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Economic implications of chemotherapy-induced febrile neutropenia (FN) in European and Australian clinical practice are largely unknown.
Data were obtained from a European (97%) and Australian (3%) observational study of patients with non-Hodgkin's lymphoma (NHL) receiving CHOP (±rituximab) chemotherapy. For each patient, each cycle of chemotherapy within the course, and each occurrence of FN within cycles, was identified. Patients developing FN in a given cycle ("FN patients"), starting with the first, were matched to those who did not develop FN in that cycle ("comparison patients"), irrespective of subsequent FN events. FN-related healthcare costs (£2010) were tallied for the initial FN event as well as follow-on care and FN events in subsequent cycles.
Mean total cost was £5776 (95%CI £4928-£6713) higher for FN patients (n=295) versus comparison patients, comprising £4051 (£3633-£4485) for the initial event and a difference of £1725 (£978-£2498) in subsequent cycles. Among FN patients requiring inpatient care (76% of all FN patients), mean total cost was higher by £7259 (£6327-£8205), comprising £5281 (£4810-£5774) for the initial hospitalization and a difference of £1978 (£1262-£2801) in subsequent cycles.
Cost of chemotherapy-induced FN among NHL patients in European and Australian clinical practice is substantial; a sizable percentage is attributable to follow-on care and subsequent FN events.
Neutropenia is a common side effect of myelosuppressive chemotherapy. Neutropenia both increases the risk of infection and diminishes patients' ability to fight infection. Since fever is a cardinal sign of infection, when neutropenic patients develop fever (i.e., febrile neutropenia [FN]), the high likelihood of infection and serious consequences usually necessitates hospitalization for urgent evaluation, ongoing monitoring, and administration of intravenous antibiotics. FN, as well as severe or prolonged neutropenia, can lead to dose-delays, dose-reductions, and/or chemotherapy discontinuations, interfering with the delivery of optimal treatment and possibly adversely affecting patient outcomes [1-5].
The economic cost of chemotherapy-induced FN is substantial [6-8]. In one study, the mean cost of FN-related hospitalizations in the US was reported to be $8100 for patients with solid tumors, $11,600 for patients with non-Hodgkin's lymphoma (NHL), and $28,000 for patients with leukemia [7]. It is likely, however, that this study--as well as other studies utilizing a cross-sectional design and hospital records--underestimated the total economic burden of FN, since the cost of follow-on care (e.g., post-discharge outpatient encounters) and subsequent FN events that may be related to the (initial) FN event were not considered. In a more recent US study employing a matched cohort design and considering all such costs, the economic burden of the initial FN event was estimated to represent only about 60% of the total cost of FN-related care, suggesting that prior studies may have underestimated the mean cost of FN-related events by as much as 40% [9].
Relatively little is known about the economic burden of chemotherapy-induced FN in European and Australian clinical practice, however, and no studies conducted outside the US have considered the burden of care for the initial FN event as well as the downstream consequences of the initial event. The current analysis, therefore, was undertaken to evaluate the full economic impact of FN among NHL patients receiving chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone every 14 or 21 days (i.e., CHOP-14 or CHOP-21) in geographically diverse centers across Europe and in Australia.
Data for this study were obtained from a large combined retrospective/prospective observational evaluation of supportive care among NHL patients receiving CHOP-14 or CHOP-21 chemotherapy in geographically diverse centers primarily across Western and Southern Europe (97% of patients) and in Australia (3% of patients). The design of this study, termed the "IMPACT NHL Study" (ClinicalTrials.gov: NCT00903812), is described in detail elsewhere in the literature [10-13]. In countries where it was required, ethical approval of the IMPACT NHL Study was obtained and patients provided written informed consent.
Briefly, approximately 1800 adult patients with NHL who were planned to receive at least three cycles of CHOP-14 or CHOP-21 chemotherapy--with or without rituximab--were recruited (about 600 retrospectively, 1200 prospectively) from 128 geographically diverse study centers. Study patients may have received a prior course of chemotherapy (~9% of study population). Patients enrolled retrospectively included those who completed all cycles of chemotherapy--regardless of actual number of cycles or outcomes thereof--after January 1, 2005 and prior to site participation in the study. Patients enrolled prospectively included all patients for whom CHOP-14 or CHOP-21 chemotherapy was planned for administration between January 2006 and December 2008; no additional interventions were required as a result of participation in the study. All patients enrolled in the IMPACT NHL Study (n=1,864) who met protocol-defined eligibility criteria and received at least one cycle of chemotherapy (n=1,829) were included in the source population for the current analysis.
For each patient, baseline data were collected on patient demographics (e.g., age, sex, race, height, weight), medical history (e.g., comorbid conditions), Eastern Cooperative Oncology Group Performance Status (ECOG PS), cancer characteristics (e.g., bulky disease, bone marrow involvement), International Prognostic Index (IPI) score (non-follicular patients only)/Follicular Lymphoma International Prognostic Index (FLIPI) score (follicular patients only), prior antineoplastic therapy, planned chemotherapy (i.e., CHOP-14 or CHOP-21, with or without rituximab ["-R"], doses, number of cycles), and predicted risk of FN (i.e., <20% vs ≥20%). Cycle-specific data collected during the chemotherapy course included actual chemotherapy regimen (i.e., drug, dose, date of administration), use of selected drugs/services (e.g., granulocyte colony-stimulating factor [G-CSF] for prophylaxis [primary or secondary] or treatment, erythropoiesis-stimulating agent [ESA], transfusions, anti-infective agents), performance status, and occurrence of FN--as well as selected other adverse outcomes--and associated setting of care (i.e., hospital, outpatient setting, home). Hospitalizations for reasons other than FN were also captured.
The study population, consisting of patients who experienced FN and matched comparison patients, was selected from the source population as follows. For each patient in the source population, all chemotherapy cycles in which FN occurred were identified. FN was defined as a single oral temperature of ≥38.30C or a temperature of ≥38.0°C for ≥1 hour, and a neutrophil count of <0.5 x 109/L or a neutrophil count of <1.0 x 109/L that is predicted to fall below 0.5 x 109/L. Patients with FN in more than one cycle were classified according to the cycle number in which FN first occurred.
Patients in the source population who developed FN during their first cycle of chemotherapy ("FN patients") were matched on selected covariates--hypothesized to be possibly associated with FN and healthcare costs--to patients who did not develop FN during their first cycle of chemotherapy ("comparison patients"), whether or not they developed FN in any subsequent cycles. Matched cycle-one FN patients and comparison patients were then removed from their respective pools. From remaining patients in the source population (i.e., those not previously matched), those who first developed FN in their second cycle of chemotherapy were matched to those who did not develop FN in that cycle. Matched cycle-two FN patients and comparison patients were then removed from their respective pools. FN patients and comparison patients were similarly matched in the third and all subsequent cycles. The cycle in which patients were matched was designated the "index cycle".
Matching was implemented--sequentially, on a cycle-specific basis--for each FN patient by identifying all candidate comparison patients matching that FN patient in terms of age (±5 years), tumor stage, and chemotherapy regimen. The candidate with the closest propensity score ("nearest neighbor") to the FN patient was selected as the matched comparison patient. Matching was conducted for FN patients randomly, and without replacement of comparison patients (i.e., comparison patients were matched to one FN patient only). Propensity scores were estimated using multivariate logistic regression; independent variables included all demographic and disease-specific characteristics (e.g., age, sex, IPI/FLIPI score, bone marrow involvement), predicted risk of FN, presence of (current/continuing) comorbidities, chemotherapy regimen, supportive care, ECOG PS, absolute neutrophil count (ANC), and presence of anemia symptoms (e.g., fatigue/tiredness, pallor/pale skin, headache, dyspnea). All of the above-listed variables--with the exception of ANC, presence of anemia symptoms, and supportive care--were characterised using data collected at baseline in the IMPACT NHL Study; the exceptions were characterised using data collected during the pre-index cycles and index cycle, as appropriate.
An alternative, more restrictive matching procedure--including age (±5 years), country of residence, tumor stage, bone marrow involvement, IPI/FLIPI score, and chemotherapy regimen when identifying candidate comparison patients--was first employed, but was ultimately deemed by study investigators to be inadequate due to small sample size (n=118). The characteristics of FN patients and comparison patients matched using this more restrictive procedure is described in Additional file 1: Table S1 of the online supplement.
FN-related healthcare utilization was tallied for each FN patient and matched comparison patient from the cycle in which FN first occurred (for the former) through the last cycle of chemotherapy. Healthcare utilisation was examined in terms of: the number of FN events requiring inpatient care, outpatient care, home care, and other/unknown care, respectively; the total number of hospital days for all FN-related admissions that occurred from the index cycle through the end of the last chemotherapy cycle; and use--and reason for use--of G-CSF (pegfilgrastim, filgrastim, and other G-CSF [presumably lenograstim]) and IV antimicrobial agents by setting of care. Use of G-CSF and antimicrobial agents as prophylaxis was considered in post-index cycles only, while use of these agents as treatment was considered beginning with the index cycle.
