical Studies from Vanderbilt. I have taken four years of Russian and Italian at the University of New Hampshire, where I won awards for excellence in both languages. I love to travel.
17 Subjects: including Latin, English, reading, Italian
Allen, TX
I earned a Bachelor degree in French and a special title to teach French (aggregation)in Europe (Belgium), a Master's degree in International Relations in Cameroun, an associate degree in philosophy (in Belgium) and a Master degree in French at University of Texas- Arlington (2013).I currently tut...
7 Subjects: including Latin, French, ESL/ESOL, grammar
Garland, TX
...I was known as "The Ball-Handling Wizard." (I can juggle three basketballs off a wall, dribble three basketballs at a time easily, spin the ball on my nose! and all my fingers, and do the so-called "impossible catch"--with TWO basketballs, a doubly impossible feat.)
I have worked with kids of...
16 Subjects: including Latin, reading, English, writing
Dallas, TX
...I graduated with my Master's degree in science education in 2015, and I am writing curriculum for my district since 2013. I am offering German lessons for every level, beginner to advanced, including conversation, test preparation, and reading German literature. Since every student has different interests and needs, I customize the lessons and reading materials to fit the individual student.
40 Subjects: including Latin, English, Spanish, chemistry
Plano, TX


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Around the Region
Published: Tuesday, January 6, 2004 at 6:01 a.m.
Last Modified: Tuesday, January 6, 2004 at 1:16 a.m.
Lake City teenager dies after crash
Hiedi Jones, 17, died at 6 a.m. Monday at Shands Jacksonville, according to the Florida Highway Patrol.
Jones was riding in the open back of a 1996 Toyota pickup truck driven by Edward Goss, 17, FHP Trooper J.R. Taylor Jr. said. A total of five teens were in the truck, but Jones was the only one in the back.
Goss was driving south on SW Mixon Road, about eight miles south of Lake City, at 2 p.m. Sunday when the truck traveled off the road and hit a dirt embankment, according to the FHP. The truck rolled over and ejected Jones from the cargo area, Taylor said.
Two passengers, Eric Britain, 17, and Ashley Hendry, 18, were treated and released from hospitals. Edward Goss and another passenger, Rachelle Goss, 13, had cuts and bruises but didn't require medical treatment. All are from Lake City.
Taylor said the crash appears to have resulted from careless driving. "They were just playing around; spinning around on the dirt road," he said. None of the victims wore a seat belt.
- Kathy Ciotola
Keystone man charged in dogfighting case
Clay County sheriff's officials charged Joseph K. Lewis, 41, with fighting and/or baiting dogs and with felony animal cruelty.
Sheriff's officials found 32 dogs at Lewis' home on Dec. 23 while investigating a theft case. The dogs were chained to each other or to trees, and had very little food or water and no shelter, authorities said.
Because of injuries on the dogs, authorities said they believe Lewis trained the dogs on his property but took them out of Clay County and out of state to fight them.
Two of the dogs have since died from their injuries and of malnutrition. One, which had been stolen from a local woman, was returned to her. The remaining 29 probably will be put to sleep this week because their training to be fighting dogs makes them poor candidates for adoption, according to Clay County sheriff's officials. But one of the dogs has delivered a healthy litter of puppies and those puppies will probably go up for adoption.
- Kathy Ciotola
Public Enemy rapper to speak at ceremony
The organization's Dr. Martin Luther King Jr. Awards Ceremony starts at 6 p.m. Tickets are $15 for UF students and $20 for the general public.
The event honors UF's black graduate students for community and academic efforts. For more information, call 665-0505
- Dave Schlenker
Deadline to sign up for emergency class today
The Community Emergency Response Team class is a seven-week, free class that covers introduction to disasters, fire suppression, disaster medical operations, search and rescue and other topics.
Each class runs from 7 p.m. to 9:30 p.m. at the Alachua County Emergency Operations Center, 1100 SE 27th St.
Anyone interested should call the Office of Emergency Management at 264-6500 or visit the Web site at www.alachua-em.org.
- Sun staff report
Measure would license genetic counselors
With the mapping of the human genome and the potential ability to determine whether people - or their unborn children - may be at genetic risk for certain diseases, the field has expanded, Sen. Anna Cowin said.
"It's been picked up by counselors who aren't medical doctors," said the Leesburg Republican, who is sponsoring a measure that would create a seven-member board to license genetic counselors and set out certain educational guidelines for the profession.
The bill (CS-SB 506) was approved unanimously Monday by the Senate Military and Veterans' Affairs Committee. It still must be approved by four other Senate committees and the full Senate as well as the House.
- The Associated Press
Reader comments posted to this article may be published in our print edition. All rights reserved. This copyrighted material may not be re-published without permission. Links are encouraged.
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Hey everyone!
Enter your best sets for 2013! Any sets that you made since New Year's Eve! Make sure that they are so totally over the top and editorial/photoshoot/fashion week worthy! I will be waiting to see your wonderful sets! 2 weeks! 10 winners! NO LIMIT!
God bless you all!


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|Message view
|« Date » · « Thread »
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|Maik Schreiber <blizzy-keyword-lucene_user.f54...@blizzy.de>
|Re: Best way to purposely corrupt an index?
|Wed, 20 Apr 2005 08:27:19 GMT
> As the index is rather critical to my program, I just wanted to make it really > robust, and able to cope should a problem occur with the index itself. > Otherwise, the user will be left with a non-functioning program with no > explanation. That's my reasoning anyway. You should perhaps go about implementing an automatic index backup feature of some sort. In the case of index corruption you would at least be able to go back to the latest backup. -- Maik Schreiber * http://www.blizzy.de GPG public key: http://pgp.mit.edu:11371/pks/lookup?op=get&search=0x1F11D713 Key fingerprint: CF19 AFCE 6E3D 5443 9599 18B5 5640 1F11 D713 --------------------------------------------------------------------- To unsubscribe, e-mail: firstname.lastname@example.com For additional commands, e-mail: email@example.com
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Welcome to the PCA Calgary website. PCA Calgary is a non-profit organization working since 1975, representing Canadians of Pakistani origin residing within Calgary and its surrounding areas.
Dear Friends We would like to confirm the visit of High Commissioner of Pakistan to Canada His Excellency Tariq Azim Khan along with Consul General Pakistan in Vancouver will be meeting the Pakistani Community on 6th March 2016 at Pakistan House in Westwinds Hall. On behalf of executives of Pakistan Canada Association we would like to invite all of you to attend this event from 2-4pm. Please see the attached poster for further details. Looking forward to greeting you Click here for more details


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A Culinary Adventure Around the World
Join us as we take you on a culinary adventure from Greece and the Middle East to Ethiopia and Vietnam, without leaving your armchair.
Olympians Among Us
This Olympic year heralds our city's unveiling of its new brand and logo. Colorado Springs is now officially and fabulously Olympic City USA!
Your child claims to be sick and can't go to school. A lot. More than 160,000 kids miss school every day in this country– because they are being bullied.
Pondering the Private School Advantage
Choosing a school is one of the most important decisions a parent will make for their child, so they must do their homework to find a good fit - be it public, private or charter.
Welcome Mat Out for Home Remodels
Millions of Americans, inspired by Cinderella makeovers, catch home improvement fever and scour websites like Houzz, DIY Network or This Old House.
A Story Like No Other-Your Own
Ever discover a dusty journal or diary your mom kept when you were a kid? Or talk your dad into telling tales of his childhood adventures? Maybe you've exchanged stories at a family reunion – and wish you'd recorded them for the kids to hear someday.
Fast & Furious
A new entertainment complex opens this month on the north end of Colorado Springs and based on the enthusiasm of its ownership, it will be on the fast track to success.
Even In Land-Locked Colorado, Life's a Beach
Summer's half over already. How can that be? But it's true – some kids go back to school in just a month or so. That said, have you been to the beach yet?
