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Neoplastic metastatic epidural spinal cord compression is a common complication of cancer that causes pain and progressive neurologic impairment. The previous standard treatment for this condition involved corticosteroids and radiotherapy (RT). Direct decompressive surgery with postoperative radiotherapy (S + RT) is now increasingly being chosen by clinicians to significantly improve patients' ability to walk and reduce their need for opioid analgesics and corticosteroids. A cost-utility analysis was conducted to compare S + RT with RT alone based on the landmark randomized clinical trial by Patchell et al. (2005). It was performed from the perspective of the Ontario Ministry of Health and Long-Term Care. Ontario-based costs were adjusted to 2010 US dollars. S + RT is more costly but also more effective than corticosteroids and RT alone, with an incremental cost-effectiveness ratio of US$250 307 per quality-adjusted life year (QALY) gained. First order probabilistic sensitivity analysis revealed that the probability of S + RT being cost-effective is 18.11%. The cost-effectiveness acceptability curve showed that there is a 91.11% probability of S + RT being cost-effective over RT alone at a willingness-to-pay of US$1 683 000 per QALY. In practice, the results of our study indicate that, by adopting the S + RT strategy, there would still be a chance of 18.11% of not paying extra at a willingness-to-pay of US$50 000 per QALY. Those results are sensitive to the costs of hospice palliative care. Our results suggest that adopting a standard S + RT approach for patients with MSCC is likely to increase health care costs but would result in improved outcomes.
Metastatic spinal cord compression (MSCC) is one of the most dreaded complications of metastatic cancer that, if untreated, causes progressive pain and irreversible loss of neurologic function.1 In a population-based study in Ontario, the estimated prevalence of MSCC was 0.23% at the time of diagnosis, which corresponds to an estimated 1700 new cases of MSCC at the time of diagnosis across Canada and approximately 17 000 new cases of MSCC in the United States annually.2
Until the past decade, nonoperative treatment of MESCC with corticosteroids and radiotherapy (RT) has been considered to be the standard of care, particularly in light of the failure of decompressive laminectomy to provide added benefit to RT in terms of pain control and neurological outcomes.3,4 However, over the past 20 years, there has been a significant evolution in decompressive and reconstructive spinal techniques, which have been increasingly applied to the management of spine oncology.5 Indeed, the beneficial impact of surgical resection and spinal reconstruction was recently shown in a randomized, multi-institutional trial comparing direct decompressive surgical resection, followed by RT (S + RT strategy), with the RT-only strategy in a selected group of patients.6 In addition to the longer survival time in the S + RT group when compared with the RT-only group, the S + RT approach allowed more patients with MSCC to remain ambulatory and continent while also reducing pain and analgesic needs.6
Despite the apparent benefits of the S + RT approach to treat MESCC, these patients have a limited life expectancy, and thus, the cost-effectiveness of such an approach could be questioned. Health care costs have been increasing worldwide over the past decades, and palliative care is likely to represent a growing share of those expenditures that will necessitate economic evaluations of palliative care interventions to inform resource allocation decisions.7 In a prior cost-effectiveness analysis, the results favor the S + RT strategy in comparison with the RT-only strategy regarding the cost per additional day of ambulation and the cost per life gained.8 However, those results should be interpreted cautiously because of the lack of rigorous compliance with the criteria for high quality of the cost-effectiveness studies and limitations regarding their outcomes, data source, and regression modeling.8–10 Because of this background, the present study aims to contribute to the body of evidence in spine oncology by undertaking a cost-utility analysis that compares the S + RT strategy with the RT-only strategy in the context of a publicly funded health care system.
This analysis adopts the perspective of the public payer, the Ontario Ministry of Health and Long Term Care. An analytic decision model was established to compare 2 strategies: S + RT versus RT alone (Fig. 1). After the decision node to select a particular treatment modality, there are 2 initial symmetric chance nodes for each therapeutic strategy that reflect the probability of having complications after each initial treatment (Fig. 1). All underlying initial health states that could influence outcomes are included in each branch of the decision tree (Fig. 1).11 Subsequent chance nodes correspond to the possible consequences of each strategy within the first 60 days after the initial treatment (Fig. 1). The subsequent node for each branch representing discharge disposition of patients at 60 days from the initial treatment is a 9-state Markov node. A Markov model or state transition model is the optimal representation of decision trees in which events recur over time.12 As shown in the bubble diagram representation, each Markov node is constructed in a 3-way factorial manner that includes 8 mutually exclusive health states based on placement (home or institution), mobility (ambulatory or not), and urinary function (continent or incontinent) (Fig. 2). In addition to these health states, a patient in the cohort could finish each 30-day cycle alive or dead, thus expanding the total number of health states to 9 in each Markov node (Fig. 2). The half-cycle correction was applied to our Markov model to avoid overestimating life expectancy.13
The probabilities and rates of clinical events for this model are based on the data from Patchell et al.6 The probability of discharge home is based on data from a cohort of patients with MSCC who underwent surgical treatment at the Toronto Western Hospital (Toronto, Ontario) from January 2001 through July 2005 (Table 1). University Health Network Research Ethics Board approval was obtained for this chart review. In addition, a prior publication and expert opinions from medical oncologists and radiation oncologists from the Grand River Regional Cancer Center (Kitchener, Ontario) were used to perform a sensitivity analysis.14
The costs of both treatment strategies are composed of physician fees and hospital expenses. The physician fees for direct decompressive surgery included surgeons' consultation fees, surgeons' procedure fees, anesthesiologists' consultation fees, anesthesiologists' procedure fees, and surgical assistants' assisting fees. The physician fees for inpatient RT included radiation oncologists' consultation fees, weekly assessment fees, and RT treatment planning fees. All physician fees were obtained from the Ontario Health Insurance Plan schedules of benefits.15 All costs were adjusted and converted to 2010 US dollars.
Hospital expenses were obtained from the Ontario Case Costing Initiative (OCCI), which was established in 1992 as a joint initiative of the Ontario Hospital Association and the Ontario Ministry of Health and Long Term Care (OMHLTC) to develop a cost database.16 The hospital costs for both study arms were adjusted for the hospitalization time based on the original trial data.6 With use of data from the OCCI, the daily costs for hospital admission with diagnosis of metastatic spinal cord tumor were estimated after excluding the costs related to surgical procedures and RT. Those costs correspond to the variable costs per diem for all hospitalizations, whereas the fixed costs for each study arm were calculated using the hospital costs related to surgical procedures and RT based on the data from the OCCI (Table 1).
