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Cardiovascular Disease
Cardiovascular disease (CVD) refers to a group of related diseases and conditions of the heart and blood vessels linked by a common set of risk factors leading to atherosclerosis. Atherosclerosis is the gradual build up of fatty material 'atheroma' in the walls of arteries leading to narrowing and stiffening of the arteries. Cardiovascular conditions include:
- Coronary heart disease (CHD) is a disease in which the coronary arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the heart muscle. This leads to angina, heart attack and heart muscle damage
- Cerebrovascular disease is a disease in which the cerebral arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the brain. This leads to transient ischaemic attacks (TIA) and stroke.
- Peripheral vascular disease is a disease in which the arteries of the arms and legs are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to arms and legs. This leads to claudication.
Other conditions such as vascular dementia, chronic kidney disease, cardiac arrhythmias, sudden cardiac death, and heart failure are related because they either share common risk factors or have an impact on the prognosis and outcome of CVD.
Nearly five million people in the UK aged 16 and over are a estimated to suffer from CVD. This means that about every 7th adult in the UK suffers from a cardiovascular condition. The older people get the more likely they are to develop CVD. .
Deaths from CVD have fallen by over a third between 2001 and 2010, but CVD is still one of the main causes of death in the UK and accounts for about one-third of all deaths. In 2011, almost 160,000 people in the UK died from CVD. 74,000 of these deaths were caused by coronary heart disease - the UK's single biggest cause of death.
A number of common risk factors are known increase the risk of arthrosclerosis leading to CVD. These risk factors can be divided into three broad groups.
- Non-modifiable and non-behavioural risk factors including age, sex, family history/genetic factors, ethnicity and deprivation are considered to estimate the overall risk of CVD for an individual.
- Modifiable and behavioural risk factors such as smoking, physical inactivity, poor diet, obesity and binge drinking are reflecting individual circumstances and choices which can be prevented or changed by lifestyle changes.
- Conditions associated with an increased risk such as hypertension (blood pressure) , hyperlipidaemia (blood fats), diabetes and atrial fibrillation can be prevented or reversed in their early stages but usually need medical treatment.
This topic links with the following JSNA topics:
1. What are the key issues?
CVD and in particularly CHD mortality has declined steeply over the past decade with a decrease of 58% in early mortality from CHD. Overall CVD mortality in Stockton is similar (men) or just below (women) the national average. Early mortality (<75) however is higher in men. CHD mortality is lower than national average but again early mortality in men is higher. Early mortality from stroke is higher and later mortality is similar to England.
High prevalence The prevalence of CVD in Stockton is high for some but not for all associated diseases i.e. the prevalence of CHD, stroke and atrial fibrillation is higher compared to England average whereas the prevalence of diabetes and chronic kidney disease is lower.
Undiagnosed disease Prevalence figures are underestimating the true extend of disease because of a significant proportion disease remains undiagnosed.
Demographic change The future prevalence of CVD will be influenced by a range of different factors such as demographic change with an older population and increasing BME population as well as a significant proportion of the population still living in deprived areas.
Lifestyle choices and behaviours such as the local and national increase in obesity and physical inactivity and a high level of binge drinking in the population are also likely to contribute to a higher CVD prevalence.
Prevention and early identification of CVD is crucial. The NHS Health Check aims to identify risk factors for CVD and refer those at higher risk to lifestyle services and treatment. The uptake of the NHS health check is below the national target. Uptake is particularly low in men and people living in deprived areas.
Availability and access to services for advice, support and treatment following the identification of risk factors is inconsistent due to lack of awareness and information about lifestyle services and management of long term conditions in primary care.
Treatment of risk factors for CVD, CHD, Stroke and associated conditions in primary care varies considerably between GP practices.
Treatment and care in secondary care varies compared to similar CCGs.
2. What commissioning priorities are recommended?
Commissioning priorities stretch across the five key areas identified by the Cardiovascular Disease Outcomes Strategy including
- prevention and risk management,
- identification of high risk individuals and case finding,
- early management and secondary prevention,
- acute care and
- rehabilitation and end of life care.
Prevention and risk management
- Prevent and reduce smoking, obesity and binge/ higher risk drinking in population.
- Identify clear and easily accessible pathways into lifestyle services and follow up in primary care for those identified as high risk or with CVD or associated conditions.
Identification of high risk individuals and case finding
- Improve uptake of the Healthy Heart Check (NHS health check) for the general population aged 40-74 but particularly among men and those living in deprived areas to identify at risk patients and those with undiagnosed disease
- Ensure consistent follow up of those identified as at high risk of CVD to identify and manage disease early – reducing exemptions and variation between practices
Early management and secondary prevention
- Ensure a minimum standard of disease management for hyperlipidaemia, hypertension, and diabetes in every general practice – reducing exemptions and variation between practices
- Prevent repeat CVD events through effective secondary prevention including lifestyle changes and management of hyperlipidaemia, hypertension, and diabetes in every general practice
Acute care and rehabilitation
- Ensure 24/7 access to effective treatment for acute CVD events
- Ensure access to high quality ward and community based rehabilitation following a CVD event
End of life care
- Offer appropriate end of life care for patients with CVD
NICE guidance CG95 Chest Pain of Recent Onset recommends use of CT calcium scoring as the first-line diagnostic investigation for CAD, and the removal of exercise ECG to diagnose or exclude stable angina for people without known CAD. These changes will need to be reflected in locality pathways; (Update 2015 TBC)
Anticoagulant therapy is embedded in primary care, but will require ongoing close monitoring moving forward; (Update 2015 GP practices are prescribing and monitoring anticoagulant therapy.)
Patient involvement. It will be important to ensure systematic patient involvement on CVD moving forward, possibly through Local Health Watch; (Update 2015 a population survey on the NHS health check/ Healthy Heart Check has been conducted through Stockton Borough Council in 2015)
Undiagnosed disease There will be benefit in utilising the Health Inequalities National Support Team (HINST) approach to active disease register management and QOF support for GP practices as recommended in 'Closing the gap - finding the missing thousands'; As part of this it will be important to ensure that this target group are engaged to consider reasons why they have not previously engage/taken up offers of support; (Update 2015 GP practices are maintaining disease registers and offer clinical follow up.)
The NHS Health Checks programme is currently undergoing an economic evaluation and also an evaluation of compliance – it will be vital to ensure the learning from this is adopted to improve this programme further. (Update 2015 The evaluation by Teesside University concluded that the Healthy Heart Check is a cost effective universal risk assessment programme which should be continued, the evaluation also found that compliance could be improved if patients received clearer communication and advise as well as support to make lifestyle changes)
3. Who is at risk and why?
A number of common risk factors are recognised to increase the risk of an individual to develop atherosclerosis leading to CVD. The more risk factors a person has the higher is the risk of developing CVD. Although some risk factors cannot be changed, the risk of developing CVD can be reduced by prevention, lifestyle changes and medical treatment.
Non modifiable and non behavioural risk factors
Age The risk of CVD increases with age. The health survey for England in 2011 has shown that 3.3% of men and 4.8% of women aged 16-24 suffer from CVD compared to 53.8% of men and 31.1% of women aged over 85.
Gender In people aged 35 and over 13.9% of men and 13.4% of women suffer from CVD. Men are more likely to develop CVD at an earlier age and to suffer from more than one condition.