Joint Replacement of the Hip and Knee
For anyone experiencing pain and restricted movement due to joint damage, disease, or degeneration, total knee replacement is a big decision.
The Health of It
Two spas in Colorado Springs are not only helping their clients to look and feel their best, but are integrating therapeutic practices and technologies that deliver health-giving benefits.
The genius behind, you guessed it, Seinfeld, comes to town for a night of awkward, uncomfortable, yet unstoppably funny stand-up comedy.
Put your paws together for an action-packed performance of human and canine acrobatics and tricks, from previous winners of the popular show...
61 years and running strong, join competitors and fans for live music, food trucks, and a beer garden in celebration of the "America's...
No strangers to gold and platinum, this legendary group with classics like "Carry On My Wayward Son" and "Dust in the Wind"...
Praised as a "comedian's comedian," Regan will crack you up with good, clean, self-deprecating humor.


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Club Cuisine: Cooking with a Master Chef Hardcover – Jun 16 2006
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Product Description
From the Back Cover
Recipes and cooking tips from the kitchen of one of the country's most exclusive clubs
Club Cuisine is the new, stunningly visual cookbook featuring Certified Master Chef Edward Leonard's dynamic club fare. It presents more than 150 recipes that, until now, have typically only been enjoyed by privileged members of private clubs. Inside, you'll find helpful hints and insights to create these scrumptious dishes, as well as inspiring photographs by renowned photographer Ron Manville, who has worked extensively with the ACF Culinary Team USA and other top chefs.
For serious chefs, Club Cuisine is a dream come true. Featured recipes include amuse-bouches, seafood, beef, and pasta dishes as well as delectable soups, salads, and sandwiches. Also included is a guest chef chapter featuring recipes from some of the top club chefs around the country that add to this impressive collection. Caterers and restaurant owners will also find complete seasonal menu items that have pleased distinguished diners at top private clubs.
For everything from a simple nosh to a hearty but elegant meal, Club Cuisine is the cookbook to keep at your fingertips.
About the Author
CHEF EDWARD G. LEONARD, CMC, is captain and team manager of the award-winning ACF Culinary Team USA, Vice President of the World Association of Cooks Societies, and Executive Chef at the Westchester Country Club, the 14th ranked Platinum Club, in Rye, New York. Chef Leonard is one of only sixty-two Certified Master Chefs in the United States.
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Belman heats up for Saddleback
With a near-school-record 475 yards passing and a record-tying six touchdowns, freshman quarterback Tim Belman led 10th-ranked Saddleback College to its fourth consecutive victory, a 66-42 Southern Conference triumph over Grossmont on Saturday night at Saddleback.
It was a return to form for a team that went through a midseason lull.
Last season, Saddleback's record-breaking offense was held under 21 points just once in 11 games.
But during a mid-September, early-October swoon this season, the Gauchos (5-4, 4-1) failed to hit that number in three consecutive losses. Then, Belman hit stride.
"We have a lot of weapons from last year's team still here so these records are a total team effort," said Belman, a Laguna Hills grad. "I give all the credit to my receivers. They're the ones who get open; all I have to do is put it in the right spots."
Freshman Eric Lauderdale hauled in 10 passes for 218 yards and three scores. Sophomore Exavier Edwards-Ford had eight grabs for 92 yards. Belman connected with four different teammates for scores.
"We know what our guys can do when the ball is in their hands," Gauchos coach Mark McElroy said. "When you're defending us, it's difficult to guard so many guys who can do something with the ball whenever they touch it."
After falling behind, 23-21, early in the second quarter, Saddleback scored on consecutive possessions — short runs by James Marshall (104 yards rushing) and Josh Hawkins — to claim the lead for good.
Grossmont (5-4, 3-2) closed to six late in the third quarter, but the Gauchos scored 24 consecutive points to thwart the rally.
"We came back from some adversity earlier in the year," Belman said. "We knew we needed to step up and felt like our backs were against the wall. ... Now we're coming together as a family and clicking on all cylinders."
BRIAN WHITEHEAD /For the Register
Santa Ana 34, Palomar 31: The Dons raised their record to 7-2 and 4-1 by beating the Comets (3-6, 1-4) at Escondido High.
Fullerton 59, Orange Coast 6: LV Johnson ran the opening kickoff back 100 yards and the Hornets (5-4) never looked back in pounding the Pirates (3-7) at Fullerton. Jamison Sterns rushed seven times for 104 yards and a score.
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The community of Hester is located in the Parish of La Salle. Businesses related to supplies of building materials, floor laying and resurfacing, oil and lubrication and tourist information services, contribute to the local economy in a positive way.
Each year as a tradition to myself and this green movement website, I write on the events of Earth Day (April 22nd) this year is no exception. I will focus more on some new ideas and representations of our planet Earth. The symbols of Earth Day have been similar throughout the years, including an image or drawing of the Earth..


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Housekeeper: You've ruined that piano! Clouseau: What is the price of one piano, compared to the terrible crime that has been committed here Housekeeper: But that's a priceless Steinway! Clouseau: Nyot Anymeur.
Peter Sellers (1925 - 1980)
Source: Pink Panther films
Contributed by: Zaady
I am here to fix the problem with yer pheaun.
Madame, that is by far the ugliest nose I have ever seen and I compliment you on it, it suits you!
Mehrder?? . . what Mehrder?
Ecstatic over the total annihilation of the Earth, Dr. Strangelove "resurrects" himself, miraculously regaining his ability to walk. His mechanical, robot-like body rises out of his wheelchair, crying exultantly: "Sir! I have a plan. Heh." (He realizes he is standing up.) "Mein Fuehrer, I can walk!"
Source: As Dr. Strangelove (one of 3 roles) in Dr. Strangelove, Or: How I Learned to Stop Worrying and Love the Bomb, 1964
Special delivery, a behm, were you expecting one? . . . A Behm? Ahhhaaaahhhaaaoooww
Clouseau: Do you have a REUM? Inn Keeper: I do not know what a REUM iz! Clouseau: Zimma Inn Keeper: Ahhh.. a RRRUUUMMM! Clouseau: That is what I have been saying you idiot! REUM!
François: Do you know what kind of a bomb it was? Clouseau: Yes, the exploding kind.
Copyright © 2016 Gaiam, Inc.


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Please enter a valid city, state or zip code
22 reviews | 4.5 out of 5
I love this product ever since I found it. I use it on bedding, carpet, rugs (especially the ones to the entrance to the house), blankets, pillows, inside of my purses, some coats, closets, mattresses, shoes, house slippers, cars (carpet), everywhere there is material that can collect bacteria and or smells bad. Please, DON'T EVER STOP MAKING THIS PRODUCT!!! I BUY IT BUY THE BUNCHES BECAUSE I USE THAT MUCH AND HAVE ONE IN EVERY ROOM. JUST TO KNOW IT KILLS THE BACTERIA IS THE BIG PLUS FOR ME...THE LITTLE EXTRA IS THE SWEET SMELL IT LEAVES BEHIND. I'm never without this product!! NEVER!!
An entire bottle of formula leaked out into my daughter's play pen and it smelled HORRIBLE like rotten milk. I doused it with this antimicrobial febreze and the smell was completely gone as soon as it dried. I've sworn by this stuff ever since!
I wanted something to spray mother in law's bed with, I am her in home caregiver. It smells nice and doesn't stain.
Least expensive I could find, this stuff is like gold on ebay, reasonable at walmart. Very difficult to find anti microbial anymore in stores. Only drawback is that the shipping takes too long anymore. Walmart used to be quick, this particular package took nearly 2 weeks and by then the trip I needed it for was over. Nonrtheless, great value, in stock when nobody else had it. Oh right, 3 bottles stuck in a bag and delivered in a box, slight leakage but nothing major.
Packaging and shipping unacceptable. They put sticky tape over the spray head that leaves a sticky residue that will not come off, ruining the spray head, Also, bought 12, so that it should have shipped in a manufacturer box neatly. Instead they were loosely repacked in an oversized box, causing spillage and making a disappointing presentation.
