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Virtual Reality in Pharmacy: Opportunities for Clinical, Research, and Educational Applications
What is Virtual Reality?
During the past century, developments in film and television, computers, the Internet, and multimedia have enhanced the power of images.7 VR was developed based on contributions from these media (see
An interactive VR system typically includes a desktop or laptop computer, a game console, or a smartphone, which is capable of real-time animation.2,4–6,8,9 The system also includes a position tracker that tracks user movement and a head-mounted display (HMD) with head-tracking systems or wall projectors for visual output.2,4,5,8,9 Display devices are particularly significant as audio-visual simulation is a key component to creating VR. The HMD fully engages the user's field of vision, allowing him or her to perceive a 3D-stereoscopic effect through LCD displays and lenses that project different images with slightly different points of view for each eye, mimicking an observer's viewpoint in the physical world.3,10 Motion-tracking sensors sense the user's position in the simulated environment and supply this data to the visualization system, which updates the scene in real time.3,8,9,11 Output devices such as data gloves, joysticks, or wands provide the user with the ability to interact with virtual objects.3 Headphones are included to supply sound effects or music.3 All of these components enable the multisensory sensation of actually moving through a simulated world created by the VR system: this virtual experience can be nearly anything imaginable––from role playing with virtual patients in a pharmacy setting to physically exploring the interaction between a drug and a receptor to introducing a patient to a healthier or sicklier "virtual future self," based upon projections of their current positive or negative habits.3
VR systems range in complexity and are available in many different arrangements.5,10 They can be as simple as a cardboard viewer and a smartphone (i.e., Google Cardboard) or as complex as whole-room arrangements known as cave automatic virtual environments (i.e., CAVEs).5,10,12 Room-scale VR navigation allows users a much greater range of motion to physically approach virtual items, whereas systems that involve a seated position use controllers to navigate the environment.5 HMD-based systems like the Oculus Rift or HTC Vive fall in the midrange of the complexity scale.10 These HMDs are relatively easy to use and program, with good display quality and affordable prices.10 The prominence of HMDs among the gaming community has been useful for health care researchers, as software programming tools that utilize HMD capabilities have become easier to use and more streamlined, even for people who don't have a background in computer graphics programming.10
Augmented and Immersive VR
All VR systems fall within the "mixed reality" spectrum (also known as the reality–virtuality continuum), where actual physical reality and VR are positioned on opposite ends (see
Although researchers began to study the health care applications of VR a number of years ago, over the past decade the technology has rapidly expanded from the entertainment industry to include uses in medicine, as well as to the currently limited but growing applications in pharmacy.3 VR systems used in health care applications are similar to those used in gaming or entertainment, but they may require specialized hardware or software.3 Sensors may be included in a system used in clinical research to allow investigators to monitor and record a patient's level of interactivity in a reliable, safe, and replicable manner.4 VR simulators for psychotherapeutic applications may focus on emotional response and feedback, whereas those for education may focus on the generation of instructive feedback.3 HMDs are also gaining importance in medicine and pharmacy because of their use for education, visualization of data, telemedicine, telemonitoring, and other applications.6
VR aims to create a virtual world parallel to reality that is both immersive and interactive.9 "Immersion" is the extent to which a user feels present in the computer-generated environment, rather than the actual physical environment.5 Users experiencing immersion within the VR-generated environment have a sense of self-location (including a feeling of being surrounded by the virtual space), and can move to explore or interact with their virtual surroundings.5 This enables them to feel a sense of actual presence in the virtual environment, and a connection between their actions and what happens within it.5