Family history/ genetic factors There is an increased risk if a first-degree blood relative has had CVD before age 55 (male relative) or 65 years (female relative).
Ethnicity The risk for CVD is higher is some BME groups, whilst it is lower in others. The Health survey for England found that Irish men and women were most likely to have been diagnosed with CVD. People with South Asian origin are one and a half times more likely to die early from coronary heart disease than the general population. There are also differences in specific conditions and risk factors. People from black African and black Caribbean ethnic groups are more likely to develop hypertension, whilst South Asian and black ethnic groups have an up to 6 times greater likelihood of developing diabetes. The risk of stroke is highest in South Asian, African and Caribbean populations.
Deprivation CVD is more common in adults living in the more deprived areas. CVD mortality of those living in the most deprived areas is 1.8 times higher than in people in the least deprived areas.
Modifiable and behavioural risk factors and conditions
Smoking is a major risk factor for CVD. About 20% of all CVD and 15% of all deaths are caused by smoking. Smoking has a number of harmful effects on the body which increase the risk for CVD. It damages the lining of the arteries thus leading to atherosclerosis and increases the levels of blood clotting factors such as fibrinogen. The carbon monoxide in tobacco smoke also reduces the amount of oxygen in the blood and in addition nicotine stimulates the body to produce adrenalin which accelerates heart rate and raises blood pressure.
Physical inactivity contributes to CVD, particularly to coronary heart disease and stroke as well as being a major cause of obesity, Type 2 diabetes and high blood pressure. Regular physical activity reduces early deaths even among those with an otherwise high CVD risk profile or with established CVD. Physical activity reduces the likelihood of developing of coronary heart disease and stroke and reduces long term blood pressure in both those with raised and with normal blood pressure.
Diet A diet based on fruit, vegetables, pulses, wholegrain foods, fish and poultry is consistently associated with lower levels of CVD risk factors and fewer deaths from CVD. Vegetarian and 'Mediterranean' diets are also associated with lower CVD mortality. Encouraging people to eat more healthily has been shown to be effective in reducing blood pressure, cholesterol and subsequently CVD. Salt intake is a key determinant of CVD in the UK, mainly because of its effect on blood pressure. High levels of salt in the diet are linked to high blood pressure which, in turn, can lead to stroke and coronary heart disease.
Obesity As well as being an independent risk factor for CHD, obesity is a major risk factor for serious chronic diseases such as Type 2 diabetes, hypertension and high blood fats (hyperlipidaemia).
Alcohol The relationship between alcohol consumption and cardiovascular diseases is complex. Light to moderate drinking can have a beneficial impact on reducing ill health and death from coronary heart disease and ischaemic stroke. However, the beneficial protective effect of drinking disappears with higher levels of drinking including binge drinking.
Conditions associated with an increased risk
Conditions such as hypertension, raised cholesterol, diabetes and chronic kidney disease can be prevented or reversed in their early stages but often need medical treatment.
Hypertension (High blood pressure) is generally defined as blood pressure over 140/90 mmHg. Uncontrolled hypertension damages the wall of the arteries and increases the risk of CVD. The risk of hypertension increases with age. Whilst only 7.4% of people aged 16 to 24 years have hypertension, 44.0% of people aged 55 to 64 years and 72.6% of people aged 75 years or older had hypertension.
Diabetes is a disease resulting from high levels of glucose in the blood due to a imbalance between insulin and glucose. High blood sugar levels damage the walls of the arteries, and make them more likely to develop fatty deposits (arteriosclerosis) leading to CVD. People with diabetes are more likely to suffer from a heart attack (48%), heart failure (65%) and stoke (25%) and up to 4 times more likely to develop peripheral vascular disease.
Hyperlipidaemia (High blood fats) is defined by high levels of LDL-cholesterol and other fats such as triglycerides cause in the blood causing fatty deposits (arteriosclerosis) in the artery walls. The risk is particularly high if there are low levels of protective HDL cholesterol. Hyperlipidaemia leads to a higher coronary heart disease (CHD) risk, but CVD risk and life expectancy is restored to near normal with early preventive treatment.
Atrial fibrillation AF is the most common form of irregular heart beat (arrhythmia) and can increase the risk of stroke five to six-fold.
4. What is the level of need in the population?
Risk prevalence
The population of Stockton has a comparably young age profile but also an increasing proportion of people over 60. There is a slightly larger female population (51%).
The population is predominately white British (93.4%), however there are minorities with white Irish and other white background (1.2%), south Asian (2.5%), other Asian (1.1%) and black African (0.5%) background. The Asian and south Asian populations are the largest BME groups.
Since 2004, the extend deprivation in the population of Stockton-on-Tees has decreased in comparison to other local authority areas in England. However, there are areas with a high proportion of people living in poverty. Relative deprivation seems to have improved particularly for older people.
Modifiable and behavioural risk factors
Some behavioural risk factors in Stockton are slightly more common compared to the English population but not significantly worse. 19.8% of the population in Stockton smoke compared to 18.4% in England. 58.4% of adults in Stockton are physically active compared to 56% in England. 26.1% of the population in Stockton is obese and 63.6% are considered overweight compared to 23% and 63.8% respectively in England. It is estimated that 28% of people over 16 in Stockton engage in binge drinking compared to 20% in England.
Figure 1 Health Profile. Stockton-on-Tees. PHE 2015
When comparing the behavioural risk factors of people living in Stockton and Hartlepool CCG in 2014 the risk profile was high. 25.2% of the CCG population smoked compared to 19.5% nationally. 66.1% of adults were overweight or obese compared to 63.8% in England. 32.2% of adults were regarded as physically inactive compared to 28.5% in England. Only 21.1% were estimated to eat at least 5-a-day of fruit or vegetable compared to 28.7% in England. When comparing behavioural risk factors in Stockton and Hartlepool CCG to the average of a number of CCGs with similar population the proportion of binge drinking, smoking, unhealthy eating and low physical activity was higher (worse). For more detail please see the risk profiles at the Cardiovascular Intelligence network.
Figure 2 CVD risk factors comparing HAST CCG (yellow) to 10 comparator CCGs (blue). CVD commissioning for value packs 2014.
15% (43,658 people) of the registered GP population in Hartlepool and Stockton CCG was diagnosed with hypertension. The proportion of people diagnosed with hypertension varied between GP practices ranging from 2% to 22%. The estimated prevalence is 25.6%. This means that 30,000 people with hypertension may not have been diagnosed and therefore do not receive treatment.
Diabetes Type 2
5.8% (16,881) of the registered GP population in Hartlepool and Stockton CCG was diagnosed with diabetes. The proportion of people diagnosed with diabetes varied between GP practices ranging from 0.4% to 7.2%. The estimated prevalence is 7.2%. This means that across the CCG area 4075 patients (1.4%) may have undiagnosed and untreated diabetes. Among people with diabetes the risk of stroke was 38% higher and the risk of a heart attack was 72% higher compared to the general population.
Figure 3 Diabetes prevalence. Source NCVIN 2014. http://www.yhpho.org.uk/ncvincvd/pdfs/Diabetes/00K_Diabetes.pdf
Atrial fibrillation
1.8% (5239) of the registered GP population in Hartlepool and Stockton CCG was diagnosed with atrial fibrillation. This is slightly higher than in comparable CCGs (1.7%) and England (1.6%). More than a quarter (26.3%) of all stroke patients admitted to hospital in Hartlepool and Stockton had a secondary diagnosis of atrial fibrillation. This proportion is similar to national average.
Disease prevalence
Coronary Heart Disease
4.2% (12,225 people) of the registered GP population in Hartlepool and Stockton CCG was diagnosed with coronary heart disease compared to 3.3% in England. The proportion of patients diagnosed with CVD varied between GP practices ranging from 0.1% - 6.9%. The estimated prevalence is 5.3%. This means that 1.1% (3201 patients) of the practice population may have undiagnosed coronary heart disease. 0.8% of the registered GP practice population were diagnosed with heart failure compared to 0.7% in England.
Figure 4 Cardiovascular disease prevalence. Source. NCVIN 2014 http://www.yhpho.org.uk/ncvincvd/pdfs/Heart/00K_Heart%20Profile.pdf
Cerebrovascular Disease
