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Finding the Best Food Processor
If you've got a food processor at home, you certainly know how versatile this gadget can be. It can make quick work of laborious jobs like shredding potatoes, slicing vegetables and chopping up nuts, cookies and more for all your favorite treats. Let's face it: Food processors are kitchen all-stars—especially if you can find a good one.
But with so many on the market, it can be hard to know which one works best. That's why our Test Kitchen put the most popular food processor brands to the test to find our Best Loved Brand. Over the course of several months, our cooks and food stylists used these machines to test all the recipes sent in from readers like you. After getting a good feel for how all these tools worked, our team put each food processor through a series of standardized tests to see how they performed side by side:
- Chopping: How uniformly could the processor chop an onion into 1/4″ pieces (approximately)? How well could it blitz up hard peppermint candies?
- Slicing: How well could the processor slice a potato? What about a tomato? Did these foods have to be trimmed to get into the feed tube?
- Blade: Did the blade reach small amounts of ingredients? How well could it process three rehydrated chiles?
- Price: Is the product affordable? Was the performance reflected in the price?
The Best Food Processor: Cuisinart 14-Cup Food Processor
After months of regular use in our Test Kitchen and rounds of testing, our culinary team crowned one food processor brand king. Cuisinart's extra-large 14-cup food processor ($199) stood up to every challenge and chopped, sliced, diced and shredded like a dream.
Features We Loved
- Simple controls: When it comes to a food processor, you don't need many settings. In fact, all you need is an on/off switch and a pulse option like this Cuisinart model. Just a couple pulses or a few seconds of whirring are all you need to prep the ingredients you toss inside.
- Size: With a 14-cup capacity, this model from Cuisinart is a great choice for jobs large and small. Got just a few hot peppers to blitz? No problem. Want to put together a giant batch of pesto? It's a pinch with this food processor.
- 3 blades: This Cuisinart model comes with a standard chopping blade, a shredding dish and a slicing disc—perfect for tackling all sorts of kitchen tasks.
How It Performed
Our cooks thought they devised some pretty tricky tests for this food processor (seriously, could a giant, 14-cup food processor ever chop up just three small chiles?), but Cuisinart sailed through every test, impressing our entire Test Kitchen.
When it came to chopping an onion, Cuisinart's food processor made quick work of it. In seconds, our cooks had a great, even chop—a few more pulses and the onions were practically minced. As for the peppermint candies, they were ground up quickly with the super sharp blade, meaning our kitchen staff was ready to add them to all sorts of minty recipes like these.
This machine did just as well slicing both a tomato and a potato with its slicing disc. The large chute on top meant that these foods only had to be sliced in half to fit into the chute.
What really impressed our Test Kitchen, though, was how well this extra-large food processor chopped up a very small amount of food. The processor's blade sits very low to the bottom of the bowl so it can capture every last bit of your ingredients. The three small peppers were instantly blitzed and ready for stirring into spicy favorites like chili.
This five-star performance is what makes our Test Kitchen happy to recommend this product for use both at Taste of Home and right in your own kitchen (Price: $159).
Buy this Cuisinart 14-Cup Food Processor here.
We Also Recommend…
It's true that "Cuisinart" has come to be synonymous with "food processor," but during our tests, we found two others that are worth a look.
- KitchenAid 7-Cup Food Processor ($100, left): If you'd only need one occasionally, this food processor will do the job. It's easy to assemble and is amazingly quiet at high speeds. However, this KitchenAid model may not be suited to heavy-duty jobs: It overheated during one of our tests.
- Black + Decker Easy Assembly 8-Cup Food Processor ($33, right): For the (very affordable) price, this Black + Decker food processor performed way above our expectations. It's lightweight yet stable—thanks to some mighty suction cups—but incredibly loud, even on the lowest speed.
What to Make with a Food Processor
At home, you might just rely on your food processor to make quick work of normally tedious tasks—like shredding cabbage for coleslaw or crushing up graham crackers for a crumb crust—but you can do so much with this tool. With even just the basics like a blade and a shredding disc (both of which come standard with our favorite food processor), you can make everything from apps to desserts. Our Test Kitchen recommends shredding up veggies—think cauliflower and cabbage—and incorporating it into meatballs for an easy appetizer with that extra healthy kick. Try our recipe for Sneaky Turkey Meatballs.
How to Care for Your Food Processor
Like all gadgets, your food processor needs a certain level of care and cleaning to keep it running like the day you brought it home. For this Cuisinart model, that mostly means giving it good wash—lucky enough all the parts (minus the motorized base) are dishwasher safe.
About Best Loved Brands
If you're like us, you want all your favorite recipes to turn out fabulous every single time you make them. That means opting for the best tasting ingredients and the best tools. While picking your favorite brand of chocolate chips or bacon is a task, it's a delicious one to be relished. Choosing the best gadgets and gear for your kitchen, though, is another story. Unless you buy several stand mixers or food processors and put them through their paces, how can you ever know which will make your recipes turn out their best? That's where our Test Kitchen comes in. Our culinary experts tried dozens of products our Test Kitchen—testing your recipes—to find out which brands came out on top.
Disclosure: This post is brought to you by Taste of Home editors, who aim to highlight products and services you might find interesting. If you buy them, we get a small share of the revenue from the sale from our commerce partners. We frequently receive products free of charge from manufacturers to test. This does not drive our decision as to whether or not a product is featured or recommended. We welcome your feedback. Have something you think we should know about? Contact us, here.


text:
Sears Gambling Credit Card Processing
Most of the people might have heard
about sears credit card. It got immense
popularity ever since it came into
being. One can make the application for
a sears credit card immediately if you
intents to do so. This credit card has
proved to be very much beneficial for
the common man. It offers the customer
with several merits along with rewarding
guidelines and conditions. With this
card in the possession, the customers
will enjoy the shopping to its maximum.
These cards offer certain rewards such
as refrigerators, ovens and washing
machines and so on. The customers need
not get concerned with regard to silly
matters. The customers have the monthly
option of repayment. The options of
repayment will be in such a way that it
will hardly hurt the pocket of the
customer. They will not be charged any
fee which must be paid annually. The
credit card firms will not make the
customer responsible for any purchases
that are done without the prior consent
of the customer. The clients are given
the option of saving a god amount of
money. The customers can make use of
these offers.
If the customer desires to get the
product returned as he or she is not
satisfied in it but have lost the
receipt, he can get the item returned.
The cards provide the customers with
several offers such as zero percent
surcharges and discount on the purchases
in the initial time span. If the
customer forgets to take the card while
he goes for purchases, he will be given
pass which can be used for a brief
period. The card will be completely
false resistant and the details in it
cannot be hacked by others. The customer
care service centre of the card will
always be accessible in order to clarify
any doubts.
One can apply for the sears credit card
through mobile phones. The applicants
can use an online code and you will get
the details of several providers. One
needs to take only a few minutes in
order to make an application online. The
applicants will not have to go through
several procedures and it can be
followed easily. The applicants can get
the application form filled by
delivering all the adequate details. The
applicant will get the approval mail
without having more delay. But before
applying for the card, one must go
through the terms and conditions given
by the provider of the card.
The stores of the credit cards are
located in almost in every corner of the
world. This availability makes this card
more preferable by the customers. The
Sears is actually a name of the house
hold in United States of America. It is
one of the biggest retail sellers and
has products ranging from furniture to
house hold items. By providing such a
wide variety of offers, this card
provides the customers with two worlds
that are the best. On one hand, the
customers will be rejoiced at having a
credit card of their own and on the
other hand, it provides them a big store
to choose and select from.
Contact one of our helpful account
representatives to assist you in the
setup of a
high risk merchant account or
offshore merchant account for a
high risk merchant.

subset: commoncrawl


text:
Sturgeon, MO Rent to Own Homes
|No Listing Found
RentUntilYouOwn.com is the #1 provider of Sturgeon, Missouri rent to own homes listings.
Our goal is to offer the highest quality results, along with helpful Sturgeon resources and support. We understand that finding genuine rent to own homes in Sturgeon can be very difficult. Even more challenging is trying to search Sturgeon, MO listings for free.
After discovering how difficult it was for Sturgeon buyers and sellers searching online, RentUntilYouOwn.com has become dedicated to providing users with the most current, accurate, and detailed listings in Sturgeon, Missouri.
If you have any questions or suggestions for improving our site, please contact us here.
Trouble Finding Local Rent to Own Homes Listings?
If the initial results in Sturgeon, Missouri did not provide any listings of interest, or you just want more selections, click any of the blue tabs just above the search results for more.
Thanks for visiting and good luck!