The two most important technological and experiential factors that contribute to a sense of presence are vividness and interactivity.5 Users become fully immersed in VR when disbelief is suspended and they believe that the VR experience is the real world.5,9 Technology facilitates users' ability to have an immersive multisensory experience, within which they can naturally interact and explore.1,9 The inclusion of stereoscopic imagery is widely thought to be the most important factor that enhances immersion in the VR experience.5 Precise control of auditory, tactile, and olfactory cues by the VR system also increases the sense of presence users experience within the virtual environment.5,9 Other technological factors, such as a wide field of view or greater display resolution, are also significant.5
The immersive quality of VR "hijacks" the user's auditory, visual, and proprioception senses, acting as a distraction that limits the ability to process stimuli from the real world.1,5 Humans have finite attentional resources, so a distraction that occupies some portion of those resources is believed to leave less cognitive ability available for processing actual physical and sensory stimuli.2,4 The entertaining and immersive effects of VR are, therefore, useful for reducing or distracting attention away from the actual internal or external environment.4 Therapeutic distraction interventions other than VR (including deep-breathing exercises, watching a video, or listening to music) have also been studied in health care.2 In a clinical context, an enhanced sense of immersion and presence is the key factor that differentiates VR from these other distractive or cognitive approaches.5 When the user is deeply engaged in such an immersive experience, it is difficult and sometimes impossible to perceive stimuli outside of the focus of attention.1
Adjunctive or Replacement Treatment for Pharmacotherapy in Pain Management
Research has demonstrated that VR is effective for the treatment of pain associated with a variety of physical and psychological illnesses.14,15 It has been found to be effective for acute or chronic pain caused by injuries, cancer, diabetic neuropathy, migraine headaches, and pruritus, as well as many other conditions.1,8,9,14 VR has also been found to be effective in treating pain associated with medical or surgical procedures, such as wound-dressing changes, intravenous-line placement, or dental work.1,8,9,14 A controlled trial comparing VR with other distraction techniques found that in children undergoing burn treatment, VR was more effective in reducing subjective pain severity than interacting with a child care worker or listening to music.16
VR is also useful in supplementing traditional pharmacotherapies and increasing analgesic efficacy.1,3,4,14 In a review of seven studies, five demonstrated that VR is an effective nonpharmacologic adjunct to standard opioid analgesic treatments.17–23 In those studies, VR was found to reduce pain, distress, and anxiety in adult and pediatric patients who were undergoing unpleasant medical procedures.17–21 Another randomized trial compared analgesia administered with and without a VR game.24 This trial demonstrated that VR combined with analgesics was significantly more effective in reducing pain in children undergoing burn treatment than were analgesics alone.24 Research has also been conducted to determine whether the benefits of VR last beyond the immediate treatment period.1 A large, randomized, controlled trial studying VR's efficacy as an adjunct to opioid and non–opioid pain medication for the treatment of pain in medical and surgical patients was recently conducted.1 This study, which followed patients during and after their hospital stay, monitored outcomes with respect to pain levels, medication requests, and quality of life.1,25 The results of the study have not yet been published.1,25
Exactly how VR works to reduce pain perception is not known.1,5 Most proposals attribute its benefits to simple distraction,1 and the ability to perceive pain is thought to depend on a patient's capacity to direct cognitive attention toward a painful stimulus.4,5,9,14 As humans have a finite attention capacity, a task that involves distraction such as immersing the patient in a VR environment is believed to leave less cognitive capacity available for processing pain.2–5,14 VR attenuates pain perception by indirectly or directly altering neurological signaling pathways involving attention, concentration, memory, emotion, sight, hearing, and touch.5 VR's entertaining and immersive effects redirect the patient's attention away from the pain, reducing anxiety, discomfort, or unpleasantness.4,14 By taking over sight, hearing, and proprioception, VR acts as a distraction to limit the patient's capacity to process painful stimuli.1,3 Studies have shown that immersive VR technology is more likely to relieve pain than non-immersive VR.3,5