2% (5709 patients) of the registered GP practice population in Hartlepool and Stockton CCG had a stroke or TIA compared to 1.7% in England. The proportion of patients who had a stroke varied between GP practices ranging from 0.1% to 2.6%. The estimated prevalence is 2.2% (6520 patients). Atrial fibrillation was diagnosed in 1.8% compared to 1.5% in England.
Figure 5 Stroke/ TIA prevalence. Source. NCVIN 2014
Kidney Disease
4.3% (9874 patients) of the registered GP population in Hartlepool and Stockton CCG have been diagnosed with chronic kidney disease which is similar to the English average. The proportion of patients with chronic kidney disease varied between GP practices ranging from 0.2% to 8%. The estimated prevalence is 6.0% (13,777 patients).
Figure 6 Chronic kidney disease prevalence. Source NCVIN 2014 http://www.yhpho.org.uk/ncvincvd/pdfs/Kidney/00K_Kidney.pdf
The mortality rate for cardiovascular disease in Stockton for men (350/100 000) is below the regional average and similar to England. CVD mortality in women (236/100 000) is below the regional and national average.
Figure 7 CVD mortality rate all age 2010-12. Source: BHF Cardiovascular disease statistics 2014
The early mortality rate for cardiovascular disease in Stockton for men (116/100 000) is below the regional average but above the England rate. CVD early mortality in women (47/100 000) is below the regional average and similar to England.
Figure 8 CVD mortality rate <75 2010-12. Source: BHF Cardiovascular disease statistics 2014
Between 2001 and 2012 early mortality (<75) from CVD has decreased significantly, in particular for women. The gap between Stockton and England has almost disappeared.
Coronary heart disease
The mortality rate for coronary heart disease in Stockton for men (182/100,000) and women (84/100,000) is below the regional and national average.
Figure 9 CHD mortality rate (all age) 2010-12. Source: BHF Cardiovascular disease statistics 2014
The early mortality rate for coronary heart disease in Stockton for men (69/100,000) is below the regional but above the national average. The early mortality rate for women (23/100,000) is just above the regional rate and above the national rate.
Figure 10 CHD mortality rate <75 2010-12. Source: BHF Cardiovascular disease statistics 2014
The mortality rate for people under 75 years for coronary heart disease in Hartlepool and Stockton was 46.2 per 100,000. Between 2002 and 2012 the coronary heart disease mortality rate has decreased by 58% and is now similar to the early mortality regionally but still higher than the national average. The early mortality rate from CHD in Hartlepool and Stockton has decreased faster than the regional and national rate.
Figure 11 Early mortality rate (n/100.000) from CHD 2002-12 in Stockton and Hartlepool CCG. Source: PHE, NCIN Cardiovascular disease profile. Heart disease
The mortality rate for people under 75 years for stroke in Hartlepool and Stockton was 19 per 100,000 compared to 14.1 in England in 2012. The later mortality rate for stroke was 661.4 per 100,000. The early and later mortality rates for stroke have decreased nationally, regionally and particularly fast at local level. The gap between Stockton and Hartlepool and national average has narrowed.
Figure 12 Stroke mortality under and over 75 years in Stockton and Hartlepool CCG. Source: PHE, NCVIN Cardiovascular disease profile Stroke
5. What services are currently provided?
Lifestyle services such as stop smoking services, weight management, dietary advice, exercise referral programmes, drug and alcohol services are offered by local authorities and general practice. General practices in Stockton and Hartlepool have recorded the smoking status of 88.4% of patients and offered support and treatment to 84.7% of those in 2012-13.
NHS Health Check – Healthy Heart Check
The NHS Health Check programme – locally branded as the Healthy Heart Check – is a national risk assessment programme for CVD. It aims to prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia through early detection, lifestyle advice and referral for further management of risk factors and conditions which can lead to the development of CVD. Everyone between the ages of 40 and 74, who has not already been diagnosed with one of these conditions, will be invited once every five years to assess their risk of developing CVD.
In Stockton 50,070 people are eligible for an NHS Health Check between 2013 and 2018. Between April 2013 and September 2015 more than half (33,203; 66%) of the eligible population has been invited and 25% (12,786) of the eligible population has already received an NHS health check.
Figure 13 NHS Health Check/ Healthy Heart Check invitations and uptake April 2013- September 2015. Source: PHE NHS health check.
Further analysis by gender showed that a higher proportion of women is eligible for NHS Health Checks/ Healthy Heart Checks (HHC) between 2013-18. In 2014/15 a higher proportion of eligible women has already been invited and also received their HHC.
Figure 14
The delivery of the NHS health check / Healthy Heart Check programme in Stockton has focussed on reducing health inequalities through prioritising and incentivising invitations and health checks for the eligible population living in the most deprived areas.
Local data shows that the uptake of the health check varies and is generally lower in men and in people living in more deprived areas. There is also considerable variation in the delivery and uptake of the programme between GP practices
Primary Care
Patients with hypertension, high blood fats, diabetes, atrial fibrillation, CHD, stroke and peripheral arterial disease are mostly identified and treated in primary care. Many GP practices offer nurse-led clinics for the management of chronic disease and secondary prevention in those who have had a heart attack or stroke.
Treatment and lifestyle advice for patients with hypertension is measured by the Quality Outcomes Framework. On average GP practices within the CCG compared well to the English average in giving lifestyle advice and management of blood pressure but did less well on performing cardiovascular risk assessments. When comparing to similar CCGs general practices in Stockton and Hartlepool could improve the following: recording of blood pressure in those over 40, management of blood pressure and provision of brief interventions and physical activity assessments. Please see the profiles at the Cardiovascular Intelligence network for further information. (http://www.yhpho.org.uk/ncvincvd/pdfs/Risk/00K_Risk.pdf)
Treatment and lifestyle advice for patients diagnosed with diabetes was similar to national average although there was significant variation between practices. For more detail please see the risk profiles at the Cardiovascular Intelligence Network. (insert link to
Care and treatment of patients with CHD in Hartlepool and Stockton CCG was similar or slightly better than national average although there was significant variation between practices. When comparing to similar CCGs the treatment for high blood pressure, hyperlipidaemia and anti platelet therapy could be improved for those with CHD and following a heart attack. For more detail please see the CHD profile (http://www.yhpho.org.uk/ncvincvd/pdfs/Heart/00K_Heart.pdf)
Care and treatment of patients with CHD in Hartlepool and Stockton CCG was similar than national average although there was significant variation between practices. For more detail please see the CHD profile (http://www.yhpho.org.uk/ncvincvd/pdfs/Kidney/00K_Stroke.pdf)
Chronic kidney disease
Care and treatment of patients with chronic kidney disease in Hartlepool and Stockton CCG was similar than national average although there was significant variation between practices. For more detail please see the CVD profile for kidney disease (http://www.yhpho.org.uk/ncvincvd/pdfs/Kidney/00K_Kidney.pdf)
Secondary Care
Secondary care services for the population in Stockton and Hartlepool are provided at the University Hospital of North Tees and the University Hospital of Hartlepool as well as at the James Cook University Hospital in Middlesbrough.
The cardiology department at UHNT offers a full range of services
- Rapid access chest pain clinic where patients are seen within two weeks of referral for further investigations and treatment.
- Cardiac investigations unit where patients receive diagnostic investigations including ECG, 24/48 hour ECG and blood pressure monitoring, echocardiography, stress echocardiography as well as pacemakers and loop recorder follow ups. The hospital also has a cardiac CT scanner.
- Cardiology day unit where coronary angiograms, transoesophageal echocardiograms, cardioversions, loop recorders and pacemaker implantations are carried out. This service is partly located at the University Hospital of Hartlepool.
- Cardiac rehabilitation providing a structured community based rehabilitation programme in four phases including education, exercise and lifestyle changes
- Community heart failure specialist nurses providing ongoing care and support to discharged patients in close cooperation with the patients GP.
Emergency admission rates for CHD have declined since 2002, with a faster decline locally. The admission rate for CHD (561/100 000) for Hartlepool and Stockton patients was just below the national average of 575/100 000) in 2012/13.