The cost of medications included the cost of corticosteroids and opioids. It was assumed that the utilization of all other medications would not be influenced by whether surgery was performed. The total cost included the cost of drugs and the pharmacy-dispensing fee. The outpatient medication expenses were counted as costs in our model because all patients who receive home care would also obtain Community Care Access Center drug cards for reimbursement of outpatient medication costs from the public health care insurer.
For patients who are discharged home, we assumed that all of them would receive palliative home care services, because this represents the optimal clinical care for patients with MSCC. The cost of home care was estimated on the basis of previously reported data from the OMHLTC (Table 1).17 The cost per patient-day of inpatient palliative care was estimated on the basis of the average cost of inpatient palliative care facilities according to the OCCI data (Table 1).
The 2 extremes (or anchor states) for all the outcomes are expressed in single values of 0–1, in which a value of 0 represents "death" and 1 represents "full health." 18 Utilities were taken from the Harvard University Catalogue from the United States and in the Health Outcomes Data Repository Data–Health Utility list from the United Kingdom (Table 1).19,20
Because there are no published data on the specific utilities for each branch in the study decision tree, those specific utilities were estimated by multiplying the utilities associated with each branch by the period that the condition or procedure affects the patient's quality of life.18
The primary outcome of this cost-utility analysis was the incremental cost (in 2010 US dollars) per quality-adjusted life year (QALY) gained.
The baseline analysis included the most likely values of the probabilities, costs, and outcomes from a variety of sources to build the decision tree (Fig. 1). In addition to the baseline analysis, a series of sensitivity analyses were performed, including 1-way and 2-way sensitivity analyses, threshold analysis, and probabilistic sensitivity analysis. The main purpose of these sensitivity analyses was to test the robustness of the model, and thus, a range of values for the costs was used in both treatment arms to assess the extent to which the results are robust to changes in costs of 50%–150% of mean costs for each item. Furthermore, sensitivity analysis tested the range of probabilities and utilities of 0–1. The threshold analysis examines whether there was a value of variable at which preferred strategy changes.
With use of Monte Carlo simulations, the probabilistic sensitivity analysis was performed using the range and mean values of probability for discharge disposition, the various costs, and survival. All simulations were performed using first-order sensitivity analysis with 100 000 trials. The results of the simulation were used to generate an incremental cost-effectiveness ratio (ICER) scatterplot and a cost-effectiveness acceptability curve (CEAC).
Data analyses were performed using TreeAge Pro 2009 Suite software (TreeAge Software).
The mean overall hospitalization costs within the first 60 days and subsequent mean monthly costs for each branch in both trial arms are shown in Tables 2 and and3.3. Although the S + RT strategy cost US$1 215 514.01 per QALY gained, the RT-only approach cost US$1 017 372.80 per QALY gained. Of importance, the expected effectiveness for the S + RT strategy (0.57 QALYs) was higher than the effectiveness for the RT-only strategy (0.46 QALY) (Fig. 3A). The ICER of S + RT when compared with RT alone is US$250 307.30. However, the cost-effectiveness ratios for both strategies were located in the northeastern quadrant, which reveals that no strategy was dominant (Fig. 3A).
The baseline analysis suggests that the RT-only approach is more cost-effective than the S + RT strategy at a willingness-to-pay of US$50 000 (Fig. 3A). The 1-way sensitivity analysis showed that S + RT becomes cost-effective with a willingness-to-pay threshold of US$50 000 when the initial cost of S + RT within the first 60 days is less than US$29 439.44 (Table 2). Furthermore, the hospice costs appear to be an important factor in distinguishing the 2 strategies (Table 3). The results of this 1-way sensitivity analysis reinforce the robustness of our model, because there is only one threshold value for this parameter (Tables 2 and and3).3). Using 2-way sensitivity analysis, the monthly hospice costs for each health state favors the RT-only approach, compared with the S + RT strategy (Fig. 3B). The 2-way sensitivity analysis also indicates that there is an extremely small chance of the utility for nonambulatory patients with urinary incontinence who underwent S + RT approach to experience higher utility than patients in the same health state treated with RT alone (Fig. 3C).
The results obtained from probabilistic sensitivity analysis using the Monte Carlo simulation approach are summarized in Table 4. The scatterplot shows that the northeastern and southeastern quadrants represented the majority of simulation results (68.5%), and, thus, the S + RT strategy is more effective than the RT-only strategy (Fig. 4A). The ICER fell into the dominant quadrant (or southeastern quadrant) 18.11% of the times in which the S + RT strategy would be more effective and less costly in comparison with the RT-only strategy. In addition, the S + RT strategy was more cost-effective in 24.02% of the simulations at a willingness-to-pay of US$50 000. Nonetheless, the ICER fell into the dominated quadrant (or northwestern quadrant) in 30.15% of the simulations in which the S + RT strategy would be less effective and more costly than the RT-only strategy. Indeed, the acceptability curve never reached the upper limit (100%) (Fig. 4B). The acceptability curve also showed that 55.86% of the ICERs were under the limit of US$100 000 per additional QALY (Fig. 4B). The proportion of ICERs covered by the willingness-to-pay reached a maximum value of 91.11% at the level of US$1 604 800 per 1 additional QALY (Fig. 4B).
This study for the first time, to our knowledge, examines the cost-utility ratios for a combined S + RT strategy compared with RT alone for patients with MSCC. The results of this study indicate that the S + RT strategy appears to be more costly and more effective than the RT-only strategy. The estimated ICER of the S + RT strategy in comparison with the RT-only strategy is US$250 307 per QALY in this patient population. These results indicate that increased expenditures are needed to impact patients' quality of life for such a morbid clinical condition. Moreover, by adopting the S + RT strategy, there would still be a reasonable chance (approximately 18.11%) of not paying extra for 1 additional QALY gained at the willingness-to-pay of US$50 000 according to our Monte Carlo simulations.
Although the practice of medicine is often driven by ability, availability, and affability, physicians need to better understand their practice cost of providing patient care in the present environment of cost containment.21,22 At present, there is mounting pressure on clinicians to provide cost-effective care, especially when equivalent alternatives are available. Because cancer care represents approximately 9% of all health care spending, there is increased impetus to cost out care services on the basis of objective evidence and an increasing demand for greater in-depth understanding of the elative clinical cost efficiency of various treatment options.23,24 In the context of spinal cancer care, however, there is still a paucity of high-quality studies focused on health economics. Brauer et al. reported a critical appraisal on articles published from 1976 to 2001 that focused on cost-utility analysis in orthopedic surgery for spinal cancer.25 In their analysis of the literature, Brauer et al. found only 14 articles that focused on spine surgery and 5 articles that specifically dealt with spine tumors. Moreover, only 5 (4.3%) of the 116 studies that focused on orthopedic surgery satisfied the 4 key criteria for high quality cost-utility analysis, as recommended by the United States Panel on Cost-Effectiveness in Health and Medicine.9,10,25