FN-related healthcare costs were calculated for FN patients and comparison patients by combining estimates of FN-related healthcare utilization--as described above--with unit-cost data from the United Kingdom (UK). UK-specific unit costs were estimated from the perspective of the National Health Service using data from readily-available secondary sources and published literature, where available, as well as expert opinion, where needed. Principal sources of cost data were the 2009–2010 National Health Service (NHS) Schedule of Reference Costs (hospital costs), the 2010 Unit Costs of Health and Social Care Report from the Personal Social Services Research Unit (outpatient, home care, and other setting costs), and the British National Formulary (BNF), 60th Edition (pharmacotherapy costs) [14]. Unit costs are set forth in Table Table1;1; a full description of methods employed to estimate unit costs is provided in Additional file 1: Table S2 of the online supplement.
The adequacy of the matching procedure was evaluated based on the similarity of matched FN and comparison patients in terms of their baseline characteristics. Categorical variables were compared using the McNemar or Bowker test, and continuous variables were compared using the paired-samples t-test. The similarity of matched patients and unmatched patients--in terms of their characteristics--also was examined.
FN-related healthcare utilization and costs from the index cycle through the end of the last cycle of chemotherapy were examined on a cumulative basis for each patient in the FN and comparison groups. Mean values were estimated for the two groups, as well as for differences between groups, on an overall basis during the index cycle and during post-index cycles. Hospital days for FN patients and comparison patients with missing data on admission/discharge dates were imputed based on corresponding subgroup-specific mean values. FN-related healthcare costs also were evaluated among subgroups of patients defined on the basis of key characteristics, including index cycle, chemotherapy regimen, and predicted FN risk. Ninety-five percent confidence intervals (95% CIs) were generated using techniques of nonparametric bootstrapping.
The appropriateness of combining FN-related healthcare utilization data from different countries with unit cost information from the UK was evaluated based on a comparison of country-specific mean numbers of patients developing FN by setting of care, and for patients requiring inpatient care, country-specific mean numbers of hospital days. These analyses were based on data from FN patients and comparison patients who were matched on the basis of the criteria set forth above (i.e., age, tumor stage, chemotherapy regimen, and propensity score) as well as country of residence. Results were summarized using means and 95% CIs; formal statistical tests for heterogeneity between patients in different countries were not undertaken due to small country-specific sample sizes.
Among the 1829 NHL patients in the source population, 331 (18%) experienced one or more FN events--a total of 479 FN events--during their course of chemotherapy; the number of events, by cycle, occurred as follows: 1st cycle, 128 (27%); 2nd cycle, 64 (13%); 3rd cycle, 67 (14%); 4th cycle, 68 (14%); and 5th or later cycle, 152 (32%). The majority of FN events (77%) required inpatient care.
A total of 295 FN patients were successfully matched (1:1)--on age (±5 years), tumor stage, and chemotherapy regimen, as well as closest propensity score--to comparison patients (Table (Table2).2). (Selected covariates are presented in Table Table2;2; a full listing of covariates is provided in Additional file 1: Table S3 of the online supplement.) Mean (±SD) age was 63 (±12) years, 69% had stage III or IV disease, and 91% received CHOP-14-R (28%) or CHOP-21-R (63%). No covariate differed significantly between FN patients and comparison patients. Most patients were matched in cycle 1 (43%) or cycle 2 (14%), and the mean number of cycles from the index cycle through the end of chemotherapy was 4.5 (±2.1) for FN patients and 4.6 (±2.1) for comparison patients. Ninety-seven percent of the study population received chemotherapy at a site in Western or Southern Europe; the remaining 3% received care in Australia.
Matched and unmatched patients were similar in terms of many of their baseline characteristics, but matched patients were older (by about 4 years, on average) and a higher percentage of them had advanced disease (58% vs 45%) and a predicted risk of FN ≥20% (73% vs 61%). These results were not unexpected, since age and presence of advanced disease are risk factors for FN, and comparison patients were matched to FN patients based on these factors. (Data on all baseline characteristics for matched and unmatched patients are available in Additional file 1: Table S4 of the online supplement.)
FN patients averaged 1.44 (95%CI 1.34-1.56) FN events from their index cycle through the end of their course of chemotherapy--0.44 (0.34-0.56) during post-index cycles--and comparison patients averaged 0.15 (0.10-0.21) such events over the same period, corresponding to a difference of 1.29 FN events (1.17-1.43) (Table (Table3).3). Among FN patients, 76% of index FN events and 79% of post-index FN events required inpatient care; for comparison patients, the corresponding percentage (during post-index cycles) was 84%. Among FN patients requiring inpatient care, the average number of FN events (irrespective of setting of care) was 1.10 (1.00-1.21) versus 0.13 (0.08-0.18) for matched comparison patients, a difference of 0.98 (0.85-1.11). Mean number of FN-related hospital days was 6.21 (5.28-7.17) for FN patients versus 0.63 (0.30-1.02) for comparison patients, a difference of 5.62 (4.64-6.62).
Levels of FN-related healthcare utilization among FN patients and comparison patients (matched on the basis of the criteria set forth above plus country of residence [n=236]) and corresponding differences between these groups, were largely comparable across countries (data available in Additional file 1: Table S5 of the online supplement). Among country-specific subgroups including ≥15 patients, mean number of FN events among FN patients ranged from 1.41-1.63, and mean number of events requiring inpatient care, 0.79-1.50; the mean number of hospital days among FN patients ranged from 3.8-5.2.
Mean overall FN-related healthcare cost among FN patients was £8066 (95%CI £7277-£8882)--£4051 (£3633-£4485) during the index cycle and £4015 (£3374-£4724) during post-index cycles (Table (Table4).4). Mean cost of FN care among comparison patients (for whom all costs were incurred during post-index cycles, by design) was £2290 (£1923-£2655). Overall mean cost thus was £5776 (£4928-£6713) higher for FN patients than comparison patients, with 71% of the difference attributable to care in the index cycle (£4051 [£3633-£4485]) and 29% attributable to care in post-index cycles (£1725 [£978-£2498]).
Stratified by the setting of care for the index FN event, the difference in mean overall cost was greatest for those who received inpatient care for FN during the index cycle versus comparison patients who were matched to them--£9688 (£8709-£10,653) versus £2430 (£1984-£2931), a difference of £7259 (£6327-£8205). Corresponding results for those patients whose index FN event was treated in other settings of care were: outpatient, £3761 (£1908-£6007) versus £1777 (£1116-£2565); and home care, £3291 (£2445-£4339) versus £1826 (£993-£2919).
Differences in mean FN-related healthcare costs between FN patients and comparison patients were comparable within subgroups defined on the basis of key characteristics, including index cycle, chemotherapy regimen, and predicted FN risk. By index cycle, differences were: cycle 1, £6024 (£4588-£7429); cycle 2, £4913 (£3123-£6875); cycle 3, £6029 (£3409-£9242); cycle 4, £6804 (£4519-£9543); and cycle ≥5, £5121 (£4084-£6220). For patients receiving CHOP-14-R and CHOP-21-R, differences were £5667 (£4002-£7261) and £6045 (£4855-£7173), respectively. For matched FN and comparison patients with a predicted FN risk ≥20%, difference was £5603 (£4603-£6605), and for those with a predicted FN risk <20%, £6006 (£4557-£7783).
Using a matched-cohort design, healthcare utilisation data for 1829 NHL patients receiving CHOP-14 or CHOP-21 chemotherapy in European and Australian clinical practice, and UK-specific unit costs, we estimated the total economic impact of FN including care for the initial event as well as downstream FN-related care. The mean economic burden of FN (i.e., the difference in costs between FN patients and comparison patients) was found to be substantial, totaling £5776 per patient. For FN patients whose index event required hospitalization, economic burden totaled £7259 (US$11,610), which is comparable to the estimate (US$12,397) from the study by Weycker et al. (2008) that employed the same study design and data from a large US healthcare claims database (2001–2003) [9]. Most of the total economic burden was attributable to FN inpatient admissions, since 76% of index events and 79% of post-index events required hospitalization, and the (unit) cost of such care is considerably higher than that for FN treated in the outpatient or home care settings. As in the study by Weycker and colleagues, while the burden of the initial event was substantial and accounted for the majority of FN-attributable costs (70%), a significant minority of these costs resulted from follow-on care and subsequent events underscoring the economic importance of accounting for the downstream consequences of this complication. The economic costs of index events averaged £4051, versus £1725 for FN-related healthcare utilization in post-index cycles.
For several reasons, our estimates of the total economic burden of FN may be conservative. First, for FN events requiring hospitalization, follow-on care that may have occurred in the outpatient setting subsequent to hospital discharge--in the index cycle or subsequently--was not collected during the IMPACT NHL study and thus could not be incorporated into our estimates of disease burden. Second, for all FN events--irrespective of care setting--additional resources that may have been used (e.g., laboratory supplies), and additional services that may have been provided (e.g., drug administration), in the treatment of FN--and that are not included in assumed unit costs/reimbursed values--could not be incorporated due to data limitations. Finally, we erred on the conservative side when making assumptions about the frequency and intensity of resource use outside the hospital setting--where such data were not available from the IMPACT NHL Study--and thus may have underestimated corresponding costs of care. We also note that estimates of disease burden were robust when employing the alternative (i.e., more stringent) matching criteria for FN patients and comparison patients, when admissions designated as "elective" were excluded from estimation of (unit) cost of hospital care, and when using Payment by Results (PbR) tariffs (rather than NHS reference costs) for hospital care (data available in Additional file 1: Tables S6-S8 of the online supplement).