Emergency admission rates for heart failure has decreased by 35% over 10 years and is now significantly lower than the England average with 110 admissions per 100 000 population.
Figure 15 Emergency Admission rates for coronary heart disease and heart failure in Stockton and Hartlepool CCG. Source PHE, NCIN Cardiovascular disease profile Heart
Time from calling for help to primary coronary intervention (PCI) for eligible patients in Durham, Darlington and Tees in 2012/13 was on average 94 minutes compared to a national average of 112 minutes. 81.3% of patients received PCI within 120 minutes.
A comparison of treatment indicators in secondary care between 10 similar CCGs shows that patients in Hartlepool and Stockton CCG are more likely to receive an angiography (women and men) and Coronary Artery Bypass Graft (women) and are staying in hospital for longer for angioplasty (women) and CABG (women and men)
The Stroke Service at UHNT offers
- assessment clinics for TIA and stroke and
- thrombolysis to those eligible for treatment.
- Physiotherapy, speech and language and occupational therapists are involved early in treatment and care to support recovery whilst at the hospital.
- A community stroke team of physiotherapists, occupational therapists, speech and language therapists, dietitians, psychologist, rehabilitation assistants, specialist nurses and Stroke Association family and carer support officer supports patients at home during the weeks and months following discharge.
Emergency admission rates for stroke have changed only little since 2002/3. In 2012/13 emergency admission rates for stoke in Hartlepool and Stockton (199/100,000) were significantly higher than in England.
Figure 16 Hospital admission rate for stroke 2002/3-2012/13. Source: PHE, NCVIN Cardiovascular disease profile Stroke
6. What is the projected level of need?
There is currently no authoritative information on the estimated or projected incidence, morbidity and mortality of cardiovascular disease.
7. What needs might be unmet?
Health needs of vulnerable or at risk groups
Health needs for CVD are generally well understood, however there are specific risk profiles and barriers to access services for vulnerable or at risk groups e.g. BME, migrants, people with learning difficulties which are currently not sufficiently recognised and addressed through mainstream care and interventions.
Lifestyle interventions and services
The high and still increasing proportion of overweight and obese people in the population is expected to lead to increasing numbers of people with diabetes. A high proportion of people in Stockton engage in binge drinking which is a risk factor for CVD. There is a need for effective and accessible lifestyle interventions and services that meet the demand.
Undiagnosed disease
The gap between the actual and estimated prevalence for hypertension, diabetes, CHD, stroke and chronic kidney disease indicates that there are high numbers of people with undiagnosed and untreated disease.
Screening for disease
The uptake of the NHS Health Check/ Healthy Heart Check varies and is generally lower in men and in people living in more deprived areas. There is also considerable variation in the delivery and uptake of the check between GP practices.
Management of risk
The referral pathway into lifestyle services following the identification of risk is not well understood by patients and practice staff. Documentation of risk management through lifestyle services and primary care is not linked to health check.
Quality and variation in care
Treatment and care for patients with hypertension, diabetes, CHD, Stroke and chronic kidney disease varies considerably between GP practices and are only partially explained by differences in practice population. Admission, interventions and outcomes in secondary care – compared to similar CCGs show the potential for improvement particularly for cost and length of stay
8. What evidence is there for effective intervention?
Public Health England
NHS Health Check: our approach to the evidence. PHE 2013
NHS Health Check LGA Frequently Asked Questions Update. PHE 2013
The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management, PHE 2012
NICE Guidance, Quality Standards, Pathways
Prevention and lifestyle change
Prevention of cardiovascular disease. NICE PH25 (2010)
Identifying and supporting people most at risk of dying prematurely. NICE PH15 (2008)
Community engagement to improve health NICE PH9 (2008)
Behaviour change: the principles for effective interventions NICE PH6 (2007 updated 2014)
Tobacco: harm-reduction approaches to smoking. NICE 45 (2013)
Smoking cessation in secondary care: acute, maternity and mental health services. NICE48 (2013)
Obesity: working with local communities. NICE PH42 (2012)
Managing overweight and obesity in adults – lifestyle weight management services NICE PH53 (2014)
Physical activity. NICE pathway
Physical activity: brief advice for adults in primary care. NICE PH44 (2013)
Exercise referral scheme to promote physical activity. NICE PH 54 (2014)
Alcohol use disorder NICE pathway
Alcohol use disorders – preventing harmful drinking NICE PH24 (2010)
Management of risk factors
Hypertension- Management of Adults with Hypertension. NICE CG127 (2011)
Atrial fibrillation- the Management of Atrial Fibrillation NICE CG180 (2014)
Lipid modification NICE pathway
Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE CG181 (2014)
Preventing type 2 diabetes: population and community-level interventions. NICE PH35 (2011)
Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. NICE PH38(2012)
Atrial Fibrillation. NICE Pathway
Management of atrial fibrillation. NICE CG180 (2014)
Clinical management of CVD
Acute coronary syndromes pathway
Chest Pain of Recent Onset. NICE CG95 (2010)t
Management of Stable Angina. NICE CG126 (2011)
Unstable Angina and NSTEMI. NICE CG94 (2010)
MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction. NICE CG172 (2013)
Chronic Heart Failure. NICE CG108 (2010)
Stroke Rehabilitation CG162 (2013)
Lower limb peripheral arterial disease. NICE pathway
9. What do people say?
In early Oct 2015, we surveyed 139 Stockton residents through the Viewpoint online survey. The residents told us that:
- Six in ten of you in the target age range did not know that everyone aged between 40-74 was entitled to a free health Heart Check. People suggested to call for better promotion of availability of Free Healthy Heart Check.
- Only 7 in 10 of those who had been offered a Check went ahead and has it done at their GP and also some at workplace or local library.
- 99% of you who has a check said you were happy with the venue for and date of your appointment and 95% said they were happy with the time it was scheduled for.
- 9 in 10 received their check results afterwards and 85% of you who said that felt that they were clearly explained to you. Of those who has a check, 1 in 3 of you said you had changed your diet afterwards, 1 in 4 of you said you had become more active and 1 in 5 had lost weight.
- Most of you who offered suggestions about improving the way that free healthy heart checks are delivered – majority said GP opening hours could usefully be more flexible.
- Whilst 8 in 10 of you who has a check were not referred to another services for care and/or information after the check. However, majority those have been referred to other services of care or information after the check felt that the information was useful.
10. What additional needs assessment is required?
The overall health and care needs of people with CVD are generally well established. Care standards have been defined by NICE.
Additional needs assessments should focus on the understanding of risk of CVD, access and uptake of early identification and interventions within the most deprived and/or vulnerable groups of the population. The information could be useful in understanding how best to engage with those at risk who are currently not or not complying once identified.
Key contact
Name: Dr Tanja Braun
Job title: Consultant in Public Health
Email: firstname.lastname@example.com
Phone number: 01642 745286
PHE. National Cardiovascular intelligence network. Key facts: Cardiovascular disease. 2014. http://www.yhpho.org.uk/default.aspx?RID=185796
British Heart Foundation.
PHE. Health Profile http://www.apho.org.uk/resource/view.aspx?QN=HP_RESULTS&GEOGRAPHY=C5
PHE. National Cardiovascular intelligence network. Commissioning for value packs: Hartlepool and Stockton CCG. http://www.yhpho.org.uk/ncvina/pdfs/00K_SlidePack.pdf
PHE. National Cardiovascular intelligence network. Commissioning for value packs: South Tees CCG http://www.yhpho.org.uk/ncvina/pdfs/00M_SlidePack.pdf
PHE. National Cardiovascular Intelligence Network. Cardiovascular Disease Profiles. 2014. http://www.yhpho.org.uk/ncvincvd/Default.aspx
LAPE. Local alcohol profiles for England. http://www.lape.org.uk/LAProfile.aspx?reg=X25003AE
DH. Living well for longer: a call to action on avoiding premature mortality. 2013
DH. CVD Outcomes Strategy: Improving outcomes for people with or at risk of cardiovascular disease. 2013
DH. Free NHS Health Check. Helping you prevent heart disease , stroke , diabetes, kidney disease and dementia. 2013


