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Recommendations for patients with Barrett's esophagus (BE) include endoscopic surveillance with esophagectomy for early-stage cancer, although new technologies to ablate dysplasia and metaplasia are available. This study compares the cost-utility of ablation with that of endoscopic surveillance strategies.
A decision analysis model was created to examine a population of patients with BE (mean age 50), with separate analyses for patients with no dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). Strategies compared were: no endoscopic surveillance; endoscopic surveillance with ablation for incident dysplasia; immediate ablation followed by endoscopic surveillance in all patients or limited to patients in whom metaplasia persisted, and esophagectomy. Ablation modalities modeled included radiofrequency, argon plasma coagulation, multipolar electrocoagulation and photodynamic therapy.
Endoscopic ablation for patients with HGD could increase life expectancy by 3 quality-adjusted years at an incremental cost of < $6,000, compared with no intervention. Patients with LGD or no dysplasia can also be optimally managed with ablation, but continued surveillance after eradication of metaplasia is expensive. If ablation permanently eradicates at least 28% of LGD or 40% of non-dysplastic metaplasias, ablation would be preferred to surveillance.
Endoscopic ablation could be the preferred strategy for managing patients with BE with HGD. Ablation might also be preferred in subjects with LGD or no dysplasia, but the cost-effectiveness depends on the long-term effectiveness of ablation and whether surveillance endoscopy can be discontinued following successful ablation. As further post-ablation data become available, the optimal management strategy will be clarified.
Barrett's esophagus (BE), the premalignant condition associated with esophageal adenocarcinoma, is a highly prevalent condition, affecting up to 10% of those with chronic reflux symptoms.1 While the standard management approach to decrease cancer mortality involves endoscopic surveillance with random biopsy of metaplastic tissue to detect cancer at a curable stage,2–4 endoscopic mucosal resection, photodynamic therapy (PDT), radiofrequency ablation (RFA), multipolar electrocoagulation (MPEC) and argon plasma coagulation (APC) are emerging endoscopic interventions that are efficacious in eliminating dysplasia and metaplasia.5–14
Under conditions of uncertainty, decision analysis may be helpful to compare competing strategies of management.15 We conducted a study to determine whether endoscopic ablation of BE is a cost-effective option to reduce mortality from esophageal adenocarcinoma. In particular we were interested in identifying the minimal efficacy required for endoscopic ablation to surpass endoscopic surveillance as the preferred method of management. We chose to examine ablation in different populations of patients with BE, including patients with high-grade dysplasia (HGD), low-grade dysplasia (LGD), and no dysplasia in order that our findings could be applied to these specific patient groups.
The hypothetical cohort consisted of 50 year old patients with a diagnosis of BE, defined as endoscopically identifiable abnormal mucosa with histologically confirmed intestinal metaplasia. In separate analyses, the cohort was modeled to consist of patients with BE with HGD, LGD or no dysplasia. It was assumed that all patients would be candidates for diagnostic and therapeutic procedures, including endoscopy, PDT, RFA, MPEC, APC and esophagectomy, and would consent to the assigned interventions. The analysis followed the cohort until age 80 years or death.
A decision analytic model was constructed in TreeAge Pro (TreeAge, Williamstown, Massachusetts) in the form of a hybrid decision tree (Figure 1A) and Markov process (Figure 1B).15,16 The natural history of the cohort was modeled to examine the costs and outcomes related to the management of esophageal adenocarcinoma in the absence of surveillance or other interventions, and compared to various strategies of management proposed for patients with BE with HGD, LGD or no dysplasia in separate analyses.17–20
Costs and discounted quality-adjusted life-years (dQALYs) without surveillance or other interventions for BE were determined. Cancer would be diagnosed if symptoms prompted endoscopic evaluation. Depending on the stage of cancer at the time of diagnosis, esophagectomy or palliation would be performed. Patients with unresectable cancer would be treated through hospice or palliative care. The outcome of surgery included peri-operative mortality or morbidity, and survivors of surgery could be cured of cancer or experience persistent or recurrent disease, rates of which depended upon the stage of cancer at the time of diagnosis. Death from causes other than esophageal adenocarcinoma was incorporated in an age-dependent fashion, based on life-tables of U.S. residents for the year 2007.
Transitions for the model were derived from published literature. To assess key variables a systematic review of the literature was conducted in the MEDLINE and EMBASE databases from 1970 to 2008 and abstracts from major gastroenterology scientific meetings from 1999 to 2008 were searched using the terms Barrett's esophagus, esophageal neoplasm, esophageal adenocarcinoma, precancerous conditions, and gastroesophageal reflux disease. If no data existed for a specified transition the authors reached consensus for the best estimate of the parameter. The details regarding the references from which data were abstracted can be found in the supplemental information for this article on the journal website.
The efficacy and complications associated with ablative therapy for BE were based on published data of PDT, RFA, MPEC and APC. Details of the systematic reviews of the literature performed to obtain these data are available in the supplemental information. Complete remission (CR) was defined as the absence of dysplasia (CR-D) or intestinal metaplasia (CR-IM) at the specified follow-up point based on histopathological interpretation of biopsy specimens obtained during specialized surveillance endoscopies. The definition of CR-IM excluded primary failure of ablation to eliminate all metaplasia as well as recurrence of metaplasia after ablation, either superficial or subsquamous to account for "buried glands." All results were reported on an intention to treat analysis.
The NIH sponsored health outcomes research workshop "Advancing an Evidence-Based Approach to Barrett's Esophagus" conducted April 9–10, 2007 in Boston, MA, identified discrepancies between published decision models of BE management. A major cause for these differences was that published rates of progression and regression between various states of dysplasia do not produce the cancer incidence reported in national health statistics when used as inputs in mathematical models. This is likely due to multiple factors including referral bias, publication bias, stochastic variation in small populations, confounding by indication and the poor discriminatory value of dysplasia. The current study utilizes methods to ensure that the model accurately reflects current knowledge of the natural history of BE with respect to development of esophageal adenocarcinoma. We chose to accomplish this by retaining the proportional relationship between transitions while altering the absolute values to fit the overall cancer incidence to the national health statistics. Thus, individual transition rates between health states were abstracted from published literature and subjected to a conversion factor that enabled the overall cancer incidence to reflect best estimates derived from published meta-analyses and the United States National Health Statistics.
In addition to the base-case scenario, extensive sensitivity analyses were conducted using variations around each of the model transitions supported by published literature (Table 1). The simulation was carried out until age 80 years or death, and transitions between various states of metaplasia, dysplasia and cancer were assumed to require at least one year.
The perspective of the analysis was that of a third-party payer, namely the Center for Medicare and Medicaid Services (CMS). Although CMS generally administers healthcare reimbursement for enrollees 65 years of age and older, the costs incurred by CMS can also be used to benchmark reimbursements for other populations since they represent a national standard that other healthcare insurers follow. Costs, not charges, were the basis for resource inputs in the analysis.15 Costs were limited to the direct health care costs for delivery of services related to BE and esophageal adenocarcinoma and excluded direct non-health care costs (borne by the patient) and productivity or indirect costs (borne by society). Costs were derived from 2007 CMS data using diagnosis-related groups and Current Procedural Terminology codes for inpatient resource expenditures and ambulatory payment classification and Current Procedural Terminology codes for outpatient services rendered. The source for these cost estimates can be found on the CMS website: http://www.cms.hhs.gov. Medication costs were derived from Pharmacy Redbook (base case) and varied in the sensitivity analysis by Internet retail sources. All costs were updated to 2008 estimates using the consumer price index for medical care. Table 1 presents the cost estimates used in the model.
Utilities, or patient preferences for different health states, were derived from published literature and used to convert absolute life-years experienced by cohort members to quality-adjusted life-years (QALYs).21–24 Costs and utilities were discounted at the standard annual rate of 3% (0–5% in sensitivity analysis).
The primary outcome of the study was the incremental cost per discounted and quality-adjusted life year (dQALY) between competing strategies of management, also known as the incremental cost-effectiveness ratio (ICER). The ICER is defined as the difference in cost when moving from one less expensive but less effective strategy to a more expensive but more effective strategy, divided by the change in dQALYs between the same two strategies. Additional outcomes included the mean cost per patient, mean dQALYs per patient and number of cases of esophageal adenocarcinoma estimated to occur with each modeled strategy.
All assumptions for the model were varied over a wide range of values in a series of one-way sensitivity analyses. Ranges were based on published data: in the absence of published data baseline rates were halved and doubled with adjustment by consensus from the authors. Parameters associated with greater than 25% variation in outcome and clinically important parameters were presented in tornado diagrams. Multivariable sensitivity analysis was performed through Monte-Carlo simulation in which all variables were simultaneously varied over 1,000 trials (second-order simulations). Results of sensitivity analyses were stratified by thresholds for dominance (more effective yet less expensive than comparator strategies) and cost-effectiveness at two levels of willingness to pay (WTP): $50,000 per dQALY gained or $100,000 per dQALY gained, which allowed identification of strategies yielding the greatest benefit without exceeding these cost thresholds. WTP indicates the amount that society is willing to pay in order to achieve a desired health outcome, in this case quality adjusted life-years.
Current management of patients with BE is stratified by the presence and severity of dysplasia diagnosed through histopathological examination of esophageal tissue.2–4 All subjects were assumed to have a correct diagnosis of BE (a change in the esophageal epithelium of any length that can be recognized at endoscopy and is confirmed to have intestinal metaplasia by biopsy of the tubular esophagus and excludes intestinal metaplasia of the cardia) on entry to the study.2 Dysplasia was assumed to consist of cytological and architectural changes in the epithelium of the esophagus, and was divided into low-grade and high-grade dysplasia based on guideline recommendations that stratify clinical management based on these features.2–4 Diagnostic error is problematic in the classification of dysplasia associated with BE and was extensively modeled to reflect the inter- and intra-observer variation in diagnosis.25–30
The management options for patients with BE and HGD were modeled to consist of no intervention, endoscopic surveillance, PDT, RFA, APC or immediate esophagectomy. No reliable estimates were identified in the literature in which MPEC was used to treat HGD; therefore this modality was not modeled for this patient group. In the absence of endoscopic surveillance, cancer would be detected only through development of symptoms at which time the management of cancer (esophagectomy or palliation) depended on the stage of cancer at the time of diagnosis. Surveillance utilized endoscopy with 4-quadrant biopsies every 1–2 cm along the Barrett's segment every 3 months. After 12 months surveillance intervals were reassessed based on the highest grade of dysplasia diagnosed during that time period. If HGD was diagnosed at any time surveillance continued at 3 month intervals, whereas LGD or no dysplasia extended surveillance to a 12 month interval. Esophagectomy or endoscopic palliation (stent placement) was utilized for a diagnosis of cancer, depending on the stage of disease at the time of diagnosis. In the base-case scenario, ablative techniques could be either ineffective, ablate dysplasia but have persistent intestinal metaplasia (including subsquamous metaplasia or "buried glands"), or ablate dysplasia and metaplasia. In order to bias the model against interventions, in sensitivity analyses (including Monte Carlo simulations) we assumed complete ablation of metaplasia was never achieved and therefore patients were at continued risk of progression to cancer. Complications of ablation were modeled and included perforation and stricture formation, in addition to mortality. Endoscopic surveillance was assumed to be necessary after ablation for HGD and was conducted based on the diagnosed grade of dysplasia. Esophagectomy was modeled to completely or incompletely remove the Barrett's segment, and carried risks of mortality or morbidity at published rates.
LGD could be managed by no intervention, endoscopic surveillance, PDT, RFA or APC ablation with continued surveillance after complete ablation of intestinal metaplasia, or ablation with surveillance reserved for patients with residual intestinal metaplasia. The base-case transition inputs for the latter strategy were based on RFA data. No reliable estimates were identified in which MPEC was used to treat LGD; therefore this modality was not modeled for this patient group. In the absence of endoscopic surveillance, cancer would be detected only through development of symptoms at which time the management of cancer (esophagectomy or palliation) depended on the stage of cancer at the time of diagnosis. Surveillance utilized endoscopy with 4-quadrant biopsies every 1–2 cm along the Barrett's segment every 12 months, with esophagectomy reserved for diagnosis of cancer. In the base-case scenario, ablation could be either ineffective, ablate dysplasia but have persistent intestinal metaplasia (including subsquamous metaplasia or "buried glands"), or ablate dysplasia and metaplasia. Again, in order to bias the model against ablation the sensitivity analyses, including Monte Carlo simulations, assumed complete ablation of metaplasia was never achieved.
Patients with BE without dysplasia could be managed by no intervention, endoscopic surveillance using ablation to treat incident dysplasia, immediate endoscopic ablation with RFA, APC or MPEC with continued endoscopic surveillance after complete ablation of intestinal metaplasia, or immediate ablation with surveillance reserved for patients with residual intestinal metaplasia. The base-case transition inputs for the strategy of surveillance with ablation for incident dysplasia, in addition to the strategy in which ablation was followed by surveillance limited to those with residual metaplasia were based on RFA data. PDT was not modeled due to the lack of suitable published data. The modeling of cancer detection, ablation complications and endoscopic surveillance was identical to the LGD scenario, except that endoscopic surveillance was modeled on current recommendations published by the American Gastroenterological Association that propose a 5-year interval after two endoscopies confirmed the absence of dysplasia.3,4 Ablation could either be ineffective or ablate intestinal metaplasia. The presence of subsquamous metaplasia or "buried glands" was incorporated as a subset of ineffective ablation, which included persistent or recurrent metaplasia after ablation.
Support for this study was provided by the National Cancer Institute (R01 CA106773) and National Institute of Diabetes and Digestive and Kidney Diseases (K24 DK080941), National Institutes of Health and an unrestricted research grant from BARRX, the company that developed, manufactures and distributes the radiofrequency ablation device modeled in one arm of this study. The study was designed, conducted, analyzed and reported without influence from BARRX. All sensitivity analyses were performed using a deliberately biased model, in which the least favorable conditions for ablation were used as inputs for the model. Articles in press were provided by the authors or the company.
To calibrate the model and compare it with cohorts reporting natural history data in BE, separate runs were conducted simulating populations of patients with BE with HGD, with LGD, and without dysplasia in the absence of interventions to decrease cancer incidence. The model calculated an annual incidence of esophageal adenocarcinoma among patients with BE and HGD equal to 2%, among BE and LGD equal to 0.7% and among BE without dysplasia equal to 0.5%. These results correlated well with recent published estimates of cancer incidence in these cohorts.17,19,29,31–33
In the absence of interventions to prevent or detect cancer, 50 year old patients with BE and HGD are predicted to live an additional 12.4 dQALYs and consume on average $1,859 in discounted health care resources (Table 2). Compared to no surveillance, strategies employing ablation with PDT, RFA or APC with post-ablation endoscopic surveillance are calculated to extend life by 3.2 dQALYs. APC and RFA are associated with cost increases of $19,000–$20,000 per person, while PDT costs are more than $30,000 greater than no surveillance. Comparison of RFA to no surveillance yields an acceptable ICER of $5,839 per dQALY gained, while the increase in benefit calculated with PDT requires more than $32 million per dQALY gained. The strategy of APC is numerically dominated by RFA; however, the costs and benefits between these ablation techniques are comparable (Figure 2A). Per 100 patients, 33 fewer cancers are predicted to develop with any of the ablation strategies compared to no surveillance. While surveillance or immediate esophagectomy increases life over a strategy of no surveillance, they are dominated by the ablative techniques, since they yield fewer dQALYs at higher cost.
Without intervention, a cohort of patients with BE and LGD is calculated to accrue 14.7 dQALYs and cost $687 per person in healthcare resources (Table 2). Ablation with PDT, RFA or APC followed by surveillance in all patients is predicted to increase life by 1 dQALY compared to no surveillance, with concomitant increases in resource utilization of approximately $13,000 using APC or RFA, or $27,000 with PDT. Numerically, RFA followed by surveillance limited to patients in whom metaplasia persists after ablation dominates all other interventions. However, similar costs and benefits are achieved with this strategy and APC ablation or RFA with surveillance in all patients (Figure 2B). Per 100 patients, 10 fewer cancers are predicted to develop after ablation of any type compared to no surveillance. Compared to ablation, a strategy of surveillance alone is dominated, being both more expensive and less effective than RFA or APC ablation.
Following the natural history of patients with BE without dysplasia, 15.2 dQALYs are expected with costs of managing incident cancers averaging $471 per person (Table 2). The most cost-effective strategy consists of endoscopic ablation (using RFA parameters) with surveillance limited to patients for whom ablation fails to eradicate metaplasia, yielding an ICER of $16,286 per dQALY gained over no surveillance. Endoscopic surveillance using RFA to treat incident dysplasia is dominated by this strategy, as are strategies employing APC, MPEC or RFA that continue surveillance in patients for whom ablation successfully eradicates metaplasia. However, if discontinuation of surveillance after successful ablation is not a clinically viable option, a strategy of surveillance using ablation for incident dysplasia is equally cost-effective compared to strategies of ablation with APC, MPEC or RFA with surveillance continued in all patients (Figure 2C).