VR has also been very effective for relaxation.3 Virtual environments can be relaxing and stress-reducing, making them widely applicable for treating stress-related physical disorders that cause pain.14 These disorders, including fibromyalgia, neuropathic pain, and postherpetic neuralgia, are very common in primary care practices.14 VR that is based on a cognitive-behavioral therapy (CBT) model can train patients to shift attention away from stressful thoughts that induce pain.14 A system has been developed in which patients take a virtual meditative walk to learn mindfulness-based stress reduction, and preliminary results in patients with chronic pain suggest that it reduces subjective pain compared to non-VR mindfulness conditioning.26 Examples of other VR experiences that could be prescribed to reduce stress might include swimming with dolphins or a virtual vacation on a tropical beach.1
A study in patients with fibromyalgia also found that VR led to significant improvements regarding functional disability compared with standard treatments.27 Self-reported patient observations of reduced anxiety, time spent thinking about pain, and pain severity during VR treatment have been corroborated by neuro-imaging studies.3,4 These studies detected reduced activity in five brain regions related to sensory and emotional pain processing (thalamus, insula, anterior cingulate cortex, and primary and secondary somatosensory cortices) during VR interventions.4,5,9,28
Overall, both physiological and psychological measures suggest that VR is a helpful clinical tool in the treatment of pain.4 Perhaps the most important implication regarding its efficacy is its potential to reduce the use of opioid analgesics. The rates of addiction and misuse of opioid analgesics are staggering.29,30 According to the National Institute on Drug Abuse (NIDA), approximately 19,354 people in the U.S. died from prescription opioid-analgesic overdose in 2016.30 Furthermore, although opioid analgesics have proven to be quite effective in providing pain relief, they don't control pain in every patient because of the development of treatmenttolerance.14 Some opioids also have a significant side-effect profile, causing nausea or increased length of hospitalization.4
VR may offer a safe and effective treatment for pain, without the many side effects or the risk of addiction associated with opioids.31 NIDA is examining the intersection of pain treatment with the abuse of and addiction to opioid medications, with the goal of developing alternative pain-management solutions (such as VR) that have less potential for addiction.14 The National Institutes of Health has also identified VR as a viable option for reducing pain and has made its development a priority, providing tens of millions of dollars in funding for research projects studying VR and pain over the past decade.29
Adjunctive or Replacement Treatment for Pharmacotherapy in Anxiety and Other Disorders
During the past few decades, the clinical application of VR has also been studied in psychotherapeutic uses for anxiety and phobia disorders.1,5 VR exposure therapy has been applied in the treatment of post-traumatic stress disorder (PTSD), generalized anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive disorder, agoraphobia, arachnophobia, and claustrophobia.1,3,6 Traditional treatment for these disorders typically requires patients to confront the situations they fear––a form of CBT known as exposure therapy.3 If the belief remains unchallenged, avoiding a dreaded situation can reinforce anxiety and phobias.8 In exposure therapy, patients are exposed gradually to the situations they fear that provoke anxiety.3 When the catastrophic events the patient expects don't materialize, sensory, affective, and cognitive processes are altered, anxiety attenuates with each exposure, and beliefs about the feared consequences subside.3–5,8,9 With each successive exposure to the anxiety or phobia-provoking scenario, anxiety is further reduced.8 VR exposure therapy has been used in combination with pharmacotherapy for the treatment of anxiety and phobic disorders.14,32 Pharmaceuticals primarily affect physiological systems, whereas VR treats cognitive systems.14,32 Similar to other forms of CBT, VR exposure therapy provides a treatment approach that may alleviate anxiety in ways that are not addressed by drug treatment.14
Studies have demonstrated that VR exposure therapy can achieve similar efficacy compared with traditional exposure interventions.9 VR has been broadly shown to have a significant impact on a patient's life, resulting in long-lasting effects that reduce anxiety.9 In a review of the medical literature, four meta-analyses and seven systematic reviews on the use of VR in the treatment of emotion-, anxiety-, and stress-related disorders were identified.8 The results of these studies support the therapeutic use of VR in panic disorder, PTSD, phobias, and stress management.8 Research also indicate that patients accept and are satisfied with VR-based therapy, sometimes more so than conventional approaches.9 In a study of exposure therapy in 150 patients with specific phobias, 3% refused VR exposure whereas 27% declined real-life exposure.33 In a study of patients with PTSD resulting from motor vehicle accidents, participants reported that they were highly satisfied with VR exposure.34 A study of 352 U.S. soldiers who had enlisted after 9/11 also suggested that the high degree of acceptance of technology-based treatments (rather than in-person counseling) such as VR may reduce barriers to seeking mental health care.35