text:
As a kid…..You hear things like 'don't go down that road, you don't know what's down there', 'You wouldn't want to visit that country', 'I wouldn't eat that if I were you', 'Why on earth would you want to take up that hobby?'
What is this teaching us?
That it's better if we just be….as we are…safe? What happens when we just tip-toe out of the 'safe' bubble, our comfort zone? Wait for it………nothing at worst and exhilarating at best.
Don't get me wrong, doing certain things can be dangerous and risky. You wouldn't just wander around aimlessly in the middle of the night looking for danger. But, what if the 'danger' wasn't death, but just …because it was different? Never been tried? Not known?
I had people tell me 'Alaska? There's nothing there'..'Why would you want to travel alone?'. You know what, Alaska has been amongst the best places I have visited. Also, travelling alone gave me so much confidence. I'm glad I didn't listen, I'm glad I didn't stay in my comfort zone.
When we fear the unknown, we are telling ourselves that the only outcome is bad, then we become anxious at trying anything knew and we never move outside of our comfort zone, never explore, never satisfy our curiosity. But what if coming out of our comfort zone is when we actually feel alive? Yes it's a risk, but I believe it's a risk that's worth taking. There maybe a time, when we have to deal with life and death, but because we have never been out of our comfort zone, we wouldn't have the skills to deal with it.
I'm writing a book at the moment, and of course, I'm not risking death by writing it of course, but I could stay in my comfort zone and just talk about it, or I could put myself out there and ……..fail. The book could absolutely flop. But I'd still be alive, and I would have satisfied a niggling curiosity. Then I would move onto the next thing that's bugging me. Or you know what?…..The book may fly off the shelves (obviously this outcome is much more appealing!) But if I never try, I'll never know.
What's the alternative?……………………


text:
Any carpet shampooer is a must have got for any proud home owner. Specifically any homeowner that entertains guests, has children, or even has pets. Over time grime and grime build up in your floor covering fibers, and after a while it will eventually leave your beautiful carpets seeking less than at their best. There are numerous things to look out for when choosing the particular carpet shampooer to meet your preferences. What could be the best design for somebody else, might be faraway from the best for yourself. Do you have a huge house, or a small house? Are your carpets on a regular basis walked over by many individuals, or is it just your current and your partner? Does significantly dirt get trodden inside from outside on the bottom of boots and sneakers? Do you captivate gusts a lot and may must deal with wine stains or perhaps similar? Do you have pets or maybe children? learn what's the best carpet shampooer?
These are all questions that you ought to ask yourself. Different carpet cleaners are generally geared towards different situations useful. Imagine the following scenarios. The particular medium sized, busy house. A couple of adults, two children, two puppies and a cat. The house is obviously busy, and there's always off-road and dirt being stepped in from the garden also. The kids are always making a chaos (of course). Felt-tip pencils, paints, spilt foods as well as drinks at mealtimes. Unsightly stains aplenty. The pets have odd accident now and then, and also fur balls are also some sort of nuisance. It's impossible to clean their particular paws every time they come in out from the rain, so things acquire can real muddy actually quickly by the doors. Parents like to entertain on saturdays and sundays and it's how they relax, together with friends and a meal. Once more, accidents are inevitable, along with coffee, wine, and other the drinks are spilt.
Their ideal new carpet shampooer and cleaner? A whopping duty domestic cleaner is good for this household. Make sure within the powerful 12-amp motor and huge water tanks. If it's a new medium to large size house you'll benefit from an extended power cord – 20 foot or more. An extendable garden hose with detachable nozzles will probably be great to reach those tiny nooks and crannies, and detachable cleans are a must for effortless cleaning and maintenance of your equipment. The small, not so busy residence or apartment. A single person, or even a couple. Maybe a cat, as well as dog, or both. The family unit isn't very busy, in addition to doesn't need cleaning all of that often. Not many parties usually are held here, and there is not enough people to make this kind of great mess… however the cat and dog are the main culprits.


text:
College Street, Bow Bazaar, Kolkata, West Bengal 700016
College Square Swimming Club (CSSC) was founded on 17th March 1917 by a group of seventeen people headed by Late Pramotho Nath Ghosh, at the north-east corner of the present college square tank, with the objective of imparting scientific training of swimming and development and promotion art of life-saving in water for the society. The present Club building with the tower clock was constructed in 1924 under the supervision of General Hathway, the then Chief Architect of Calcutta Municipal Corporation.
The Club has been through a glorious past continuously delivering success and moving towards a century full of splendid performances. College Square Swimming Club had produced the first Indian swimmer to participate in the Olympic Games – Late Dwarka Das Mulji in the year 1928 at Amsterdam. Apart from him many more Olympians and other International figures have been shaped by the Club.The Club has included in its curriculum novice training and Multi Gym provision in general and advanced swimming, water polo training and diving for the competitive levels.


text:
Join the FlySafair Team and Make Your Career Fly!
- We are an aviation company based at the O.R. Tambo International Airport in Kempton Park South Africa.
- At FlySafair we are always on the lookout for smart, savvy and professional individuals who can join our team and grow with an exciting brand that's going places.
- We seek people who truly live the values of respect, integrity, professionalism, commitment, open communication and collaboration as these are what our airline is founded upon.
- Our mission is simple: To be a low cost, high – value carrier where every single passenger experiences efficient, professional and reliable service.
- Would you like to join our exciting team?


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No fear! Below you will find all the info you need to not get bored during your relaxing holiday in Val di Fassa!
When you are at the hotel, you can of course request all the necessary information and Barbara, Roberta and Daniela and all the staff of the Cima Dodici hotel, but in the meantime we already suggest some ideas ...
The Val di Fassa is so beautiful that even when it rains, it has a unique and irresistible charm: everything around becomes even more fascinating!
What to do when it rains in the mountains?
Enjoy the relaxation ... it won't happen so often to take advantage of a rainy day to relax at 360 °!
Treat yourself to intense moments in the wellness center and Spa with sauna, whirlpool and Turkish bath ... and maybe, why not, a relaxing massage and detox!
In addition to the wellness and wellness center of the Cima Dodici hotel you can also go to the Eghes Wellness Health Center and SPA in Canazei, to the Dolomia Spa and to the QC Terme in Pozza di Fassa.
Discovering the aromas and flavors of the Val di Fassa
From a visit to the pastures, to the milking of cows at high altitude, from a snack in a refuge with the aromas of the land to the exit with the horses.
Ladin culture and more ...
And then you can visit the Ladin de Fascia Museum in Vigo di Fassa, discovering Ladin tradition and culture. Or you can visit the Marmolada Museum, the highest in Europe located at an altitude of 2950 m, the Great War exhibitions in Moena, Fedaia and Pordoi and the Mineralogical Museum in Vigo di Fassa.
Sportspeople not only at high altitudes
If you don't want to give up the fun and physical activity, you will find many alternatives for all ages. You can try climbing at the ADEL indoor facility in Campitello di Fassa, or slip on the skates at the Ghiaccio stadium open both in summer and winter in Alba di Canazei. At the Aquatic Center Dòlaondes of Canazei and the Acquapark Vidor di Pozza, even the little ones can have fun thanks to the pools and water slides.


text:
Bryan Chaffin and Andrew Orr join host Kelly Guimont to discuss Apple's latest company acquisition, and Phil Schiller's new role.
Apple Pay Cash is Apple's peer-to-peer payment platform, and is part of the Apple Pay system. Apple Pay Cash allows Apple customers to send money to one another, and to use that money as all or part of an Apple Pay transaction. Users can also withdraw any Apple Pay Cash balance to their bank accounts.
Security Friday, Apple Card Updates – TMO Daily Observations 2020-05-29
Andrew Orr joins host Kelly Guimont to discuss Security Friday news and some updates to Apple Card data in the Wallet app.
Apple Card Obtained! – TMO Daily Observations 2019-08-08
Today John F Braun of Mac Geek Gab fame joins host Kelly Guimont to discuss the process of getting and managing Apple's shiny new credit card.
Apple Applies for Apple Card Trademark in Canada
Apple filed applications for Canadian trademarks for Apple Card, Apple Cash, and Apple Pay Cash earlier this month.
Wi-Fi 6, Apple Pay Tips – TMO Daily Observations 2019-05-15
John Martellaro and Andrew Orr join host Kelly Guimont for a discussion of the new designations for Wi-Fi networks, and some Apple Pay tips.
How to Transfer Money Out of Apple Pay Cash
Apple is giving customers the option to transfer money out of Apple Pay Cash and into a bank account or a debit card.
Should Apple Have its own Debit Card?
John Detrixhe argues that Apple should release its own debit card to prepare for the wave of contactless cards.
But consumers typically avoid moving their financial accounts and tend to be faithful, even when they dislike the service. An Apple debit card is a chance for the Silicon Valley-based company to give customers what they want—for God's sake—before someone else does.
I'm not sure I'm sold on this idea. For a debit card maybe Apple could work with the bank it uses for device financing. I think what would be nice though is for Apple Pay Cash to work more like its own bank.
Apple Has 3 New Spots to Promote Apple Pay Cash in iMessage
The spots show Apple Pay Cash being used by family members to share costs and directly pay for stuff.
Duke it out over Who Pays for Dinner with Apple Pay Cash [Video]
Apple has a new spot out that demonstrates the modern fight over who gets to pay for dinner (if you're friends are awesome). It's s short commercial that illustrates the ease with which one can pass money back and forth with your friends and family using Apple Pay Cash in iMessage. The spot's called Just Text Them the Money, and it's a scenario most of us have played out.
Apple Pay Cash Best P2P Payment Service, says Consumer Reports
According to eMarketer, a market research company, an estimated 79 million Americans will use a P2P payment service this year.
Apple Pay Cash PSA: Be Careful When Carrying a Big Balance
Redditor u/Sometimesexaggerates found out the hard way.
Apple Highlights Apple Pay Cash in Three New Ads
Apple has three new short ads showing off Apple Pay Cash. They're all 15 seconds long and highlight different scenarios where using the feature could be handy.
These Are the Five Most Important Apple Software Products of 2017
Apple shipped more than 20 new products in 2017, but here are the five most important software products.
Here's How to Add Money to Apple Pay Cash or Change Linked Bank Card
Want to add money to your Apple Pay Cash account, or change the card it uses for payments? Read on to learn how to do both.
The Big Apple Pay Cash How To Show - TMO Daily Observations 2017-12-05
Kelly Guimont and Andrew Orr join Jeff Gamet to share tips and tricks on using Apple Pay Cash.
watchOS 4.2 Available with Apple Pay Cash Support
Now that Apple seems to have the kinks worked out from its Apple Pay Cash launch for iOS 11.2, watchOS 4.2 is out and ready to install on your Apple Watch.
Apple Pay Cash Begins Rolling Out - [Update: It's Back Again]
Really, we promise, and we have some screenshots that sort of prove it. [Update: Apple Pay Cash is back for some users, and TMO staff and TMO readers are reporting that it's active.]
Apple's Update and Security Stumbles, Amazon Prime on Apple TV - TMO Daily Observations 2017-12-04
John Martellaro and Bryan Chaffin join Jeff Gamet to look at Apple's recent security and update stumbles, plus they share their thoughts on Amazon saying their Apple TV Prime video app is still coming this year.