All sensitivity analyses conducted in the population of patients with BE and HGD were biased against ablation by assuming that complete elimination of metaplasia was never achieved. The remaining variables in the model were subject to one-way sensitivity analysis using the range of values indicated in Table 1. The results of these analyses (Table 3) illustrate that ablation is cost-effective as long as at least 25% of patients achieve complete remission from dysplasia. RFA is the preferred ablation strategy as long as the proportion of patients with residual HGD after RFA is less than 17%–18%, otherwise APC is preferred. If the residual HGD after RFA or APC is greater than 23% (WTP $100,000) or 30% (WTP $50,000), PDT is a cost-effective alternative. The costs of competing ablation strategies impact the preferred technique, and the range of variation is well within the plausible boundaries of clinical practice. Figure 3A illustrates the change in the ICER comparing strategies of RFA versus APC among patients with BE and HGD. The greatest variation in ICER results from changes in the cost of ablation therapy and the proportion of patients in whom HGD persists after ablation therapy. Minor changes occur with variation in the complications of ablation therapy.
Figure 4A presents the results of the Monte Carlo simulation illustrating the proportion of trials in which each strategy is preferred for management of patients with BE and HGD. Using a threshold WTP between $0 and $100,000 per dQALY gained, ablation is the preferred strategy for the majority of trials. RFA, APC and PDT are preferred to surveillance or esophagectomy in the majority of simulations at even low thresholds, and are preferred in all trials above a WTP threshold of $50,000 per QALY. No surveillance is viable when the WTP less than $30,000, while surveillance alone or esophagectomy are preferred in less than 1% of trials overall.
As with HGD, all sensitivity analyses conducted in the population of patients with BE and LGD were biased against ablation by assuming complete elimination of metaplasia is never achieved. Note that with this assumption, the strategy in which surveillance is halted after complete ablation of metaplasia becomes identical to the strategy in which surveillance continues despite absence of metaplasia. Since little difference in outcomes exists between different ablation techniques these are collectively modeled and compared to surveillance or no surveillance strategies. The model is sensitive to the proportion of patients in whom residual LGD persists after ablation. The preferred strategy changes from ablation to surveillance if the proportion is greater than 54% (WTP $50,000) or greater than 72% (WTP $100,000) (Table 3). When the cost of ablation exceeds $15,000 (WTP $50,000) or $26,000 (WTP $100,000), surveillance also becomes cost-effective. No variation in the cost of surveillance endoscopy or the rate of complications associated with ablation within the ranges identified in Table 1 change the preferred strategy (Figure 3B).
Figure 4B presents the results of the Monte Carlo simulation illustrating the proportion of trials in which each strategy was preferred for management of patients with BE and LGD. Using a threshold WTP between $0 and $100,000 per dQALY gained, ablation is the preferred strategy in the majority of trials. No surveillance is preferred in the majority of trials when the WTP drops below $30,000 per QALY. Surveillance is preferred in less than 1% of trials.
In the base case scenario the optimal strategy requires discontinuation of surveillance after successful ablation of metaplasia. Sensitivity analysis reveals this to be a robust finding as long as complete ablation of metaplasia is achieved in at least 40% (WTP $100,000 per dQALY gained) to 47% (WTP $50,000 per dQALY gained) of cases (Table 3). If ablation is completely successful in less than 40% of cases then surveillance is optimal. Comparing endoscopic surveillance to ablation with no surveillance after complete ablation, the influential variables include the proportion of patients in whom complete ablation of metaplasia is achieved and the cost of ablation. The cost of surgery or endoscopy influences the cost-effectiveness to a smaller degree, while patient preference (utility) of the post-esophagectomy state has little impact on the ICER (Figure 3C). The effectiveness of surgery or complications of surgery and ablation also do not impact the preferred strategy (data not shown).
Monte Carlo simulation reveals that ablation followed by surveillance limited to those with residual metaplasia is optimal in up to 85% of trials, increasing with higher levels of willingness to pay (Figure 4C). Surveillance using ablation for incident dysplasia is preferred in 20% or fewer trials, depending on the WTP. More importantly, ablation with continued surveillance in all patients is optimal in 1% or less of trials. No surveillance is preferred in this population more often than either of the two latter strategies, and is optimal among all strategies if the WTP is less than $25,000.
Our analysis of the cost-effectiveness of endoscopic ablation of BE demonstrates that ablation of HGD in subjects with BE is probably cost-effective, capable of providing over three years of additional quality-adjusted life expectancy at a cost of less than $6,000 per dQALY gained. Despite biasing the model against ablation, this strategy is estimated to be more effective and less costly than surveillance or esophagectomy for patients with BE and HGD. The effectiveness of the different ablation techniques appears similar, with variation only in costs. In LGD, ablative therapy may be cost-effective compared to surveillance; however, continued endoscopic surveillance of patients after successful reversion to normal squamous epithelium yields little benefit. In the setting of non-dysplastic BE, ablation may be the preferred strategy if the proportion of patients in whom complete and permanent ablation is achieved is greater than 40% (WTP $100,000 per dQALY gained), and endoscopic surveillance can be discontinued in patients in whom ablation is successful.
A goal of decision analysis is to illuminate important gaps in our knowledge and to highlight key questions that must be answered in order to determine whether a proposed intervention should be implemented. In the present analysis, perhaps the single most important "unknown" is the prognosis of subjects who have undergone ablation, and are now endoscopically and histologically normal. Are these patients no longer at risk for developing cancer, and can they be released from endoscopic surveillance? Currently insufficient data exist to answer this question and presently, we and others are retaining these subjects in endoscopic surveillance programs. Because of uncertainty regarding the prognosis of these patients, we modeled both the currently practiced strategy of maintaining surveillance in these subjects, as well as the strategy of releasing successfully ablated patients from surveillance. Recent studies have questioned the benefit of endoscopic surveillance and our analyses illustrate only a nominal benefit of endoscopic surveillance.34 In all scenarios continuation of surveillance after successful ablation is not a preferred strategy. Whether a strategy of selective follow-up of patients based on ablation results can be justified awaits further outcomes data from cohorts having undergone ablative therapy.
Ablative strategies may appear cost-effective either by being superior modes of therapy, or because the comparator strategies are poor interventions. This analysis suggests that endoscopic surveillance may be an especially inefficient and cost-ineffective strategy. Previous studies have demonstrated the poor cost-effectiveness of surveillance to decrease mortality from esophageal adenocarcinoma.35 From a broad perspective, it is more effective (and cost-effective) to prevent cancer than to treat cancer. It is the intent of this analysis not to promote one specific preventive or ablative technique, but rather to highlight the fundamental advantages of interventions that reduce cancer incidence, especially if the complications associated with the intervention are uncommon. This concept is exemplified in the model of no dysplasia. Ablation is preferred in this group, but only if we are willing to forego continued surveillance for patients in whom metaplasia has been eliminated, even if there remains a small risk of progression to malignancy.
The sensitivity analyses illustrate the key factors influential in the decisions regarding management of patients with BE. Common to all scenarios is the dependence of the results on the efficacy of ablation, the durability of these effects and ultimately whether cancer incidence is reduced after ablation is achieved. Thus, the effectiveness and cost-effectiveness of ablative methods will not be fully understood until such data can be accumulated from patients enrolled in research protocols. The costs of various interventions are also influential but rarely change the order of preferred strategies. Other variables, including the risk or cost of complications, the effectiveness of surgery and the preference of patients for various health states (utilities) do not appear to influence the outcomes.
Our analysis has some important limitations. The values used to populate the model were derived from selected groups of patients in most cases referred to specialized centers and prone to selection and publication bias. Because we felt it important to have our model conform to national cancer statistics we calibrated the natural history of the model to the lowest rates of cancer incidence reported in published literature, thereby biasing our results against the use of any intervention. Also, we have assumed that subjects in whom ablation was unsuccessful or in whom metaplasia recurred after ablation retained the cancer risk of their initial level of dysplasia. Some data suggest that a failed attempt at ablation may actually result in the expression of precancerous markers that could potentially put these patients at a higher risk for neoplasia.36
We chose to examine the management of patients with established BE in this study while excluding the question of whether screening to identify this group is cost-effective. Our earlier work compared the relative impact of screening vs. surveillance and found that while screening 50-year old white men with heartburn to detect cancer and dysplasia would likely be cost-effective, continued surveillance of patients without dysplasia was an expensive strategy.35 The current study expands upon this theme in which surveillance is illustrated to be both ineffective and costly, due to the relatively infrequent development of dysplasia and cancer among patients not diagnosed with dysplasia during the initial screening and the inaccuracy of dysplasia as a marker of progression to malignancy. Development and validation of biomarkers that better predict the development of cancer among people with BE would improve the effectiveness of surveillance, as well as enhance selection of patients most appropriate for ablation.37 A greater question raised through these studies is whether any intervention for patients diagnosed with BE without dysplasia is warranted. Based on the marginal differences in cost-effectiveness between ablation and surveillance, perhaps even ablation in non-dysplastic BE requires resources that are beyond the threshold society is willing to expend; however, this study focuses on optimizing management of patients with established BE while our previous work focused comparing the benefit of the initial screen vs. subsequent surveillance to detect early cancer. More broadly, the results of this study are not limited to valuation of endoscopic ablation but rather provide a set of general principles upon which interventions may be compared to current standards of care. The threshold analyses provided in this paper may be used as a benchmark for any future intervention developed to reduce mortality from esophageal adenocarcinoma. The main concept we wish to convey is that strategies that reduce cancer development should be preferred over strategies that rely on early diagnosis of cancer.
Our data are in line with previous studies of cost-effectiveness of ablation for BE compared to either surveillance or esophagectomy.38–41 Although absolute results have varied across studies, these have shown ablation to be superior to comparator arms in the treatment of HGD. Even when ablation is used to treat incident dysplasia identified through surveillance, the recurrent costs of endoscopy, poor reproducibility of histological interpretation and low incidence of cancer in subjects under surveillance combine to make endoscopic surveillance strategies unfavorable, especially in those with non-dysplastic disease.
In conclusion, our data suggest that endoscopic ablation may be the preferred strategy for the management of BE with HGD. Ablation may also be preferred in subjects with LGD and non-dysplastic disease, but the cost-effectiveness of this strategy is highly dependent on the long-term effectiveness of ablation therapy and whether surveillance endoscopy can be discontinued following a successful ablative procedure. As further post-ablation data become available, the optimal strategy to be implemented will be clarified.
Grant Support: National Cancer Institute (R01 CA106773 - JMI) and National Institute of Diabetes and Digestive and Kidney Diseases (K24 DK080941 - JMI), National Institutes of Health Unrestricted research grant from BARRX
Financial Disclosures: R. Madanick has received an honorarium and N. Shaheen and J. Inadomi have received research support from Barrx Medical, maker of the radiofrequency ablation device; the other authors do not have conflicts to disclose.
Writing Disclosures: None
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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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5167 W Jeffers Street, Irons 49644
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Solid, Maple Island log home with over 1600 sq ft. that was built in 2005. On the main level is 1 bedroom that could be converted into an office, full bath and entryway mudroom that attaches the 2 stall garage. Upper level contains 2 BR, full BA and open are laundry room. The upper level of the garage is currently being used for storage but could be easily made into fun room. Heated by wood stove and radiant floor heat. The home is in need of finishing touches to make this your ''Northern home or get away'' on 6.5 private wooded acres. JUST REDUCED BY $20,000 THE SELLER IS MOTIVATED
Property Information
- Status
- Active
- Address
- 5167 W Jeffers Street
- City
- Irons
- Zip
- 49644
- County
- Lake
- Township
- Eden Twp
- Possession
- Close of Escrow
- Total Finished SqFt
- 1,600
- Above Grade SqFt
- 1,600
- Garage
- 2.0
- Garage Desc.
- 2, Attached
- Water
- Well
- Sewer
- Septic System
- Year Built
- 2005
- Taxes
- $2,084
Rooms and Land
- Basement
- Slab
- Heating
- Propane, Radiant, Wood, Wood/Pellet Furnace
- Acreage
- 6.55
- Lot Dimensions
- irr
- Appliances
- Dishwasher, Dryer, Microwave, Oven, Range, Refrigerator, Washer
- Features
- Ceiling Fans, Ceramic Floor, Garage Door Opener, Gas/Wood Stove
- Exterior Materials
- Log, Wood
- Exterior Features
- Porch(es)
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Cook Regentec
Introduce The CellSeal Automated Thawing System
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Enables detailed control in thawing of cell and gene therapies
Indianapolis, US, and Cambridge UK, 29th November 2016: Cook Regentec, focused on developing research and clinical tools to advance regenerative medicine therapies from the lab to the patient, and Asymptote Ltd., specialists in cryochain for regenerative medicine, today announced the launch of the CellSeal® Automated Thawing System. The new system, which has been developed as part of a collaboration between the two companies, provides users with thorough control in the thawing of cryogenically frozen cells, a critical step in the delivery of cell and gene therapies.
The CellSeal® Automated Thawing System solves a vital and overlooked aspect of cell-based therapy development. The current practice of thawing these potentially fragile, living therapies relies on a manual process using a water bath. The new system works through dry conduction with no need of water, a potential source of contamination, and provides an effective, reliable and scalable solution which supports Good Manufacturing Practice (GMP) requirements.
The CellSeal® Automated Thawing System has demonstrated performance. In a recent study with mesenchymal stem cells (MSC), the system consistently equaled viability results obtained from water bath thawing. The system's effectiveness comes from the extraordinary control it provides over the thawing process. Therapy manufacturers can tune a thaw profile to suit the specific needs of their cellular therapy, then lock the profile down for one-touch repeatability. The system removes any user subjectivity by detecting the precise thaw end-point—extremely difficult to achieve using the standard water bath process. The technology offers manufacturers consistent control over the thawing process of their cell therapy.
An important feature of the new system is instant access to vital data. Until this new system, the collection and collation of data from thaw sites, often using paper records, could produce significant challenges to cell and gene therapy manufacturers. Now, data recording in each CellSeal® Automated Thawing System captures a record of the thaw process. With appropriate software, hardware and connectivity, this data can be viewed anywhere in the world to validate and implement a manufacturer's end-to-end thawing protocol.
Brad King, Director of Advanced Laboratory Products at Cook Regentec, explained the challenge: "We created our CellSeal® product line to support cell and gene therapy companies through every bioprocessing step. Thawing of cryopreserved therapies often happens outside the lab in conditions that up to now have been very difficult to control; thaw-site personnel have had to take great care to avoid contamination risks from the use of warm water. Also, manually produced records for thawing and administering the product at a remote site can take a long time to return to a manufacturer, if they are returned at all. The CellSeal® Automated Thawing System makes it easy to ensure an effective, controlled and auditable thaw."
Cook partnered with Asymptote for the technology behind the thawing system because of their long established cryopreservation expertise and innovative cryochain technologies for regenerative medicine.
John Morris, Asymptote CEO shared some details: "Today's announcement builds on thawing technology we have been working on for over two years in collaboration with The Cell and Gene Therapy Catapult. Over that period, Asymptote built many different thawing engines for testing at the Catapult labs and captured requirements from a wide cross-section of stakeholders across the industry. By partnering that foundation with Cook Regentec's development of closed-system vials, we're able to offer the industry a unique level of control over the thawing process. No other solution allows the same flexibility to customise thawing settings in the lab, then lock them down for quick and easy operation every time after. Combine this with the ability to transmit a record of the entire process instantly to a web browser anywhere in the world, and you have a system that can give manufacturers complete confidence in their thawing protocol."
The CellSeal® Automated Thawing System will be on display at the Cell Therapy Manufacturing & Gene Therapy Congress, Amsterdam on 29 & 30 November 2016 with first shipments in January 2017.
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Manufacturer: Royal Canin
Royal Canin German Shepherd Junior is a complete feed that has been specially formulated for the German Shepherd puppy.
Made with high quality ingredients to meet the needs of the breed, Royal Canin German Shepherd Junior provides optimal support for their unique physiology.
Main Benefits:
Feeding Guide:
Indredients:rice, dehydrated poultry protein, vegetable protein isolate*, animal fats, hydrolysed animal proteins, vegetable fibres, beet pulp, minerals, fish oil, soya oil, fructo-oligo-saccharides, psyllium husks and seeds, hydrolysed yeast (source of manno-oligo-saccharides), hydrolysed crustaceans (source of glucosamine), marigold extract (source of lutein), hydrolysed cartilage (source of chondroitin).
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Why Me?
I've always had a passion for Real Estate. I understand that Real Estate is an emotional business and I'm here to listen to your needs, advise you on your options, and walk you through the details in order to get you the best deal. If you come to me as a buyer I won't rush you, I will remain focused on your goals, and I will negotiate to make the most of your money.
If you sell with me, I will make sure you know what needs to be done to make your home sell faster, market with the latest technologies, and be available and responsive to your calls or questions. Give me an opportunity to show you what I can do to help - call me at 678-358-3369
Why I love Atlanta
I've lived in Atlanta long enough that I can call myself a native. I grew up in the suburbs, but have lived intown for over a decade. I started out in Midtown and now live in the Lake Claire/Candler Park area. There's something really special about Intown Atlanta - most people don't realize that what people think of as the large city of "Atlanta" is really nothing more than numerous small communities with their own distinct personalities and charm. These are the "small towns" where you can walk to what you need and you know your neighbor. They have strong neighborhood associations and many opportunities to get involved. This is why I love living in Atlanta and think you will too! Won't you be my neighbor?