I love love love using this spray when the household has got a cold or virus because not only does it keep the house fresh, I also know that it's killing germs and keeping the house smelling fantastic and clean with a super quick spritz. It's Super easy to use and efficient,also very very reliable and handy. There's something about a very clean smell that makes you feel great knowing that this spray does its job. It's also a great product for when you have kids in the house and want to keep a clean and fresh environment for them! It's also very great for a home with pets of all kinds! Defiantly recommend this product. [This review was collected as part of a promotion.]
I've been skeptical watching the commercials about this product, but now I'm a believer. This works great!
I had purchased some fabric refresher-antimicrobial about one year prior and it was just sitting there.....I did not think it would work to rid the air of spores as I was using another more expensive product that I was very dissatisfied with and decided to try refresher antimicrobial. To my pleasant surprise it worked very well indeed.
I was so happy I bought 10 bottles in fear that it would be discontinued.
Please keep this product on the shelves. Of course, I cannot find it locally, I bought it on line!
I moved last month from Southern California to Northern Washington state. I used this product often and loved it. I could find it at many local stores there.
Here in Bellingham, WA 98225, I have been unable to locate this product anywhere.
Is there some way I can look up where it might be available in the 982-- area??
Thanks. I'd hate to have to order it online for shipping.
LOVE LOVE LOVE! 2 dogs, 1 cat, and a hard working husband = smelly furniture!I'm always worried about the bacteria & microbial agents in the air/furniture that can cause illnesses. But I feel confident using Febreze AntiMicrobial Fabric Refresher. It has a very fresh light scent, not perfumey like most fabric refreshers or air scent sprays. I use this product & aaaahhh FRESH & CLEAN!
Love the product, hate the container. Top is easily dislodged. I buy from Amazon and when shipped the box is soaked and at least two of the Fabreze bottles are emptied. The top is just not secure. it pops off too easily. Good product. Please redesign so that top screws on securely.
I absolutely LOVE!!! this product--the smell isn't overwhelming but works fantastically--gets rid of every kind of smell [This review was collected as part of a promotion.]
The spray head on this bottle untwisted and left a mess in my car before I even got it home! It spilled out of the bag and ruined many of my other groceries. To remove the lid only requires a quarter turn of the spray lid - DO NOT USE this product around children or pets!
This product is excellent for refreshing pillows, mattresses, and especially pet beds. I'm in Michigan, and I can no longer find this product.
The scent is OK, but I love this product because it is the only Febreze Fabric Refresher that is antimicrobial. I use it on pillows, blankets, sofas, chairs and virtually everything in my home. Walmart.com just needs to keep it instock and allow customers to purchase more than 2 at a time.
I love this. I use it in my dogs room. No matter what kind of accident they have it stays fresh. I'am just sorry they don't have it in the NOTICEABLES anymore.
As long as you don't really have much carpeting or furniture that you want to use this product on it may be a good deal for you otherwise in just one day of use you'll probably use up at least half of the bottle because it goes pretty quickly.
Arrived safely and fairly quickly. I was/am? unable to get this product locally that I have seen.


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John Keib
Executive Vice President and Chief Operating Officer, Residential Services
John Keib serves as Executive Vice President and Chief Operating Officer, Residential Services for Time Warner Cable. In this role, Mr. Keib leads the service delivery, customer care, marketing and sales operations for the company's residential services business. Previously, Mr. Keib served as Executive Vice President, Residential Operations.
Throughout his career, Mr. Keib has been instrumental in the launch and growth of new products and services, including high-speed Internet, video, digital phone, business class and local programming. He got his start in the industry with Thomson Multimedia and later with DirecTV in New York City. Subsequently, he joined Time Warner Cable's marketing team in 1998 working on the launch of Road Runner® high-speed Internet service in Central New York.
In 2006, Mr. Keib was promoted to Regional Vice President of Marketing and Sales, overseeing projects for the Northeast. In 2007, he was named RVP of Marketing and Sales for the Southern California Region, and then RVP of Marketing and Sales in the New York City Region in 2008. In 2009, Mr. Keib returned to upstate New York as President of Residential Services for the Northeast/National Region. In 2010, he served as President of Residential Services for the company's West Region, before returning to New York City as EVP, Chief Care and Technical Operations Officer in 2013.
Mr. Keib received his B.S. from Cornell University and his M.S. from the S.I. Newhouse School of Public Communications at Syracuse University.
Time Warner Cable is among the largest providers of video, high-speed data and voice services in the U.S., connecting 16 million customers to entertainment, information and each other.
We Are Listening
Last updated: November 2015


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|Home | About | Journals | Submit | Contact Us | Français
We examined the cost-effectiveness of 2- and 3-dimensional computerized tomography (CT) colonography as a screening test for colorectal neoplasia.
We created a Markov model of the natural history of colorectal cancer. Effectiveness of screening was based upon the diagnostic accuracy of tests in detecting polyps and cancer.
CT colonography every 5 or 10 yr was effective and cost-effective relative to no screening. Optical colonoscopy dominates 2-dimensional CT colonography done every 5 or 10 yr. Optical colonoscopy is weakly dominant over 3-dimensional CT colonography done every 10 yr. 3-D CT colonography done every 5 yr is more effective than optical colonoscopy every 10 yr, but costs an incremental $156,000 per life-year gained. Sensitivity analyses show that test costs, accuracy, and adherence are critical determinants of incremental cost-effectiveness. 3-D CT colonography every 5 yr is a dominant strategy if optical colonoscopy costs 1.6 times more than CT colonography. However, optical colonoscopy is a dominant strategy if the sensitivity of CT colonography for 1 cm adenomas is 83% or lower.
CT colonography is an effective screening test for colorectal neoplasia. However, it is more expensive and generally less effective than optical colonoscopy. CT colonography can be reasonably cost-effective when the diagnostic accuracy of CT colonography is high, as with primary 3-dimensional technology, and if costs are about 60% of those of optical colonoscopy. Overall, CT colonography technology will need to improve its accuracy and reliability to be a cost-effective screening option.
Colorectal cancer is the second leading cause of cancer death in the United States (1, 2). The majority of cancer arises from adenomatous polyps that can be detected and removed by screening tests (3–7). Colorectal cancer incidence and mortality can clearly be reduced by fecal occult blood testing (FOBT), and indirect evidence supports the effectiveness of sigmoidoscopy and colonoscopy. Despite recommendations from professional organizations and interventions such as media campaigns (8), adherence to screening remains low (9, 10). Among the reasons for nonadherence are the unpleasant nature of the tests, the inaccuracy of non-invasive tests such as FOBT, and the fear of invasive tests (9, 11, 12).
Computed tomography (CT) colonography is a new imaging modality that aims to overcome some of the limitations of existing tests. It is an evolving technique in which CT data are used to generate two- and three-dimensional displays of the colon and rectum. Studies have shown that the sensitivity of CT colonography for 1 cm adenomas ranges from 48–100%; sensitivity for smaller adenomas is lower, ranging from 14–86% for adenomas <6 mm, and 30–95% for adenomas 6–9 mm. These figures are highly variable and meta-analyses have found significant heterogeneity depending on imaging modality used. In contrast, specificity is more homogeneous and pooled estimates range from 91% for <6 mm adenomas to 97% for 1 cm adenomas (13). While CT colonography is an exciting technology, there remain questions about its broad-scale applicability. Foremost among these are projections of its benefit and costs relative to existing tests.
We examined the cost-effectiveness of screening with CT colonography using an updated version of a previous model (14). The model is a Markov state-transition model based on the natural history of colorectal cancer. The basic structure is outlined in Figure 1. It tracks the evolution of malignancy from adenoma growth through malignant transformation. Specifically, the simulated cohort is distributed in initial states at age 50 based on adenoma and cancer prevalence studies. The cohort moves through the model states based on progression rates derived from studies of the natural history of colorectal cancer: rates of adenoma incidence and prevalence, general mortality rates, and cancer incidence as detailed below. For the purposes of our analyses, we assumed that screening began at age 50 and continued through age 80, though the cohort was modeled to age 100.