text: ThomasTheTGV 405 Posted August 3, 2018 Share Posted August 3, 2018 We (a couple of Dutch XRP community members) like you to join us for the XRP Midsummer Meetup on Thursday august 16 around 18.30 at the Garage Royal, Koningsweg 23A in Arnhem (https://goo.gl/amfPXe)! Goal of the evening at the garage is an informal meetup; share stories and experiences about blockchain in general and #XRP in particular. Everyone that's interested is welcome to join us for drinks and great pizza! Please register below so that we can inform the restaurant of our numbers:https://goo.gl/forms/yNCuv0wdbDqCZ9w43 Joining us is free but you have to buy your own consumptions. PS: Twitter handle for the meetup is #XRPMSM Ripple-Stiltskin, XRPfan_Eelco, DutchDividend and 3 others 5 1 Link to post Share on other sites


text:
Hop hop... Time to sing and dance... The concert begins!
Imagine children's slippers that offer them the pleasure of walking as if they were barefoot. Imagine finally that these slippers are without laces or Velcro and that the feet only have to slide into them in order to be cosseted. Imagine finally slippers that can give the feet all their natural flexibility while protecting them from the cold and from the roughness of the ground. Imagine, they're Didoodam slippers.
24,99 €
You must add 1 as a minimum quantity to buy this product.


text:
Have you wondered whether you are getting the most out of your current financial software?
Have you questioned if you were paying too much?
Have you been concerned your partner chose the right system for your specific business goals?
You are not alone.
Whether you're searching for a new partner to support your financial software system or confirmation that you are already on the right track, Rand Group has got you covered. Our full-scale assessments of your Customer Relationship Management (CRM) and Enterprise Resource Planning (ERP) systems can give you the insight you're looking for to help you rest assured that your business strategy is intact.
No matter your situation, here are three ways that our assessment package can set you up for success:
A routine health check.
If you are satisfied with your current partner and system but want to make sure that your system is being optimized, then this service is for you. Consider taking advantage of Rand Group as a valuable, third-party resource.
Rand Group can perform a full evaluation of your current system and processes and will provide insight into how you measure up. This consultative service is beneficial when determining if you are getting the most out of your software.
Insight into what's next.


text:
3PL Financial Support
Expert order-to-cash solutions delivered with unmatched accuracy and speed
Cardinal Health 3PL Services provides accurate and personalized solutions for converting finished goods to cash. We are measured on accuracy and speed, with a fully-dedicated customer service team trained to support you every step of the way.
Take advantage of our best-in-class order-to-cash solutions
From order management and verification to account reconciliation and invoice collection, Cardinal Health 3PL Services removes the guesswork and burden from order-to-cash. We manage $27 billion in accounts receivable every year, with unmatched accuracy and speed. With 99.91 percent order accuracy, our dedicated, full-service financial support team expertly delivers:
- branded customer service
- accounts receivable management
- chargeback management
- returns management
Track your product – and your ROI – throughout the chargeback and returns process
With complex contracts and pricing variability, chargebacks and returns can be a costly administrative challenge. Our comprehensive contracts and chargebacks program can:
- monitor your contract obligations and eligibility
- process new contracts and make updates within 24 hours
- process chargeback submissions, reconciliations and notifications
- fully manage your returns, from product receipt through certificate of disposal
- process returns of control room temperature, refrigerated, controlled (CII-CV) and hazmat products and product samples
- facilitate chargebacks at wholesale, retail, price-sold vs. current WAC levels
Need order-to-cash expertise?
Our fully dedicated customer service team can expertly handle your accounts and chargeback management, with 99.91 percent order accuracy. Contact us today.
Order accuracy


text:
I. Call to order In attendance: Baumler, Deckert, Hyde, Knight, Lewis, McCombie, Metz, Migyanka, Muchtar, Pistole, Sechrist, Rost Excused: Boser, Potts, Turner Absent: Intemann (Onwueme attended to represent the Provost) Guest: Dennis Ausel II. On a Baumler/Knight motion the minutes from the January 18, 2011 meeting were approved. III. Co-Chairs Report: A. No report IV. Liberal Studies Committee Report A. Minutes of the January 20, 2011 Liberal Studies Committee meeting were distributed. V. Items for Review/ Possible Action: A. 10-53 Certificate in Photography and Digital Imaging, new certificate
B. 10-54a JRNL 105 Journalism and Mass Media, distance education
C. 10-54b JRNL 243 History of the American Press, distance education
D. Liberal Studies Revision


text:
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by Adrian Black, Friday 20 May 2016
We often get asked how the length of a lease can affect the value of a property. It is a pretty well defined det...
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Eh, there's better mail clients in the repositories
Domain Name: PROTONMAIL.COM Registry Domain ID: 1612103273_DOMAIN_COM-VRSN Registrar WHOIS Server: whois.godaddy.com Registrar URL: http://www.godaddy.com Updated Date: 2018-11-03T20:19:23Z Creation Date: 2010-08-21T09:10:58Z Registry Expiry Date: 2019-08-21T09:10:58Z Registrar: GoDaddy.com, LLC Registrar IANA ID: 146 Registrar Abuse Contact Email: firstname.lastname@example.com Registrar Abuse Contact Phone: 480-624-2505 Domain Status: clientDeleteProhibited https://icann.org/epp#clientDeleteProhibited Domain Status: clientRenewProhibited https://icann.org/epp#clientRenewProhibited Domain Status: clientTransferProhibited https://icann.org/epp#clientTransferProhibited Domain Status: clientUpdateProhibited https://icann.org/epp#clientUpdateProhibited Name Server: NS1.PROTONMAIL.CH Name Server: NS3.PROTONMAIL.CH
Quote from: DavidEh, there's better mail clients in the repositoriesExplain better in detail ... You can'tWhat's better for you is not better for me or him/herThe best is what works best for youYou should know that as a "programmer"
Bad Behavior has blocked 1522 access attempts in the last 7 days.
Page created in 0.075 seconds with 32 queries.


text:
The Office of International Programs will host a one-day compulsory orientation for incoming international students on Friday, 21 August. Topics like health insurance, immigration, cultural issues, and practical resources will be covered. You will get a chance to meet other Puget Sound students and staff members. See the tentative schedule for the day here.
International Student Orientation isn't just for international students on F-1 or J-1 Visas. Third Culture Kids are welcome to attend the international student orientation as well.
You will have the opportunity to move into your residence hall on Thursday, 20 August.
Airport Pick-Up
Please plan your flight to arrive at Seattle-Tacoma International Airport (SEA) before 5pm on Thursday, 20 August.
We are only able to provide airport pick-up services on Thursday, 20 August.
If you would like to be picked up at the airport please email Eowyn Greeno (firstname.lastname@example.com) with your flight information (airline, departure city and departure time, as well as scheduled arrival time) at least two weeks in advance.
See here for more information about the full new student orientation.


text:
TECHTEAM truss size series: For Exhibition, decoration, wedding, advertising, hotel category: 100x100mm; 120x120mm; 220x220mmFor Small celebrations, concerts, party: 290x290mm; 390x390mm; 400x400mmFor Medium sized festivals, concerts, parties: 530*530mm; 470*610mmFor Big celebrations, concerts, parties: 520*760mm; 580*1010mmAbove is the common size.Usage:Concert, indoor or outdoor performance, exhibition booth, car show, wedding, event, party, night clubs, trade show display, school activities; hang stage lighting, speaker.Truss Specification:
Price term
EXW price, FOB price, CIF price, we can accept any price term.
Shipping method
By DHL ,UPS,TNT ,Fedax if small order, and ship by sea or air if bulk order
Payment terms
T/T,Western union, Paypal
Sample time
3-5 working days
Production time
15-20 working day depends on the quantity
Bubble Film/Carton/ flight case/Wooden box
Three years
After sells service
If there is the problem with the product, firstly you need send the picture or the video to us, then let us make sure what's problem about the product, we will try our best to help you. Generally we send spare part with shipment to ensure that customers always have spare part backup. In case customers need more parts, we offer free parts during warranty period (365 days after shipping date), and send them at our expenses.
We are 7 days by 24 hours available online for technical supports.
(1)Q:What is your payment terms?
A: Our payment is T/T, 30% deposit and 70% balance paid beford shipment .We also accept Western Union.
(2) Q:Can you accept customers' design?
A: Certainly! Our company have professional designer can help you
(3)Q:How can I visit your company?
A: You can take underground to South of station Guangzhou,then we will pick you up to our company .Just one hour from Baiyun airport to our company.Warmly welcome you to visit our company.
(4)Q:Why you choice our company product ?
A: Because our company was founded in 2012.All of our products have high quality ,competitive price,well design and warmly welcome home and board by our customers.
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Comedian and Nollywood actress Etinosa took to her Instagram page to share this video about rape, and she is currently facing some backlash.
In the video, she says when a lady is being raped she should think of it as having a one night stand to avoid the psychological effect of the abuse.
A lot of comments on the video have stated that rape is a very sensitive topic and shouldn't be spoken about lightly.
What are your thoughts?
The video has since been taken down from Etinosa's page.
She said:
Esohe thinks, In order to combat the psychological after effect of rape- the feeling of dejection, loss of self worth/esteem, humiliation, pain, trauma, emotional and psychological imbalance, a woman, haven discovered she can't escape the situation, should "make the best" out of it by converting it to having sex practically and also in her mind. This is not to say that justice should not be served to offenders but for the sanity of the victim, she should live in denial and tell herself she just had a one night stand…… Do you agree? What do you think?