In addition to other benefits, VR is a versatile tool with which one can build as many scenarios as needed that can be replicated, monitored, and modified much more easily than real-life environments.1,5,8,9 War, storms, injury, social situations, and other anxiety- or phobia-inducing stimuli can be very challenging or expensive to recreate solely for the purpose of exposure therapy.3,9 VR offers a convenient and inexpensive option for constructing complex or impractical exposure scenarios.3,9 For example, for veterans with PTSD, VR has been used to simulate traumatic scenarios, complete with the sound of artillery blasts, the vibration of rolling military vehicles, and the smell of burning oil.1,5 VR also permits the adjustment of elements that are present in a virtual simulation to make them more or less threatening, such as the physical characteristics of a space, the presence of protective elements, or the duration of a situation.8,9
Recent studies have also shown that exposure to multiple VR contexts reduces recurrent fear to a greater extent than exposure to a single scenario.36 In addition, VR allows the construction of "virtual adventures" at different difficulty levels in which subjects are immersed in an environment that allows them to experience themselves as competent and effective.8 While immersed in a virtual adventure, patients discover that they can overcome the conflicts or situations they fear through effort and confrontation.8 An even more fantastic feature of VR is that unrealistic worlds can be simulated, if necessary.8 For example, patients can experience a world that enables them to travel back in time, allowing them to relive a sequence of events in which they can intervene to change the outcome, which can lead to transformative effects.8
VR has also been employed in the treatment of addiction, eating disorders, and autism.6,8 Two systematic reviews revealed that VR stimuli (e.g., drugs, alcoholic drinks, or cigarettes) and environments (e.g., a party or bar) are effective at inducing cravings for alcohol, cigarettes, or cocaine in dependent subjects.37,38 Using VR in patients with addictions allows them to develop coping skills in response to a cue that induces cravings, through repeated exposure and practice in a controlled setting.39 As reported by three systematic literature reviews, VR was also found to be effective in changing a patient's response to cue exposure involving food stimuli in the treatment of obesity and eating disorders.40–43 In these disorders, VR is used to reinforce nutritional education and provide visual feedback and simulations that improve self-perception and body image.5 Furthermore, VR has been used in the treatment of autistic spectrum disorder because of its ability to provide a controlled setting in which patients can develop new skills.8 Two systematic reviews support the use of VR to help patients with autism learn communication and imitation skills, to assist them in coping with social situations.44,45
Pharmacological Modeling for Drug Discovery
VR offers a number of advantages compared to other computer-based approaches used in drug design and discovery, including a far superior 3D-view of molecular structures and targets.46 Over the last few decades, the number of drugs approved by the FDA has not kept pace with rising drug-development costs, so a rapid and efficient approach to drug development is critical.46 There are also numerous drug targets that have not yet been exploited.46 In 2017, there were a total of 1,578 FDA-approved drugs that act against 893 pathogen-derived and human targets.46 This is a small portion of the more than 4,479 potential drug targets listed in Ensembl (ensembl.org.) that can be investigated for the potential development of novel, more effective drugs.46,47
Immersive VR has tremendous prospects for its use in molecular modeling for the identification and design of novel candidates for drug development.10,46 In drug design and discovery, visualization tools serve an important role with respect to the investigation of interactions between ligands that are potential drugs and macromolecules.10,46 Accurate visualization of the way ligands bind to large, complex structures like proteins is critical.10,46 VR allows researchers to observe the dynamics of protein-structure configurations while they focus on ligand-binding sites and other areas of interest.10 In the context of antimicrobial resistance, viewing protein structures and understanding how mutations lead to changes in their binding regions is essential.10 This ability is crucial for predicting the modifications that are necessary to create more effective next-generation drugs.10