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Lo, Yu-Hwa
Professor, Electrical and Computer Engineering
Bio: Yu-Hwa Lo came to the Jacobs School in July of 1999. He has established a new lab to investigate biologically inspired photonic systems. A member of the Materials and Device Layer for the California Institute of Technology and Telecommuncations, he is collaborating with Professors Andy Kummel and William Trogler (Chemistry and Biochemistry) on early-warning biosensors. He is responsible for designing infrared photon counters in a joint effort with IBM's Almaden Research Center to build a quantum-communications system. He was Associate Professor of electrical engineering at Cornell University, prior to coming to UCSD. He received his Ph.D. from UC Berkeley in electrical engineering in 1987.

subset: commoncrawl


text:
Forex vba excel
Title of archive: excel macro for turtle trading Date added: 6.06.2012 Size: 35.92 MB Type of compression: zip Total downloads: 4606 Uploaded by: retraithroug File.
Download Forex Indicator
Programando Excel Vba Para Leigos + 3500 Planilhas De ExcelI found a great VBA script that can do this for any currency pairs that you.Tag: excel Free Forex Historical Data Update for May 2016 (2nd Update) Posted on 15 May, 2016 in Forex Historical Data, Quotes Update.Trading Indicators for Excel is an Excel add-in comprising a library of technical analysis functions for financial market data analysis.To get stock quotes in excel,. a couple of dates, and then Excel import the daily forex bid.
Interactive Brokers Excel Trader 1.6 - YouTubeThis is a discussion on FX platform selection: VBA algorithm with API within the First Steps forums, part of the.The Trading Journal Spreadsheet is an easy to use, extremely informative (trade tracking) spreadsheet.Jun, trade signals excel against. Calculated by using the calculator spreadsheet for forex lot sizing calculator excel spreadsheet with.
I am using the following VBA code to download yahoo historical stock quotes.
Forex Historical Exchange Rate
Microsoft Visual Basic LogoI read your documentation but I had a question regarding the VBA code.
Data Range in ExcelLearn to Build an Automated Trading System in Excel for Stocks, ETFs and Forex.
Forex trading system excel. A supplementary statistical data and forex trading using excel vba and traders first enter forex options trading analysis system.This article describes how to create currency pair (Forex) icons using country flag images for use with an Excel Ribbon Gallery.
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Forex Stop LossThis spreadsheet is designed to help you import the historical foreign exchange rates for any currency pair in the excel sheet.
Of the software system for excel spreadsheet binary options within excel adapter from wikipedia.I can get live data from a Metatrader forex chart through DDE link to excel.
Exchange Rates Historical DataA reader comments on trading using Excel VBA and Factor Model. a little bit of luck will not interfere in the forex Monday, April 6,.Like microsoft excel vba of products in excel away with moving. Forex investors advantages central tendency functions, along with periods calculation.Forex data feed excel, bac stock worth buying. posted on 07-May-2016 13:20 by admin.
Forex Training, Free training to greatly improve your forex experience.How to Import Market Data Into Excel: Part 2 Text File Excel Import. FREE STUFF. or automatically using Excel VBA data import functionality.How to backtest a strategy in Excel (This is a guest post by Damian from Skill Analytics and ETF Prophet).Pivot Tables In Excel, Pivot Table reports help summarize, analyze, explore and present basic summary data.
Forex Currency Exchange RateThis Online Course shows you step-by-step how to build a sophisticated automated stock trading model using Microsoft Excel.We provide various Forex related data analytics using Excel.
The DDE function in Excel seems to work and the syntax in an Excel cell is.Forex Trading Worksheet Forex Trading Worksheet is a software selection with 90 downloads.Apply, or post a similar freelance job: Accepting proposals for the development of Excel VBA functions that will enable me to manage my FOREX accounts (1249355).
Excel Spreadsheet ForexImport FOREX data to Excel for Technical Analysis Technical vs Fundamental Analysis in FOREX Technical analysis on FOREX attempts to forecast future currency price.
Real-Time Forex Exchange RateThis Excel spreadsheet has a VBA function (UDF) that scrapes live foreign exchange rates from Yahoo Finance.
You are just one click away to get the most complete All-In-One Excel Forex Calculator, which includes.Consider this list of (mostly) free Excel add-ins to extend the native functionality of Microsoft Excel.


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Is Pearl V Puri Dating Karishma Tanna? Here's What The Actor Has To Say
Pearl V Puri, who got popular with Star Plus' show, Phir Bhi Na Maane...Badtameez Dil, was linked to all his co-actresses. He was first linked to his Badtameez Dil co-actress, Asmita Sood, Hiba Nawab from Meri Saasu Maa and then to Naagarjuna - Ek Yoddha actress, Karishma Tanna.
The actor will now be seen in Naagin 3, which also stars Karishma Tanna. Recently, the actors were spotted promoting the Colors' upcoming show. When asked about dating rumours with Karishma Tanna, the actor denied it and said that her respects her as she is a senior actor. Not just that he denied rumours of dating any of his co-stars!
Pearl V Puri Is Single!
Pearl V Puri was quoted by TOI as saying, "I am single and have not dated any of my co-stars. The only relationship I was in was before I entered the TV industry."
The Actor Feels Bad As Media Ignores His Works & Writes About His Link-ups
"I dated a girl for 9 years that was my only relationship. It was when I was in class 10th and today if I am an actor it is because of her because she liked Shahrukh Khan a lot. I feel bad that media ignores my work and only writes about my link-ups."
'All My Co-Stars Are Just Friends & These Are Just Rumours'
"I have worked really hard to reach where I am today. I have come to Mumbai to work not to have affairs. I work really hard for all my shows and feel disappointed when my hard work gets sidelined. I genuinely want people to talk about my work. All my co-stars are just friends and these are just rumours."
Karishma Is Senior To Him & He Respects Her As A Friend
When asked about dating rumours with Karishma, he told the leading daily, "Karishma is a very senior actor. She is very senior to me and I respect her a lot as a friend. We are working together but we are not dating each other. She has been in the industry for such a long time."
Asmita Was Upset About Pearl & Hiba's Closeness!
It was said that is co-star Asmita was upset with him as he got close to Meri Sasu Maa co-star, Hiba Nawab. Regarding the same the actor clarified that bonding with co-stars doesn't mean that he has an affair with everyone!
Pearl V Puri Clarifies
He was quoted as saying, "I would say when you study in a school you have a bunch of friends who are really close to you. But when you change the school and go to another one, you tend to talk less with your old friends."
'Bonding Well With Co-Stars Doesn't Mean, I Have An Affair With Everyone'
"The same has happened to me, I bonded well with Suyyash Rai also during Batameez Dil we are still friends, but we don't talk on regular basis. Bonding well with co-stars doesn't mean, I have an affair with everyone."
Bepannaah: Post Aditya & Zoya's Marriage, Mahi Turns Psycho Lover, Is The Show Going Beyhadh Way?


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LA Williams
LA Williams is a New York-based director focused primarily on new work. Upcoming: Rated Black by Kareem M. Lucas (New York Theatre Workshop @ Next Door); Hype Man by Idris Goodwin (Interact Theatre Company); Too Heavy for Your Pocket by Jiréh Breon Holder (George Street Playhouse). Recent credits include Father Comes Home from the Wars, Parts 1, 2 & 3 by Suzan-Lori Parks (The Juilliard School); Richard in 9 Poses by Sarah DeLappe (Clubbed Thumb). He has developed and directed new work at Eugene O'Neill Theater Center, The Public Theater, Rattlestick Playwrights Theater, The New Group, The Classical Theatre of Harlem, Dramatists Guild of America, Brooklyn Arts Exchange, LaMama, National Black Theatre, McCarter Theatre Center, The Kennedy Center, Alliance Theatre, New York International Fringe Festival, Baltimore Center Stage, Firebone Theater, Quicksilver Theatre Company, Horse Trade Theater Group and Crowded Outlet. Assistant Director credits include: The Royale by Marco Ramirez (Lincoln Center Theater); Ugly Lies the Bone by Lindsey Ferrentino (Roundabout Theatre Company); brownsville song (b-side for Tray) by Kimber Lee (LCT3);Romeo & Juliet (The Classical Theatre of Harlem); APPROPRIATE by Branden Jacobs-Jenkins (Signature Theatre Company); and The Insurgents by Lucy Thurber (Labyrinth Theatre Company). LA is the founding Artistic Director of the Black Directors Studio, a new play reading series for emerging Black directors. In 2012, he created and executive produced Celebrate! with LA Williams: a multimedia docu-series that celebrates early career theater artists. LA currently serves on the ENCORES! Off-Center Artist Board at New York City Center, and is a 2017-18 National Directors Fellow and a 2016-17 Clubbed Thumb Directing Fellow. He is a member of the Lincoln Center Theater Directors Lab, SDCF Observership program, and was the Kenny Leon Directing Fellow in 2009. Education: M.A. Emerson College, B.A. Alabama State University