text: 4. Ignore the twin gods of biotech -- risk and failure -- at your peril. On Sept. 21, Peregrine was up 829% for the third quarter. Enough said. 5. Why the hell was Savient up 363% in the third quarter? No one has a clue. -- Reported by Adam Feuerstein in Boston. Follow @AdamFeuerstein


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We talk with Alan from White Dragon Miniatures about their spaceship dogfighting game, Shattered Void, which is currently on Kickstarter.
White Dragon Miniatures have been hitting more of their stretch goal targets for Shattered Void and the next one focuses towards adding the New Corvettes to their respective factions…
Weekender: Hobby Lab Challenge Ideas & Getting Groovy With The Evil Dead 2 Board Game398 days ago 52
We announced winners for Shattered Void and Infinity Week as well as diving into our ideas for Scatter Terrain and the Hobby Lab Open Challenge!
Weekender: Shattered Void Prize, Awesome Infinity Vehicles & New 4Ground Buildings in the Studio405 days ago 115
Join us for a great Weekender with a great competition to win yourself a fantastic Shattered Void prize!
White Dragon's Shattered Void Spaceships Reviewed!405 days ago 12
Christian Schlumpberger reviews some of the
ships available for White Dragon Miniatures'
Shattered Void which is on Kickstarter now…
A new race added to the mix, rules downloads and plenty of new ships are on the horizon for Shattered Void.
White Dragon's Shattered Void Kickstarter Launches!412 days ago 7
White Dragon Miniatures are now on Kickstarter with the launch of their Sci-Fi dogfighting game called Shattered Void.
White Dragon's Shattered Void Kickstarter Coming Soon487 days ago 6
White Dragon Miniatures have now revealed the start date for their Kickstarter for Shattered Void. Their dogfighting space ship game is going to be looking for fundraising from July 1st 2016!
Get A Primer For Shattered Void By White Dragon727 days ago 3
White Dragon Miniatures have continued their updates for the Marine Tactical Unit Kickstarter in 15mm as well as an introduction for Shattered Void, their 3mm dogfighting space combat game coming soon too in the same universe…
See what the ships looked like on White Dragon Miniatures' Shattered Void board at Salute 2015.
Check out not only the awesome Proteus Battle Mech for 15mm scale but also a host of the new Troops and even Ships for the world of Shattered Void by White Dragon Miniatures.
See what you think of another little preview for Shattered Void and the news that White Dragon will be at Salute 2015!
White Dragon Defend Your Troops With An Armadilo1024 days ago 7
Another amazing piece of 3D sculpting work has popped up from White Dragon Miniatures and if their previous reveal is anything to go by this is going to be another great addition to their 15mm line-up.
White Dragon Show Off Shattered Void 15mm Troopers!1033 days ago 11
Some amazing looking 15mm miniatures have popped up before the launch of the Shattered Void Kickstarter by White Dragon Miniatures. What do you think?
White Dragon Tease A 15mm Sci-Fi Kickstarter This Year!1075 days ago 2
Check out some teasers for the coming of a Kickstarter later this year to help fund a range of 15mm Marines for the Shattered Void universe. Oh and some cool Print & Play information too!