To our knowledge, this is the first study to focus on a cost-utility analysis comparing stand-alone radiotherapy with S + RT to treat patients with MSCC. Our results suggest that the S + RT strategy is more costly and more effective than that of RT alone. From the perspective of a public health care insurer, it would cost an extra US$ 250,307 to gain 1 additional QALY by adopting the S + RT strategy, compared with the costs and effects of the RT-only strategy. On the basis of the Monte Carlo simulation method, the probabilistic sensitivity analysis confirmed the robustness of our model. This also supports the results with regard to the acceptability curve that suggest that, for instance, by adopting the S + RT strategy, there is a 65% chance that S + RT strategy is cost-effective, compared with RT alone, at a willingness-to-pay of US$500 000 per QALY.
In terms of broader policy implications, the results also highlight that palliative care interventions are likely to generate high ICERs. This is because patients have short remaining life spans over which to benefit from any treatment. Furthermore, patients at the end of life tend to have low QALYs because of very poor health status, and it is difficult for treatments to generate large QALY increases under these circumstances. This raises the question of whether economic evaluations, even cost-utility analyses that attempt to take account of quality of life not just length of life, ought to use some adjustment that would give additional weight to gains to health occurring at the end of life. This is a question that perhaps merits investigation in future research.
One potential limitation of this economic evaluation refers to the use of data from a single randomized trial that enrolled a selected group of patients.4,6 Although those features may limit the generalizability of its conclusions and implications, that randomized trial has strong internal validity.4,6 The conclusions of our study apply only to a highly selected population nonetheless.
Ideally, cost data would be more accurately obtained if the economic evaluation were being conducted along with the randomized study. Despite the advantages of more specific costs for both treatment strategies, there are multiple parties working as health care payers in the United States, where the original trial was conducted.6 In contrast to this scenario, Ontario has a universal health care system with OMHLTC as the single payer. Although there are notable differences between the American and Ontario health care systems, the homogeneity of cost in Ontario appears to minimize the potential bias that may arise when using costs from a mixed health market with private insurers.
The most generalizable perspective in any health economic evaluation is the societal perspective. Nevertheless, the economic analysis under the societal perspective requires a variety of cost information, including productivity losses and loss of leisure time by patients and caregivers, which were unfortunately unavailable for this specific patient population in Ontario. Therefore, for feasibility, the perspective of a public health care insurer was adopted in this study.
We assume that the utilities of all health states involved in the studies are independent of each other so that we could apply multiplication of multiple utilities to derive the combined utilities for each of the arms of the analytic decision model. In reality, these utilities may not be independent of each other. Patients in this population may have adjusted to multiple symptoms arising from their cancers that may influence their reported utility. Furthermore, new symptoms may not necessarily decrease the utilities of their health state in an independent way.
Furthermore, our economic analysis did not consider other important clinical features, including stage of the disease and histopathological diagnosis. Given the sample size of 101 cases, any subgroup analysis would not have sufficient statistical power to draw relevant conclusions.
Given the increasing focus on the provision of cost-effective medical care, our results suggest that a change of the palliative treatment protocols for patients with MSCC toward S+RT is more likely to increase the health care costs. However, the gain in terms of patients' quality of life is relatively significant and should be considered by health care policy makers. Our results further suggest that economic evaluations should perhaps account for remaining life left in palliative care interventions. This may reduce the potential bias in economic evaluations away from interventions aimed at the very ill (at the end of life, with no hope of cure), to recognize that, although gains to health or QALYs for this group may be difficult to achieve, they are not necessarily less valuable from the patient's perspective.
This work was supported by the Lawson Postdoctoral Fellowship at the University Health Network (J.F.) and the Krembil Chair in Neural Repair and Regeneration (M.F.).
We thank Dr. Stephen Wong, Dr. Stephen Lewis, Dr. Eric Massicotte, Dr. Y. Raja Rampersaud, Dr. Senti Senthelal, Dr. Donna Ward, and Ms. Claire Zhang.
Conflict of interest statement. None declared.
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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About the author:
Monica P. Castaneda obtained her degree as an architect in Ecuador, South America. Upon moving to the United States she found she would not be allowed to practice unless she went back to school for four years. Instead, she devoted over 9 years to study and research Feng Shui. She looked at all the schools and all the systems and compared them with reliable knowledge from Traditional Chinese Medicine, which shares the same philosophical source as Feng Shui, to find out what was useful and applicable in the world today. Monica is a Feng Shui consultant, speaker, and teacher.
For more information about Feng Shui please visit:
Bill Austin is a spiritual healer, teacher, artist and writer living in St Petersburg, FL in the United States. He is the author of Transform Your Relationship with Money, the founder of several energy healing modalities and has trained alternative healing practitioners in over twelve countries.
For more information about Bill, please visit www.HealingReikiMaster.com.
Feng Shui Cures for the Five Elements
Authored by Monica P. Castaneda, William M. Austin III
Are you ready to be happy? Experience More Love, Joy and Bliss...
Life is forever changing and presenting challenges to us. For every different challenge we need varying moods and attitudes: to go forward in life, to understand people around you, to be able to transcend difficulties, to live and let others live in happiness... it's all modeled in the natural world.
The section of the manual that addresses the Five Western Elements provides you with images and artwork that contain healing frequencies to help you achieve the fluidity of water, the groundedness of earth, the passion of fire, and the clarity of air.
Are you ready to be healthy? Gain Access to the Original Blueprint...
The original design of all that comprises you (your mind, body and soul) is perfect and complete. Eastern Five Elements Theory is an excellent starting point to lay down the spiritual groundwork that can allow you to manifest a healthier you. This manual is very easy to use. Bill Austin encoded the healing frequencies of the Five Eastern Elements in his wonderful artwork so you can get the spiritual benefits by looking at and interacting with this work. Monica P. Castaneda provides healing templates based on Traditional Chinese Medicine and Feng Shui templates based on the elements. Monica also included an extensive chart with information on the five elements and their relationships to your body's organs, systems and emotions.
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1452870926 / 9781452870922
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Spillproof: This battery is tightly sealed, which allows you to position it anyway you want without having any toxic spills.
Stopped Charging: Some customers claim the battery stopped charging after only six months, which may impact overall performance.
Not Rated: This product doesn't have a cold cranking rating, nor does it have a reserve capacity rating, mainly because it is a universal battery.