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Michelle Garnett
JKP publications by Michelle Garnett
Spectrum Women
Walking to the Beat of Autism
Edited by Barb Cook and Dr Michelle Garnett. Foreword by Lisa Morgan.This is an edited collection that tackles a range of issues that affect autistic women, including chapters on growing up, identity, diversity, parenting, independence and self-care. Well-known writers provide advice, support and empowerment to fellow autistic women, and expert Michelle Garnett provides professional commentary for each chapter. Learn More2018, Paperback / softback, 9.02in x 6.30in / 229mm x 160mm, 336pp, £15.99ISBN: 97817859243472018, Ebook, ePUB, 288pp, £15.99ISBN: 978-1-78450-806-7
Exploring Depression, and Beating the Blues
A CBT Self-Help Guide to Understanding and Coping with Depression in Asperger's Syndrome [ASD-Level 1]
Tony Attwood and Michelle Garnett, illustrated by Colin ThompsonUnderstand depression and how to cope with this self-help guide designed specifically for individuals on the autism spectrum. It includes a 10-stage CBT self-help programme with self-assessment tools and activities. Learn More2016, Paperback / softback, 9.76in x 7.20in / 248mm x 183mm, 272pp, £13.99ISBN: 978-1-84905-502-42016, Ebook, ePUB, 272pp, £13.99ISBN: 978-0-85700-907-4
From Like to Love for Young People with Asperger's Syndrome (Autism Spectrum Disorder)
Learning How to Express and Enjoy Affection with Family and Friends
Tony Attwood and Michelle GarnettChildren with an Autism Spectrum Disorder (ASD) often find it difficult to express like or love for someone. This book, by the leading experts, addresses this issue in practical terms, providing carefully created activities in which parents can help a child with ASD to develop their ability to understand affection and to express it appropriately. Learn More2013, Paperback / softback, 9.02in x 6.18in / 229mm x 157mm, 176pp, £12.99ISBN: 978-1-84905-436-22013, Ebook, ePUB, 224pp, £12.99ISBN: 978-0-85700-777-3
CBT to Help Young People with Asperger's Syndrome (Autism Spectrum Disorder) to Understand and Express Affection
A Manual for Professionals
Tony Attwood and Michelle GarnettThe authors provide CBT programme for use by professionals to address the difficulty children and young people with Autism Spectrum Disorders have in expressing, experiencing and enjoying affection appropriately with friends, family members and other adults. Learn More2013, Paperback / softback, 11.02in x 8.50in / 280mm x 216mm, 152pp, £19.99ISBN: 978-1-84905-412-62013, Ebook, ePUB, 208pp, £19.99ISBN: 978-0-85700-801-5


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"We're late, we're late, for a very important date!" I want to shout to my kids as they wrestle each other for a place at the bathroom sink, trying to out-muscle each other to see who gets their teeth brushed first. I pause, reminding myself that our tardiness may just be Providence's way of protecting … Continue reading Hedge of Protection
Author: karikim21
Stronger Together – Life Lessons from "When Calls the Heart"
Inspiration sparks in the most unlikely places: I get the next twist in my novel's plot line while the water warms up in the shower. The title for a poem emerges from the scattered thoughts parading through my mind as I wait in the drop-off line at my sons' school. Today, the little life lesson … Continue reading Stronger Together – Life Lessons from "When Calls the Heart"
Connecting with Don McDonald
An Interview with Super Channel's CEO Don McDonald, CEO of Super Channel, greets viewers from the set of When Calls the Heart. PC: Super Channel Over the past few years, both US and Canadian audiences have been clamoring for companies to provide family-friendly entertainment, from movies to television to on-demand services. In 2017, Canada's Super … Continue reading Connecting with Don McDonald
We turned off all of the lights in the house and stood around our wondrous man-made evergreen tree. My boys' eyes sparkled in joy as they anticipated the coming Christmas season. I, on the other hand, settled in to revel in one of my very favorite feelings of Christmas: the warmth of clear, white lights … Continue reading Shine!
To Be Fearless with Love
As we enter the Christmas season, I begin begging my husband to watch "just one more Hallmark show" with me. While I know which parts of the movies I love and which movies are my all-time favorites, it wasn't until recently that I discovered the one simple truth that draws me in to each show … Continue reading To Be Fearless with Love


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While headlights are relatively easy to replace, it does not necessarily mean that you should replace them yourself. Sure, I mean if you want to save yourself a few dollars, go ahead and install them yourself.
While this task is one of the easiest tasks to do on a car, it does not mean that it will be easy for you to do. If you break the lens housing surrounding the headlight, there is a chance that your headlights could be ruined by causing condensation to get inside of the housing which will short out your lightbulb or headlight.
If you notice that your bulbs are not as bright as you want them to be, you can visit the dealer to purchase better bulbs and it could be that it is just that time to make sure that your bulbs are replaced. Replacing them when they start to dim will help ensure that your headlights stay in pristine condition.
Visit our service team here at Larry H. Miller Dodge Ram Peoria, located in Peoria, AZ to learn more.


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The best knife set under 200 established can be a mix of probably the most well known knives while in the Wusthof line. We're going to examine these knives to know if they are very best fitted to you.
Wusthof knives are created in Solingen, Germany because of the Wusthof Business. This proud cutlery corporation is a family owned small business since its commencing 197 many years back. These are universally renowned for a manufacturer of top of the range knives. The organization adheres to your stringent 40 phase producing prepare to make sure the high quality in their knives.
The Traditional knives tend to be the prime of your Wusthof line and are available by using a life time warranty. They are really regarded for his or her sharpness which can be a consequence of currently being solid from a person piece of rust-resistant stainless steel. They may have extraordinary stability that is served with the blade extending through the knife manage which also supplies longevity and strength.
The Wusthof Vintage Knife Set Selection
The Wusthof Classic knives is often purchased a single in a time. Nonetheless, obtaining them in the established will help you save dollars. To do that it truly is essential to initial establish what your preferences are and exactly how you utilize your knives. Accomplishing this can allow it to be less complicated to produce a decision on the knife set that is appropriate in your case. The following would be the more well-known Wusthof knife sets:
The 7 knives Common Knife Established is excellent for those that wish a generally handy mixture of knives which might be most commonly utilized in the kitchen. Additions to the set may be purchased when needed. The set will come with the 8″ Cooks knife, a 3 1/2″ Paring knife, a 6″ Sandwich knife, a Bread knife, a 9″ Sharpening metal, and Kitchen shears. It also which has a appealing thirteen slot knife block to retailer the knives.
The nine knife Wusthof Classic set incorporates the identical knives which can be while in the seven piece set. What's more, it consists of an 8″ carving knife in addition to a 3″ paring knife. People that have modest hands report that the small take care of design and style on both of these knives are much easier to implement and they're just a little lighter than the even larger knives. The 13 slot knife block provides with the addition from the Basic steak knives that could be bought individually.
The eleven piece Vintage set consists of pretty much every one of the knives a person would at any time need to have. It's the identical 7 knives that happen to be present in the initial set and likewise features four steak knives. This established leaves only two addition knives to obtain to have the many knives you would probably, most certainly, ever want from the kitchen. Many people that appreciate cooking love having a whole knife set in the kitchen that could fulfill all their requirements.
Ensure that kitchen area shears are incorporated in any knife established you select to acquire. Kitchen area shears are wonderful for approximately any tricky reducing jobs for example; meat de-boning, trimming, correcting slice bouquets as well as other these tasks. The Wusthof shears are easy to wash than lots of other folks simply because they could be divided.
The most beneficial guidance on paying for knives will be to examine your cooking routines and needs right before choosing your knife established that best fits your needs. Obtaining high quality kitchen knives are essential to taking pleasure in the enjoyment of cooking in your house. Good quality knives may very well be a bit more high priced than simple kitchen area knives. But it is crucial to recall that buying top quality knives much like the Wusthof Basic knife sets, will be a after in a very lifetime time acquire.
The various knife combinations provided inside the Wusthof Typical sets are intended to meet the necessities of virtually any cook, regardless of their encounter degree. When your cutlery desires transform knives can be included to fulfill these new needs. Every one of the Typical knife sets include a 13 slot knife block that gives for that long run addition of knives to any established. When each of the details are included up, you can certainly not go erroneous by buying a Wusthof Classic knife set.