Several limitations of our study are noteworthy. First, although FN patients and comparison patients were matched on several characteristics, it is possible that the two cohorts differed in terms of unobserved characteristics that predispose them to FN. To the extent that FN patients in our study population were more likely to develop FN than comparison patients, some downstream costs--in particular, those occurring in cycles after the one in which the initial (i.e., index) FN event occurred--may not be attributable to the initial FN event per se. Especially problematic in this regard are the costs of subsequent FN events. To what extent does experiencing a first episode of FN increase a patient's risk of subsequent episodes, relative to the extent to which the risk of subsequent episodes is predicted by the same risk factors associated with the initial episode? If largely the latter, the actual burden of chemotherapy-induced FN may be closer to the total costs of the index event plus any additional follow-on care that is directly related to the initial event--most of which, presumably, would occur in the same cycle. Second, it is possible that certain biases in recording may exist such that patients who experience an FN event may be more likely to have FN noted on future encounters versus patients without a history of these complications, all else equal, which could upwardly bias our estimates. Third, although FN-related healthcare utilization appears to be comparable across countries, differences between the UK and other countries in the services or intensity of services that are provided within a given setting (and that are not captured in the study database) are not reflected in study results. Accordingly, caution should be exercised in generalizing the results of this study to other settings. Fourth, we note that FN patients comprise those whose index course was their first course of chemotherapy as well as those who previously received chemotherapy. To the extent that the consequences of FN are different based on prior receipt of chemotherapy, results may not be generalizable to these two subgroups (i.e., subgroups comprising solely patients who previously received chemotherapy and those who did not, respectively). Fifth, we note that various patient- and provider-specific factors may influence the pattern and intensity of FN treatment, on an inpatient and outpatient basis, and that to the extent these factors vary across settings, study results may not be fully generalizable to other patient populations. Sixth, the IMPACT NHL Study was not designed for economic analyses, and thus data on certain types of healthcare utilization (e.g., outpatient visits for follow-on care) were not collected, while other data (e.g., identification and use of IV antimicrobial agents as treatment or prophylaxis) may not always have been collected or classified consistently and comprehensively. Therefore, the results of this analysis may underestimate the total attributable cost of FN. Finally, while our study population comprised adult patients with NHL, we note that the Healthcare Resource Group version 4 (HRG4) code--PA45Z--that was used to cost FN-related inpatient care is grouped in the chapter "Diseases of Childhood and Neonates". We also note, however, that this code has been employed in several single technology appraisals (STAs) and evidence review group's (ERG) reports to cost chemotherapy-related febrile neutropenia among adults with HER2-negative metastatic breast cancer, adults with chronic lymphocytic leukemia, adults with metastatic prostate cancer, and adults with squamous cell carcinoma of the head and neck, respectively [15-18].
In conclusion, the economic burden of FN among NHL patients in European and Australian clinical practice is substantial, and a significant proportion of this burden is due to the downstream consequences of the condition. Studies focusing only on the initial FN event may underestimate the total attributable cost of these complications.
Authorship was designated based on the guidelines promulgated by the International Committee of Medical Journal Editors (2004). All persons who meet criteria for authorship are listed as authors on the title page. The contribution of each of these individuals to this study--by task--is as follows: conception and supervision (Weycker, Danel), development of design (Weycker, Danel, Marciniak, Bendall), conduct of analyses (Weycker, Lipsitz), interpretation of results (all authors), preparation of manuscript (Weycker, Lipsitz), and review of manuscript (all authors). All authors have read and approved the final version of the manuscript.
Funding for this research was provided by Amgen Europe. The study sponsor reviewed and approved the study research plan and study manuscript; data management, processing, and analyses were conducted by PAI, and all final analytic decisions were made by study authors.
Derek Weycker and Michael Lipsitz are employed by PAI (Brookline, MA, USA). Aurelie Danel is employed by Amgen Europe (Zug, Switzerland). Anne Marciniak was employed by Amgen Ltd. (Uxbridge, UK) at the time the study was conducted. Kate Bendall is a consultant and funded by Amgen Ltd. (Uxbridge, UK). Ruth Pettengell is employed by St. George's University of London, Department of Haemotology (London, UK), and was a principal investigator for the IMPACT Study.
Funding for this research was provided by Amgen Europe GmbH to Policy Analysis Inc. (PAI).
The pre-publication history for this paper can be accessed here:
Table S1. Characteristics of FN and comparison patients matched on basis of original criteria in sSAP; Table S2. UK-specific unit costs of FN-related care; Table S3. Characteristics of FN patients and comparison patients matched on basis of age (±5 years), tumor stage, chemotherapy regimen, and propensity score; Table S4. Characteristics of full patient population, unmatched patients, and matched patients; Table S5. Healthcare utilization among FN patients and matched comparison patients matched, by country; Table S6. Healthcare costs among FN patients and comparison patients matched on basis of age (±5 years), country of residence, tumor stage, bone marrow involvement, IPI/FLIPI score, and chemotherapy regimen; Table S7. Healthcare costs among FN patients and matched comparison patients, excluding hospital admissions designated as "elective" from calculation of unit costs; Table S8. Healthcare costs among FN patients and matched comparison patients, using PbR tariffs as basis of unit cost of hospital care.(XLS 469 kb)
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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Intera casa/apt
5 ospiti
1 camera da letto
3 letti
Su questo annuncio
Located at the very best beach of Cancun (rated such by National Geographic Channel) and at the heart of the hotel zone. This hotel type room has a terrace with a front view to a private garden and 24/7 access to luxury hotel quality services.
This standard hotel room has two double size beds, a single size sofa bed, one bathroom, microwave and minifrige.
It also has a terrace with front views to a private garden and a small partial view to the bay of Isla Mujeres. This terrace has a small table and two chairs.
The room is in a third floor and it has elevator access. Free parking available.
There is also a phone in order to request any of the 24/7 hotel type services at the front desk.
Accesso ospiti
This is a private room with access to luxury services such as: room service (extra charge), free wifi, 24/7 front desk and concierge, safe deposit box at the front desk, wake up calling service by the front desk, 24/7 bell boy, 24/7 manteinance service, free pool towels, convenience store service to your door (extra charge), travel agency (extra charge), daily hotel type cleaning service (extra charge), 24/7 gym, Massage service (extra charge), spa (not included), nanny service (not included), all inclusive packages (extra charge), bar and two great restaurants with amazing sea views of the bay of Isla Mujeres (one serves the breakfast buffet and also serves mainly mexican cuisine and the other serves mainly seafood specialties, free parking, coin laundry machines are in the common areas. All personel is bilingual.
You can pay all extra charge services at the front desk by credit card or by leaving an open voucher just as you would in a hotel.
You will be handed electronic card keys at the front desk upon arrival just by saying your name. Front desk will also give you cards to pick up pool towels at a stand located by the pool.
These apartments are privately owned but have accesss to 24/7 service from highly skilled personel with hotel training experience. Their mission is to make you feel as if you were in a luxury resort.
Guests will have access to all the regular services provided by the apartments management and personel.
As guests of these apartments you can also have free beach and street access to the restaurants and bars (not included) of the 6 star Presidente Intercontinental hotel which is located right next door.
There are also honey moon, wedding and events packages.
Interazione con gli ospiti
I travel frequently but I try to be around the property whenever I can to meet guests and say hi. I really enjoy this part whenever I can make it to the property.
These are luxury type apartments and as owners we have invested greatly in our in house hotel type services. All personel has been trained and is constantly supervised by highly qualified luxury hotel professionals.
Therefore I do expect you to receive paramount treatment from the minute you arrive by the apartment´s staff (from management, front desk personel to waiters, chefs, bell boys, security staff, lifeguards, travel agency people and cleaning service employees).
Any complaint, suggestions or just to say hi...I WILL be available 24/7 at my cell phone, mail or through airbnb messages.
I take great pride in offering a top of the line service and therefore guarantee total satisfaction so please feel free to contact me at anytime.
You DONT have to bring anything else than a good attitude. Everything else (bed sheets, towels, soaps,, shampoos, kichen apliances, etc..) will be provided for, enjoy!
You can leave the air conditioner on 24/7.
Cancella la prenotazione fino a 7 giorni prima del viaggio per ottenere un rimborso del 50%. Puoi cancellare la prenotazione anche entro 7 giorni dal tuo arrivo, ma non riceverai alcun rimborso.
60 Recensioni
Questo host ha 165 recensioni per altri annunci.Vedi altre recensioni
Soy de Mérida, Yucatán pero vivo en Cancun. Desde pequeño he tenido la fortuna de poder disfrutar esta increíble playa y departamentos familiares.
Soy abogado corporativo y junto con mi familia también produzco miel de abeja gourmet.
He pasado buena parte de mi vida estudiando, trabajando y viajando en el extranjero por lo que aprecio y agradezco mucho la buena hospitalidad a los huéspedes y foráneos en general.