VR offers several advantages over traditional visualization tools such as 2D projections or 3D physical models, which can obscure important molecular features.10 For example, it can provide researchers with a more accurate perception of a protein's catalytic pocket than 2D projections can provide.10 Such information can translate into modifications that can be incorporated into the design of more effective drugs.10 Through VR systems, researchers can also participate in the simulation process, rather than merely being observers of automatic simulations.10,46 VR drug modeling allows real-time haptic interaction with the molecule, as well as the ability to customize representations of macromolecules (e.g., DNA, RNA, protein, sugar molecules, or whole viruses).10,46 The immersive nature of VR can conceivably provide solutions to issues encountered during visualization, as it allows the scientist to experience and interact with molecular models by "stepping inside" them.10,46
Researchers can explore and select ligands for investigation based on biochemical parameters such as distance, binding energy, and bonding information.46 They can then drag and rotate the ligand within the binding site to make instantaneous modifications.46 In this way, scientists can observe and interact with the ligand-target complex to identify more efficiently conformational changes and the ligands that are suitable candidates for drug development.10,46 The information gathered can then be translated to the design and synthesis of new drug candidates in the laboratory.46 This approach is much more informative and less tedious and time-consuming than the traditional use of algorithms for this purpose.46
Moreover, VR is reportedly more accurate and efficient at identifying drug-like ligands compared to traditional approaches such as fragment or diversity-oriented methods.46 With the rapid advancement and increasing affordability of computer hardware and software packages, VR is becoming more accessible to researchers; thus, its application in drug development will likely become more widespread and accelerate the development of new drugs.10,46 VR can also serve as an educational tool for the general public to enhance their understanding of biochemical research and drug discovery.10
Pharmacist Education and Training
The use of VR in pharmacist education and training offers a new method for novel instructive experiences, reinforcing lessons, and learning assessment.6,11,48–50 VR is currently more commonly used in nursing and medical education, although several features favor its use for pharmacist training.48,50 Using VR in pharmacy education affords opportunities for engaged and active learning, as well as an entertaining instructional experience.48,50 VR may also be helpful to pharmacy students who prefer visual learning opportunities rather than reading textbooks.31 It can also create difficult-to-simulate scenarios, or be used to standardize situations during testing.49 The use of VR to simulate pharmacy environments could help students practice techniques such as compounding medications, or the procedures required for working in a community or hospital pharmacy setting.50 VR's ability to simulate a real-life experience through role playing allows users to improve clinical and communication skills by learning from their mistakes when providing care to virtual patients.6,48–51 Through VR, this can be done without the health or financial consequences brought about by mistakes that can occur in a real-life environment.6,48,50,51
VR can also be used to teach pharmacology. When learning pharmacology, pharmacy students are required to understand how drugs and receptors interact,31 but as drugs and receptors are three-dimensional, this information can be difficult to illustrate and explain during classroom sessions.31 Therefore, students may be better able to learn drug-receptor interactions by viewing a 3D model rather than the 2D graphics that are often presented during lectures.31,50 Anatomy and physiology could also be taught through 3D schematics that incorporate demonstrations of how drugs affect specific organ systems to achieve clinical outcomes.50 At present, although researchers have access to VR software and hardware that could be used for medical education, the technology is not yet widely applied in undergraduate programs.31 Instead, 2D representations are still commonly used during pharmacy lectures, as they can be easily viewed by a large group of students.31