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Europa League: Juande Ramos says relationship with Spurs is fine ahead of Dnipro tie
Juande Ramos says he has no personal axe to grind with Tottenham as he prepares to face his old club on Thursday.
Last Updated: 19/02/14 4:57pm
The former Spurs manager - and the only one to win a trophy in the past 14 years - is now in charge of the club's Europa League last-32 opponents Dnipro.
Ramos was sacked by chairman Daniel Levy months after lifting the League Cup at Wembley, and weeks after strikers Dimitar Berbatov and Robbie Keane were sold for a huge profit.
The Spaniard could not resist mentioning those sales when asked for his view of Levy and Spurs ahead of the first leg in Ukraine, but his overall tone was conciliatory.
He said: "Of course I would shake hands - not only with him, but I have good relations with all of the managerial staff of Tottenham.
"I'm sure that all chairmen and the leaders of teams do what they have to do to take care of their teams.
"He has done a lot, he was able to sell Berbatov for £35m and Robbie Keane for £17m and some other players, he has done a lot in ruling the team."
Tottenham are now in the business of forking out huge fees of their own having three times broken their club record last summer to sign Paulinho, Roberto Soldado and Erik Lamela.
Ramos said: "Tottenham will have 11 players on the pitch and seven on the bench, and all of those players have high ability.
"I have to emphasise that the budgets are really different, in Tottenham and in Dnipro. In Tottenham it is three or four times larger and they can afford buying such players as Roberto Soldado."