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This is the top that made Bestop famous! Jeep owners wanted a complete soft top replacement kit that did more than the factory top. Bestop took its OEM fabric design and developed adjustable frame hardware that folded back behind the rear seat, and added the BeltRail attachment system. The Supertop® Classic was born. It set a new standard when introduced nearly 30 years ago. And today, it's still in demand as a premium quality replacement soft top that folds back like a true convertible top.
the instructions where very unclear on how the bows and frame went together. The top once installed is a great top but if you are looking for a top to remove/ install quickly this is not it. I bought it to take hard to off when i went on vacation. It ended up being more of a pain to take off than the hard top would have been; so I ended up just leaving the top on and taking all the windows out. I would recommend this to a friend but I would explain what they where getting into.
The top is a great buy for a Jeep Cj5. It fits perfect and is easy to install with the proper knowledge and tools. It looks great on the jeep and has many great features like the two piece doors and zip out windows. It keeps rain out and makes the jeep a quieter ride. I get the most enjoyment out of the top on sunny days with the doors off and the windows out. The only con to this top is that during installation I didn't know you had to bend the doors where the top piece connects to get a proper fit between the door and the top.
Easy to install.Fit is really tight.
Does this top come with replacement snaps also
Asked by Ed from on
Hey Ed, the Bestop Supertop with Tinted Windows without Doors does not use snaps to mount and will eliminate the snaps on your Jeep. Thanks for your question.
Answered by Devin B. ext 4835 from on
Will this top work with a 1976 cj5 with a fiberglass body?
Asked by Jon from Pa on
Hi Jon, This Bestop Supertop with Two-Piece Soft Doors fits fine on the CJ 5's with the fiberglass body. It's very complete with the channel attachments, bow assemblies, fabric, windows and doors. For the thicker fiberglass body we recommend obtaining some longer sheet metal screws to install the body channels, such as a 14x3/4 inch screw, also 1/4 inch flat washers (25 of both) and a 7/32 inch drill bit. Thank you for your question.
Answered by Jim G Ext 4806 from Pa on
Does this kit include spare tire cover?
Asked by Mark from Rogers, AR on
Mark, Unfortunately the Bestop Supertop with Two-Piece Soft Doors does not come with a spare tire cover. The tire cover is available separate and is dependent on tire size for correct fitment. Please let us know if you have any other questions. Thanks!
Answered by Tom S @ Ext 4876 from Rogers, AR on
Rugged Ridge Soft Top Storage Boots
Smittybilt Door Entry Guards
Smittybilt Grab Handles
Smittybilt Soft Top Storage Bags
Smittybilt Spare Tire Covers
Smittybilt SRC GEN1 Tubular Doors
Smittybilt Trail Gear Bags
Smittybilt Soft Upper Door Storage Bags
Bestop Cargo Liners
Bestop Floor Liners
Bestop HighRock 4x4 Door Sill Entry Guards
Bestop HighRock 4x4 Element Doors
Bestop HOSS Window Storage Duffles
Bestop Soft Door Kits
Bestop Spare Tire Covers
Bestop Tinted Window Kits
Bestop Upper Fabric Half Doors
Jeep Backbone Security Enclosures
Lange Originals Wall Mounted Door Hanger
Kentrol Entry Guards
Your Jeep's top reflects personal style and protects against the elements of sun, rain, snow and mud and Bestop's soft tops are popular choices for replacing OEM soft tops. Whether it's a tough top that will be exposed to harsh elements or a refined one that you think fits your Jeep's style better, Bestop has the track record and the complete line to make your journey more memorable. A classic Supertop, Bikini or Halftop or Sunrider instantly transforms your 4x4, providing protection, ventilation, tinting and maintaining its shape through temperature fluctuations. Easy to attach and easy to get attached to, Bestop is the premium brand when it comes to Jeep tops. Shop Bestop Now