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I had a discussion recently about the available storage from the Exadata storage cells in this case it was an X2. Please note the disks are advertised as 2TB in size however there is a small overhead at each stage from the physicaldisk layer then to the celldisk layer which I show in this posting.
From the below example we can see the physical disk size is 2TB from the makemodel property but the physicalsize is about 1862.66GB this is a drop of 185.34GB from 2048G.
CellCLI> list physicaldisk 20:0 detail
name: 20:0
deviceId: 19
diskType: HardDisk
enclosureDeviceId: 20
errMediaCount: 0
errOtherCount: 0
foreignState: false
luns: 0_0
makeModel: "SEAGATE ST32000SSSUN2.0T"
physicalFirmware: 061A
physicalInsertTime: xxxxxxxxxxxxxxxxxxx
physicalInterface: sas
physicalSerial: xxxxxxxxxxxxxxxxxxx
physicalSize: 1862.6559999994934G
slotNumber: 0
status: normal
We can see from the celldisk level the size is being reported as about 1832.59GB another drop of about 30GB.
CellCLI> list celldisk CD_00_cel01 detail
name: CD_00_cel01
creationTime: xxxxxxxxxxxxxxxxxxx
deviceName: /dev/sda
devicePartition: /dev/sda3
diskType: HardDisk
errorCount: 0
freeSpace: 0
id: xxxxxxxxxxxxxxxxxxx
interleaving: none
lun: 0_0
physicalDisk: xxxxxxxxxxxxxxxxxxx
raidLevel: 0
size: 1832.59375G
status: normal
cel01: size: 1832.59375G
cel01: size: 1832.59375G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
cel01: size: 1861.703125G
Finally we can see with the overhead at each level starting from a 2TB physical disk down to 1832GB of usable space to be used in ASM before we add the disk to a diskgroup with a NORMAL or HIGH redundancy level which will reduce the available space even further with ASM mirroring. We get about 89.5% of usable disk storage for each 2TB disk for an overhead of 10.5% which only applies to the first and second disk for overhead in the cell storage node. The remaining celldisks have 1861.7GB disks which is small overhead of about 1GB.
One more item to note the grid disk size will match the size reported in v$asm_disk since the grid disks are presented in ASM.
CellCLI> list griddisk DATA_CD_00_cel01 detail
name: DATA_CD_00_cel01
asmDiskgroupName: DATA
asmDiskName: DATA_CD_00_CEL01
asmFailGroupName: CEL01
cachingPolicy: default
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diskType: HardDisk
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select name, TOTAL_MB/1024 from v$asm_disk ;
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Please keep this in mind when doing sizing for diskgroups and future capacity planning in setting up your Exadata storage.


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Kosanji Temple4.4
This temple located on an island of Onomichi city is also a museum of Buddhist architectures, which were modeled after many of most renowned temple buildings in Japan. You will be ushered in under a replica gate of the Kyoto Imperial Palace, go through a Romon Gate of Horyuji Temple in Nara and utter a gasp of awe at an imposing Yomeimon Gate in Nikko.
The main hall is copied from that of Shitennoji Temple in Osaka, the five-story pagoda from Muroji Temple to the south of Nara, and the two-story pagoda from Ishiyama Temple from Otsu. You will also find symbolic structures similar to Byodoin's Phoenix Hall and Gingakuji Temple (Silver Pavilion). The 5-hectare grounds also host a modern marble garden, Miraishin-no-oka ('hill of hope'), on the hill. The founder is a successful businessman who became a priest in 1930s and spent 30 years to complete this temple wonderland.
Purposeshould go,couple,LMFAO,elderly,surreal&cool,that you'll never forget,family,first time in Japan,knows a lot about Japan,if you are free,let's go,shrine/temple,art,sightseeing,major,let's hang out!
Airport/Sta.Hiroshima Airport (about 21.8km) Google Transit
We guide this spot.
5.0a month ago
Pleasantly surprise by the entry charges. But it is definitely worth paying. Never had such pleasant experience since a long long time. Thousand Buddha Cave still give me goosebumps thinking about it.
5.0a month ago
I am usually a cheapskate and don't like to pay to get into places. This place, however, is worth it. Pretty amazing collection of wooden!(not concrete) buildings. Sure, the buildings are replicates of older buildings that may have existed somewhere and that no longer exist, but that does not lessen the impressiveness of the buildings in the complex. Amazing craftsmanship.
Worth a visit, and the price to get in - in my opinion.
4.09 months ago
Loved the Italian marble Hill of Hope! Fusion art of Italian marble architecture and Japanese traditional temple building.
5.09 months ago
Amazing Shrine, and hour is not near enough time.
4.02 months ago
nice place
Spot Reviews (1)
The Nishiseto Expressway, commonly known as the Setouchi Shimanami Kaido Expressway, links Onomichi, Hiroshima Prefecture, with Imabari, Ehime Prefecture. It's a 60 kilometer-long highway exclusively for automobiles that links the i...
The Nishiseto Expressway, commonly known as the Setouchi Shimanami Kaido Expressway, links Onomichi, Hiroshima Prefecture, with Imabari, Ehime Prefecture. It's a 60 kilometer-long highway exclusively for automobiles that links the islands of the Seto Inland Sea with nine individual bridges.
Each bridge consists of a road way and a pedestrian walkway. That enables people to enjoy the sea breeze as they walk or cycle across the bridge.
The area along the Shimanami Kaido linked by bridges is blessed by the temperate climate of the Seto Inland Sea. There is much to delight visitors, including the loveliness of nature on the islands, sites of history and culture.
You can enjoy beautiful sea in a relax manner.


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Innovatio Awards celebrate in-house counsel, both individuals and teams, who have found ways to show leadership by becoming more efficient, innovative and creative in meeting the needs of their organizations within the Canadian legal markets
When: September 20, 2018
Where: Arcadian Court, Toronto
Event Detail: 2018 Nominations are now closed
Presented by Lexpert, the prestigious Rising Stars Awards Gala honours winners from across Canada and welcomes law firm and in-house leaders and distinguished guests to celebrate and network with others who are at the top of the legal profession
When: November 8, 2018
Where: Fairmont Royal York Hotel, Toronto
Event Detail: 2018 Nominations open June 4th
Presented by Lexpert, these awards recognize individuals and teams from law firms, academia, law societies and corporations that have made a significant contribution to the legal community
When: June 19, 2018
Where: Toronto
Event Detail: To purchase a table and explore sponsorship opportunities click here
Lawsuits arose out of airline crash in which people died. Appellants manufactured engine that failed and was identified as one of causes of crash. Appellants were ordered to produce documents concerning parts, counterweights and accidents. Documents were found to be relevant to show appellants had propensity to manufacture improperly and that they knew of issues with similar systems. Appellants complained they were being asked to produce large number of documents over substantial period of time. Appellants appealed. Appeal dismissed. There was no error in assessment of relevancy. Documents were relevant to product liability and to duty to warn causes of action pleaded. Appellants were in regulated field where information was routinely updated as state of knowledge advanced. Without evidence from appellants with description of hardship to counterbalance relevancy and discretionary factors, there was no basis to conclude there was error of law, principle, or appreciation of facts.
Hudson v. ATC Aviation Technical Consultants (Mar. 4, 2014, Ont. S.C.J., Myers J., File No. CV-09-37858800-0000) 239 A.C.W.S. (3d) 54.