subset: commoncrawl


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Baffles are pieces of fabric that are sewn to the inside corners of a bag to maintain its cube shape after filling. The baffles have holes that allow the product to flow freely through them. The baffles also prevent the bag from bulging, which makes the bag stand up straight and in turn allows the bags to be more efficient in their use of space.
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Little Miss Organised has always wanted to make a difference to people's lives both individually and collectively. We actively support charities such as St Vincent de Paul Society, Endeavour Foundation, Making a Difference - Brisbane, Redlands Centre for Women, and Redland Community Centre.
Do you have items to donate? Please click here for links for donating.
One of our biggest charitable projects is supporting the New Life Orphanage in Yangon, Myanmar. Every year we send a container packed full of educational resources, clothing, building materials, books, etc. Many of the contents are donated by our clients, who not only felt more organised and empowered but also benefitted from a warm, fuzzy glow for their generous spirit.
If you want to do more to help and increase that warm glow then you can sponsor a child or member of staff at the Orphanage. Contact us for more details and together let's bring a little sunshine into people's lives.
Find more information at Links and Resouces and Where to Donate


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Kindle in Manila
Kindle in Manila? Does anybody know if I can buy and/or use Kindle in the Philippines?
Kindle: Amazon's Wireless Reading Device
It seems some people arrive at my blog using the keywords "Kindle in Manila". I am not sure about how to get one from here. However, after some research about Kindle, it led me to goILOILO.com. His blog post about Using the Amazon Kindle in the Philippines has provided wonderful information and it will help the people who need to know. As for me, I am waiting for someone to give to me a Kindle as a gift.
Happy reading!


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Getting Here
Latest News
Web Cams
What's On?
Summer Activities
Events Calendar
Bike Events
Flora & Fauna
Eco Tourism
Conferences & Functions
Take a self-guided tour of the mystical gnome world of the mountain village and if you're lucky catch a glimpse of resident Mt Buller gnomes, learn about their favourite places to play as well as some interesting facts about the gnome way of life.
Download the free Mt Buller Walks app and enjoy an audio tour of the roam along with a copy of the Mt Buller Gnome Roam keepsake booklet available from the Clock Tower or Alpine Central or here online.
On your way up the mountain, you can also stop in at the Gnome Home for a visit. Located about 3km up the Mt Buller Tourist Rd, keep an eye out for the Gnome Crossing sign and just past that you will find the Gnome Home, in a majestic Mountain Ash tree.
The Mt Buller Gnomes have long resided outdoors in the Mt Buller Village, and recently we've found new clans that have moved indoors!
Some very special people have welcomed gnomes into their venues, so now your little folk can come indoors and catch up with our little folk.
Breathtaker Rd, Bus Stop 11Come inside out of the cold and visit the Austrian gnome family living at Hotel Pension Grimus. Treat your little folk to a mug of gnome Tyrolean hot chocolate with a gnome apple strudel muffin or a gnome gingerbread cookie.
Available Mon - Fri 4pm-6pm, Sat & Sun 12 noon-6pm, during winter.
Stirling Road, Bus Stop 3After a hard day's gnome hunting, reward the kids with a special gnome hot chocolate and cookie.Available daily, during winter.
Goal Post Road, Bus Stop 6Little folk have big appetites, so the Duck Inn's Gnometti Bolognese is sure to hit the spot!Available nightly, 5pm - 7pm, during winter.
Summit Road, Bus Stop 13
Available daily, during the Garage Cafe hours of operation, from 7am. Not available from The Whitt Bar & Restaurant.
There is so much happening here during summer! Check out the What's On for the latest.
Mt Buller has a great range of summer activities to keep everyone entertained.
Mt Buller has established itself as a premier mountain biking destination.
Mt Buller is the ideal trail running destination.
Your browser is out of date (Internet Explorer version 8 or under), and may not be compatible with our website. A list of the most popular web browsers can be found below.
Just click on the icons to get to the download page


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The tubing was pretty epic, different than in the states. The current got more advanced as we went, but that made it fun. We were in the water two h...... read moreKayla, Costa Rica
Starting with a hike for around 15 minutes between secondary forest trails you'll get to Río Arenal (Arenal River). Right after an instructive talk from the guides the adventure of "Tubing" begins.
While 1.3 miles on crystal water you will enjoy natural landscapes surrounded by beautiful wildlife such as monkeys and birds, they are typical of this area located in the Arenal Volcano base. Adrenaline is felt as we go through this river combining adventure with security provided by professional guides.
At the end of the tour you will be go to a changed room to get out of your wet clothes for dry to go back where we picked you up.
|Departure time
|Approximate duration time
|Price per adult
|Price per child
|Total Price
2.5 hours
2.5 hours
Rafting Sarapiqui River Class 3-4$908 hours
Horseback Riding to La Fortuna Waterfall$553 hours
Safari Float Penas Blancas River$604 hours
Canyoning with Rafting in Arenal$1558 hours
Arenal Volcano Hike & La Fortuna Waterfall$1057 hours