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Recent Examples of camerawoman from the Web
Our regional camerawoman, whose office sits on a hill overlooking one of the settlements.
But BBC camerawoman Rachel Price will probably need some new outerwear.
These example sentences are selected automatically from various online news sources to reflect current usage of the word 'camerawoman.' Views expressed in the examples do not represent the opinion of Merriam-Webster or its editors. Send us feedback.
First Known Use of camerawoman
CAMERAWOMAN Defined for English Language Learners
Definition of camerawoman for English Language Learners
: a woman who uses a camera to film something (such as a movie or television show)
Seen and Heard
What made you want to look up camerawoman? Please tell us where you read or heard it (including the quote, if possible).


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Call Us Toll Free
Email Us
Customer Services
Call Us Toll Free
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Customer Services
Was $90.00 Now $45.00
If you're looking for a special gift for a baby shower or a shawl for a christening, this stunning white blanket should be top of your list. Incredibly soft and lightweight, it's exclusively designed to feature a vintage-inspired diamond boarder with detailed scalloped edge. It's so lovely, we think it's the type of blanket you'll treasure and want to pass down the family in years to come.
Available in white
100% cotton
W47'' x 47''
Machine washable
STANDARD NON-TRACKABLE SHIPPING - $9.95 (unless a promotion has been applied) Please allow 6-10 business days for delivery. May require a signature.
STANDARD TRACKABLE SHIPPING - $13.95 (unless a promotion has been applied) Please allow 5-9 business days for delivery. May require a signature.
EXPRESS SHIPPING - $35.95 Please allow up to 4 business days for delivery. Order by 12pm EST Monday to receive by Friday. May require a signature.
SHIPPING OUTSIDE THE US - Please allow 14 business days for delivery. Click here for International shipping charges
Please select your preferred shipping option at checkout
The White Company pays all import taxes and duties on your behalf.
More shipping information including charges
Returns – FREE (for the US) – Smart label returns are convenient and easy.
Click here for more returns information, including smart returns labels
Here are some reviews from people who have bought from us
Just tick the gift-box option during checkout to make it even more special.
FREE standard delivery on orders over £50 (usually £4.95). For next day delivery, order before midday (£7.95).
Our delivery rates to Europe start from £7 and usually take 5 - 7 working days. If ordering from the US (rates from £15) or Australia (rates from £20), please allow 10 - 14 days for delivery.