The key assumptions of the model are outlined in Table 1. The primary updates to the model were to use standardized assumptions established by the Institute of Medicine workshop on the economics of colorectal cancer screening (47). We also conducted an updated review of the literature to establish ranges for sensitivity analyses. The initial search for modalities other than CT colonography was conducted in 2000; this was updated to assess the accuracy of CT colonography in February 2004. We did a literature search using the terms "CT colonography" and "virtual colonoscopy," and supplemented this with review articles and meta-analyses.
The main sources of the estimates for natural history were colonoscopic screening studies and autopsy studies for the prevalence of adenomas (15–19) and surveillance, epidemiology and end-results (SEER) registry data for the incidence and mortality rates of colorectal cancer (1, 2). We intentionally used older rates of cancer incidence, primarily from the 1970s through mid-1980s, to minimize biases that might be imparted by increasing CRC screening at later dates. Mortality rates for the general population were derived from National Center for Health Statistics publications (53).
We calculated the incidence of adenomas using the age-specific adenoma prevalence observed in screening and autopsy studies (15–19). Adenomas were subdivided into two major risk groups: low-risk (less than 10 mm, without high-risk histology) and high-risk (≥10 mm, or smaller adenomas with villous features or high-grade dysplasia). Transition from low to high-risk adenoma was calibrated so that the distribution of low and high-risk adenomas matched those observed in prevalence studies. The incidence and size of hyperplastic polyps was defined in the same manner; the prevalence ranged from 20% at age 50 yr to 15% at age 80 yr (not shown in table) (15, 16).
We forced rates of adenoma to cancer conversion into the model in order to match observed national cancer incidence rates (1, 2). The proportion of incident cancers arising from adenomas was assumed to be 100%, reflecting a growing consensus that most cancers arise through the adenoma–carcinoma sequence (3, 4, 6, 54). We further assumed that it takes 10 yr for an adenoma to transform from benign to malignant. This 10-yr adenoma "dwell time" is supported by consensus opinion (55), but is based upon indirect evidence, including studies showing that screening sigmoidoscopy provides a 10-yr window of protection from colorectal cancer (56). A way to think of this estimation is that a certain proportion of adenomas, at a rate that matches 10-yr downstream cancer incidence, is tagged to become malignant, then becomes truly invasive in 10 yr.
If a colorectal malignancy developed, we assumed that it took 2 yr to progress through localized cancer and an additional year to progress through regional cancer, as defined in the SEER registry (1, 2). Patients who developed disseminated cancer were diagnosed within 1 yr, whether or not screening was employed. Mortality was varied by stage of colorectal cancer based upon published results from the SEER registry (1, 2).
The effectiveness of screening was modeled using the characteristics in Table 1. We identified 39 studies evaluating the diagnostic accuracy of CT colonography; we used data from a recent meta-analysis of these studies to provide primary estimates of diagnostic accuracy (13). CT colonography technology is changing rapidly, and includes 2- and 3-dimensional interpretation, flythrough technology ("virtual colonoscopy"), and a variety of preparatory and imaging techniques; not surprisingly, there is wide discrepancy in the reporting of diagnostic accuracy. The meta-analysis used for primary inputs reported heterogeneity of accuracy by imaging type. However, because only two studies have examined flythrough technology, we modeled the first two technologies: primarily 2-D imaging with 3-D confirmation when necessary ("2-D"), and primary 2-D and 3-D imaging ("3-D").
The sensitivity, specificity and complication rates of traditional screening tests were derived from observational studies and in the base case were standardized to those used in the Institute of Medicine workshop on the economics of colorectal cancer screening (21–27, 29, 31–36, 47, 57). For flexible sigmoidoscopy, we assumed that a sigmoidoscope could detect 55% of all adenomas and cancers (5, 28–30).
Test adherence was assumed to be 60% in the base case, as recent estimates suggest that about 53% of the U.S. population is current with screening and this is increasing over time (10). Differential adherence between tests seems likely, but there are no studies of the adherence to different tests; we explore this in sensitivity analyses for FOBT in particular given its clear differences in burden and invasiveness. After a positive initial screening test (e.g., FOBT or sigmoidoscopy), a colonoscopy for diagnosis (and polypectomy, if necessary) is performed; adherence to this colonoscopy in the FOBT trials has been about 75%, and we used this figure in the base case (58–60). We did not model dropout from screening because of symptomatic endoscopy.
Those with a negative screening test maintained the average risk of developing new adenomas (61–63). In our base case, we assumed that all adenomas detected on CT colonography, and all adenomas (based on biopsy) detected at sigmoidoscopy are referred for optical colonoscopy. We acknowledge that there are changing perceptions on the need for routine surveillance (7, 64); however, we suspect that at present nearly all adenomas are referred for follow-up.
Those who had polypectomy at optical colonoscopy were referred for surveillance at 3 yr for high-risk adenomas, and at 5 yr for low-risk adenomas. Adenomatous polyp recurrence rates at surveillance optical colonoscopy were taken from the National Polyp Study; patients remained in the surveillance program as long as screening was ongoing (65). Adherence with adenoma surveillance was assumed to be 90% in the base case analysis; this was varied from 50–100% in sensitivity analyses.
All costs and years of life were discounted at 3%. We took the perspective of a third-party payer; we also conducted analyses from a societal perspective by including lost productivity costs in a sensitivity analyses, but estimates of lost productivity from screening tests are not particularly well defined and did not have major effects on cost-effectiveness, so we focus on the third-party payer analysis. We also briefly examined the possible effect of evaluation of extracolonic findings on CT colonography, based on a recent study (66). However, the benefits and costs of detection of these findings are unclear. In a sensitivity analysis, we assumed an incremental cost of $1,000 for diagnostic workup for each of the 6% of subjects with findings.
The costs of screening tests and interventions were taken from the 2003 Medicare reimbursement schedule (41). Because CT colonography is not yet an approved reimbursable test by Medicare or other insurers, we conducted analyses at various cost levels to help provide benchmarks for payers. In the base case, CT colonography was reimbursed as an abdominal and pelvic computed tomography scan. We included both Medicare physician fees and facility expenses in costs. Polypectomy costs included reimbursement for tissue pathology. Costs of caring for procedural complications have been estimated by Eddy (28, 40) and the OMB (44); these were inflated to 2003 U.S. dollars using the consumer price index. Costs of cancer care range widely in the literature and in prior models; in the base case we used approximate midpoint figures from various sources, including the Institute of Medicine, prior models, and three published analyses of costs (28, 44–52). We then examined a wide range in sensitivity analyses.
Because there are no current guidelines for screening with CT colonography, we examined CT colonography screening every 5 yr and every 10 yr. We chose these figures because they correspond to existing guidelines for colorectal neoplasia screening using sigmoidoscopy and optical colonoscopy (7).
We tested each variable in the model in one-way sensitivity analyses; the ranges of values used for these analyses are presented in Table 1. The ranges were derived from the literature where possible; however, to make the analysis robust, we used broad ranges. The focus of the presented analyses is on assumptions that affected the incremental cost-effectiveness of CT colonography versus other tests, because the choice of optimal test is the primary subject of current debate (7). We then examined the most influential variables in two-way sensitivity analyses.
We conducted multivariable sensitivity analyses using Monte Carlo modeling, sampling from the distributions of parameter estimates, to examine the global impact of uncertainty on incremental cost-effectiveness ratios (67, 68). For continuous variables, we assumed that estimates were distributed normally; the range of the estimates outlined in Table 1 encompassed six standard deviations. This is analogous to a 99% rather than a 95% credible interval, as we used broad ranges for most variables. For cost variables, procedural costs were normally distributed; however, for treatment of cancer and complications, we assumed a log-normal distribution. We conducted 10,000 simulations to establish the distribution of the incremental cost-effectiveness ratios.