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Want to learn why you should stop proving yourself to the narcissist? We've all been there. Doing the humiliating dance of trying to prove our worth to the narcissist. Stripping ourselves bareRead More
Abusive relationships often reshape your entire belief system. If you are like most victims of narcissistic abuse, you experienced a distorted sense of reality throughout the majority of the relationshipRead More
**Warning – Trigger Alert** For those of you who read my article, Why Going to Therapy with a Narcissist is a Bad Idea, you may have read the many interesting comments that were left on my blog. IRead More
If you're reading this article, perhaps you're searching for reasons why No Contact is the best way to sever ties with the Narcissist in your life. You may have already read some articles and nowRead More
Part of the reason targets of narcissistic abuse stay in the relationship beyond a reasonable and rational point is because they find it too hard to accept the idea that some people are cunning,Read More
A common question as it relates to a toxic relationship is whether the narcissist feels any guilt or remorse for what they've done to their partner (a.k.a. source of supply). The short answer is no. InRead More
SHE LET GO ~By Rev. Safire Rose~ She let go. Without a thought or a word, she let go. She let go of the fear. She let go of the judgments. She let go of the committee of indecision within her. She letRead More
I talk to people rather frequently who've come out of the relationship with their Narcissist and cannot seem to work through their feelings of anger and resentment. This is natural; something we allRead More
I Bargained with Life for a Penny I bargained with Life for a penny, And Life would pay no more, However I begged at evening When I counted my scanty store; For Life is a just employer, He gives you whatRead More


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Gianluca D'Agostino is a successful entrepreneur and innovative business pioneer within the mobile field. He has acquired almost 25 years of work experience abroad as a manager, entrepreneur, and investor in the tech sector with a particular focus on content and payment ecosystems. Today, Gianluca is an Angel Investor who is passionate about startups and committed to fostering the success of tech companies, where he plays the role of Non-executive Director on the Boards of Bango plc (listed on AIM London) and Coolgames B.V. Before founding Neomobile, which is one of the most important Italian digital companies, he had held various managerial positions in corporations such as KPMG and TIM/Telecom Italia. He was named among the 'Top 50 Execs' in 2009-2011, not to mention the 2011 'Media Momentum Man of the Year' according to Mobile Entertainment Magazine, the market's publication authority.
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Transcend has launched a new Premium Series memory card, which provides 64GB of space and ultra-high class 1 speeds.
Transcend, a Taiwan-based company which manufactures memory products, has introduced the new 64GB microSDXC Ultra-High Speed Class 1 memory card.
This UHS-I storage card is a part of the company's so-called Premium Series. It is a high-end product, which provides very fast transfer speeds and is aimed at electronic device users.
New Transcend 64GB microSDXC UHS-I memory card can transfer data at speeds of 45MBps
The latest microSDXC card of the Taipei-headquartered corporation can offer speeds of up to 45 megabytes per second. However, the 300x transfer raters only apply in certain conditions, as usual.
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Transcend claims that the new microSDXC UHS-I memory card is compatible with all the gadgets which support 64GB cards, such as digital cameras, smartphones, and tablets.
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BUSAs 2006
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Mining Mangocoin (MNG)
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Available in the Android SDK (SDK Tools) and therefore also in both Intellij IDEA and Android Studio, the Android emulator allows apps be run on a computer used for development in place of running on a phone. This page describes how to run the Android emulator from Intellij IDEA/Android Studio or from a the command… Continue reading Android Emulator
Category: deployment
Web Server Logic: Overview and Evolution
When thinking of the internet and servers, the first type of server that comes to mind is a web server. Not all servers on the internet are actually web servers, but as far as front of mind and siginificance, the web server is way up there. The previous post covered hosting, and this post covers… Continue reading Web Server Logic: Overview and Evolution
Hosting: Shared, VPS, Bare Metal and Cloud & Containers
A full web site starts with a server, this page provides an overview of the options. Terminology: What is a server?Bare Metal DIY Hosted "Pizza Boxes" Sharing Pizza Boxes Virtual Private Servers Shared Hosting Slice and Dice! WHM/CPanel Cloud Superceding the Server: What is cloud? Docker & Kubernetes Private Cloud Public Cloud Serverless? Costing and… Continue reading Hosting: Shared, VPS, Bare Metal and Cloud & Containers


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Neckpro II Overdoor Cervical Traction Device
This product contains natural rubber latex which may cause allergic reactions.
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WARNING: Cancer and Reproductive Harm. www.p65warnings.ca.gov/