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Update - Your Halloween-L & Haunters Everywhere Video Compilation.....by haunters, of haunters, for haunters!
Expand Messages
- Your Halloween-L & Haunters Everywhere Video Compilation.....by haunters, of
haunters, for haunters!
There are only 15 days until the deadline to submit your haunts,
http://www.hauntvids.com/submit.htm. We know you haven't heard that much
from The Halloween-L & Haunters Everywhere 2006 Video Compilation lately.
Updates will be more frequent now that HauntVids.com is near complete and
the FTP servers are up.
We would like to thank everybody who has submitted so far, we've been
averaging about 2 entry's per day and have been getting confirmations from
people saying that they'll have theirs on the 15th or just after.
If your going to be late with an entry contact Chris at
p8balls@... so he can plan accordingly.
You don't want to miss out! It doesn't matter how short your video is, or
how few pictures you have to submit. If you don't think you have enough,
think again, we've had people submit as little as 10 pictures. Everything is
welcome, and we all want to see what you have done, we are all haunt
If you can't put a compilation together yourself and/or don't know how to
convert your media to digital or the correct format, don't let that hold you
back. You should mail it to Chris at p8balls@... and the HauntVids
team will convert it for you!
All questions we have been receiving are being posted to the FAQ section of
HauntVids.com, http://www.hauntvids.com/faq.htm.
Review the FAQ before sending questions, for new questions submitted, we
will update the FAQ.
All past compilations and additional videos are/or will be available for
download on the MinionsWeb ICFear server, http://www.minionsweb.com/vids.htm
To find out who's haunt is on what year compilation, visit
http://www.hauntvids.com/compilations.htm. Each years haunters have been
listed for each video, and there are hyperlinks from the haunters name to
their website if available. If you don't see a link to your site contact us
and it will be added.
We'll have more exciting things to announce regarding HauntVids.com shortly,
make sure to check back often.
There are some exciting announcements coming from the Haunters Choice Awards
folks too.
If you have any hauntvids questions you can contact us off list -
Stay Tuned!!
The Hauntvids team
Your message has been successfully submitted and would be delivered to recipients shortly.


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Questioning Polemics
Some months ago someone made an offhand comment about my natural inclination towards polemics which made me seriously rethink the nature of my blogging and online interaction, and I've certainly made a concerted effort to be more proactive, and less reactionary in what I write about; but I've been musing over a couple of things.
The first thing is that I've noticed that a tend to write better when I'm writing polemically. I find that I have more focus and can structure a piece better. I find that I tend to run with suggestions much more easily than coming up with original ideas, which suits me fine as a performer, I have to say – I love working with directors and musicians who give me things to play with. Give me props and I'll improvise well, give me a blank stage and I struggle and gravitate towards the generic.
The second thing is that I've started to question my knee-jerk assumption that polemics is necessarily a bad thing. Of course, any style or approach can be bad in the wrong contexts or if taken too far, but I'm starting to think about the place of polemics in my writing, and not being worried about writing in that style, but harnessing it somehow. Where I certainly see an issue is if one were to be polemic for the sake of it, which is perhaps simply just being contrarian and argumentative, and in the context of the original comment, that was very likely the case! The other side is my desire to write more creatively and not necessarily cerebrally, which I guess is the natural environment of polemical writing. My fear there, however, is that I'll just sound pretentious, which brings me back to the issue of writing in a style that comes naturally.
Do you think there's value in polemic writing?


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Sur ton mur
New prints by Isabelle Arsenault
I just added four beautiful new prints by Isabelle Arsenault, taken from her books "Colette's Lost Pet" and "Cloth Lullaby"! Click on the below images for more info.
Matt Forsythe and the New York Times
Matt Forsythe drawing and discussing his work with The New York Times Books !
Guillaume Perreault
I'm very excited to share the work of the latest artist to join Sur ton mur - Guillaume Perreault! Click on the below image to see his entire collection.
Mary Poppins
Through the end of February, if you buy one or more Mary Poppins prints, illustrator Genevieve Godbout will gift you the book (or books) corresponding to your print(s)! Offer valid while stocks last, so don't wait!
Coming soon!
I'm excited to share the latest artist to join Sur ton mur - Guillaume Perreault! I love his vibrant, playful illustrations.
Guillaume began his career as a graphic designer, but quickly turned to freelance illustration. He has illustrated many graphic novels and children's books, and has also worked with diverse advertising clients. Guillaume has also explored the world of writing, having written and illustrated two graphic novels. In 2016, he received a Reader's Choice Pepite prize at the Salon du livre et de la presse jeunesse Seine-Saint-Denis. A native of Rimouski, he currently lives in Gatineau. Visit his website for more information!
Holiday Season
Marché Nënë
Marché Nënë is coming up this weekend in Montreal! I'll be there from 9am-6pm each day with art prints and temporary tattoos for sale.
Marché Nënë features more than 40 local artists and designers specializing in everything kid-related - clothing, toys, art, homewares - as well as workshops, food, film projections, a treasure hunt, and more.
FOR MORE INFO (in French only) http://www.marchenene.com/
November 19th/20th, 2016
Soupesoup & La Gare - 5333 Ave Casgrain (Montréal)
Free and open to all!
Paul is back!
I'm excited to show you our four new art prints by Michel Rabagliati. Which one is your favorite?
Click on the images to see his complete collection.
I just added a new print by Elise Gravel to the shop!


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The Betrayal Of Lancelot is the one book, which on the face of things, completely distorts the Arthurian legend. However – it would not have been possible to do this if there were not already stories of Roman legionaries who are cursed to wander the world forever and a once and future king likely to come back to rescue us… Now would be good!
I went into this with one thought in mind – who is the Once and Future King?
I will admit a part of me wanted to see what Lancelot would be like in heavy motorcycle leathers with a gun… But… Mad Max had a heavily influence during my disturbing adolescent. I loved writing this book, the twists and turns with the different characters; playing out Lancelot's life over six hundred years of being alone; the effects on him and the others when they found it out. I also realised something profound – Tancred deserves better. Lancelot needs to see the consequences of his actions on those he professes to love. He damages all despite spending centuries believing himself the victim. How often have we considered ourselves hard done by when we've forgotten to think about things from someone else's point of view? Tancred once more is the character who is used to propel the narrative into uncomfortable places for some. I promise. He will be alright in the end. Again, these are traditional themes within stories both old and new.
During this book I return Lancelot to his home and we meet familiar enemies. Mordred. This is the beginning of the end perhaps. Will Lancelot find himself facing Mordred on a battlefield? Or will it be the boy's father who faces him? To be honest I don't think I'll know for sure until we get there.
A great many things are thrown into this story, perhaps there are too many, from the rights of gay marriage to the decimation of the environment and the consequences for society. Once more these things are reflected in the return to Camelot and The City. They are themes I touch on frequently in my work. I will say this – whatever anyone else thinks of this book – it is my favourite so far.