Because model estimates had to be calculated in several instances, we confirmed calibration versus our original data sources for adenoma prevalence and cancer incidence and prevalence (1, 2, 15–19). We also tested the predictive validity of the model by setting up a population similar to that of the Minnesota randomized trial of fecal occult-blood testing, and found that our model predictions for colorectal cancer mortality reduction were similar and within the confidence interval of those seen in the trial (model prediction of mortality reduction = 36%, trial = 33%). This does not verify the accuracy of CT colonography screening, but serves as a more general test that the model reasonably predicts results from the only CRC screening modality that has been examined in randomized trials.
The base case analyses are presented in Table 2. The model predicts that no screening leads to a lifetime colorectal cancer risk of 5.6% and mortality of 2.1%. The average discounted life expectancy is 17.1215 yr and the average discounted cost is $1,240 per person. For 2-D imaging, CT colonography done every 10 yr reduces cancer risk to 2.7% and cancer mortality to 0.9%, and costs $17,280 per life yr saved. Done at 5-yr intervals, it reduces cancer risk to 1.6% and cancer mortality to 0.5%, and costs $14,290 per life-year gained.
For 3-D imaging, CT colonography done every 10 yr reduces cancer risk to 2.3% and mortality to 0.8%; compared with no screening it has a cost-effectiveness of $8,150 per year of life gained. CT colonography done every 5 yr is more effective, decreasing cancer risk to 1.3% and mortality to 0.4%, and, compared with no screening, costs $13,460 per year of life gained.
Table 2 also shows the costs and outcomes of other screening tests. We found that annual fecal occult-blood testing costs $1,400, and increases discounted life expectancy by an average of 10.5 days. Of the existing strategies, optical colonoscopy every 10 yr is the most effective test, increasing discounted life expectancy by 19.3 days at an incremental cost of $430. Compared with annual FOBT, optical colonoscopy every 10 yr costs about $11,160 per additional life-year gained.
CT colonography, depending on interval and imaging modality, varies widely in terms of costs and effectiveness relative to other strategies, though it is uniformly more effective than FOBT or FS alone. 3-D CT colonography done every 5 yr is the most effective of the strategies in Table 2, with a discounted life expectancy gain of about 20.1 days, about 0.8 days more than optical colonoscopy. 2-D CT colonography is less effective and more expensive than 3-D CT colonography (thus, 3-D imaging is "dominant" relative to 2-D imaging), and we therefore focus our incremental comparisons on 3-D imaging. These results can be seen in Table 3. Done every 5 yr, 3-D CT colonography is dominant over sigmoidoscopy-based strategies, and costs $22,400 per life-year gained compared with annual FOBT. It is relatively expensive, however, compared with optical colonoscopy, costing $156,000 per life-year gained. At 10-yr intervals, 3-D CT colonography is less effective than either optical colonoscopy or combined FOBT and sigmoidoscopy. Optical colonoscopy done every 10 yr costs only $7,840 per life-year gained compared with 3-D colonography done every 10 yr, but after exclusion of dominated strategies, optical colonoscopy is weakly dominant over 3-D CT colonography done every 10 yr.
The results of one-way sensitivity analyses are found in Table 4. All assumptions were robust for all tests compared with no screening; notably, at the higher end of cost of caring for cancer, most tests were actually cost-saving. However, our focus is on the incremental cost-effectiveness comparing various tests; we chose optical colonoscopy every 10 yr as our major point of reference. Under only extreme scenarios (e.g., very low cost for CT colonography and very high cost for optical colonoscopy) was 2-D CT colonography incrementally cost-effective; therefore, our sensitivity analyses are focused on 3-D CT colonography.
For 3-D CT colonography every 10 yr, only one variable affected conclusions: the rate of adherence with follow-up colonoscopy in those with adenomas on CT colonography. If adherence with follow-up optical colonoscopy can be increased from the base estimate of 75 to 95%, then optical colonoscopy remains more effective, but costs an incremental $107,530 per life-year gained compared with CT colonography every 10 yr.
In contrast, the incremental cost-effectiveness of 3-D CT colonography every 5 yr was highly sensitive to a number of assumptions. The cost of screening tests were the most critical; for example, if the cost of CT colonography is reduced from the base case estimate (about $560) down to $400, then CT colonography every 5 yr is a dominant strategy; it costs less than $50,000 per life-year gained at a test cost of about $450, and less than $100,000 per life-year gained at a test cost of $500. The cost of optical colonoscopy is also important; CT colonography every 5 yr is a dominant strategy at an optical colonoscopy cost of about $950, costs less than $50,000 per life-year gained if optical colonoscopy costs $820, and less than $100,000 per life-year gained if optical colonoscopy costs $750. Variation in other costs, such as cancer care or the workup of extracolonic findings, had little impact on incremental cost-effectiveness ratios.
Test characteristics and adherence were also very important. If the sensitivity of 3-D CT colonography for 1 cm adenomas is below 83% (as it is with 2-D imaging), then optical colonoscopy every 10 yr is a dominant strategy over CT colonography. Alternatively, if sensitivity is as high as 99%, as reported in some flythrough studies, the cost-effectiveness of CT colonography is about $75,220 per life-year saved. Adherence had an impact both in evaluating initial screening and with follow-up testing after CT colonography. For example, if adherence with initial screening is 20%, then CT colonography costs about $20,150 per life-year gained relative to optical colonoscopy; however, if adherence is 80% or higher, then optical colonoscopy dominates. Not surprisingly, modeling differential adherence between tests had large effects on incremental cost-effectiveness. We explored this with FOBT, given its clear distinction from other screening tests. If FOBT has 100% adherence, while 3-D CT colonography every 5 yr has 30% adherence, then FOBT is a dominant strategy; however, at 60% FOBT adherence and 30% CT adherence, CT colonography is more effective and costs about $23,000 per life-year gained, similar to our base case findings. These effects are nonlinear because of frequency of testing, as we found in prior analyses (14).
An uncertain issue in natural history estimates is the dwell time of adenomas. Shorter dwell times improve the cost-effectiveness of 5-yr CT colonography relative to optical colonoscopy every 10 yr. For example, with a 5-yr dwell time, 3-D CT colonography costs an incremental $138,000 per life-year gained relative to optical colonoscopy, compared with $156,000 in the base case.
Two-way sensitivity analyses show that the relative cost of CT colonography to optical colonoscopy is the key factor in establishing the incremental cost-effectiveness of screening with CT colonography (Fig. 2). 3-D CT colonography every 5 yr is a dominant strategy if optical colonoscopy costs more than 1.6 times as much as CT colonography, while it is incrementally cost-effective at the $50,000 per life-year gained threshold at a ratio of about 1.5, and at $100,000 per life-year gained at a ratio of about 1.3. However, for 3-D CT colonography every 10 yr, optical colonoscopy every 10 yr is dominant under most circumstances; only at fairly extreme cost ratios (about 3.5 for $50,000 per life-year gained, or 5.5 for $100,000 per life-year gained) is optical colonoscopy at the threshold of being not cost-effective.
We also conducted multivariate sensitivity analyses using Monte Carlo simulation with sampling from the ranges of the distributions of variables (Table 5). Optical colonoscopy every 10 yr dominated CT colonography every 5 yr in 17.0% of simulations, while CT colonography dominated in 10.9% of simulations. In the simulations without dominance, the incremental cost-effectiveness ratios were for 3-D CT colonography every 5 yr compared with optical colonoscopy every 10 yr were highly skewed; the median was $137,345 (IQ range $67,112–$292,347). The acceptability at various levels of willingness to pay can also be seen in Table 5; 3-D CT colonography done every 5 yr cost less than $100,000 per life-year gained in about 38% of simulations compared with optical colonoscopy.