VR also allows pharmacy students to access and interact with different VR scenarios remotely, facilitating distance learning or training.49,50 Students can participate in continuing education courses or attend lectures or medical conferences irrespective of geographical location.48,50 This is particularly important in rural areas where pharmacists have limited access to training opportunities.48 Umeå University in northern Sweden has been using VR for instruction since the inception of its clinical pharmacy course in 2011.48 All pharmacy courses at the university are offered as distance-education courses in a web-based online format, and most of the teaching takes place online.48 Students can access training opportunities in a 3D VR world, where simulated ward rounds and patient meetings occur.48 Eighty-three percent of the 42 students who completed an online evaluation stated that they felt they could adopt the role of a clinical pharmacist while using this technology.48 The environment was described as feeling authentic by 60% of the students, although some participants noted that it "could never be the same" as interacting with real patients.48 The students described their experiences as "fun," "new and exciting," "exceeding expectations," and helpful for easing into the role of a clinical pharmacist.48 However, some students commented that the technical aspects of VR took too much time, distracting them from work for other courses.48
Despite the positive results from this and other studies, more research is needed to assess the effectiveness of VR instruction and barriers to its implementation.49 Beyond pharmacy education, VR can also be used in pharmacy practice to simulate work processes, consumer or staff behavior, or some other study of the work environment to improve procedures and outcomes.7 Further, VR scenarios incorporating facts and values can be used in the context of decision making regarding pharmaceutical care.7
Patient Counseling and Behavior Modification
In recent years, the practice of pharmacy has evolved from simply dispensing drugs to a more service-based model, where pharmacists counsel patients on how to prevent and manage disease.51 Trends in health care are moving toward a stronger emphasis on preventive medicine and healthier behaviors, and pharmacist expertise can help to achieve these goals.51 The implementation of VR for patient counseling and care can assist pharmacists in serving this function.51
Pharmacist–patient meetings have been shown to be important for patient compliance.48 The availability of VR systems in pharmacies can promote medication-therapy management and help patients develop a medication-related action plan, advancing safe and efficacious medication use.11,51 VR applications for medication management are available for use by geriatric patients and in inpatient aftercare.6 The educational use of VR apps that provide visual and auditory instructions regarding standard medication safety and efficacy could be implemented when a patient receives a new prescription.11 For more complex medication regimens, the VR system could demonstrate techniques or administration procedures, such as how to self-administer an injectable medication.11 Patients could then use the system to perform these behaviors virtually, allowing them to practice without harming themselves or wasting medication.11 Through feedback, VR can also be used to confirm that patients correctly understand and can perform the technique they were taught.11 While the immediate recitation of what was just experienced in a VR session does not necessarily equate to long-term retention and application of what was learned, it does allow for patient practice and the opportunity for the pharmacist to identify misunderstandings.11
As VR technologies grow and evolve, they can play an even greater role in the promotion of health and disease prevention to combat one of the major challenges of chronic disease management and/or prevention—the lack of reinforcement that patients experience when implementing healthy behavior changes.51 VR centers in pharmacies could use computer algorithms to predict how positive and negative changes made in patients' behavior today may affect their body and health in a number of years or decades.51 Predicted conditions could be generated from extensive data programmed into these machines based on existing knowledge of how nutrition, activity, medication use, current laboratory measures, ethnicity, and family history predict disease and health in the future.51 VR could be used to demonstrate the deleterious effects that cigarette smoking, weight gain, or alcohol abuse has on a patient's body at designated time intervals in the future.51
Patients could experience their predicted reality using HMDs with head tracking, motion tracking, surround-sound audio, olfactory stimulus, and an advanced bodysuit with sensors that provide feedback—emphasizing strength with improved health and exercise, or accentuating fatigue in sickly individuals who are sedentary.51 Having patients actually experience or "live" in this predicted body could be an effective means of demonstrating the importance of healthy behaviors and incentivizing them to modify their lifestyles.4,51 Indeed, research has shown future health status to be an important motivator for patients to change.51 If patients with diabetes suddenly see themselves hooked up to a dialysis machine or missing a foot, they may become more motivated to control their blood glucose and blood pressure.51 Generating a future virtual body that is better (or less) able to function in the world as a result of current deleterious or future improved habits is the focus for VR use in patient behavior modification.51