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The 10 Best budget Travel Vacation Destinations For 2019
Quick Links
Best Travel Destination 2019: You might be wondering where to begin while planning a vacation trip with your family. If you're one of those that are seeking inspiration from online travel portals, it's essential to consider a few things while narrowing down your choices. A few countries can show you through some great vacation destinations for your family; however, you need to consider the norms concerning documentation, transportation, exchange rates, safety measures, and create a budget accordingly. Tour guides and magazines can give you an idea of the tourism stats of some of the best vacation spots. While some of these countries have developed a few new hotspots, others have revamped some of their old destinations.
You'll enjoy visiting some global vacation destinations that let you explore the remote trails and new hotspots that very few globetrotters have discovered.
Make sure you consider these vacation destinations while zeroing in on one:
1. London
London offers some exciting escapades from your business tours. The dazzle of the Crown Jewels and the Tower of London are enough to grasp your attention between your business meetings. You must visit the St. Paul's Cathedral after visiting the Tower Bridge. You can't miss out on the first planned square in London –the Covent Garden is bound to keep you engrossed. The live ambiance of the place ensures quality leisure time for the Globetrotters. The Buckingham Palace, the Houses of the Parliament, the Trafalgar Square, and the Westminster Abbey are among the most notable tourist hotspots that you need to visit. If you're inclined to Panoramas, you can even take your flight at the London Eye for a spectacular show. If you still find time to do some shopping, you could visit the Harrods.
2. Paris
Visiting the Arc de Triomphe and the Eiffel Tower marks the beginning of your Parisian adventure. Once you've been through the Champs- Elysées, you could head towards the Ile de la Cité. The place is famous for its Gothic architecture at the Sainte- Chapelle. You may even opt for a ride to the Notre-Dame Cathedral in the afternoon. The Louvre Museum is another place of interest for international visitors. It has a sprawling Palace that was once the royal residence of French Kings. With Venus de Milo and Mona Lisa, it stands as a popular hub of rare art objects and masterpieces that leave their footprints on the western world.
A drive to Versailles is next in line as you visit the palace of the 'Sun King', Louis XIV, which was built in the 17th Century. Once you're here, you can't overlook the Gallery of Mirror that yields magnificent scenery for those that visit the State Apartments. The fountains of the formal ornamental gardens aren't too far to take a stroll in the afternoon. Then again, you also have the Grand Canal stretching across the park to catch your attention.
3. Rome
Visiting Rome is like spending quality time in the company of your loved ones. Once you're here, you'll find a long list of historical sites to visit. The Colosseum is an excellent symbol of Roman architecture that marks the golden era. The largest amphitheater of the world, the place is also termed as the Coliseum. Every year, travelers flock to the Colosseum in large numbers and experience the concrete and stone construction of this fantastic building. Once the place stood witness to a unique instance of public sport known as the gladiatorial contests. A few favorite sites that can add up to your list are the Pyramid of Cestius, Trajan's column, Piazza Del Popolo, Piazza Venezia, and the Pantheon. For all the lovers' of art, Rome is the home of Michelangelo, the world-famous architect, sculptor, and painter.
4. Cancun
Cancun doesn't have any competitors when it comes to shopping, night-life, activities, and resorts. It has some of the pristine beaches in the nation. Vacation Destinations for families offer numerous options to explore in Cancun, while other travelers may consider it as a spring vacation destination or a party venue. The beachfront resorts come under all-inclusive packages that often tempt you to stay indoors; however, you can't afford to skip a few cheap vacation destinations in the region. You may consider opting for a few of the most enjoyable day-trips in Cancun.
5. New York
Once you step into New York, you can explore the best vacation spots in the world at your free will or opt for a guided tour. You have endless options to explore like that checking different landmarks and museums. The Times Square, the Statue of Liberty, MoMA, Empire State Building, and the Staten Island Ferry are a few that deserve mentioning. Apart from visiting Central Park, you may even check out the museum and avail the "Pay-What-You-Wish" or free offers that you come across so often. You may also go for sight-seeing by opting for a boat ride as you get off the land. You'll be overwhelmed by the number of companies that offer cruises within the city limits and beyond. New York has a few fun activities on offer for all tourists. Apart from surfing, you may choose to fly on the trapeze for fun.
6. Miami
Miami is your ultimate cross-culture destination in the USA. It's a city wherein immigrants from Latin America and the rest of the world experience the hustle and bustle on arrival. It is one of the most happening places wherein you may buy a condo from a stripper or define your favorite custom wear. People tend to vary in their customs and practices. Everyone seems to be enjoying the spirit of this city amid a wide variety of drinks and foods to celebrate their party mood. Regardless of whether you're enjoying a stay on the Hibiscus Island or viewing the cockfight in Hialeah, you're never far away from the pristine beach. The warmth of the South Beach will mesmerize you irrespective of whether you stay put to the Art Deco district, Hollywood of the East or the American Riviera. The architecture, sandy shores, and the long night-life will keep you engaged amid a lot of luxury and splendor. You can beat the heat by taking a dip in the hotel pools.
7. Orlando
Disney World is probably the most popular vacation destination in Florida. It's also one of the most sought after tourist destinations in the world. It pays when you plan things and makes the most of your earnings. Apart from being a convention center that's the second largest in the world, Orlando has a few other tourist attractions in its vicinity like the Discovery Cove, Aquatica, the newest water park, Wet 'n Wild, Sea World Orlando, and Universal Studios and Islands of Adventure. Orlando Odditorium, Ripley's Believe It or Not, Pirate's Cove Mini Golf, and the Fun Spot Action Park are among the other entertainment hotspots.
8. San Francisco
San Francisco lies between the Pacific Coast and the San Francisco Bay. Situated in the tip of a peninsula, it's the favorite tourist hub for numerous globetrotters. The city is known for its cable cars, Victorian architecture, graceful vistas, and summer fogs. Surrounded by water on three sides, the city looks compact in appearance with its steep rolling hills. The visitors should carry warm clothing since its pretty cold even during the summer time.
9. Myrtle Beach
Myrtle Beach has earned a reputation as a golf destination and family hotspot. However, it remains a favorite destination for couples. At the same time, a woman needs to keep her from being a "golf widow" by teeing it up with her life partner. Both of you will find enough opportunity to be occupied. You can indulge in several fun activities, visit a few tourist spots, and set your position in the golf course.
Myrtle Beach invites travelers that seek quality food and golf. You may visit the Grand Strand area and try having the delicacies at any of the 1,000 restaurants. You can be there on your next trip and check out your favorite dishes on each meal that you enjoy.
10. Branson
Branson is one of the chief attractions in South Missouri. It stands tall on the Ozark Mountains. It was a river town that grew from a small tourist spot to the Midwest capital. The natural attractions of the city act as a backdrop to the live music and fantastic night-life. You can relate the high influx of travelers to the history of this place. The place is of great interest to the inhabitants and tourists alike for the last 100 years. Apart from the live entertainment, the city even yields lush scenic beauty and marvels beneath the ground within the vicinity of the Branson Scenic Railway. You're bound to have much fun around the museums and theatres of the city. A combination of the urban entertainment and the charm of a small town are a surefire recipe of fun for any unassuming vacation destination. Millions of visitors throng to this hotspot every year to enjoy a roller coaster ride and stand witness to other amusements.
This is the top 10 travel destination for 2019 trip with your family and friends. share your thoughts with us.
- May 13, 2019
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Increased Hospitalizations and Overall Healthcare Utilization in Patients Receiving Implantable Cardioverter-Defibrillator Shocks Compared With Antitachycardia Pacing
Author + information
- Received June 1, 2017
- Revision received September 14, 2017
- Accepted September 14, 2017
- Published online February 19, 2018.
Article Versions
- previous version (November 15, 2017 - 11:00).
- You are viewing the most recent version of this article.
Author Information
- Prashanthan Sanders, MBBS, PhDa,∗ (prash.sanders{at}adelaide.edu.au),
- Allison T. Connolly, PhDb,
- Yelena Nabutovsky, MScb,
- Avi Fischer, MDb and
- Mohammad Saeed, MDc
- aCentre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
- bAbbott, Chicago, Illinois
- cTexas Heart Institute, Houston, Texas
- ↵∗Address for correspondence:
Dr. Prashanthan Sanders, Centre for Heart Rhythm Disorders, Department of Cardiology, Royal Adelaide Hospital, North Terrace Adelaide, SA 5000, Australia.
Graphical abstract
Objectives The purpose of this study was to evaluate the effect of these therapies on healthcare utilization in a large patient cohort.
Background Antitachycardia pacing (ATP) terminates ventricular tachycardia and avoids delivery of high-voltage shocks. Few data exist on the impact of shocks on healthcare resource utilization compared with ATP.
Methods PROVIDE (Programming Implantable Cardioverter Defibrillators in Patients With Primary Prevention Indication) was a prospective study of patients who received an implantable cardioverter-defibrillator (ICD) for primary prevention at 97 U.S. centers (2008 to 2010). We categorized the PROVIDE patients by the type of therapy delivered: no therapy, ATP only, or at least 1 shock. All ICD therapies, hospitalizations, and deaths were adjudicated. Cumulative cardiac hospitalizations, risk of all-cause death or cardiac hospitalization, and annual costs were compared between groups.
Results Of the 1,670 patients in PROVIDE, followed up for 18.1 ± 7.6 months, 1,316 received no therapy, 152 had ATP only, and 202 received at least 1 shock. Patients receiving no therapy and those receiving only ATP had a lower cumulative hospitalization rate and were at lower risk for death or hospitalization (hazard ratio: 0.33 [p < 0.001] and 0.33 [p < 0.002], respectively). The cost of hospitalization was $2,874 per patient-year (95% confidence interval: $877 to $5,140; p = 0.002) higher for those receiving at least 1 shock than for those who received ATP only. There was no difference in outcomes or cost between patients receiving only ATP and those without therapy.
Conclusions Among patients implanted with an ICD for primary prevention, those who received only ATP therapy had reduced hospitalizations, mortality, and cost compared with those who received at least 1 high-voltage shock and had equivalent outcomes to patients who did not require any therapy. (Programming Implantable Cardioverter Defibrillators in Patients With Primary Prevention Indication [PROVIDE]; NCT00743522)
- antitachycardia pacing
- healthcare resource utilization
- hospitalization
- implantable cardioverter-defibrillator
Implantable cardioverter-defibrillators (ICDs) successfully terminate ventricular arrhythmias by delivering antitachycardia pacing (ATP) or high voltage shocks (1–3); however, shocks have been associated with an increase in mortality (4,5) and heart failure (6). The introduction of ATP has allowed for termination of ventricular tachycardia (VT) by delivery of rapid pacing pulses in place of high-voltage shocks (7). Expansion of the use of ATP for faster ventricular arrhythmias and the application of ATP during charging has resulted in a reduction in shocks, with a concurrent reduction in mortality (8,9). Although significant literature exists regarding the benefits of ATP over delivery of high-voltage shocks, there is little information available on the impact of shock therapy compared with ATP on healthcare resource utilization (HCRU).
The aim of this analysis was to directly compare rates of cardiac hospitalization and associated costs in ICD patients receiving ATP only, shocks, and no therapy. We hypothesized that patients receiving only ATP would have a reduced HCRU burden compared with those experiencing shocks. Patients followed up in the PROVIDE (Programming Implantable Cardioverter Defibrillators in Patients With Primary Prevention Indication) clinical trial were studied because complete documentation of clinical history, device therapies, and clinical events allowed for a controlled model with robust results.
Analysis cohort
PROVIDE was a prospective, randomized, multicenter study in the United States that enrolled patients who met primary prevention criteria for ICD or cardiac resynchronization therapy defibrillator (CRT-D) and had a St. Jude Medical device inserted (NCT00743522). The study has been described in detail (10). In this analysis, we used the entire PROVIDE patient cohort to examine the effects of the type of ICD therapy delivered on HCRU.
Hospitalizations and death
Follow-up visits were conducted in office or via remote monitoring at 3, 6, 9, and 12 months and every 3 months thereafter until study closure, with at least 1 in-office follow-up per year. During these visits, information about hospitalization was collected via direct patient interviews by a healthcare provider. The reason for each hospitalization was documented as cardiac (including syncope), noncardiac, or other. The types of hospital admissions included emergency department (ED) visit only, short stay (<24 h), and long stay (≥24 h). Date of death was also reported. Patient behavior and standard clinical practice often dictate that patients might visit the ED after receiving 1 or more ICD shocks (11). To separate an increase in HCRU that was directly related to patient behavior in response to knowledge of having received a shock from HCRU that was related to worsening patient status, a subanalysis was performed that excluded all hospitalizations on the same day or within 5 days of an ICD therapy.
ICD therapy
Device data, including stored electrograms, were collected during in-clinic and remote follow-up visits. Episodes that resulted in delivery of ATP or shock therapy were de-identified and adjudicated by 2 electrophysiologists as being appropriate or inappropriate based on determination of underlying arrhythmia. Therapy was deemed appropriate if VT or ventricular fibrillation was the cause of arrhythmia leading to ATP or shock delivery. Each episode could contain either ATP only, ATP and shock, or shock only as therapy.
Therapy groups
For the primary analysis, all patients were categorized into 4 groups based on therapy received during the entire study duration: those who received no therapy, those who received only ATP, those who received 1 shock, and those who received multiple shocks. Patients were classified into the shock groups if they received 1 or more shocks, regardless of ATP delivery.
The primary outcome of this analysis was cumulative cardiac hospitalization rate. Secondary outcomes were time to first cardiac hospitalization and time to first cardiac hospitalization or death. We compared all 3 groups against each other with and without adjustment for relevant covariates, from implantation until censor date (end of follow-up or date of death).
Effect of appropriate and inappropriate therapy on outcomes
We subdivided the therapy groups into those with at least 1 episode of appropriate therapy and those with only inappropriate therapy for both the ATP and shock groups. We compared the event rates for cardiac hospitalization, death, and a composite outcome of cardiac hospitalization or death between the resulting groups.
Cost of hospitalizations
Case report forms with clinic notes were available for a subset of the reported hospitalization events. Medical coding was performed for each available form (Healthicity, Salt Lake City, Utah) (Online Appendix). Billing codes were converted to national unadjusted payments using MediRegs (Wolters Kluwer, Needham, Massachusetts). Overall costs per event and average cost per patient were compared between groups. All costs were calculated in 2016 U.S. dollars based on data from the Centers for Medicare and Medicaid Services.
Statistical analysis
Basic patient characteristics were summarized for the 4 groups using mean and SD for continuous variables, median and interquartile ranges (IQRs) for time and cost variables, and number and percentage for categorical variables. ANOVA was used to compare continuous variables, the rank sum test was used for time variables, and the chi-square test was used to compare categorical variables among pairs of groups.
Survival free from cardiac hospitalization and the composite outcome of cardiac hospitalization or death were compared between groups using Kaplan-Meier analysis and a Cox proportional hazards model. To identify covariates for the multivariate model, we used a univariate Cox proportional hazards model applied to each baseline demographic variable. Baseline demographic variables with a proportional hazard for cardiac hospitalization with significant p < 0.25 and relevant baseline characteristics were included in the multivariate Cox regression model. These included prior myocardial infarction, unstable angina, diabetes, chronic obstructive pulmonary disease, hyperlipidemia, ejection fraction, age, sex, New York Heart Association functional class, and randomization arm.
Cumulative cardiac hospitalization rate was compared with Kaplan-Meier multiple-events curves and Cox regression with the Andersen-Gill model. Event rates were reported per 100 patient-years. Poisson regression was used to model the rates of cardiac hospitalizations, death, and the composite measure of hospitalizations or death, with adjustment for therapy group, follow-up time, and other significant covariates (Online Appendix). Pairwise comparisons of event rates between therapy groups were compared with Poisson regression.
To account for low counts, missing data, differences in populations, and non-normal distributions in the cost data, bootstrapping of a 2-part model with 100,000 repetitions was used to examine the difference in cost between therapy groups (12). The probability that the cost difference between therapy groups was positive was estimated from the bootstrapped differences. The level of significance was α = 0.05, and a Bonferroni correction was used for multiple comparisons. Revolution R version 7.1.0 (Revolution Analytics, Mountain View, California) with R version 3.0.2 was used for statistical analysis and data visualization.
Baseline characteristics
Of the 1,670 patients in the PROVIDE study, 1,316 (79%) did not receive any device therapy, 152 (9%) received only ATP, 108 (6%) received 1 shock, and 94 (6%) received multiple shocks during the study duration. Median (IQR) follow-up time was 17.8 (12.2 to 23.9), 20.8 (14.9 to 25.0), 20.6 (15.3 to 26.1), and 19.5 (14.8 to 25.2) months, respectively, with median (IQR) follow-up of 18.1 (12.4 to 24.1) months per patient. Comparison between baseline characteristics for the patients in the 4 therapy groups is shown in Table 1.
ICD therapy
There were 1,745 therapy episodes in 354 patients, of which 1,215 (69.6%) contained only ATP, 242 (13.9%) only shock, and 288 (16.5%) ATP followed by a shock. The 152 patients who received only ATP had an average of 2.6 ATP episodes per year. The remaining 202 patients with episodes received 4 ATP only, 1.4 ATP and shock, and 1.2 shock episodes per year. Shocks were delivered for all episode rates, and ATP was delivered for episode rates <250 beats/min (Figure 1). Of the episodes for which ATP was delivered, 80.8% were successfully terminated by ATP. ATP was successful for 91.7% of episodes in which ICD therapy was appropriate.
There were 343 cardiac hospitalizations among 233 patients (Figure 2). The reasons for cardiac hospitalizations are listed in Table 2. Median (IQR) length of long-stay hospitalizations was not significantly different by therapy type (3 [2 to 5] days without ICD therapy, 3 [2 to 6] days with ATP only, 3 [2 to 6] days with at least 1 shock; p = 0.508). The overall cardiac hospitalization rate was significantly higher in patients with 1 and multiple shocks compared with the ATP and no-therapy groups (Table 3). In addition, multiple shocks led to a significant increase in cardiac hospitalization rate compared with a single shock. This result was persistent for multiple shocks, but not 1 shock, when hospitalizations were broken down by type.
There were 98 deaths in the no-therapy group, 12 in the ATP group, 10 in the 1-shock group, and 18 in the multiple-shock group. The death rate was only significantly different in patients with multiple shocks compared with patients with ATP and no therapy (Table 3). The composite event rate of cardiac hospitalization or death was higher in patients with single and multiple shocks than in patients with ATP and no therapy and higher in patients with multiple shocks than in those with a single shock (Table 3). There were no differences in these outcomes between the ATP and the no-therapy groups.