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Few people look forward to a visit with their doctor.
Fewer still can truly say they have a relationship with one that they can count on.
Founder & Medical Director
Practice Manager
Welcome to Our Medical Center
At Insight LifeCare we focus on personal attention and service – something sorely missing with primary care doctors and the patient experience these days. Our approach brings old school medicine back and marries it with a modern day, one-on-one interaction with an expert physician without the hassles and long wait.
Front Office Manager
RN/Clinical Assistant
RN/Clinical Assistant
Our Promise to You
A return to the traditional values of medicine, with complete attention,
personalized physician relationships, and simply a better experience.


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*I may be affiliated with some of these recommendations, resources, and tools below. This means I will get a small commission if you purchase through my link.
Building Your Blog Foundation + Storing your Digital Assets
Beaver Builder – Beaver Builder is an easy-to-use website builder that helps you customize your website's main pages like your home page, about page, contact page, resources page, etc. Your website will look less cookie-cutter and optimized to the way you want. If you just want a blog design, then you won't need to use Beaver Builder. But if you want to build a website that caters to your needs, then you'll want to look into this!
Bluehost – My favorite hosting service that hosts a few of my websites. They have good tech support whenever you need help whether it's regarding a tech glitch or a hosting upgrade.
Dropbox – When you're blogging, you're going to have so many digital assets you want to keep organized. Dropbox starts with a free plan. You can use this to share across teams, host your content upgrades, or just store all your digital inventory. Trust me, you will have a lot and it can get out of hand (lol).
Ebates – Ebates is a cashback site and you get anywhere from 2-10% cash back if you purchase through their website. This is especially helpful if you buy tools from Amazon, Target, Walmart, etc. often. A few percentages might not seem a lot, but it can add up. I recommend adding this link to your Bookmarks.
Google Drive – Google Drive is free to use and it's become so invaluable that I use it both for my personal life and for work. Every rough draft of my blog posts, guest posts, or marketing plans are all written in my Google Drive.
Teachable – An easy-to-use to course or digital asset hosting service for your courses, membership sites, or e-books. They even come with a free plan!
WordPress – The content management system (CMS) I've been using for almost 10 years now. It's plugins and customizability is enormous. It's a one-click install if you're using Bluehost as your hosting service provider.
Zapier – Eliminate the routine and automate some of your processes and systems with Zapier. It integrates with almost all major tech service providers from ConvertKit, WordPress, to Trello. You can automatically create a new Google doc every time you create a new card in Trello. Sounds like magic?
Getting More Traffic + Subscribers
ActiveCampaign – My favorite email service provider and I've tried Mailchimp (which I hated) and Mailerlite (which isn't as robust). ActiveCampaign makes you feel like you're the real deal and if you're building your list, you need some place to store your contacts and fire out your automation sequences.
Facebook groups – There are groups for every interest group on Facebook. It's a great place to get started, get nosy on what other people are up to, or get started with finding clients.
KW Finder – This is similar to Google Keyword Planner, but it dives deep into specific numbers and how many monthly searches per keyword. It also gives you suggested and similar keywords you want to target as other options for every keyword you search. Takes the time out of brainstorming? I think yes.
Pinterest – Pinterest is a powerhouse for driving traffic because like Google, it's a search engine!
Popup Ally Pro – Want to build out your lead collection and marketing tool in-house instead of using something pricey like Leadpages? Popup Ally Pro is a plugin that helps you create embed forms and pop forms inside WordPress.
Quora – Quora is another powerhouse whether you want to learn from the most intelligent and experienced professionals or use it as a way to add value and then drive traffic back to your site. It's also a great source to check out when you want to know what questions people are asking in your industry and then answering it in a blog post.
Planning for Domination
Trello – Some people swear by Asana, but Trello is the first planning tool I've used. I use it to keep and break down all the micro-tasks I need to do to get to each bigger goal. My social promotion, editorial calendar, and course creation to-do lists are all inside Trello.
XMind – It's just hard to dive right into writing without ever planning. That's like selling without knowing your value proposition. XMind lets you mind map and structures your blog posts before you dive into writing.
Writing Like a Ninja
Evernote – Evernote is a tool that you use to organize your notebooks and write your blog posts.
Hemingway App – I use Hemingway to edit all my blog post drafts for any passive voice or long sentences before copying and pasting it into WordPress. It's free to use and while the name "app" may throw you off, it's actually something you use on your desktop and not iPhone.
Designing Graphics + Producing Videos
Canva – Canva is my go-to tool for designing my pins and blog graphics. It's free to use and 1000x faster and friendly to use than Photoshop.
iPhone – Don't forget this baby. I use mine to film any face-to-face portions of any video.
Optimizilla – Use this handy dandy tool to compress your image files before uploading them to WordPress. Large files will decrease your website loading time, which can result in you losing traffic.
Screencast-o-matic – At $15/year, this screen recording tool is unbeatable! You can also use it to film webcam videos or share both your face and screen at the same time. It comes with its own base of mini editing tools, which is enough for the starter.
YouTube – Since YouTube is a search engine, you can use it to drive traffic to your website. Otherwise, the video itself can be a much more engaging medium to deliver your content when you're ready to shine!


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The Handmaid's Tale
| Great and terrible
|On our shelf:
|—Chapter 34[1]
The Handmaid's Tale (1985) is a dystopian science fiction novel by Canadian author Margaret Atwood that presents a scary future in a religious totalitarian society in which women have lost all control over their reproductive lives.
Criticial reaction can be summarized as "Oh, this loony Canuck is overreacting about Christian influence in American politi-DEAR GOAT! WHAT HAVE WE DONE?"
It won the first Arthur C. Clarke Award in 1987.
Background to the story[edit]
Set in the
United States following its transformation into a theocracy "Republic of Gilead," it follows the tribulations of Offred, a "handmaid" who belongs to a man named Commander Fred (hence the name, "Of Fred"). The premise allowing Atwood to critique control of women's sexuality and reproduction is the fact that in the book's post-apocalyptic setting, most women have become infertile. Women lose all value as anything but walking incubators. Women are classified by their economic background and their ability to have children. Those that have financial status are, or become, "wives." If they are unable to conceive, they are given a "handmaid" whose job is to conceive and bear the wife's child. Any handmaid who has had three failed pregnancies is killed. All women are denied any education, and reading is a criminal offense for them.
This dystopian (or utopian to a fundamentalist) novel is apparently considered a handbook for how to run the country by some people. Gender treachery has the death penalty, as do many other crimes. The Jews have been forced to convert or go back to Israel, though many (perhaps all) of the boats were scuttled, while the Children of Ham (what black people are called in Gilead) have been resettled in North Dakota (it's implied they are being killed there). And all are safe under the ever vigilant Eyes of God.
Modern comparisons[edit]
In the Handmaid's Tale, women's only true role is that of reproduction. For the Elite, sex is not supposed to be an act of pleasure, but a job that demands minimal time spent in the act itself.[2] The clear ties to a Puritan existence, where pleasure and sin are conflated, is easily apparent.
Caste system[edit]
Women in Gilead are divided into castes based on their "job":
- Handmaids (The aforementioned walking incubators) wear red.
- Wives wear blue.
MaidsMarthas wear green.
- Econowives, wearing a mix of red, blue, and green, serve men who cannot afford a more elaborate
- Daughters wear white.
- Jezebels who are sterilized prostitutes.
- And so on.
Why you should read the book or see the movie[edit]
- Pat Robertson hates both.
There have been two adaptations of the book. The first, made in 1990, was a film starring Natasha Richardson, Faye Dunaway, and Robert Duvall, while the second, a TV series on Hulu starring Elisabeth Moss, Alexis Bledel, Yvonne Strahovsky, and Joseph Fiennes, premiered in April 2017, to critical acclaim.
See also[edit]
External links[edit]
- The Handmaid's Tale at TV Tropes
- See the Wikipedia article on The Handmaid's Tale.
- IMDb: The Handmaid's Tale (1990)
- IMDb: The Handmaid's Tale (2017)
- ↑ https://sushublog.wordpress.com/2010/04/23/the-handmaids-tale-margaret-atwood/
- ↑ And exceptionally creepy, no matter the reader's sexual tastes.