We found that, compared with no screening, either 2-D or 3-D CT colonography is an effective and cost-effective test. Indeed, screening with 3-D CT colonography every 5 yr is more effective than any of our other modeled tests. Screening with 3-D CT colonography every 10 yr costs about $8,150 per life-year gained, and screening every 5 yr costs about $13,460 per life-year gained. Although there is no firmly established threshold for cost-effectiveness, these estimates are both comparable to those of generally accepted medical interventions (69, 70). One other recently published analysis reported similar findings for CT colonography every 10 yr; however, they did not examine the possibility of other intervals for testing, an important consideration given the non-invasive nature of CT colonography, and its status as a first screening step, analogous to sigmoidoscopy (71).
While these findings support the argument that CT colonography be added to our armamentarium, the critical question is how CT colonography fares in comparison to current screening standards, particularly the gold standard of optical colonoscopy. Under base case assumptions, and indeed under most modeled conditions, 2-D CT colonography, and 3-D CT colonography every 10 yr, are not cost-effective relative to optical colonoscopy every 10 yr. There were only two exceptions to this rule. The first is if the costs of CT colonography are substantially (at least three to four times) lower than those of optical colonoscopy. The second is if nearly all of those with adenomas found on CT have a follow-up optical colonoscopy and polypectomy. However, in randomized trials of screening, follow-up happens in about 75% of cases (58–60). Exceeding this would require dedicated resources; an intriguing option, now done at some centers, is same-day optical colonoscopy after CT colonography. Indeed, given the difficulty in bowel preparation for these procedures, such "all-in-one" type screening visits may be the preferable option to optimize adherence and the only way to ensure the cost-effectiveness of CT colonography.
We found that 3-D CT colonography done every 5 yr is the most effective of our primary modeled tests. However, in the base case, it costs $156,000 per life-year gained compared with optical colonoscopy every 10 yr, a figure that is considered expensive relative to most medical interventions (69, 70). Our sensitivity analyses suggest that there is substantial uncertainty around this incremental cost-effectiveness ratio. CT colonography every 5 yr is a dominant strategy if CT colonography costs less than $400 or if optical colonoscopy costs more than $1,000. Similarly, CT colonography every 5 yr is a dominant strategy if the ratio of the cost of optical colonoscopy to CT colonography is greater than 1.6; a ratio of 1.5 leads to an incremental cost-effectiveness ratio for CT colonography of less than $50,000 per life-year gained, and a ratio of 1.3 to an incremental cost-effectiveness ratio of less than $100,000 per life-year gained. Our figures can help to guide a reasonable reimbursement for CT colonography.
Perhaps most important from a clinical perspective is that the incremental cost-effectiveness of 3-D CT colonography done every 5 yr is highly sensitive to test accuracy, particularly test sensitivity for 1 cm adenomas. If test sensitivity is lower than 83%, then CT colonography is almost never a preferred strategy versus optical colonoscopy. There is little or no data on the diagnostic accuracy or reliability of primary 3-D interpretation of CT colonography in non-academic settings. Our analyses suggest that even with primary 3-D interpretation, CT colonography has a fairly small margin of error for adenoma sensitivity; thus, it is critical that issues of training and utilization of optimal technology be considered before CT colonography is disseminated (72). Lower sensitivity levels, such as those found in trials with primary 2-D interpretation, essentially rule out CT colonography as a cost-effective option compared with optical colonoscopy (13, 73, 74).
Another important issue is that of adherence. In our base analyses, we have only compared adherence under the assumption that it is comparable between tests. However, our analyses examining how differential adherence between FOBT and CT colonography impact cost-effectiveness are revealing; FOBT may be dominant if it is highly adhered to and CT colonography is not. We would note that for patients that would refuse screening other than CT colonography, nearly any application of CT colonography is cost-effective, as shown by the cost-effectiveness compared with no screening.
Our study has several limitations. There are no trials showing mortality reduction with CT colonography, and as with most models based on the natural history of a disease process, we relied on multiple data sources, which may bias results. We also have little data to guide us on reimbursement rates; indeed, we would view this analysis as a tool to help establish those rates. Further, there are several issues that are difficult to model accurately. One of these relates to extracolonic findings on CT colonography; the costs and benefits of these findings are completely uncertain. Another issue is the possibility of increased cancer risk related to radiation exposure. Recent analyses have suggested that these risks are very small for colonic imaging in a screening age population (75). There are also resource implications to any shift in screening that may occur; we and others have shown that one limitation of colonoscopic screening is a lack of endoscopist supply (76–78), and CT colonography may help to ameliorate this. This is the reason that we did not examine using more frequent (e.g., every 5 yr) colonoscopy in our scenarios; additionally, guidelines at present endorse 10 yr intervals for optical colonoscopy (7). On the other hand, demands would be placed on radiologists and CT scanners, and it is uncertain whether increased demand for CT colonography can be met given current staffing models, although outsourcing of radiology interpretation may make this a more feasible alternative than increasing endoscopist supply.
Overall, our findings suggest that CT colonography is an effective test, particularly when done with primary 3-D interpretation at 5-yr intervals. Compared with no screening, it is cost-effective, and from this perspective we would argue that it belongs in our screening armamentarium. However, under our base case assumptions, screening with CT colonography is not likely to be cost-effective relative to screening with optical colonoscopy. There are conditions, particularly those related to the relative costs of optical and CT colonography, under which 3-D CT colonography done every 5 yr is a cost-effective or even a dominant strategy. On the other hand, the lower diagnostic test accuracy that is likely to be seen in general practice compared with academic settings, particularly early in the deployment of a new technique, may substantially decrease the effectiveness of CT colonography compared with optical colonoscopy (72–74). CT colonography as a primary screening test should be implemented cautiously, with careful attention to ensuring accurate interpretation in non-academic settings, and a reimbursement rate that is significantly less than that of optical colonoscopy.
What Is Current Knowledge
What Is New Here
The study was supported in part by NCI R01 CA106782. Dr. Vijan was supported by a Veterans Affairs Advanced Career Development Award during part of the study. The funding agencies played no role in the design, conduct, or reporting of this study.
Dr. Perry J. Pickhardt is a consultant for Viatronix, Medic-sight, and Fleet.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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The polar bear is going to go extinct within our lifetime.
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Translation of coupe in Spanish:
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Spanish-born artist Paco Cao's work is characterized by an interest in establishing new forms of communication between the artist, the work of art, and the audience. He highlights the creative process, challenging the notion of what is a "final product." Consequently, most of his projects are process-oriented, taking place in the public realm, as site-specific creations that span long periods of time. His works usually require active audience participation, as well as the engagement of art institutions, the media, and the general public.
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Along the two lane road winding through the Rio Grande gorge, are small valleys, fruit orchards, and
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May 6, 2012
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Dan Dicker has been a floor trader at the New York Mercantile Exchange with more than 25 years of oil trading experience. He is a licensed commodities trade adviser.
Dan is currently President of MercBloc LLC, a wealth management firm and is the author of "Oil's Endless Bid", published in March of 2011 by John Wiley and Sons.
Dan Dicker has appeared as an energy analyst since 2002 with all the major financial news networks. He has lent his expertise in hundreds of live radio and television broadcasts on CNBC, Bloomberg US and UK and CNNfn.
Dan obtained a bachelor of arts degree from the State University of New York at Stony Brook in 1982.
Those who have continued to be bearish about oil prices are being proven totally wrong.
There will be far fewer changes in policy and strategy than a switch in oil minister suggests.
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Charts point to a market that has little respect for Baker Hughes as a standalone concern.
Hess is the opportunity to be embraced.
These names have gotten ahead of themselves, but should deliver outstanding mid-term profits.
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Family infighting among oil producers at Doha could be the best news in a long time for investors in oil firms.
The prospects for an agreement on production cuts is quite good.


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"it was to be considered a divine commandment"
Please explain why Brigham Young built a whiskey distillery in Utah?