The Cox proportional hazards model was used to identify clinical covariates with a univariate effect on cardiac hospitalizations. Multivariate analyses included the significant covariates of age and history of angina (p < 0.05); covariates that trended toward significance, including ejection fraction and history of myocardial infarction, diabetes mellitus, chronic obstructive pulmonary disease, or hyperlipidemia (p < 0.25); and other relevant demographics, including sex, New York Heart Association functional class, and PROVIDE study randomization. Cumulative cardiac hospitalization rate was significantly lower in patients who received only ATP (hazard ratio [HR]: 0.32; 95% confidence interval [CI]: 0.16 to 0.65; p = 0.002) or no therapy (HR: 0.38; 95% CI: 0.28 to 0.52; p < 0.001) than in patients who received shocks (Figure 3). Similarly, patients who received only ATP and those receiving no therapy were at a lower risk for a cardiac hospitalization (Figure 4A) and a composite outcome of cardiac hospitalization or death (Figure 4B) than patients who received shock. There was no difference in cumulative cardiac hospitalization rate, risk of first hospitalization, or risk of hospitalization or death between patients who received only ATP and those without therapy. Subgroup analyses stratified by PROVIDE study randomization were consistent with the overall results except for cases when the group size was too small to show significance.
Hospitalizations occurring close to device therapy
Of the 208 cardiac hospitalizations, 39 occurred on the day of or within 5 days of an episode with ATP and/or shock. Of these, 11 were ED visits, 4 were short-stay hospitalizations, and 24 were long-stay hospitalizations. Using the remaining 169 hospitalizations, we found that cumulative cardiac hospitalization rate remained significantly lower in patients who received only ATP (HR: 0.40; 95% CI: 0.2 to 0.8; p = 0.010) or no therapy (HR: 0.57; 95% CI: 0.4 to 0.8; p = 0.001) than in patients who received shock (Online Figure 1).
Appropriate and inappropriate therapy
Rates of death, cardiac hospitalization, and composite outcome of hospitalization or death were not different between patients receiving no therapy and those receiving only ATP, regardless of appropriateness of the ATP therapy (Table 4). Rates of cardiac hospitalization and composite outcome of hospitalization or death were significantly higher in patients who received appropriate or inappropriate shocks than in patients receiving no therapy, but rate of death was only elevated in patients with appropriate shock (Table 4). Hospitalization rate and the composite event rate were lower in patients receiving only inappropriate shocks than in those with appropriate shocks (Table 4).
Cost of hospitalizations
Total cost for all hospitalizations was compared between the no-therapy, ATP-only, and shock groups. Cost information was available for 127 hospitalizations (37.0%) among 101 patients (28.5%). Costs were not available for short-stay events in the ATP-only group, so costs for these events were imputed from other short-stay events. There was no statistical difference in cost for any type of hospitalization observed between therapy groups. Median (IQR) cost for an individual long-stay hospitalization was $6,394 ($3,979 to $11,082) for patients receiving no therapy, $8,396 ($5,733 to $11,304) for ATP only, and $5,733 ($4,637 to $8,265) for shock. For ED events, median (IQR) cost was $451 ($350 to $534) for no therapy, $456 ($438 to $488) for ATP only, and $467 ($361 to $520) for shock. For short-stay events, median (IQR) cost was $4,698 ($863 to $12,713) for no therapy and $2,247 ($671 to $4,698) for shock. On average, the bootstrapped total cost per patient-year was $1,817 ($1,142 to $2,732) for no therapy, $1,405 ($447 to $2,663) for ATP only, and $4,278 ($2,356 to $6,573) for shock (Figure 5). Total cost for shock was $2,461 per patient-year ($494 to $4,620) higher than no therapy (p = 0.008) and $2,874 per patient-year ($877 to $5,140) higher than ATP only (p = 0.002), whereas the total costs for no therapy and ATP only were not significantly different.
This study leveraged the PROVIDE patient population, which consisted of primary prevention ICD/CRT-D patients with thorough documentation of clinical history and events, to compare the HCRU of patients receiving different types of device therapies. The rates of cardiac hospitalizations and death were not increased for patients receiving only ATP compared with those receiving no therapy, but the rate of hospitalization and the associated cost were significantly higher in patients receiving shocks. When the therapy was broken down by subtype, even inappropriate shocks increased the rate of cardiac hospitalization compared with appropriate ATP, and just 1 shock was enough to increase the hospitalization rate above that for ATP. Only appropriate shocks and receiving at least 2 shocks significantly increased the risk of death above that for ATP and no therapy. The use of a patient cohort from the PROVIDE clinical trial allowed for adjustment of baseline patient demographics, comorbidities, and device indications in the evaluation of these outcomes (13,14). For example, patients receiving at least 1 shock had a higher incidence of atrial fibrillation (AF) than those receiving no therapy, whereas patients receiving only ATP had lower rates of some clinical comorbidities and had similar rates of AF as the no-therapy group. However, adjustment did not change the effect of shock on cardiac hospitalizations, death, or HCRU, which indicates that these results were robust to patient characteristics and primarily dependent on therapy.
Previous clinical studies have shown that programming strategies that promote the use of ATP are safe and effective, reduce mortality, and reduce the incidence of shocks (4,5,7,9,15,16), but the impact of ATP on hospitalizations and cost is less understood. We have shown that patients who received only ATP therapy had equivalent HCRU to patients who received no therapies from their implantable device, but those who received at least 1 shock had significantly higher HCRU than those with either ATP only or no therapy. Furthermore, multiple shocks were associated with an even greater rate of hospitalizations, which corroborates earlier findings that showed an increased risk of mortality with multiple shocks (14,17–19). The increased rate of cardiac hospitalizations for the shock group compared with ATP persisted for long-stay hospitalizations and after removal of hospitalizations that occurred immediately after shock therapy, which suggests that the increased HCRU was not driven by patient behavior in response to feeling a shock nor the numerous and often repetitive tests performed as a direct result of hospital admission. In this analysis, the rate of death alone was elevated with multiple shocks and appropriate shocks compared with no therapy, which aligns with other studies that show an increased risk of mortality with shocks (20,21) but not with ATP (17–19). There is a longstanding debate concerning the role of defibrillation shock itself versus the underlying arrhythmia in cardiac damage and negative outcomes. High-energy defibrillation shocks have been shown to cause myocardial dysfunction in animal models (22,23) and in small studies in humans (24–26). A reduction in the number of inappropriate shocks, but not appropriate shocks, was associated with a decrease in mortality in both the MADIT-RIT (Multicenter Automatic Defibrillator Implantation Trial–Reduce Inappropriate Therapy) (16) and the PROVIDE (10) studies, whereas receipt of all types of shocks increased the risk of death in the ALTITUDE study (21). These studies suggest that high-voltage therapy contributes significantly to myocardial damage and mortality, which could extend to increased HCRU.
In our cohort, patients who received only inappropriate shocks had a higher rate of cardiac hospitalization than those who received any type of ATP or no therapy, which might indicate that shocks in the absence of ventricular arrhythmia have a negative effect. Patients who received at least 1 appropriate shock had a significantly higher rate of hospitalization than those who received inappropriate shocks (p = 0.008). Receipt of appropriate and inappropriate ATP was equivalent and had no effect on hospitalization or death, which indicates that having a ventricular arrhythmia treatable by ATP does not significantly increase the risk of hospitalization. Only appropriate shocks were associated with an increased rate of death, which might suggest a multiplicative effect of ventricular arrhythmia and high-voltage therapy. We did not address the issue of necessity of therapy, because we could not tell whether the arrhythmias would have self-terminated without therapy. However, even if many ATP therapies were not necessary, our results show no difference in outcomes between patients who received ATP only and those who received no therapy, regardless of appropriateness of ATP.
In addition to the important clinical benefits of ATP established by this and previous studies (27,28), our study demonstrates significant cost savings associated with the use of ATP. A recent study showed substantial healthcare utilization associated with both appropriate and inappropriate shocks (29). We show that patients who experienced only ATP incurred $2,873 per patient-year lower costs associated with hospitalizations than those who received shocks and equivalent costs as those without therapy. Our analysis used average costs based on payments by Medicare, and total costs were similar to those reported from a Medicare-based economic analysis of patients in MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) (30). Costs incurred by individuals covered by commercial insurance are likely to be even higher, which would result in an even greater cost savings with use of ATP. Using commercial insurance data, the average cost of a cardiovascular hospitalization is $10,908, which is substantially more than reported in our study (31), and the cost of inappropriate shocks from the hospital perspective rather than a payer perspective has been shown to be substantially different between patients who received inappropriate shocks and those who did not receive any therapy (32). With rising healthcare costs and heightened awareness of the need to look for cost-saving technology, the use of ATP to avoid shocks should be required for patients who are at risk for VT. Although new ICD technologies using nonvascular approaches to deliver high-voltage therapy exist, these devices are incapable of delivering ATP. The EFFORTLESS subcutaneous ICD registry reported that of 111 treated VT/ventricular fibrillation episodes, 60 (in 40 patients) were from monomorphic VT (33). These shocks could likely have been avoided in a device capable of delivering ATP. Both clinical and economic implications should be considered when deciding which device type to implant, and this decision should account for both current therapeutic needs and the potential for ATP in the future.
Study limitations
The results of this study were confined to primary prevention ICD/CRT-D patients enrolled in the PROVIDE trial and should not be assumed to extend to secondary prevention patients without further investigation. In addition, the therapy groups were not pre-determined but rather based on treatment after the start of the study, such that patients were not matched on demographic or clinical covariates. Even after adjustment for clinical covariates, the association between shocks and increased HCRU might derive from a sicker patient group receiving shocks than no therapy. AF differed between therapy groups but was not an independent predictor of cardiac hospitalization rate; however, this contradicts previous studies that showed worse outcomes in patients with AF (15,34). The small sample size in this study prevents the analysis of interaction effects of AF with device therapy. Because of missing case report forms, some cost data were unknown and had to be imputed. When billing codes were present, cost data were estimated with Centers for Medicare and Medicaid Services national average payments, which might underestimate the cost of patients with private insurance.
Patients with primary prevention ICDs who received ATP had lower rates of cardiac hospitalization, composite rate of hospitalization or death, and healthcare costs than those who received shock therapy. There was no difference in clinical or economic outcomes between patients who received ATP only and those who did not receive any therapy. Although the increased rate of hospitalization was observed in patients with both appropriate and inappropriate shocks, the increased the rate of death was seen only in those who received appropriate shocks.
COMPETENCY IN MEDICAL KNOWLEDGE: The primary prevention ICD patient has improved outcomes when programming of ATP is enabled. Shocks present a high burden to the healthcare system that can be reduced if shocks can be avoided through the use of ATP.
TRANSLATIONAL OUTLOOK 1: The adjudication of clinical covariates, device therapies, and outcomes in the PROVIDE study allowed for investigation into the negative outcomes associated with shock and the relative association due to the underlying disease or to the therapy itself.
TRANSLATIONAL OUTLOOK 2: The results from this paper should be incorporated into practice by implanting ATP-capable devices and by programming devices with ATP, providing an additional opportunity not just to reduce shock delivery but to reduce healthcare expense.
This work was supported by Abbott (St. Jude Medical). Dr. Sanders has served on advisory boards for Biosense-Webster, Medtronic, St. Jude Medical, Boston Scientific, and CathRx; received research funding from Medtronic, St. Jude Medical, Boston Scientific, Biotronik, and Sorin; and received consulting or lecture fees from Biosense-Webster, Medtronic, St. Jude Medical, and Boston Scientific. Dr. Sanders is supported by a practitioner fellowship from the National Health and Medical Research Council of Australia and by the National Heart Foundation of Australia. Dr. Connolly, Ms. Nabutovsky, and Dr. Fischer are employees of Abbott. Dr. Saeed has reported that he has no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Abbreviations and Acronyms
- atrial fibrillation
- antitachycardia pacing
- confidence interval
- cardiac resynchronization therapy defibrillator
- emergency department
- healthcare resource utilization
- hazard ratio
- implantable cardioverter-defibrillator
- interquartile range
- ventricular tachycardia
- Received June 1, 2017.
- Revision received September 14, 2017.
- Accepted September 14, 2017.
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1. Detroit Tigers (6-0, previous No. 9) – Some wondered how the Tigers would be after losing two of their top pitchers, but they clearly haven't missed them so far. At the plate, they are led by Miguel Cabrera who is batting .520, and also have the top three batting averages in the American League.
2. Kansas City Royals (6-0, previous No. 8) – Few saw this coming from the defending AL champs.They're allowing an American League-low 15 runs so far this season and that pace will allow them to win a ton of games in 2015.
3. Atlanta Braves (5-1, previous No. 27) – Nobody, I mean nobody, saw this start coming from the Braves who swept the Marlins in Miami to open the season. Jason Grilli already has a league-leading three saves. If the Braves hitthen they will be able to continue to surprise.
4. Toronto Blue Jays (4-2, previous No. 10) – Toronto is going to hit, as shown by itsoffensive explosion last year. So far in 2015 they are led by Jose Reyes' .417 average. The biggest thing to watch with the Blue Jays is if they will be able to pitch with the rest of the AL East.
5. Boston Red Sox (4-2, previous No. 12) – The first turn through the rotation went tremendous for the Red Soxbut Clay Buchholzhad the worst outing of his career, allowing 10 runs against the Yankees, in his second start of 2015. The Red Sox are going to hit, but how will their pitching hold up?
6. Cincinnati Reds (4-2, previous No. 25) – Cincinnati was picked to finish at the bottom of the NL Central, but the long-ball has led them to a 4-2 start. They did lose two-of-three to the Cardinals over the weekend, so will they go back to the basement of the division?
7. Colorado Rockies (4-2, previous No. 28) – By now it's clear the Rockies are going to score a ton of runs – so far an NL-leading 35 – but as has been the case for many years, pitching is an issue. Does Colorado have enough strong arms to keep them in the mix all year?
8. San Diego Padres (4-3, previous No. 13) – All the offseason additions, and a big trade last week would seem to say the Padres are primed for a big year. They swept the Giants over the weekend and have a plus-8 run differential, the second-best in the NL West.
9. Los Angeles Dodgers (3-3, previous No. 3) – Los Angeles didn't get off to the start ithad hoped for, but there's no doubt the Dodgerswill rise quickly in the rankings and be there in the end. Clayton Kershaw allowed six runs in a 6-0 loss to the Diamondbacks on Saturday, but Adrian Gonzalez already has five home runs.
10. Seattle Mariners (3-3, previous No. 4) – The Mariners are going to be a fun team to watch this season, as shown this weekend in their series with the Athletics. Fernando Rodney has two saves to open the year and Seattle should be able to go neck-and-neck with the A's and Angels all season long.
11. Baltimore Orioles (3-3, previous No. 14) – Baltimore's pitching is going to be the biggest thing to watch all year, as it has allowed 32 runs so far, and no team in the American League has allowed more than 33. Can Ubaldo Jimenez get back to his old form and lead the rotation?
12. Houston Astros (3-3, previous No. 24) – With a few years of developing talent, the Astros may not be a playoff team, but they certainly appear – on paper – to be better than in years past and could surprise some this year.
13. New York Mets (3-3, previous No. 21) – Led by Bartolo Colon, the Mets are 3-3 and sit in second place in the NL East. Colon has won both of his starts thus far, and despite his age he's proving he can pitch with anyone. With Matt Harvey back, just how good can the Mets be?
14. St. Louis Cardinals (3-2, previous No. 3) – St. Louis' plus-five run differential is the best mark in the NL Central. With the Cubs and Reds getting off to decent starts to the year, the division is shaping up to be much more competitive than in years past.
15. Chicago Cubs (3-2, previous No. 17) – The Cubs went out and made some big moves this offseason, but will it be enough for Theo Epstein to lead a winning organization? Although Chicago might be a long-shot to in the World Series, Cubs fans are itching for just a playoff appearance.
16. Tampa Bay Rays (3-3, previous No. 19) – The Rays survived the first week with some pitching injuries still hanging over them from spring training, but it will be interesting to see how they can handle not having David Price. There isn't much optimism.
17. Philadelphia Phillies (3-3, previous No. 29) – The Phillies didn't do much in the first week to give the team much hope. Cole Hamels rebounded over the weekend after a rough Opening Day start, and Jonathan Papelbon continues to voice his displeasure overbeing in a Phillies uniform.
18. San Francisco Giants (3-4, previous No. 6) – The defending World Series champions are struggling to score runs, just 23 through their first seven games. The offense took a hit in the offseason, and it's hard for one pitcher – Madison Bumgarner – to carry a team on his back during the regular season.
19. Oakland Athletics (3-4, previous No. 11) – Oakland parted ways with a number of its stars this offseason, but the first week showed it will still be an exciting team. The Athletics'plus-17 run differential is best in the AL West, and led by young stud Sonny Gray, Oakland will surely rise inthese rankings as the weeks go by.
20. Texas Rangers (3-4, previous No. 22) – A tough season last year was made even worse this spring when they learned Yu Darvish would be out for the season. Known for being in playoff contention year-in and year-out, it's hard to imagine October baseball for Texas it this year.
21. Washington Nationals (2-4, previous No. 2) – Washington certainly won't be this low in the rankings for long. The Natshad a tough opening week, but once they settle in and their pitching gets a few games under their belts, they surely will be one of the best teams in baseball.
22. Arizona Diamondbacks (3-3, previous No. 30) – Going 3-3 was a good week by Diamondbacks standards. How long can they stay at the .500 mark?
23. New York Yankees (2-4, previous No. 18) – The Yankees avoided a sweep by the Red Sox with a 10-run win Sunday night, but the defense has been a major issue as they have allowed at least one unearned run in the first six games of the season.
24. Los Angeles Angels (2-4, previous No. 5) – It's been a strange start to the season in Los Angeles with drama off the field with Josh Hamilton. Being swept at home by Kansas Citycertainly wasn't what the Angels hadhoped for either.
25. Pittsburgh Pirates (2-4, previous No. 7) – Picked by some to surprise this season, Pittsburgh hasn't gottenoff to the best of starts, but it hopes by returning home with a dominant pitching staff itcan turn things around.
26. Cleveland Indians (2-4, previous No. 15) – Things aren't going so well for the Indians, both on the field and off the field, to open the season. It was learned over the weekend that catcher Yan Gomes is out 6-8 weeks with a knee injury.
27. Chicago White Sox (2-4, previous No. 20) – The White Sox made some noise in the offseason, but through the first week it hasn't paid off, as their lineup has only managed 13 runs through the first six games.
28. Miami Marlins (1-5, previous No. 16) – The Marlins have struggled out of the gate, owning the fewest wins in the National League. Miami hashigh expectations this year. Can Giancarlo Stanton right the ship?
29. Milwaukee Brewers (1-5, previous No. 23) – Milwaukee seems to be picking upfrom where it left offlast year. The Brewerswere the last team in baseball to get their first win – starting the year 0-4.
30. Minnesota Twins (1-5, previous No. 26) – With1-5 start and some of the otherbasement teams getting off to good starts, Minnesota is no doubt a candidate to be the worst team in MLB.