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I just found a website that has a cake pricing calculator and I thought some of you would appreciate it. Here's the link: http://bakecalc.com/
I think that if people use that they're going to fall over in horror to see how they're underpricing things. Especially if you add in ALL of your time, including answering phone calls and emails, shopping, paperwork etc.
I think that calculator should be auto-replied to every single pricing thread...here you go, do the math.
Thank you so much! That was exactly what I was looking for.
Thanks for sharing the link. It's similar to how I was pricing myself by hand and calculator but actually seeing it layed out like that it's really awesome. Although we are not to the charging/public selling phase I still work out prices for everything we make for future reference. I also searched pricing on CC and found very valuable info and made a base price sheet for quick reference and also to make it easier to figure in the cost of more custom work. Another baker in my area who has really come alongside us and wants to have a friendly business relationship messaged us her price list so we would be comparible. She feels our work is of good quality and would like to be able refer clients to us as well when we are fully operating. So I've really done some work in the pricing department and I'm convinced that is most vital part of being successful.
I do have a question and it may be an obvious answer lol but do you factor in time spent sketching and consulting into your final price?
Quote by @Webake2gether on 7 hours ago
I do have a question and it may be an obvious answer lol but do you factor in time spent sketching and consulting into your final price?
Yes. If it's time that you wouldn't have been doing what you're doing unless you were working on that job, it's charge-able.


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Healthy living
Whether you're trying to lose weight, stop smoking, or need expert guidance for coping with a medical condition, our articles will help you achieve your healthy living goals.
Teen drug abuse: 5 mistakes parents can avoid
Keep your children safe from substance abuse by avoiding these common parenting mistakes.
What you need to know about Lady Gaga's PTSD
Here are the facts about the star's battle with post-traumatic stress disorder.
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These famous faces have spoken openly and honestly about their battle with mental health.
Ways to combat mental decline as you age
Struggling with a foggy memory or the inability to focus? Here's what you can do about it.
Lewy body dementia: The disease that lead to Robin Williams' suicide
Beloved late actor Robin Williams suffered from this little known form of dementia.
What you should know about codeine addiction
Painkillers containing codeine can become addictive if abused.
'How I survived my addiction to painkillers containing codeine'
A retired accountant from Port Elizabeth relates how she became addicted to painkillers.
Latest study: How workplace stress can shorten employees' lives
A recent study has found that stressful workplace conditions can affect mortality.


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Cowboy costumes have always been popular with children. Putting on a cowboy vest, hat and chaps transports a child to a Wild West fantasy world. Traditional chaps are made to serve as sturdy coverings for the legs and designed to buckle at the waist. Although chaps are worn in other parts of the world and are a basic piece of clothing for equestrian riders, they are most often associated with the American west. By rustling up a few simple items and following a few steps, you will make chaps that will delight your little cowboy.
Things You'll Need
- Paper
- Pencil
- Measuring tape
- Ultrasuede fabric
- Fringe
- Scissors
- Thread
- Sewing machine
Measure from the waist to the top of the foot to determine the length of the chaps. Measure your child's leg circumference and divide by two. This is the width. Record the measurements on paper.
Place the fabric on a clean flat surface. Using scissors, cut two rectangular shapes using the length and width measurements in Step 1. Lay one rectangular fabric piece, front side facing up, with one of the width sides closest to you. Round the two corners of the width side closest to you, using scissors. Repeat this process with the second fabric rectangle. These rounded sides will be the bottoms of the chap pieces.
Fold the edges toward the back side of the fabric, creating a 1/2--inch seam around each entire chap. Sew the seam flat, using a sewing machine. Stitch the chap fringe up the outside length of each chap. The amount of fringe needed for both chaps is determined by the chap length measurement multiplied by two.
Make belt openings in the top of each chap. At each end of the chap top, measure 1 inch down and 1 inch in and cut a slit large enough to allow a belt to be threaded through. Repeat this process on the second chap. Starting with the right leg chap, thread the belt through the slit closest to the middle of the body first, then through the slit next to the chap fringe. Bring the belt around the body to the left leg chap. Thread the belt through the slit closest to the fringe first and then through the slit nearest the center of the body. Fasten the belt buckle.
Tips & Warnings
- Since children's chaps are generally worn over jeans, threading the belt used for the chaps through a couple of pant belt loops will make the chaps more stable and less likely to move around the body.
- Washable ultrasuede fabrics and all other items for this project are available at local fabric stores and centers.
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- Photo Credit Thinkstock/Comstock/Getty Images
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There are many, many, many, (you get the point) mysteries of lost, there are some that will be answered and some that won't. Mysteries like... How the Black Rock ending up inland on the island? Who is in control at ann arbor and if there were inquiries after the "purge"? Why Alpert and the "others" aren't effected by the sonar fence, as he tells Horace "that fence can't keep me out"? How about what was the big fallout between Eloise and Charles? Did Charles over take her as leader of the others, thus banning her from the island?
So let's see if anyone else has more or maybe some answers, cause I think we all know so mysteries will never be solved and possibly always L O S T--ThePolarBearsConstant 02:24, February 1, 2010 (UTC)


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I read an online blogger article on a magazine not to long ago.. The subject was on how guys couldn't resist sexualizing women wearing pigtails hairstyle. So... yay or nay is it your thing? Why do you like it or do you prefer a different hairdo?
Most Helpful Girl
Really? That sucks, since I wear them whenever I feel lazy during Summer time.11|00|0


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Uganda's Government Vs. The LRA
By Eman Hardy
In the African country Uganda, there is a war brewing in itself. A terrorist group named The Lord's Resistance Army ( LRA ) lead by a man named Joseph Kony has waged war on the Ugandan Government. Their purpose, to impose their religious beliefs on the entire government, then the whole country of Uganda. Uganda won't give up without a fight.
The LRA is the group that is causing these problems in Uganda. Originally called The Uganda Christian Democratic Army ( UCDA ) they were an army group who broke off and started going to war with Uganda after they didn't agree with The Gulu Peace Accord of 1988. They decided they wanted to overthrow the government and takeover and implement the biblical Ten Commandments to their new government. In their quest, they lay a path of death and destruction. They are responsible for the death and enslavement of over 30,000 children in Uganda whom they rape, torture, kill and enslave. They even use them as child soldiers.
The country of uganda
This is where Kony and his operation have been terrorizing for nearly 30 years.


text: Chunkout provides a great puzzle game for young and old, with simple pick up and play gameplay that hides a depth of strategy. It is an addictive puzzle game where you need to delete chunks of two or more coloured blocks to try and clear the level and beat your high score. Build up the power meter to activate the multiplier and really boost your score!


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Japanese car manufacturer Toyota Motor Corporation's Indian subsidiary Toyota Kirloskar Motor (TKM) has confirmed that it will launch the new Prius hybrid car in January 2017.
The new Prius made its official debut at the 2015 Frankfurt Motor Show. Later in 2016 the new Prius was showcased at the Auto Expo in Delhi. The Prius is the maiden car to be produced worldwide based on the TNGA platform.
Toyota claims that the low centre of gravity of TNGA platform will result in better handling of the car. The TNGA chassis are also being used in Toyota's other global models as well.
The new Prius is powered by hybrid powertrain which includes a petrol engine and an electric motor. The 1.8-litre four cylinder engine with Eco and Power modes produces 97bhp and 142Nm of torque.
The electric motor develops 71bhp and 136Nm of torque which draws power from lithium-ion/nickel-metal hydride batteries.
Toyota claims that the new Prius will deliver ten percent more fuel economy and 40 percent increase in thermal efficiency. The new Prius is spacious compared to its older sibling and the boot space is also increased.
The interior of the new Prius features touchscreen infotainment system, 4.2-inch instrument cluster, automatic climate control and colour heads up display.
The new Prius is expected to be launched with a price tag of around Rs 30 to Rs 40 lakh (ex-showroom Delhi). Prius was the first hybrid car to hit Indian market back in 2010. Later on, in 2012 the facelifted Prius was also launched.


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Haven't joined yet? Join MYX |
MYXPH would like to greet the glamorous and talented Alicia Keys a happy birthday. This singer, who was in fact the first to ever receive five Grammy Awards in one go, is turning 33 today.
This "Girl On Fire" and "No One" singer recently visited the Philippines for a concert.
If you weren't able to watch the show, then maybe you should read here. While you're at it, why not view some photos from the show as well? Find out what you missed out on.
Do you have any wishes for Alicia? Let us knw by leaving a comment below.