- 9:05 a.m. Sept. 2, 2014
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About your question why Brigham Young had a whiskey distillery, let me remind you of the church at that time. From Nauvoo right up to the last 10 years of Brigham Young's presidency, there were no temples; not in Utah, nor anywhere in the world. The saints were still rebuilding from the most perilous period in church history. At the time Brigham Young was president, the word of wisdom as you know the church today was not yet in force, nor would it be for another 30 years. I may be wrong about the exact times. Considering that the word of wisdom was not yet vital to the obtaining a temple recommend, what drinks do you think would have been made?
- 9:05 a.m. Sept. 3, 2014
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Something else to consider; water purification was not a known science at that time. If you know the 1800's, water was not a trusted source of quenching thirst back then. In fact the water was dangerous to drink and was the reason so many saints died of things like dysentery before water purification began. Alcohol was the safest source of quenching thirst back then. The word of wisdom is and was revealed truth. However, the saints were not asked to live fully up to it at that time.
- 9:06 a.m. Sept. 3, 2014
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UT Brit,
"....Please explain why Brigham Young built a whiskey distillery in Utah?"
Observance of the Word of Wisdom was not mandatory until the Presidency of Heber J. Grant who not coincidentally had also long been a proponent of prohibition. President Grant made the Word of Wisdom mandatory and a worthiness standard shortly after prohibition went into effect nationally. Coincidence? Maybe, but I'm not so sure.
I would add that in Brigham Young's time, distilled spirits including home brewed beer and wine were often used as barter in many places in America. Of course there were Latter-day Saints who cheerfully imbibed and saw no need back then to be discreet about it.
- 4:16 p.m. Sept. 3, 2014
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Hmmm you guys are not reading the line I put, let me repeat the line from
Brigham Young:
"President Brigham Young stated that the members of the Church had had sufficient time to be taught the import of this revelation, and that henceforth it was to be considered a divine commandment."
Lets read what the D+C says about the drinking of alcohol:
7 And, again, strong drinks are not for the belly, but for the washing of your bodies.
Now, I dont think there was much washing of the bodies going off using whiskey.
Hmmm whiskey as a substitute for water? We are recommended to drink around 2 liters of water a day. How did the saints manage to function on that much whiskey? As alcohol dehydrates the body it would have caused even more problems.
"However, the saints were not asked to live fully up to it at that time."
From what Brigham said above to what you are saying now, we have a different definition of the word "commandment".
- 3:40 a.m. Sept. 4, 2014
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text: Wind Waker, In First Person, on the Oculus RiftPatricia Hernandez3/07/14 1:00pmFiled to: The Legend of ZeldaWatch ThisOculus RiftZeldaWind WakerThe Legend of Zelda: Wind WakerNintendo881EditInvite manuallyPromoteDismissUndismissHideShare to KinjaToggle Conversation toolsGo to permalink The prettiest Zelda game, now playable in virtual reality and in a new perspective. Awesome. As you can see in this video by Chadtronic, unlike the Ocarina demo, this isn't a proof of concept that's missing a lot of key elements. You can battle and interact with the world normally, and all the characters are present. There are some slight hiccups, of course, since Wind Waker was never meant to be played in this perspective, but still! It's neat to watch. One thing I really appreciate about looking this version of the game is that it gives you a better sense of how tiny Link really is when you wade through the grass or pick a pot up. D'aaw. He's just a little kid, you know? Advertisement Zelda: Wind Waker on Oculus Rift in True First Person [Chadtronic]Reply88 repliesLeave a reply


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This story was written by David Kaplan.
Discovery (NSDQ: DISAB) Communications (NSDQ: DISCA) offered further proof that cable growth is cutting through the downturn, a day after Cablevision (NYSE: CVC) swung to profit and saw revenues gain 15 percent year-over-year. The Silver Spring, Md.-based network posted an 11 percent revenue gain to $845 million, while net income from continuing operations of $94 million ($0.31 per share) from $30 million last year. The programmer's ad revenue was up a decent 5 percent to $249 million as distribution revs grew 8 percent to $231 million. The former benefited from higher sellouts and pricing, which were partially offset by lower ratings at TLC and Discovery Channel, while the latter got a boost from additional subscribers.
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Earnings: Discovery Networks Revs Rise 11 Percent; Ad Revs Gain 5 Percent


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Start now! www.SmallBizChamber.org Small Business Chamber of Commerce, Inc. "We help local chambers and others give more real help to startups." 1881 Buchtel Blvd. #501, Denver, CO 80210 Twitter @IDEACafe http://Facebook/Small.Business.Chamber +AMDG+ Want help? Call the Startup Line, (303)861-1447. This life is very short, call now! Leave a complete, confidential message about you and what help you want, a volunteer will call you back. Emergency? First call 911.
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Here in Denver we're celebrating Ben Franklin's birthday with a Dutch lunch at Beau Jo's, and we will talk about Ben on my radio show next Monday. More info about both, RSVP "no" if you can't make it today but you'd like to get on the invitation list, at http://Meetup.com/Small-Business-Chamber
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Visual Studio 2015
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Arts Feature
Maximum King
Downtown gallery brings the ho-ho-horror
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The Creepshow: A Tribute to Stephen King is the twisted brainchild of three artists, and it offers a chance to delight in all kinds of nightmarish images.
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Picture Show
A new wave of artistic film posters comes aboveground
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Showcasing the pictorial renaissance in upwards of 200 posters from over 100 artists, this glossy, gifty book is packed with deep affection for—and great examples of—the art of the one-sheet.
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Pulp Tweed
Review by Geoffrey Plant
New biography of Raymond Chandler digs into why he began writing and why Hollywood hated him.
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Never Trust Anyone Over 30
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Stay Solid! A Radical Handbook for Youth is a handbook written by and for activist youth and the adult allies who want to empower them.
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Big Trouble in Little China
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Once you settle into the realization that this 1986 John Carpenter (Halloween) film is not going to be one of the director's more masterful works, Big Trouble in Little China just becomes a full-tilt comic blast. Kurt Russell is hilarious as a drawling, would-be John Wayne hero who steps into the middle of a supernatural war in the heart of Chinatown. While kung fu warriors and otherworldly spirits battle over the fate of two women (Kim Cattrall and Suzee Pai), Russell's swaggering idiot manages to knock himself out or underestimate the forces he's dealing with. The whole thing is dopey, but it's supposed to be dopey and Russell's game performance brings an ironic edge. Carpenter directs some nifty spook effects (the sudden arrival of three martial arts demigods from out of nowhere is worth applause), and he also wrote the music. --Tom Keogh
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- Jack Burton (played by Kurt Russell)
*PLOT* - By reading the above I'm sure by now you've guessed what kind of a movie "Big Trouble in Little China" is: strange, wacky, silly, but INCREDIBLY funny! Kurt Russell is Jack Burton, a guy who has an ego even bigger than the truck he drives. While stopping by Chinatown to see his buddy Wang Chi (Dennis Dun), Jack gets entangled into a supernatural war involving the 'supposedly dead' David Lo Pan (James Hong), two beautiful green eyed ladies Gracie Law and Miao Yin (Kim Cattrall & Suzee Pai), the Chinese tour guide Egg Shen (Victor Wong), and three spirit warriors Thunder (Carter Wong), Rain (Peter Kwong), and Lightning (James Pax). I know, the movie sounds pretty far out, but this is the type of movie where it doesn't matter if the plot is believable. This is the type of movie where you can kick back in your sofa with a bowl of popcorn and prepare yourself for some mindless fun.
*ACTING* - Kurt Russell steals every single scene as the egomaniac Jack Burton. He is so extremely funny you can't help but love him! Dennis Dun as Wang is also a very likable character. Jack and Wang are a great duo.
*ACTION* - The kung fu is surprisingly good for what some people might call a 'B grade movie'. Dennis Dun's fight between him and one of the spirit warriors is very cool. The kung fu is also not like the stylized fighting we see in more recent films, much more realistic though some 'deaths' are a bit fake.Read more ›
Why? Everything about it is absurd..and purposefully so. Try to read the plot aloud without laughing: A mullet-wearing truck driver teams up with his Chinese-American buddy to battle ancient Chinatown demons commanded by the ethereal 2000 year old Lo Pan and rescue their respective green-eyed (would-be) girlfriends, all with the aid of local magician/tour bus driver Egg Sheng and his lazy-eyed sorcery.