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Eclipse-Watching Tourists Are Causing Congestion at Rural Airports
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Skift is an immersive and fun learning environment, everything that comes with a fast growing company. But many of us are family people too, so we know, live and actively work to encourage work life balance.Learn More


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Randall Lesaffer eBooks
eBooks found: 1
European Legal History
Jan Arriens & Randall Lesaffer
Cambridge University Press, June 2009
Format: PDF
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text:
Spicy Vegetable Soup With (Or Without ) Pork
Recipe by ellison52
Living in Japan, I miss my Mexican food! I used the Japanese equivalent of American vegetables, imported Rotel Tomatos and Swansons Chicken Broth and came up with a pretty good substitute. In Japan, you can't find large cuts of meat. Most of the meat is cut almost paper thin. The pork I use in this is very thin and I usually add it to the soup during the last 15 minutes or so. It cooks quickly in the simmering soup. If you can't find thinly sliced pork, buy a lean pork chop, partially freeze it and then slice it into thin strips. If you like more veggies in your soup, add green beans, zucchini squash or whatever else you have in the frige! Vegetarian? Omit the pork.
Top Review by Charlotte J
The Rotel tomatoes gave this soup a nice little kick. I'm sure my DH will think it to hot but the rest of us enjoyed it very much. I used about 1 pound of pork in making this tonight. Very easy to make and I'll make it again. Made for *Zaar Chef Alphabet Soup 2008* game
See Discussion:1 Review
Ingredients Nutrition
- 1⁄2 head cabbage, chopped
- 2 (14 ounce) cans chicken broth
- 1 (10 ounce) can Rotel Tomatoes
- 4 celery ribs, including leaves chopped
- 1 (15 ounce) can diced tomatoes
- 3 garlic cloves, minced
- 1 onion, coursely chopped
- 1 lb carrot, thinly sliced
- 1 teaspoon salt
- 1⁄4 lb pork, thinly sliced
- Pam cooking spray
Directions See How It's Made
- Spray the bottom of a soup pot with Pam.
- Add garlic, onion, and carrots. Let veggies get a little soft, stirring occasionally, for about 6-8 minutes.
- Add the rest of the ingredient EXCEPT the pork.
- Bring to a boil and then reduce heat. Let soup simmer for 45 minutes, stirring occasionally. .
- Add sliced pork, stir well, Let cook for 15 more minutes.


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Rate this App
feelDweb is a program belonging to the category html, with a license being 免费 which is offered in 中文. It is developed by David García for windows platforms with the version or higher. The version 1.9.2 Beta 4, updated on 2014.04.25, takes up 1.08MB of space in comparison with 17.22MB of media with respect to other programs in the same category such as Macromedia DreamWeaver, WinHex, SWiSH Max, Editor HTML, Web Page Maker, Amaya. Its 554 downloads rank feelDweb in the position number 91 within its category and 59209 of all windows apps. The 8 images available on Uptodown, along with the link to the official website (https://sites.google.com/site/darmuchoquehablar/obras-y-creaciones/feeldweb), also allow us to understand the workings of the app we want to download. Lastly, the official report from Virus Total gives you the guarantee that the app is 100% 安全 for this and any of its previous versions.
Rate this App
3 个评论


text:
Download Bloons TD Battles Latest Mod Version for Android
Developed By ninja kiwi
Last Updated: July 20, 2017
Here is Latest version Mod of Bloons TD Battles .Manage your train company from modest engine to multi-car masterpiece in this immersive, world-spanning game from Tiny Titan Studios. Deliver passengers and cargo across the world, while upgrading and customizing your train cars to become the ultimate railroad tycoon!
Bloons TD Battles File Information:
Version: 4.5.1
Category: Strategy
Uploaded: July 21, 2017
File size: 67.1MB
Android Required: 2.3.3 and up
Install : 10,000,000+ downloads
Download Bloons TD Battles APK Mod V4.5.1 :
Download APK Mod from secure server ; File Size:67.1MB
Install Bloons TD Battles from Google Play


text:
- June 18: Takata and Honda Get Some Airbag Claims Dismissed news | 62 days ago
- June 16: Subaru Cracked Windshields Cause Lawsuit news | 64 days ago
- June 3: BMW, Mazda, Subaru and Toyota Will Settle Takata Lawsuits news | 77 days ago
2001 Subaru Outback
exhaust system Problems
Worst 2001 Outback exhaust system Problems
Click on a problem below to read more.
- exhaust fumes entering vehicle1
- NHTSA: Engine And Engine Cooling: Exhaust System: Emission ...2
- NHTSA: Engine And Engine Cooling: Exhaust System: Manifold/Header/Muffler/Tail ...2
- NHTSA: Engine And Engine Cooling: Exhaust System1
Loading ...
one sec.
Stay Up to Date
Compare Subaru Outback Model Years
Curious how the 2001 Outback compares to other years?
Check out our Subaru Outback overview to see the most problematic years, worst problems and most recently reported complaints with the Outback.


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Lenovo Y700-17ISK 80Q0 - Core i7 6700HQ / 2.6 GHz - Win 10 Home 64-bit - 8 GB RAM - 128 GB SSD + 1 TB HDD - DVD-Writer - 17.3" IPS 1920 x 1080 (Full HD) - GF GTX 960M - Wi-Fi - black - kbd: English -Item#: 40133647 | Model#: 80Q0008YUS
Currently Out Of Stock!
You May Consider This Alternative
Lenovo Y700-17ISK 80Q0 - 17.3" - Core i7 6700HQ Product Details
Product Type: Notebook
Operating System: Windows 10 Home 64-bit Edition - English
Processor / Chipset
CPU: Intel Core i7 (6th Gen) 6700HQ / 2.6 GHz
Max Turbo Speed: 3.5 GHz
Number of Cores: Quad-Core
Cache: 6 MB
64-bit Computing: Yes
Chipset: Intel HM170
Features: Integrated memory controller
Max RAM Supported: 16 GB
Technology: DDR4 SDRAM
Speed: 2133 MHz / PC4-17000
Form Factor: SO-DIMM 260-pin
Slots Qty: 2
Main Storage: 128 GB SSD - (M.2) PCIe
Secondary Storage: 1 TB HDD - SATA 6Gb/s / 5400 rpm
Optical Drive: DVD-Writer external
Type: 17.3" - IPS
LCD Backlight Technology: LED backlight
Resolution: 1920 x 1080 (Full HD)
Widescreen: Yes
Image Aspect Ratio: 16:9
Image Brightness: 300 cd/m²
Features: Anti-glare
Audio & Video
Graphics Processor: NVIDIA GeForce GTX 960M - 4 GB GDDR5 SDRAM
Camera: Yes - 720p
Resolution: 1 Megapixel
Sound: Stereo speakers, two microphones
Compliant Standards: High Definition Audio, Dolby Home Theater
Audio Features: JBL
Type: Keyboard, touchpad
Backlight: Yes
Keyboard Layout: English - US
Features: Built-in numeric keyboard, multi-touch touchpad
Wireless: Bluetooth 4.0, 802.11a/b/g/n/ac
Wireless Controller: Intel Dual Band Wireless-AC 8260 - M.2 Card
Network Interface: Gigabit Ethernet
Technology: 4-cell lithium polymer
Capacity: 60 Wh
Run Time: Up to 7 hours
AC Adapter
Input: AC 120/230 V (50/60 Hz)
Output: 135 Watt, 20 V, 6.75 A
Connections & Expansion
Interfaces: 2 x USB 3.0 ¦ USB 2.0 (for power charge) ¦ HDMI ¦ LAN ¦ Headphone/microphone combo jack
Memory Card Reader: 4 in 1 (SD Card, MultiMediaCard, SDHC Card, SDXC Card)
Color: Black
Features: Security lock slot (cable lock sold separately), administrator password, hard drive password, power-on password
Included Accessories: Power adapter
Compliant Standards: RoHS
Localization: English
Dimensions & Weight
Dimensions (WxDxH): 16.7 in x 12 in x 1.1 in
Weight: 7.72 lbs
Environmental Standards
ENERGY STAR Qualified: Yes
Manufacturer Warranty
Service & Support: Limited warranty - 1 year - pick-up and return
Recommended ItemsPrevious
Related ItemsPrevious
Manufactured by: Lenovo
Warranty provided by: Lenovo
UPC No: 0190576352716
Mfg Part No: 80Q0008YUS
Box Size:
( Length:0, Width:0, Depth:0)
Shipping Weight: 7.0000 pound(s)
Click here for full warranty and support information
- Lenovo logos are registered trademarks of Lenovo. All others trademarks and copyrights mentioned herein are the property of their respective owners.