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Franz Joseph Haydn's creative life spanned the latter half of the 18th century, and more than any other musician of his period, he was responsible for the evolution of the Viennese classical style. He was a humble man, largely self-taught, who in his later years became the doyen of the English musical scene. This program is a must for lovers of the Viennese style.More
Music lovers, and especially Viennese enthusiasts, may find much of interest in this straightforward, articulately performed, informative audiobook about the life and work of Franz Joseph Haydn, an Austrian composer often referred to as the "Father of the Symphony". Haydn, a close friend and contemporary of composers including Ludwig van Beethoven and Wolfgang Amadeus Mozart, was himself an acclaimed composer whose contributions to classical music still resonate in and shape the musical world to this day.
Written by Rosemary Hughes and performed by Michael Burrell, this enchanting audiobook features performances of Haydn's work alongside light, vibrant narration, interspersed with excerpts from pertinent letters and writings relating to Haydn's compositions.
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Contains relatively little biographical detail.
Audio recordings seem to be of low quality, as if you are listening to them through a pillow.
I have enjoyed most of my previous Audible purchases but would advise prospective buyers to steer clear of this title. The text provides only very cursory information about Haydn's life. It plays long passages from recordings (of low-ish quality) without always telling you which work it is (this accounts for at least 50% of the length). There is no musical analysis, so there's no inside look on how Haydn was innovative; instead all you are told is things like Haydn is the father of the string quartet, that his music was passionate, etc.
- Malcolm B. Brown


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Relentless Ranger was a Naga Scout Great Lesson that taught to push aside the stresses of his own body when on the hunt, relying on the focus of the Akasha to continue beyond his own means. The scout might function at full capacity without sleep, food, or water for few days. [1]
- ↑ Enemies of the Empire, p. 84
|This article is a stub. That means that it has been started, but is incomplete. You can help by adding to the information here.


text: Maintree Unknown Ubbinck (c1563-?) Gerrijt Ubbinck (c1609-?) Retrieved from "http://familypedia.wikia.com/wiki/Gerrijt_Ubbinck_(c1609-%3F)/tree?oldid=558419" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Hidden category: Tree pages


text:
Chocolate Pecan Pie
Be the first to review
READY IN: 1hr 20mins
Recipe by English_Rose
Kids and adults alike will go nutty for this delicious dark chocolate pecan pie.
See Discussion:
Ingredients Nutrition
For the sweet pastry
- 160 g caster sugar
- 2 egg yolks
- 300 g unsalted butter
- 500 g strong white flour
- 50 ml water
For the filling
- 80 g dark chocolate, broken into pieces
- 45 g unsalted butter
- 160 g granulated sugar
- 235 ml golden syrup
- 3 eggs
- 1 teaspoon vanilla extract
- 235 g pecans, chopped
Directions See How It's Made
- First make the sweet pastry. Mix together the sugar, egg yolks and butter in a large bowl. Sift the flour onto the buttery mixture and, using your fingers, rub it all together until you get a sandy texture.
- Add the water and quickly press it into soft dough. Wrap the dough in cling film and refrigerate for a minimum of four hours.
- Preheat the oven to 200C/gas 6/400°F.
- Roll out the pastry and use it to line a 25cm tart tin. Prick the base and chill until required.
- Melt the chocolate and the butter together in a heatproof bowl over simmering water; set aside.
- In a medium sized saucepan, combine the sugar and corn syrup and bring to the boil, stirring constantly. Set aside to cool.
- Beat the eggs in a large bowl, then stir in the melted chocolate-butter mixture. Whisk in the sugar syrup mixture and thoroughly combine.
- Add the vanilla extract and stir in the pecans. Set aside until completely cool.
- Pour the pecan filling into the chilled pastry and bake in the oven for 20 minutes. Lower the temperature to 180C/gas 4/350F and continue to bake for about 20 minutes until the pastry is golden and the filling is set.


text: Introducing a wonderful new Snuggie called "Feather Burst." It features a colorful splash of beautiful feathers and bright yellow trim - sure to look great on your feathered friend! Our Birdie Snuggie is designed for larger birds who would like a little extra cuddling and warmth – perfect for mild pluckers or cool weather comfort. It covers the front chest of the bird and features adjustable Velcro straps around the wing area. The rolled neck with adjustable beaded toggle makes it easy to get on and off over your bird's head and the cotton flannel/fleece back panel covers the backside of the bird. NOTE: Color of Feather Burst fabric may vary from photo. Available in the following sizes: Wide/Wide Plus, X-Wide/X-Wide Plus, X-Large/Jumbo, Mammoth and Colossal. Price: $29.99


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4.11 acres in Phelps County, Missouri
4.11 m/l acres of vacant commercial land with Hwy 68 N & Sidney Street frontage. Zoned B-1. Owner may be willing to divide property.
Hwy 68 N just past Sidney Street on right
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Michael Woessner
Investment Realty, Inc
Rolla, MO 65401
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NOTE: The information contained herein is provided as general information only and has been obtained from sources deemed reliable. It is provided without any guaranty, warranty or representation, expressed or implied, made by Lands of America, or any related entity, as to the accuracy or completeness of the information. The information is presented subject to errors, omissions, change of price or conditions, prior sale or withdrawal without notice. Prospective purchasers should make their own investigations, projections and conclusions concerning the information.


text:
Big Story
Separate names with a comma.
Discussion in 'The Vestibule' started by TheGreatCucumber, Nov 18, 2012.
I mean, you never know when she could slut it up and when you need revenge, right?
You never need revenge
For that reason, no.
Nudes of your girlfriend is so you can look back at how nice she was to have when she inevitably stops giving out.
If she's under 18 then no
Oh but you do...
I have never obtained them. I feel like a dick asking for them
So for all the ladies out there I really want to see you naked, even if I don't ask


text:
Bon Jovi - Ride Cowboy Ride & Wanted Dead Or Alive - Live In Tokyo 1988 MP3
No copyright infringement intended. Neither do I own the rights to the original song. FACEBOOK: https://www.facebook.com/DxHbk09 FACEBOOK APP: ...
Marty Robbins Sings 'Ride Cowboy Ride.' MP3
Lee Emerson's poignant saga of the cowboy on a desperate mission to see his dying sweetheart before she dies of fever is given a wonderful emotive treatment ...
Ride Cowboy Ride and Stick To Your Guns by Bon Jovi MP3
Ride Cowboy Ride and Stick To Your Guns by Bon Jovi put to pictures of Jon Bon Jovi, Richie Sambora, and the rest of the band. Both songs are on their album ...
Big & Rich - Save A Horse [Ride A Cowboy] (Official Music Video) MP3
New album GRAVITY in stores now! Available on iTunes: http://bit.ly/brytgitunes Amazon: http://bit.ly/brytamazon CD also available at Walmart: ...
Bon Jovi - Ride Cowboy Ride MP3
Ride Cowboy Ride by Bon Jovi.
Bon Jovi Ride cowboy Ride & Stick to your Guns Lyrics MP3
Lyric video & HQ sound Bon Jovi Ride Cowboy Ride & Stick to your Guns Album:New Jersey Year:1988 by Sinke ;)
Riders In the Sky - Ride Cowboy Ride MP3
A musical test for the feature length animated film: Riders in the Sky, Cartoon Cowboys starring the performances and songs of two-time Grammy winning (Toy ...
Paul Bogart | Cowboy Ride | A Video Tribute to Legendary Cowboys MP3
"Cowboy Ride" is one of my favorite songs that I have ever recorded and this video is so special to me because it pays tribute to some of my mentors and heroes ...
Save a Horse Ride a Cowboy Lyrics MP3
Save a Horse Ride a Cowboy by Big and Rich I really like this song and saw that no one made a lyrics video of it, and the ones that did have the lyrics really off.
Bon Jovi Wanted/Ride Cowboy Ride MP3
Bon Jovi playing in the streets of Moscow during the New Jersey Tour.
Bon Jovi - Ride Cowboy Ride + Stick To Your Guns (Subtitulado) MP3
Ride Cowboy Ride: escrita por Capt. Kidd & The King Of Swing Stick To Your Guns: escrita por Jon Bon Jovi, Richie Sambora & H. Knight Incluidas en el álbum ...
Bon Jovi Ride Cowboy Ride Lyrics MP3
Bon Jovi Ride Cowboy Ride with Lyrics from their album called New Jersey (1988)
Bon Jovi - Ride Cowboy Ride (live in Japan) MP3
live version of "ride cowboy ride" (from 'New Jersey' LP)
Ride Cowboy Ride - Bon Jovi cover MP3
Rex Allen Jr. - Ride Cowboy Ride MP3
Rex Allen Jr. - Ride Cowboy Ride - #85 hit in 1982 - big thanks to Muzikgirl67 for providing this one - go check out her playlists!
Marty Robbins - Ride Cowboy Ride MP3
"Marty Robbins sings Ride Cowboy Ride.
Good Ride Cowboy, Good Ride MP3
Randy's first NCHA cutting horse show...Placed 1st!!!
Good Ride Cowboy MP3
Provided to YouTube by The Orchard Enterprises Good Ride Cowboy · The Sounds Of Garth Brooks A Salute To Garth Brooks ℗ 2006 Suite 102 ℗ 2008 Suite ...
Karaoke The Cowboy Rides Away - George Strait * MP3
Download MP3: http://www.karaoke-version.com/mp3-backingtrack/george-strait/the-cowboy-rides-away.html Sing Online: ...
The Chippendales - Most wanted tour 2011 - Save a Horse Ride a Cowboy - Germany - Lingen MP3
Bon Jovi - Ride Cowboy Ride (Philadelphia 2000) MP3
Live at First Union Center, Philadelphia, PA,.USA - November 10, 2000 (Intercambio DVD / Trade DVD)
Big and Rich - Save a Horse Ride a Cowboy Lyrics MP3
Lyrics to save a horse ride a cowboy by big and rich. From their album horse of a different color.
Big & Rich - 'Save A Horse, Ride A Cowboy' live from CMC Rocks The Hunter 2013 MP3
Save a Cowboy, Ride a Camel MP3
The Kings of Camelot's world premiere! **Subscribe for Future Videos!** Available on iTunes! http://itunes.apple.com/album/id1031967878?ls=1&app=itunes ...
Roy Rogers - Ride Concrete Cowboy Ride MP3
Roy Rogers - Ride Concrete Cowboy Ride don't know what happens for it to delete. had to re-post.
Bon Jovi - Ride Cowboy Ride - HD Legendado MP3
www.blogoiton.com Bon Jovi - The Best Live of Ride Cowboy Ride - Legendado Pt - BR.
Bon Jovi - Ride Cowboy Ride MP3
Ride Cowboy Ride by Bon Jovi Album: New Jersey (1988) Lyrics: Ride cowboy ride Through the back door to heaven To the other side I wanna know the ...
"Ride Cowboy Ride" Rex Allen Jr. live from Music City Roots MP3
The classic Western song from Rex. Taped August 5, 2015.
Ride, Cowboy Ride MP3
From the Choo Choo Records' CD, 'Little Cowpoke', Sean and Sara Watkins and Chris and Scott Thile sing and play a spirited version of a cowboy favorite.
"Let's Ride Cowboys!" - Oklahoma State Rap Anthem - DubNasty and The Phoenix Bros. MP3
http://www.dubnasty.com - DOWNLOAD FREE MP3! This is the new Oklahoma State Rap Anthem written and performed by DubNasty; with the help of The ...