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"That c--ksucker must have some kind of death wish."I abruptly turned in the drivers seat and said "What the hell did you just say! Who has a death wish?" I'm thinking someone's flipped us off or whatever. He said, "Toni, I said, that hawk sitting up there must see a fish." I busted my chitterlings, people, and was unable to tell him for a few minutes what I was laughing about. He hates this with a passion and gets very grumpy. He says I'll laugh at anything, which may or may not be true, but this was funny with a capital FUH.
And, so anyhow, not only is my hearing shot, but I cannot remember what the hell I'm doing from one minute to the next. I put some garlic bread in the oven at 400 degrees. Remember this temperature as it is vital to the story, okay? My darling is late getting home from shrimp dragging; it's after 7 p.m. so I'm a little frazzled. He comes in and I dish up a very nice dinner, we dine, wash the dishes and chat awhile before trundling off to bed. The whole while I can smell something burning like toast, and I realize I haven't turned off the oven. Simple enough.
I awaken the next morning at 4 a.m. with a start, realizing that I never took the garlic bread out of the oven for dinner the night before. I leap from bed - why I don't know - and dash into the kitchen. What I find are two extremely large croutons at this point, drier than a old maid's...tears.
The next night, I left the lovely and highly coveted bread stuffing from the lovely roast chicken in the microwave overnight and had to toss that out the next day around 2 p.m. when I finally discovered it. That was a bummer. My bread stuffing is phenomenal. I nearly cried.
Menopause brain? Ennui? I think I'm off in my own little world much of the time, staring and absorbing my surroundings, "writing them," as it were. I've turned into quite the little geeker of late, giant purse that can hold my new read, Elizabeth Berg's "Escaping Into the Open," my notebook and pen, along with all my "girl" stuff. Pretty quick I'm going to have to have the voice recorder to record all my jaunty little thoughts as they pop up 'cause I'm too damned important/lazy/artistically fartzy to use a pen.