text:
- ayaaki
- USA, Male, 31-40
- Novice Nomad
- 4 reviews
This is less a hostel and more a place to sleep. No common area. I spent some time in the lobby on the couch and was told I couldn't lounge around there. Also left a day early and asked if there was any way to be reimbursed for the day I was paying for. I rented a solo room for $76 USD a night. The hostel is clean enough though other than that I have nothing else to say. I didn't enjoy my stay here and will never stay here again.
- Anonymous
- USA, Couple, 25-30
- Avid Traveller
- 10 reviews
Awesomeness place! The staff is really nice and very helpful. The walking tour associated with the hostel was really good and we enjoyed it a lot. They change towels everyday if you want which is awesome. The room was always clean. It's really close to a lot of things and the metro to get to all of the attractions. Loved it here!
- Anonymous
- Ireland, Female, 25-30
- Novice Nomad
- 2 reviews
I booked this hostel due to its high rating on hostel world and wasn't c disappointed. Pros: the staff were friendly and helpful and they let me check in early, the cleaning staff were also friendly Cons: place feels run down, no common area, bathroom doesn't have a properly private door and no way to dry hands, could hear everything my neighbour was doing, no bolt or lock on the inside of the door, no blanket or cover on the bed just a sheet, dirty cushions, stained towels didn't feel safe.
- Anonymous
- USA, Male, 18-24
- Avid Traveller
- 10 reviews
As recent college grads my friends and I hoped this hostel's location would have been closer to the best clubs, bar areas, and the beach. It was much further away from all of these than advertised. Luckily the metro system is easy to use and taxis were cheap. 20-30 min walk from the beach and good clubs. Our 6 person room was tiny and the ceiling was leaking the entire time. Felt very crammed in there. Only one set of showers on the first floor. Tiny bathroom stalls; hard to wipe your ass
- Anonymous
- USA, Female, 31-40
- Novice Nomad
- 3 reviews
OK. It was a place to sleep. One of the staff was nice, but the others seemed like they didn't want to be there. I asked about night events and they told me there was nothing happening even though they have a bar hop every night. Location was good. Walls are thin. Can hear my neighbors.
Hostelworld Mobile Apps
Book on the go with the new Hostelworld mobile apps.


text: If held by a Pokémon, it reduces a foe's super-effective Nuclear-type move. The berry is consumed upon use, but may be restored with Recycle or Harvest. When used with Natural Gift, a Hafli Berry will take on the Nuclear type with a power of 60. Retrieved from "http://pokemon-uranium.wikia.com/wiki/Hafli_Berry?oldid=48164" Categories: Bag Berries


text:
It's no secret that I love risotto. I've posted recipes before for Kale and Bacon Risotto and Butternut Squash, Chicken, and Asparagus Risotto. One of the things I like most about this rice dish is that, by changing out the mix-ins, you can completely change the meal for each season. For this Mushroom Asparagus Risotto, I used spring veggies and chicken to make it a one-dish meal. The best part is, I haven't found a risotto recipe my daughter won't eat!
Mushroom Asparagus Risotto
1 1/3 cup uncooked arborio rice
4 tbsp olive oil
2 cloves minced garlic
4 cups chicken broth
2 medium chicken breasts
1 cup frozen peas
1 bunch asparagus, cut into 1-inch pieces
2 cups fresh sliced mushrooms
½ cup Parmesan cheese
1. Heat 1 tbsp olive oil in a sauté pan over medium high heat. Add chicken breasts and cook to 170°, turning occasionally. Set the chicken aside to rest and then cut into bite-sized pieces.
2. In another sauté pan, heat 1 tbsp olive oil over medium heat. Add asparagus and cook for a few minutes before adding peas and mushrooms. Cook for 10-15 minutes or until veggies are tender. Set aside.
3. Heat broth in a small sauce pan over low heat.
4. In a deep sauté pan or dutch oven, heat remaining olive oil over medium heat. Add garlic and sauté for 1 minute. Add rice and stir for about 2 minutes.
5. Add in 1 cup of broth and stir continually until the liquid is absorbed. Gradually stir in remaining broth ½ cup at a time, stirring continually each time until the liquid is absorbed before adding the next ½ cup.
6. Once the rice is cooked and the broth is gone, stir in vegetables, chicken, cheese, salt, and pepper. Cook for a few minutes to heat everything through and then serve immediately.


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Branching out
Ideally, the git work cycle looks like this:
- Create a branch
- Do your work
- Merge back to master
This keeps developers from stepping on eachothers toes and allows prolonged efforts on major features. Here are some handy commands for actually doing it:
Assuming you have alread git clone'd a repository, you can create a new branch like so:
git checkout -b mynewbranch
Alternatively, to clone an existing branch
git clone -b mynewbranch https://github.com/YourSoftware/YourRepo.git
Then make your changes, and push to the remote branch
git commit -am "message"
git push origin mynewbranch
Finally, when you are ready to push your changes back to the master you can:
git checkout -b master
git merge mynewbranch
#(then git push???)
If all goes well (or if it doesn't but you resolve the conflicts), you can remove the branch
git -d mynewbranch


text:
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text:
Home - About Me - GIS - Wildlife Photography - Links - SKRalston Home - Contact Me - My Résumé
I was born in 1980 in Fargo, ND and I now live in Windom, MN. I graduated from West Fargo High School in 1998, In 2002 I graduated from North Dakota State University in Fargo with a B.S. degree in Zoology/Wildlife Management. Immediately after graduation I started my masters degree at NDSU under Dr. William Bleier. My masters research involved aspects of blackbirds damaging sunflower crops and cattail habitat management to mitigate the problem. I graduated in Dec. of 2004 with a masters degree in zoology (emphasis in wildlife management). For more information on my masters research click on the "Masters Research" link. I then went to work for the U.S. Fish and Wildlife Service in Devils Lake, ND as a GIS Specialist/Biological technition. My specialty is using GIS and aerial photography in conjunction with wildlife management applications in the prairie pothole region. I designed new wetland mapping methods for conservation easements using GIS as well as designed new aerial photography and flight surveillance methods. Due to funding cuts I took a different position within the same office and was employed by Ducks Unlimited to assist with the Partners for Fish and Wildlife program in the USFWS including habitat restoration and protection. I also maintained the web pages for the Devils Lake Wetland Management District Office. in 2009 I accepted a new position with the U.S. Fish & Wildlife Service in Windom, MN. I am a Wildlife Biologist for the Private Lands/Partners for Fish & Wildlife Program. I assist private landowners with habitat improvements & restorations in 12 counties within southwestern Minnesota by providing technical & financial assistance. I LOVE MY JOB!
I married Kathryn Adamson on July 10th 2004, after a little over three years of dating her. We made a wedding web page. If your would like more information about the wedding, click on the "Wedding" link. Our honeymoon was an Alaskan cruise / land tour. It was the best trip I have ever been on and highly recommend the trip to anyone! For more details and pictures see the honeymoon page.
We have a son named Caelen who was born on Feb. 9th 2009. He is our pride an joy and keeps us very busy. Most of our photos of Caelen can be found on Facebook. If you are a facebook member you can add me or Kathryn as a friend to view our pictures and video there.
My major hobby is martial arts. I have been in tae kwon do since 1988. I trained at Northwest Martial Arts in Fargo under Master Roy Gilbertson. I am currently a master (4th degree black belt). Until my move from Fargo I was also one of the senior instructors at the Fargo gym. During my time in Devils Lake I ran my own TKD school there called the Devils Lake Black Belt Academy. My wife Kathryn was my assistant instructor. I have also become the web master for NWMA and design/create/maintain their web page. Check it out by following the "Tae Kwon Do" link. Several years ago I also started training in Hapkido under one the the worlds best Hapkidoists, Master Geoff Booth (7th degree black belt). He is a great instructor however I only got the opportunity to train with him a few times a year since he is from Australia. I am currently a brown belt in Hapkido.
I also setup and help maintain the web page for the Alumni Association of the Northern Lights Camps. I got involved with this after working for Camp Wilderness Boy Scout Camp for several years. You can check out that web page at northernlightsalumni.com
Other interests include many outdoor activities such as camping, hiking, backpacking, hunting, fishing, shooting sports and many other wilderness related activities. I also enjoy dabbling in armature web page design and digital graphic arts. During college I picked up a new hobby which is armature photography which mostly includes wildlife photos. I use a Cannon EOS 10D digital SLR camera with various lenses. I have been very please with the equipment I have chosen thus far. To see some of my results so far, check out the "Photography" link to see a selection of my photos.