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Vogue Special Design 5821; ca. 1963; Jacket, Blouse, Skirt, Pants. Easy fitting jacket has below elbow length sleeves. Short, sleeveless, overblouse buttons at back. All around released pleated skirt in two lengths. Regulation pants.
Featured in Vogue Pattern Book April/May 1963 and June/July 1963
Links to reviews/blog posts Edit
Sources/Vendors Edit
Gallery Edit
[insert your photos of this pattern made up]
Wishlist Edit
[insert your username, and make sure your preferences allow for people to contact you via e-mail. Do not list your email address here!]


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|Message view
|« Date » · « Thread »
|« Date » · « Thread »
|André Malo ...@perlig.de>
|Re: cvs commit: httpd-2.0/modules/filters mod_deflate.c
|Thu, 02 Jan 2003 04:23:11 GMT
* Justin Erenkrantz wrote: > We don't use mixed case for any definitions, and we require braces at > all times, and for macros longer than one line, we wrap it with a do > {} while (0) clause so that some compilers are a bit happier. ah ok, thanks. <snip> > All of that said, I'm not really sure this code even merits being a > macro. I'd rather see the conditional execution clear at the scope > where LeaveNote is called rather than hidden in its definition. > Yeah, it's slightly repetitive, but I'm not really buying what the > macro is getting us here. IMHO, there should be an extremely high bar > to creating a macro. My thought was mainly to get some (perhaps subtle) semantics and better readability. But I've no problem to put this directly into the code; it's not so much, that one would loose the overview. ...tomorrow, if the time is ok ;-) nd -- s;.*;aaaaaoaaaoaaaaooooaaoaaaomaaaa:a:alataa:aaoat:a:a:a maoaa:a:laoata:a:oia:a:o:a:m:a:o:alaoooat:aaool:aaoaa matooololaaatoto:aaa:o:a:o:m;;s:\s:\::g;y;mailto:; \40\51/\134\137|ndparker <email@example.com>;;print;
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This Morning Freshness showcases a dedicated Juggalette artist, Miss Cyainide. This voluptuous beauty was featured in a Gathering documentary last year surrounding her participation in the Miss Juggalette Pageant. Now she has unleashed a wonderfully scrubbalo music video, Hate Me Now, I must share with the Family.
Miss Cyainide is part of a duo dubbed Lethal Injexions. This music video admittedly a low budget production really brings the freshness. I just love the super high guy in the ICP shirt. He's the only one without a hard look upon his face.
So, without farther ado I bring you "Hate You Now." If you don't like it, you can Fuck Off!
Hate Me Now
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- Thank the reader for attending the party.
- Appreciate the gift given.
- Thank the reader for the gift.
[Recipients Name]
[Senders Name]
[Address line]
[State, ZIP Code]
[Address line]
[State, ZIP Code]
[Letter Date]
[Address line]
[State, ZIP Code]
[Subject: Normally bold, summarizes the intention of the letter] -Optional-
Dear [Recipients Name],
I would like to thank you for attending my party. It was such a pleasure to see you there.
The gift brought by you is incredible. I loved it as soon as I seen it and so did my family.
It was a very thoughtful gift. Thanks once again.
[Senders Name]
[Senders Title] -Optional-
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cc: [Name of copy recipient] - Optional -


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Buying a house!!
Finally buying a house and getting out of the apartment. 3 bed 2 bath and I am so excited!! When Olivia gets older, planning on getting a kitten for them ><
GOOD for you.. I can't wait.. We too have come a long way.. From a one bedroom apartment to a two bedroom and I look forward in the next year to go to a little house with three or four bedrooms.. I would LOVE an office.. My kids will need separate rooms soon though.. boy and girl.. My son in 4th grade and is starting to really crave his privacy..
So happy for you!!!!
So happy for you!!!!
It's about a half hour away from the apartment where we are living now. Also away from family which is good in a way. Having a new baby, I'll never get any alone time. Everyone will be over all the time. Plus my daughter will start school at the elementary school I went to, so I am happy about that. It's a great school.
My favorite teacher retired, but there are some teachers I had that she will have. So I am excited to bring her in and talk to all of them again.
Moms also like
About Jerika Pike
Current: Maple Falls, Washington
Birth: August 16
On Moms.com since: Nov 20, 2013
I am a stay at home mom who one day hopes to open my own restaurant.
All Recent Jerika's Posts


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I'm not a vocalist/singer at all... but I do like to (try to) sing now and then. I have a weird problem that I have not been able to find any information on.
Whenever I sing, my nose burns and my eyes will water. I thought you guys would be the best people to ask... google has been unhelpful so far.


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Sundown City
A city in the sunset light
by Raffaello Ferrari
About the Book
The city of Lucca in the sunset light. Shadows,lights and darkness, mixed together,embrace the people unaware of their presence. I'm a photographer (perhaps), I'm not a writer ( and thus for sure) so I'll stop here: the pictures will tell my little story. Raffaello
Features & Details
- Category Arts & Photography
Standard Landscape, 10×8 in, 25×20 cm
40 Pages
- Hardcover, Dust Jacket: 9781457987373
- Publish Date Oct 04, 2013
- Language English
- Tags fotografia di strada, Raffaello Ferrari, street photography, costruzione, declino, strada, percorso, città, tramonto, luce, ombre, luci, buio, persone, presenza, fotografo, scrittore, immagini, Fujifilm, via, urbano, Toscana, Italia, architettura, uomo, uomini, donna, donne, bambino, bambini, children, child, women, woman, men, man, architecture, Lucchesia, Ferrari, Raffaello, Italy, Tuscany, urban, streetphotography, street, fujifilm, x100, fujifilmx100, pictures, writer, photographer, presence, people, darkness, lights, shadows, light, sunset, Lucca, city, sundown, path, way, fading, decline, building, palace, house, shade, obscurity, glare, span, black, gloom, murkiness, gloominess, folk, persons, photography, photo, print, images, walk, walking, town, bike, bicycle, kid, bicicletta, camminare, fotografia, nero, arco, abbagliamento, oscurità, ombra, casa, palazzo
About the Creator
I approach photography in 1998, attending first-level courses and then "Educazione all'Immagine". In 2000, I was one of the founders of "Photolife Lucca" circle of photography. In 2006, I took part in the workshops ("Reportage and Social landscape") held by the photographer Ivo Saglietti and I start solo exhibitions. My reportage "Young Fishermen" is earmarked in the Lucca DigitalPhoto Contest and exhibited during the photographic exhibition. From 2008 I followed the associations of role-play GrvItalia and Camarilla Italy. My photographs are published in the their association guides. In 2010 the photographs of the walls of Lucca are acquired by the photographic archives of Lucca and become part of the city's history. I participate in the international contest "The First Bends International Internet-based Photography Competition":one of my photos reenters in the first 500 (on over 32000) and it was exposed in China. In 2013 about 60 photos are in Vogue's site: Art+Commerce.
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In just a few years a new airport will be built in Jebel Ali.
The airport will be called the Dubai World Central International Airport.
They say that this airport will be the fourth biggest one in the world. They construction team expects to finish it in 2017.
This amazing airport will be able to receive almost 70 million people!
You can say that the flights that come now from North America are a bit limited at the moment. Still, the Emirates and some other airlines have developed new flight options.
Many tourists say that flying to Dubai costs a lot but you can find good deals everywhere. It all depends if you are flying business or just for pleasure.
Your best choice is the Emirates Airlines. They give very good prices for the last minute flights to Dubai. Most of the year, the other offers are few.
The rapidly developing state of Dubai has made the cost of the seat to climb, in the last couple of years.
The second best choice would be an online travel vendor like Expedia.
You can find many cheap deals there. Sometimes, you can even book some cheaper flights, cheaper than the Emirates. The best solution to do that is to watch everyday for offers and once you see it, reserve immediately or somebody else will.
But if you are sent by your company in a business trip, you could book a private jet. There are good prices there too and they are eco friendly. The most important thing is that a jet helps you save money because the cost with the fuel is not that high, like on a big airplane. Plus, it is much more comfortable and you can have your own timetable.
In just a few years Dubai will be the next Vegas and all the eyes will be set on them.