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We admit that State of Origin and the lead-up to the 2018 FIFA World Cup tournament has dominated our attention is recent days and weeks until we noticed, to our mild chagrin that we have been neglecting events in the Ultimate Fighting Championship in the code of mixed martial arts.
The Mouth That Roared has been relatively silent of late, and without Conor McGregor to stir the pot, the only thing upon which we can lean is Aussie Rob Whittaker, who is paving a path for the Aussie contingent, leading them out of the fighting for free environment of the boozers and showing them that an octagon will substitute nicely for a pub and carries the addition benefit of steady pay for steady work.
Whitaker is of the opinion that he has barely scratched the surface of his upside potential and his middleweight class certainly provides a draw for those who follow the sport.
"A big factor for me is that I do try to be a role model for my kids, and by virtue of that, for other athletes, other young guys trying to get up in the sport," he told foxsports.com.au.
It may sound slightly odd that Whittaker aspires to be a role model for John, Jack and Lilliana, until you remember that Gandhi had no children.
Whittaker will be the main draw at UFC 225 on June 10 when he defends his title for the first time against Yoel Romero of Cuba.
Two other Aussies will be on the card.
Number 12 ranked heavyweight Tai Tuivasa will fight Andrei Arlovski. Tuivasa has yet to lose in MMA contests. Like Whittaker, a Sydney-sider, he boasts successful stints as a boxer and kick boxer.
Megan Anderson will represent Aussie womanhood, making her debut agasint Holly Holm.
MMA is ascendant in Australia, something not lost on Whittaker, who views himself as a prophet of sorts, saying, "That's a major objective of mine, with my own career, to try promote the sport in a positive light for Australian mixed martial artists."
Painters use canvas and oil paints. MMA artists use canvas and blood to create their artworks.