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Christ does not give Christians love, peace, joy, hope, salvation, righteous, wisdom, holiness or the victory, because His is all the above and more living in you. If you are still looking in the external realm for God to give you things, you will never come to know Him. When God sees you, He sees His Son living in you. That is the Mystery of the Gospel and the greatest gift of all!
Col 1:27 To whom God would make known what is the riches of the glory of this mystery among the Gentiles; which is CHRIST IN YOU, the hope of glory:
1Co 1:30 But of him are ye in Christ Jesus, who of God is made unto us wisdom, and righteousness, and sanctification, and redemption:
If Christ lives in you, He is your fruit of the Spirit. You don't have to work on any of them to get them to flow out of you. Just stay in union with Him. Christ said I am the Vine and you are the branches (container- vessel) and if you are connected to Me I will flow right through you in 9 different expressions. Gal. 5:22, 23 Love, joy, peace, faith etc. is a person and it is Christ In You.
Tags: Only His Son


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- Book in 14 day advance and enjoy 15% off discount of Benchmark Rate
- Book in 30 day advance and enjoy 20% off discount of Benchmark Rate
Terms and Conditions:
- Package is subject to availability and cannot be combined with any other offer.
- Bookings in three day advance are required; rates do not apply to groups.
- Fully Prepaid, could not cancel or change the booking
- Rates listed are per room, per night, single or double occupancy, and exclusive of taxes, gratuities and other charges unless otherwise noted.
- Rates are subject to 16.6% service charges and tax.
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Mount Shuksan: Sulphide Glacier
The North Cascades are a climber's playground. They offer big mountain terrain in an unbelievable setting. Their jagged ridges and rocky summits are surrounded by snowfields and glaciers, which will put all of your previous mountaineering skills to the test. On this trip we will attempt the Sulphide Glacier route on Mt. Shuksan, which is the world's most photographed mountain. This is a classic route, which involves 3rd-5th class rock, steep snow up to 50 degrees and glacier travel.
Price: $950 Per Person
Length: 2 days
Guide-to-Client Ratio: 1:2
Difficulty: Strenuous
When: July 15-19, 2017
Type: Mountaineering
2:1 NEM Guide Ratio
Camping throughout
All Group Gear
Emergency Gear
NCNP Climbing Permit
Personal Gear
Lodging when in town (unless listed otherwise)
Rental gear
Most of the required equipment [listed below] is available for rent from our affiliate mtnGEAR. NEM climbers will receive an exclusive discount of 20% discount on all rental equipment and clothing.
We are now booking summer 2017 from June-August. Do you have a date in mind? Let us know and we will work to make your dream come true!
Day 2: Today, we will meet at 8AM at our hotel. Here we will meet and greet our fellow teammates and get a briefing of what to expect for the next 3 days. Following this meeting, we will conduct a full gear check to ensure everyone has what they will need to complete the climbs safely and efficiently. We will have the opportunity to rent or purchase any missing gear. We will drive into the North Cascades National Park (3hr drive) and camp at a local campground.
Day 3: We will wake early and drive to the Trailhead. Our climb will begin on steep switchbacks through the forest before gaining the glacier to high camp at approximately 6,000 feet. This day is physically demanding due to heavy packs.
Day 4: A mellow walk on the Sulphide puts us at the base of the summit pyramid, the highlight of the summit climb. 4-5 pitches of 4th and 5th class rock and some steep snow will put us on the small exposed summit. We will descend all the way back to the car today and camp at the campground again.
Day 5: We will begin the drive back to Seattle and say our goodbyes. Afternoon flights can be booked, but we encourage you to take an extra day and to visit Pike Place Market, the Space Needle, and the amazing city of Seattle.
More Technical on Fisher Chimneys
A classic climbing route of mixed 4th/5th class rock scrambles and glacier travel and otherworldly camping locations. From the trailhead we follow the valley to Lake Ann. We spend the night below the chimneys. The chimneys are a highlight of the route with 4th/5th class scrambling that will get your attention. High camp is established above the Chimneys at 6,700 feet before going for the summit early the following day.
Length: 3 Days
1 person: $1200 per person
2 people: $950 per person
Ski Mountaineering the Sulphide Glacier
Our traditional itinerary with a twist. For those with backcountry skiing experience, a ski descent of the Sulphide Glacier provides a faster, more enjoyable descent. After a moderate skin up the Sulphide Glacier, we stash the boards for the summit pyramid scramble - strapping in upon return. Participants must have a suitable touring setup with boots and skins for the climb. Almost 4,000 vert of ski descent.
When: June 9-11, 2017
1 person: $1200 per person
2 people: $950 per person
Book Online Now
Searching Availability...
How Difficult is the North Cascades Climbing trip?The mountains in the North Cascades are long climbs with heavy backpacks. They can be very strenuous at times. These peaks require technical rock climbing and long approaches as well as steep snow. Prior rock climbing experience is required. You will need to be in top physical condition.
Do I Need Any Prior Experience?The rock climbing and scrambles are beginner grades. The most difficult climbing is rated 5.6 but mostly it is 4th-5th class. Due to the alpine environment, these climbs take on a more serious perspective than rock climbs of harder grades closer to civilization. Prior rock climbing and camping experience are required.
What Are the Age Limits for This Climb?We encourage participants to be age 16 or over, although exceptions can be made based on previous experience. Participants under the age of 16 will need to submit a climbing resume for review. As long as you are in excellent physical condition, are approved by your doctor, and have are able to legally sign the liability waiver, you are welcome to join us!
How Long are the Climbing Days?Each day is challenging. At the beginning of the climb altitude is not an issue. However, pack weight is heavy. As we ascend, packs get lighter but altitude takes its toll. Summit day is 14-16 hours long.
What are the Sleeping Arrangements on the Mountain?We will provide tents. To minimize the amount of necessary gear, climbers will share a tent. Your tent will be designed to sleep the number of climbers assigned in it [i.e. a 3-person tent will sleep 3 climbers and a 2-person tent will sleep 2 climbers]. We will only make exceptions to this on rare occasions. Please feel free to contact us if you feel you need your own tent.
How Heavy Will My Pack Be?You can expect a 45lb-55lb pack for the first two days. Summit day will require 10lb-15lb packs.
Why Do We Begin Our Summit Attempt in the Dark?We get an alpine start for many reasons. In general everything is safer at night when the temperatures are cold and the sun has not begun to melt the snow and ice. The terrain is firmer for easier climbing, snow bridges over crevasses are frozen, the snowpack is more stable and rock fall is less of a hazard.
GENERAL POLICIESNEMs Adventure plans and itineraries are subject to change or adjustment based on a number of factors. These include, but are not limited to, route conditions, weather, terrain, and many other factors. NEM has complete discretion to change plans to accommodate any of these or other factors, including discretion to change program schedule or itinerary, and change guides or staff, as necessary for the proper and safe conduct of the program.
We reserve the right to cancel any program due to inadequate signups, weather or route conditions. In such a case, an NEM credit for the full value is given; however, NEM cannot be responsible for any additional expenses incurred in preparing for the program (i.e., airline tickets, equipment purchase or rental, hotel reservations).
NEM reserves the right to dismiss the Participant from a trip at any time if NEM determines, in its sole discretion, that the Participant is not physically, technically, or psychologically prepared for or capable of participating in the program. This includes being under the influence of alcohol and/or drugs.


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Self Confidence In Public Speaking
There is a definite link between public speaking and self confidence. You need enough self confidence to be able to get up on stage and deliver a speech. And once you get there and discover that you can actually do it, your self confidence soars. Speaking in public is a powerful way to boost your self confidence.
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