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What technologies will you be highlighting?
We will showcase new versions and enhancements to four key products: Paint 7.4, our telestration and analysis tool for sports production; Virtual Placement, our tool for placing striking virtual graphics into any live broadcast; PRIME 3.0, a flexible and integrated graphics hub for any type of application from video news, sports, and entertainment, to government and corporate; and Neon, our all-in-one, trackless solution for creating highly compelling virtual sets.
At BroadcastAsia, we expect to see a big focus on virtualised infrastructures and, more specifically, solutions for virtualised production, broadcast, and playout. Virtualisation is highly appealing to Asian broadcasters. It means they're no longer tied to expensive capital equipment that might only be used part of the time but consumes power and space 24/7. These production systems are category defining because they let people pay only for the resources they need and when they need them.
What challenges do broadcasting and media and entertainment companies in the region face?
Media enterprises in APAC region face challenges that are universal to companies everywhere: the need to generate more revenues in an increasingly competitive environment, and to do more with less equipment and limited budgets. Because APAC is such a vast area, broadcasters there face additional fiscal challenges such as currency and exchange rate fluctuations. They also need tools that make it easy to regionalise content to reflect the cultural and regional diversity of APAC countries.
In areas such as Japan, Singapore, and Hong Kong where real estate is at a premium, it is critical to get maximum functionality out of equipment that fits in a very limited physical space. There is also a big requirement for solutions that are easier to install, use, and maintain.
Given that language is a big barrier in the countries you mentioned, how can technology help in addressing these challenges?
Many people in APAC are not fluent in English; therefore, products that are easier and more intuitive to use will go a long way towards getting them up to speed quickly and starting to reap the benefit of the tools.


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Brand Name: JERMYN Frame: No Technics: Spray Painting Original: No Frame mode: Unframed Subjects: Landscape Medium: Waterproof Ink Shape: Rectangle
Type: Canvas Printings Style: Modern Form: Multi-picture Combination
Material: Canvas Calgraphy and painting type: Canvas Painting Support Base: Canvas
Model Number: YQ072
Type: Canvas Printings
Material: Canvas Frame: No Medium: Waterproof Ink Form: Multi-picture Combination
Pls note all of our paintings are unframed /no frame ,if you need frames pls contact us for new price size1:20x30cmx2p,20x40cmx2p,20x50cmx1p (8x12inchx2p,8x16inchx2p,8x20inchx1p); size2:30x40cmx2p,30x60cmx2p,30x80cmx1p (12x16inchx2p,12x24inchx2p,12x32inchx1p); size3:30x60cmx2p,30x80cmx2p,30x100cmx1p (12x24inchx2p,12x32inchx2p,12x40inchx1p); Product Details Painting Size/Taille: de peinture: Materials/Mieu: printing art OEM is available Detail: Unframed/Unstretched Technique : giclee printing No reason to return pocy support We offer a 5-Day, Money-back guarantee on all of our oil paintings.We will refund the purchase price, excluding shipping costs. The oil painting must be returned in its original packaging and under new condition with all accessories, and seller must be contacted within 5 days of your receipt of the item. Return shipping is buyer's responsibity, and it is recommended that you return item with insurance or tracking number. Seller is not responsible for lost items. Refunds will be issued once we have received the item.
Dear My FriendPLEASE VIEW THE NOTICE BEFORE YOU BID AND PAY 1.The product is made in CHINA . 2.Negative feedback does not solve anything. If you have a problem about our transactions, please contact us first. We are always wilng to work things out. 3.If you do not get the item after you payed 28 days,please contact us; we would do our best to solve it ! 4. We will ship to the aress you left on Aexpress when you ordered, please confirm your shipping aress on Aexpress is correct when you pay. If you need to change your shipping aress, please must leave us a message with payment. Product Show FAQ-Frequently Asked Questions About Our Paintings : _Do you have a guarantee and return pocy? Yes, we offer a 30 day money back satisfaction guarantee on your oil paintings, so there is no risk or headaches for you. If for any reason, you are not completely satisfied, you may return your oil paintings. _How can you sell your paintings at these low prices? We feel art should be affordable to everyone. With us you can buy direct at wholesale prices with no mileman and no obscene gallery mark up. We have a high volume purchasing power, low overhead, non-brick and mortars approach. This includes low overhead and a high volume purchasing power, so we are able to pass the savings onto our customers. _Can you reproduce paintings from my picture? Yes, we can reproduce an oil painting from any clear picture or photograph. You can contact us onne directly _Customization & Reproduction To order our painting in other size/style; To convert your favorite photo into high quaty oil painting on canvas; To reproduce or customize any painting; We will create a special buy-it-now sting for your order Please leave message to us,we will reply you within 12hours _How we packing? No frame painting: rolled as a tube. _What is our shipment? When you place an order,please choose a shipping method and pay for the order. Shipping time:China Post Air: We will give you the tracking number after shipment. _What forms of payment do you accept? we can accept Escrow payment (fast, easy and safe) and Paypal. Credit Card (all kinds of credit card ),Moneybookers and Bank Transfer. _Feedback Your positive feedback will make us go further. We do our best to supply the high quaty painting , and thank you for leaving positive feedback. We hope this order is the start of our nice cooperation and long time friendship. About us: Welcome to our store!
We are wholesale supper of oil painting in China! There are hundreds of great painting artists here. They love art, ves and have special creativity. We can paint for your pictures and different kinds of style paintings such as abstract art, landscape, etc. Of course, we can provide the product according to your requirement. Large studio, experienced artists but the cheapest price that we make a very ttle profit from each painting ! Handmade oil paintings and giclee printings are our main business
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Packaging Details
Type: lot (5 pieces/lot)
Weight: 0.300kg (0.66lb.)
Package Size: 54cm x 5cm x 5cm (21.26in x 1.97in x 1.97in)
If you would like to pay by PayPal, you can pay to our PayPal account: email@example.com and email us. Please email us the name of the product, the quantity and other product attributes. The email address is email@example.com. No matter how many goods you buy in one order, the freight you need to pay is only 15 dollars
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Displaying 1 to 6 (of 6 reviews)


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Martin Luther's 95 thesis
by: kamia washington
Number 4
The consequences for sins will stay long as internal conflict last. That is until we enter the kingdom of heaven
Number 22
God excludes souls in purgatory, not penalty.which means they will be paying for the way they live their lives
Number 36
Any Christian who truly repents has the right to full access of penalty and guilt without indulgences
Number 37
Any real Christian, living or died, can/will participate in all the blessings of Christ and the church even without indulgences
Number 42
Christian should be taught that the pope does not present the buying of indulgences should in any way be compared with the works of mercy
Number 47
Christians should be taught that them buying indulgences is a free choice not a command
Number 62
The treasure of the church is the most important gospel of the glory and the grace of God
Number 64
treasure of indulgences are what men want more, making the least important become first on the list
Numbner 65
the treasure of gospels are now things to catch the men of riches
Number 67
indulgences in the eyes of the priest is the "greatest grace" are known truly as gain.
95 Theses Rap


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Haverhill Bank Branches
Haverhill city is located in Grafton County, New Hampshire State, US.
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text:
33. The LORD said to Moses,
34. "Say to the Israelites: `On the fifteenth day of the seventh month the LORD's Feast of Tabernacles begins, and it lasts for seven days.
35. The first day is a sacred assembly; do no regular work.
36. For seven days present offerings made to the LORD by fire, and on the eighth day hold a sacred assembly and present an offering made to the LORD by fire. It is the closing assembly; do no regular work.
37. ("`These are the LORD's appointed feasts, which you are to proclaim as sacred assemblies for bringing offerings made to the LORD by fire--the burnt offerings and grain offerings, sacrifices and drink offerings required for each day.
38. These offerings are in addition to those for the LORD's Sabbaths and in addition to your gifts and whatever you have vowed and all the freewill offerings you give to the LORD.)
39. "`So beginning with the fifteenth day of the seventh month, after you have gathered the crops of the land, celebrate the festival to the LORD for seven days; the first day is a day of rest, and the eighth day also is a day of rest.
40. On the first day you are to take choice fruit from the trees, and palm fronds, leafy branches and poplars, and rejoice before the LORD your God for seven days.
41. Celebrate this as a festival to the LORD for seven days each year. This is to be a lasting ordinance for the generations to come; celebrate it in the seventh month.
42. Live in booths for seven days: All native-born Israelites are to live in booths
43. so your descendants will know that I had the Israelites live in booths when I brought them out of Egypt. I am the LORD your God.'"
44. So Moses announced to the Israelites the appointed feasts of the LORD.


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