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Dining Room Furniture
Sopwell Oak
Sopwell Oak Papillon Table
From £2845
Introducing the new Papillon dining table, taking oak furniture to a new level. Created from splitting a tree trunk in half to give a mirrored image either side of a stylish gap down the middle makes this table a real show stopper. The solid wood 4cm top shows the natural grain of the tree and exposes its annual rings and structures. What makes the Papillon table even more attractive, is the fact that each table with its unique look and grain is made from solid sustainable European Oak.
The Papillion is available in many sizes, and can come in 90, 95 and 100cm widths. Please note that the width does not affect the price.
Length............................. Price
180cm............................ £2845
For more information about our Sopwell Oak Papillon Table, call Ian or Steve on 01727 856 053. Or send us your details, and well call or email you back.
Available Finishes
We deliver all our own furniture. Were proud of our solid wood furniture and would never leave it in the hands of external couriers.
Of course, if you prefer, you can arrange collection yourself.
Delivery Time: 10 Weeks
Delivery Costs
|London & Home Counties
|Rest of England
|Rest of the UK including Scotland
|Orders under £500
|£60 - £90
|Orders over £500
|£60 - £90
- When your furniture is ready we contact you to arrange convenient delivery date.
- Dont want to wait in all day? We deliver in a 2 hour delivery window so you dont have to.
- Items are placed in the room of your choice. Its no problem if thats up stairs, as most of our larger items dismantle for easy delivery.
- We dismantle / assemble all furniture as required, and all packaging is removed.
- Our team will be happy to explain the on-going care for your new piece of furniture.
View our gallery to see how Sopwell Oak Furniture might look in your home. Click the images for a larger view.
Other Products You Might Like
View our complete collection of Dining Tables
ORDER THIS ITEM - Phone : 01727 856 053
This item can be made to measure. Email us with your dimensions, and well get back to you with a price!
All our wood furniture is certified PEFC
Sustainably sourced
All our wood furniture is certified PEFC which guarantees the forest grows more quickly than it is felled. The PEFC Council (Program for the Endorsement of Forest Certification schemes) is an independent, non-profit, non-governmental organization, founded in 1999 which promotes sustainable managed forests through independent third party certification. The PEFC provides an assurance mechanism to purchasers of wood and paper products that they are promoting the sustainable management of forests.
Sustainably sourced
Weve been making furniture for nearly 25 years and have absolute faith in the quality of our wooden furniture. If you buy a piece of furniture from us that develops a structural fault, well either fix it or replace the item for free. This guarantee is valid for all our wooden furniture with the exception of chairs and upholstery. Its a personal use guarantee, which means its not valid for furniture used in the workplace (e.g. pubs or restaurants). This guarantee does not cover wear and tear which naturally occurs with time, and it doesnt apply if you cause damage yourself (e.g. spillages, burns, etc.)


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Today, the U.S. House of Representatives passed an amendment offered by U.S. Representative Patrick E. Murphy (FL-18) to the National Defense Authorization Act that addresses wasteful government spending by the Department of Defense on unused and underutilized facilities. The Department of Defense has hundreds, possibly thousands, of buildings and structures that it has rated at zero percent utilization, which are maintained by taxpayer funding. Prior to the vote, the Council for Citizens Against Government Waste announced their support for Rep. Murphy's amendment to make more efficient use of defense facilities. (Please find attached a copy of the amendment).
"By forcing the Department of Defense to take a serious look at its facilities, gather data on how these facilities are managed, and develop a coherent plan for reducing costs and improving efficiency, my amendment seeks to eliminate this wasteful government spending," said Rep. Murphy. "We all agree that we need to reduce government spending and that the best place to start is by rooting out waste. I was pleased to see my colleagues from both sides of the aisle come together to support this common-sense solution to do just that."
Source: http://patrickmurphy.house.gov/news/documentsingle.aspx?DocumentID=338951


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This is part of the whole experience in terms of a retro look and style. The room was adequate, probably as clean as it could get. The fridge and coffee pot were greatly appreciated. The river was a very short walk. The front desk person...More
Getting you more information on this room
Getting you more information on this room
"All "hotel" questions are answered as they applied to RV sites. I know nothing about the motel..."
"There is no bad room. They are all neat and clean, and close to the beach."


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Campaign: Tonal Takeover
For our first-ever specs campaign shoot, we wanted to play with a tone-on-tone look. Inspired by landscape paintings, we selected ultramarine, crimson, and mocha as our three campaign colors. These rich hues paired with our neutral-colored frames are the perfect transition into fall.
Outfit: Sharp and Sophisticated
It's all about layering and accessorizing this time around. Our stylist, Lora, came with racks and racks of tonal pieces for us to choose from. She created beautifully modern looks and pulled everything together with fun accessories. The fringe earrings Qi wore are our favorite!
Hair & Makeup: Autumn Bronze
Golden, glowing skin was the inspiration behind our makeup look. We wanted light lips with bronzy shadows. For Qi, we kept her eye makeup minimal and added a nude pink lip color. Hair was the fun part; we wanted to liven up Qi's looks with messy top buns and loose curls. For Yan, his hair was swept loosely to one side.
Work outfit inspiration? Qi in Rigel Beige.
Shout out to an awesome team! THANK YOU!
Photography: Pierce Harrison
Models: Qi Wen Feng, Yan K
Stylist: Lora Schlein
Hair & Makeup: Sandradene Fearon


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Two Tudor Subsidy Rolls for the City of London, 1541 and 1582
(21 vols. and Addenda, 1862–1932) Schofield, dissertation Schofield, R.View result
Editorial note
A History of the County of Lancaster: Volume 7
Parker, Mr. W. Parker, Captain C. B. Petre, the Rev. D. Schofield, Mr. W. W.View result
A Survey of Documentary Sources for Property Holding in London before the Great Fire
Schofield, Anne Sutton, and Colin Taylor. Joanna Mattingly, assistantView result
The later middle ages: The Wars of the Roses
A History of the County of York: the City of York
Paston Letters, i. 193–4. C. Schofield, Life and Reign of Edw. IV, i. 134. ... (1843), 2 sqq.; Schofield, Life and Reign Edw. IV, i. 263. Schofield, Life ... York Corp. Rec., Chamberlains' Roll,...View result
Prebendaries: Ilminster
Fasti Ecclesiae Anglicanae 1066-1300: Volume 7, Bath and Wells
Canonical Houses pp. 169-70). See also Muchelney Memoranda, ed. B. SchofieldView result
Late Georgian and Victorian Chester 1762-1914: Appendix, migration trends in the Chester region, 1801-1911
A History of the County of Chester: Volume 5 Part 1, the City of Chester: General History and Topography
and R. S. Schofield, Population Hist. of Eng. 1541-1871, 636 (table A8.5).View result
Townships: Cowpe, Lench, Newhall, Hey and Hall Carr
A History of the County of Lancaster: Volume 5
surrendered to the use of Vane or Evan son of John Schofield; the fine, 21 s.View result
Townships: Over Wyresdale
A History of the County of Lancaster: Volume 8
1894 Daniel Schofield 41 1910 John Leonard Gamble, M.A. (Dur.) A free ... is taken, 712. Note by Rev. D. Schofield from a report by Sir W. Hardy ... Schofield adds the following1688, William...View result
The stables: Helpers in the Stables c. 1704-1837
Office-Holders in Modern Britain: Volume 11 (Revised), Court Officers, 1660-1837
By 1721 Barke, G. By 1721 Schofield, W. 1721 13 Jan. Fouch, J. 1721 19 Sept.View result
Townships: Castleton
A History of the County of Lancaster: Volume 5
38 The other tenants were Richard Schofield, who held 72 acres ... 32 acres for which a rent of 6 d. was due to Richard Schofield. Newbold ... in Hundersfield. 'A close called Lyrol' had been occupied by Richard...View result


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Two characters personalities will be discussed in depth in this mind map. These are the characters of Eva and Erin.
Eva had most of her needs meet however not in a productive and healthy way. Her need for belongingness was found in her father's gang. This altered her personality to cause her to believe it was ok what they did, the fighting and killing and to be unable to fully understand what kind of consequences this could have. She grew to be unable to understand right from wrong.
It shows in Erin's drive to teach the kids, that as a child she received from her father everything Maslow believed she needed. Which ultimately lead to her self-actualization of wanting to become a teacher, as she says in the beginning of the movie "The battle is already lost once you reach the court room, the real fighting begins in the classroom" (not direct)
Is the ablilty to control impulses and delayed gratification
Erin has a high self-efficacy which was created from her father's constant encouragement and love. She believes that she can help the kids in her class if she tries hard enough.
She has low self-efficacy because she has been unable to develop all other parts of her self-esteem properly. This is because she never received positive influences and role models.
Kicked out of his home because of his gang live, Marcus was given back an opportunity for nurture, as Mrs. Gruwell taught them there is more to life then gangs.
Humanism is the idea that all people start off good and will want to do well, until something causes that to change.
He believed that people need three conditions for growth and fulfillment; 1) Genuineness 2) Acceptance 3) Empathy
the psycodynamic theory was created by sigmond freud, it entails the idea that personality is created form past events. mostly ones steming from childhood.
There are a variety of defense mechanisms that people will use to help them cope with traumas in their lives.
There are 5 stages that Freud believes children went through. He said that a child can become stuck in a certain stage if they received to much or not enough care during it.
These are three stages of the mind which each develop during different stages of childhood.
The theory that our mind is divided into 3 sections only one of which a person is aware of.
The social cognitive theory created by Albert Bandura is built on the idea that biological influences, psychological influences and personality, are all interrelated to create an outcome in any situation.
There are two different locus's of control 1) Internal: the perception that you control your one fate 2) External: the perception that chance or outside forces beyond your personal control determine your fate.
Is the interacting influences of behavior, internal cognition, and environment.
Is the idea that behaviours can be learned and taught, through different methods.
This is the idea of reinforcement and punishment in order to train a new behaviour.
Is the process of using an unconditioned response to create a neutral response which then creates a conditioned response.
Observational learning consideres 4 processes 1. Attention 2. Retention 3. Reproductive 4. Motivation