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Feyenoord - Shakhtar Donetsk
Champions League - 17 October 2017
Champions League – Follow the Football match between Feyenoord and Shakhtar Donetsk live with Eurosport. The match starts at 19:45 on 17 October 2017. Our live coverage lets you follow all the key moments as they happen.
Who will come out on top in the battle of the managers Giovanni van Bronckhorst or Paulo Fonseca? Find out by following our live matchcast.
Have your say by voting on who will win between Feyenoord and Shakhtar Donetsk? Enjoy some pre-match reading with related articles about these two Enjoy some pre-match reading with related articles about these two Football teams.
Head-to-head: see historical stats and visit our detailed profiles for Feyenoord vs Shakhtar Donetsk. Get all the latest on Football: fixtures, results and tables.
No comments for this event.


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Right now I make my own bc icing, which as we know takes a bit of time. Has anyone used the pre-made stuff? Like CK Products butter cream? It says it's crusting... is it any good? Does it arrive as a stiff consistency and you have to thin it to your desired consistency?
Looks for opinions and recommendations!!
1 reply
Whaddya mean bc takes a bit of time? If you're making the Wilton recipe a batch takes maybe 2 minutes once all the ingredients are measured out.


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another one down - week 5 run 2 beaten
Tried a new route today and was a little worried about how I was going to manage 8 minutes continuous running but the first 8 passed quite easily and I felt I could have gone further.
This first 8 had however been mostly down hill but the brief uphill was taken in stride.The five minute walk was a pleasant stroll down a back lane.
Then came the the 2nd and final 8, it started well but then I turned off the lane and hit an evil hill that felt like hell on earth and destroyed any feeling that this was going to be a simple run.
I am pleased to say though that with legs like lead and thighs complaining at every step I kept going and eventually my favoutite phrase was heard "slow to an easy walk to cool down" and another run had been defeated.
Up next the dreaded 20 minutes.
Featured Content
Join the NHS Couch to 5K community
Couch to 5K has been designed to get you off the couch and running 5km in just 9 weeksStart today!
Featured by HealthUnlocked


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Louis Weisdorf Copper Pendant for Fog and Morup
Weisdorf is best known for his lighting designs featured throughout Tivoli park in Copenhagen. Fog and Morup produced this lamp in a variety of finishes, copper being the most desirable. 8 Streamlined highly polished shades are arranged about the interior light source, creating lovely reflective surfaces. 14" H 12" Diameter.


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Girls Panties for Men: The Best Styles for Your Body Type
Just like with women, girl's panties for men can come in a variety of styles that are perfect for most any body type. Men's body types can be similar to women's, but the panties will always fit a little differently on the male bodies. To find that perfect fit, consider both your size and your hip shape. For heavy men, boy shorts and bikinis can be great options. The boy shorts would be best on a heavier man with a thick booty.
The most amazing panties and swimwear for men including the extreme male to female transformation designs are all at www.koalaswim.com
The bikinis are good if the butt is not as full around or the hips crease is hidden under a fold of excess skin. Briefs may ONLY look sexy on large men with a bit of a dip at the waist. Slim men can look cute in a thong or bikini. The thong is best for a cute little bubble butt. The bikini is best if you carry a little shapeliness to your hips. Muscular men can look great in thongs, bikinis, or boy shorts as a muscular frame generally fills the material better.
Speaking of material, there are so many fabrics to choose from for girls panties for men also! Lace, silk, satin, cotton, spandex, polyester to name a good selection. The fabric you pick is less dependent on your size and more so relies on your personality and how you wish to personify yourself. Lace is for the more feminine men; the men who are more gentle and sweet, and utilize innocence as a form of seduction. Men who enjoy silk or satin may be a little more fiery and passionate. These are men that do not just want to feel pretty. They want to feel sexy. Cotton is the best material for the simple guy who just likes the experience of feeling feminine. He may not even go out of his way to hook up with anyone or let them see his panties. Cotton girls panties for men are meant to be felt more than they are meant to be seen. Spandex is for the gym. Polyester is more for people who like to feel uncomfortable, am I right? There is a pair of panties for men all around the world for each individual male. Hopefully. the above advice helps in your selection.


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At least 200 people were stranded Thursday evening on a FrontRunner train that broke down near the Point of the Mountain.
"It's the most inconvenient location [for this to occur] on the entire line," said Utah Transit Authority spokesman Gerry Carpenter.
About 5:30 p.m., a southbound train broke down in the Jordan River Narrows area near the Point of the Mountain, a spot between the Draper and Lehi stations that blocks any other trains from going around the interruption and one that's difficult for UTA personnel to access.