Yet, somehow, it all works perfectly. Kurt Russell is a riot as Jack Burton, a bumbling and inept, yet surprisingly hardy, truck driver with a lot of buddies in Chinatown who has to take on a world of Chinese legends. His loud-mouthed bravado at all times (presumably he's intended to be a classic jerk American foreign devil) forms the basis for his irrepressible camaraderie with the other heroes in the movie. He may have no idea what he's doing, but darn it he's gonna do it anyway. Some folks may be misled (as I was by the USA Up All Night tidbits) into thinking this was some sort of cheesy martial arts film. It isn't. This is a flat-out comedy that just happens to involve a lot of swordfights, demons, and electrical discharges.Read more ›
Following the `Escape from New York' and `The Thing,' John Carpenter and Kurt Russell re-unite for this mystical, action, adventure, comedy, kung-fu, monster and a spooky ghost story!
Kurt Russell plays Jack Burton, a reasonable guy who is about to experience some unreasonable things in San Francisco s Chinatown. As his friend s fiancée is kidnapped Jack becomes embroiled in a centuries-old battle between good and evil. At the root of it all is Lo Pan, a 2000-year-old magician who rules an empire of evil spirits. Jack goes to the rescue dodging demons, goblins and the unstoppable Three Storms as he battles through Lo Pan's dark domain.
One of Carpenters most enjoyable and best loved films, `Big Trouble in Little China' brilliantly juggles delirious set-pieces, comedy and kung-fu action with a razor sharp script of corking one-liners, as Jack would say "It's all in the reflexes". The super-deluxe package, which is available both as a standard Blu-ray and as a Limited Edition SteelBook Blu-ray, is full of special features and bonus materials.
Cast: Kurt Russell, Kim Cattrall, Dennis Dun, James Hong, Victor Wong, Kate Burton, Donald Li, Carter Wong, Peter Kwong, James Pax, Suzee Pai, Chao-Li Chi, Jeff Imada, Rummel Mor, Craig Ng, June Kyoto Lu, Noel Toy, Jade Go, Jerry Hardin, Jimmy Jue, Noble Craig, Danny Kwan, Min Luong, Paul J.Q. Lee, Al Leong, Gerald Okamura, William S. Wong, Eric Lee, Yukio G. Collins, Bill M. Ryusaki, Brian Imada, Nathan Jung, Dan Inosanto, Vernon Rieta, Daniel Wong, Daniel Lee, Lia Chang, Diana Tanaka, Donna L.Read more ›
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It is formatted region 2, so it does not work in North America. when you buy DVDs you really have to check to be sure, the problem is the region is not always indicated.Published 15 days ago by Amazon Customer
I absolutely love this movie. Have since the first time I saw it.
The case was cracked, but it's not so bad that it causes a problem.
Unplayable due to being a different region DVD. It was not advertised as such.Published 3 months ago by Jules
John Carpenter and Kurt Russell team up again for another classic this movie is just fun all around and so enjoyable. Read morePublished 4 months ago by Paul
not happy can't play the movie wrong region and to ship it will cost me more than it worthPublished 4 months ago by chris laurin
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The New Twist on Luxury Part Deux
Private Cocktail at the Tiah Residence
Tucked away in the heights of the British Properties, celebration of the announcement of Trump International Hotel and Tower Vancouver resumed at the private residence of Joo Kim Tiah. To experience the full-blown beauty of Vancouver, this was the epitome of the perfect location.
— "We have so many people saying, "Enjoy Vancouver, Mr. Trump". It's an amazing place, it's a beautiful place". – Donald J. Trump
"I am honored to welcome you to my home this evening to celebrate the announcement of the Trump International Hotel and Tower Vancouver. I would like to extend a special welcome and thank you to Mr. Donald Trump and his children, Donald Jr., Ivanka and Eric Trump for gracing this occasion.
This project is indeed very close to the hearts of Vancouverites and I truly believe that this is a once in a life time opportunity. When the building is completed, it will serve as an icon for the City of Vancouver.
So in celebration I would like to make a toast to Mr Trump, Donald Jr, Ivanka and Eric, as well as all of you here. I know that we can count on your support as we bring this project to reality." — Joo Kim Tiah


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Tel: (425)454-5880
Grades: PK-8 | 258 students
St. Thomas School began in 1951 with a class of 17 students; today enrollment is 295 students.
The state-of-the-art campus provides an innovative and dynamic learning environment, purposefully designed to support the educational program.
Our campus is aesthetically stunning, and provides unique learning spaces such as a science lab, technology center, media publishing lab, library/multi-media center, a dedicated foreign language classroom, music room, and four plazas to support collaboration and research.
Our LEED Gold certification is a public statement about the school's commitment to the environment. St. Thomas School offers a rigorous program that emphasizes mastery of core academic knowledge and skills, the integration of technological, thinking, decision-making, and research skills, and the development of character and core virtues.
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|School Membership(s)School Assoc.
|National Association for the Education of Young Children
National Association of Independent Schools (NAIS)
Other school association(s)
|Grades Offered
|Grades Prekindergarten-8
|Year Founded
Student Body
|Total Students
|258 students
|Student Body Type
|% Students of Color
State avg.: 27%
|Students by Grade
Academics and Faculty
|Total Classroom Teachers
|36 teachers
|Student : Teacher Ratio
National avg.: 13:1
|% Faculty w/Advanced Degree
|Average Class Size
|16 students
|Classroom Dress Code
Finances and Admission
|Admission Deadline
|Jan. 14 / rolling
|Tuition Notes
|Tuition varies between preschool and elementary/middle school grades.
|% on Financial Aid
|Average Financial Aid Grant
|Acceptance Rate
National avg.: 85%
|Admissions Director
|Lyn-Felice Calvin
|Admissions Associate
|Emily Honig
|Total Sports Offered
|7 sports
|Baseball, Basketball, Cross Country, Golf, Softball, Ultimate Frisbee, VolleyballBaseball, Basketball,
Cross Country, Golf,
Softball, Ultimate Frisbee,
|Total ExtracurricularsTotal Extra-curric.
|12 extracurriculars
|Chess, Chorus, Drama, Falcon's Ledge Middle School Club, Guitar Lessons, Lego Robotics, Photography, Piano Lessons, Softball, Toothpick Construction, Unicycling, Yearbook Chess, Chorus, Drama, Guitar Lessons, Lego Robotics, Photography, Piano Lessons, Softball, Unicycling, Yearbook, Falcon's Ledge Middle School Club,
Toothpick Construction,
School Notes
- The mission of St. Thomas School is to develop responsible citizens of a global society. In partnership with parents, we inspire and motivate intellectually curious students. Our small, nurturing environment supports the acquisition of a broad academic foundation with an emphasis on critical thinking, leadership skills, and the development of strong character and spiritual awareness. St. Thomas School invites, welcomes, and celebrates diverse cultures, individuals, experiences, and perspectives within our school community and the world beyond our doors. The members of our school community comprise a partnership of all constituents, including students, families, faculty, staff, trustees, alumni, and neighbors. We believe our most critical role is to nurture the development of tomorrow's responsible and engaged global citizens. Further, we believe that understanding and exploring the connections among us makes us stronger. Together, our shared values of gratitude, responsibility, respect, courage, integrity, tolerance, compassion, perseverance, and generosity foster an inclusive and multicultural learning environment.
- Being a part of the St. Thomas School family means being open to the contributions of every member and recognizing that a sense of belonging stimulates our institution's growth and strengthens our community. Celebrating and appreciating diversity is an ongoing process that requires open dialogue and exploration of ideas and beliefs. At St. Thomas School, our students begin a journey toward global citizenship that they will follow throughout their lives.
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Eames (Character)
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