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Practicing in the Appellate Courts is for the purpose of reviewing trial court judgments to correct of errors committed by the trial court, development of the law, achieve a uniform approach across courts, and the pursuit of justice, more generally. Appellate courts are not a forum to make a new case, but instead they determine if the rulings and judgment of the court below were made correctly.
Duncan Falls is an unincorporated community in southeastern Wayne Township, Muskingum County, Ohio, United States, located on State Route 60 south of the city of Zanesville. Although it is unincorporated, it has a post office, with the ZIP code of 43734. According to the Census Bureau the population for zip code 43734 is 1200.
Appellate Law Lawyers In Duncan Falls Ohio


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Put your ego, pride, and independence aside.
No one can do it alone.
So many times the answers are right there in front of your eyes.
Be positive, and address and acknowledge your emotions.
You can rise above the negativity
And re-shape the perceptions you have of the world around you.
When my life exploded into a fireball after Victor's death, I lost friends, my marriage, my house, my possessions, my formerly good physical and mental health, and countless other things that I had grown accustomed to as an everyday part of my life.
For consolation and clarity I resorted to my background upbringing in Christianity.
I also looked to others areas of spirituality for answers.
I found a very prfound answer in mythology.
The Rising of the Phoenix!
Putting my pride aside,
I vocalized my feelings with counselors and close friends.
I was determined to figure out what had started the fire that had consumed my life.
Finally I can honestly say that through many years of study, therapy, and learning…
Like the mythological Phoenix,
I rose out of the ashes.
I have always admired the Phoenix's immortality,
its ability to endure everything and anything,
and still strive.
Legend has it that the Phoenix was a creature of unparallel beauty, a paragon, and a model of absolute perfection.
To "rise like a phoenix from the ashes"
Means that you now have the skills to overcome seemingly insurmountable obstacles.
That is the very reason that I have chosen the Phoenix as the symbol for my life.
It is a beautiful and very powerful reminder of the life-changing events that had reduced me to ashes,
And then allowed me to "rise again."
We have much more in common as human beings than we are prone to believe.
We are all sailors in the same boat,
Looking for light and inspiration to guide us on our journey.
Any person,
of whatever persuasion,
can become a phoenix in his or her own struggles.
We must not remain mired in own labyrinths of self-pity and doubt.
No matter how abandoned, isolated, and lonely we may feel at times, things will get better.
Perhaps not today,
or tomorrow,
or when we think they should,
but with patience,
and thinking positively
we will get through the rough times.
Positives make individuals feel good about themselves and others.
They permeate emotions and create momentum for change.
Emotions, not statistics, data, or hard facts, are the energies that fuel thinking and choices in life.
In fact, an estimated 90% of decisions are emotionally derived.
If we feel hopeful and POSITIVE,
we will radiate POSITIVITY,
I want to encourage all of you reading this to make 2015 the year that you begin to combine the lessons of the Phoenix with a positive attitude.
Lets all work together to master the art of using positive thinking and positive behavior to manifest and achieve success.
I love this quote by Albert Einstein and feel that it is apropriate to post here:
Most of us are subjected to more than our daily dose of negativity.
Ultimately, we control our own thoughts and "we become what we think."
Remember the old adage… "You are what you eat."
Positivity and all positive thoughts come from our own individual perspectives and perceptions of the world and events around us.
We are responsible for what we think.
We control our positive and negative energies.
We need to find the positive in everything.
We must cultivate positivity, not only think about it.
Embrace the positives in life.
And remember the Phoenix!


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Seal and Stripe
Project: Ontario Mills Mall
- Contract: $240,000
- Size: 2.3 million sq ft
- Scope: Seal and Strip
- Application: (2) coats
Seal coating your asphalt is the necessary routine work required to keep your pavement as nearly as possible in it's original condition. This is synonymous to waxing your car and protecting the paint from the elements while helping to preserve it's original luster. There are also seals that are designed to rejuvenate the asphalt binders. A third category of seals provide new wearing surfaces at a fraction of the cost of new asphalt overlays.
These all can be a highly disruptive processes, and our Project Managers are acutely aware of public safety and the impact upon business. Our team coordinates all aspects of this endeavor so the process can proceed as smoothly as possible.


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On the day DENNIS RODMAN was supposedly settling down, he brought chaos -- and his autobiography -- to midtown Manhattan.
Mr. Rodman, the Chicago Bulls basketball star, had said he was in town to marry his girlfriend, Stacy Yarborough. He arrived in a police-escorted horse-drawn carriage at Barnes & Noble on Fifth Avenue yesterday in a lacy white wedding dress with long gloves and a veil over his neatly coiffed, bright orange hair.
The bridegroom (or was he the bride?) was surrounded by a group of beautiful ushers (or were they bridesmaids?), all in black tie. The 6-foot-8, 210-pound forward, his tattooed biceps glistening beneath see-through sleeves, waved to hundreds of cheering spectators as he made his way to the bookstore to autograph copies of his autobiography, ''Bad as I Wanna Be'' (Delacorte), which has been a best seller since spring.
Asked whether he had indeed married, Mr. Rodman shrugged his shoulders. He said he was going to Rome on his honeymoon, ''me and someone else.''
Miss Yarborough, who dances at Scores, a nightclub on East 60th Street, was nowhere to be found. Lonnie Hanover, a spokesman for the club, said he did not know her plans.Continue reading the main story