Long recognized as the most accessible providers in the health care system, pharmacists are in an excellent position to encourage behavior modification in patients.51 Pharmacists could act as coaches, helping patients to prioritize their behavior changes and work toward finding feasible goals and achievements that can be maintained over time.51 Pharmacists could work with patients to identify behavioral changes that could be programmed into the VR system to demonstrate how their new habits might change their future appearance and health.51 Through the availability of VR technologies to reinforce pharmacist recommendations, patients could be instantly gratified by actually seeing, feeling, and even smelling what the future may hold for them if they were to implement the healthy strategies recommended by the pharmacist.4,51
VR technology can be extremely effective in motivating patients to implement and sustain positive lifestyle changes.51 For behavior modification, patients have used VR to facilitate weight loss and increase physical activity, helping to combat eating disorders, diabetes, and obesity.4,51 VR has also been used to help patients improve body-image perceptions and self-sufficiency, promote healthier eating habits, and help patients practice healthy decision making through inhabiting realistic avatars in stress-inducing virtual situations, such as food shopping.4
Validation of Clinical Efficacy
Although it generally yields positive results, the use of VR in clinical research presents multiple challenges.5 A list of these challenges and other barriers to the use of VR is included in
Researchers have recommended that future clinical studies of VR should utilize larger samples, assess patient adherence, follow better standardized clinical protocols, and investigate long-term effects.1,4,8 Post-treatment assessments should ideally occur over a follow-up period of at least 12 months, to assess treatment effects over time.9 These issues need to be addressed to improve the rigor of VR clinical research and the significance of its findings.5 To this end, an international working group of VR experts recently met to standardize and create best practices for VR clinical research; an article summarizing the committee's recommendations was published in January 2019.52
VR applications and hardware introduce another variable that can differ greatly between clinical studies.5 Some studies involve 2D images that are projected onto video screens; 360° 2D presentations in HMDs; or room-sized virtual environments created by CAVE projection systems.5 Other studies involve a 3D virtual environment viewed with motion-tracked stereoscopic HMDs.5 The audio used in clinical studies also varies: some studies use non-spatial audio and others use positional stereo sound that changes as users moves their head or body.5 In other cases, the VR equipment that was used in a clinical study is not well defined.5 VR hardware and software also change quickly as a result of rapid advancements in the field.5 Clinical studies only one year apart may differ with regard to hardware or software capabilities, which may affect the consistency and reproducibility of results.5
If VR is to be used for clinical applications, then a "virtual pharmacy" also needs to be developed so that the correct VR experiences can be prescribed for and accessed by patients.1 According to the medical literature, VR software influences treatment outcomes, and virtual environments for medical therapies should vary according to the patient's specific symptoms.3 For example, for psychotherapeutic applications, software that allows the therapist to control panoramic photos, videos, and interaction methods according to therapeutic progress may be helpful.3 The best features for VR treatments to relieve pain symptoms also need to be further investigated.14 VR simulations that allow the "cyber dosage" for pain relief to be dialed up or down as appropriate, either by the health care provider or the patient, may be helpful.14 A system to evaluate and quantify the effects of the clinical application of VR therapy alone or combined with other therapeutic methods is also needed.3,14
Early VR studies used costly platforms that were unlikely to be adopted for widespread use; however, the affordability and accessibility of VR has since improved.4 Nevertheless, in some circumstances, the cost of VR equipment may remain a barrier to its use,49 and development of VR software applications is also expensive.5 This presents a significant disadvantage for disseminating VR in clinical settings, especially large-scale trials or settings involving multiple users.5,9 Although the cost of HMDs has dropped, quality VR environments still require expensive, high-end computer systems with advanced graphics processing.5 As of October 2018, the cost of a portable system to run a quality VR clinical experience was estimated at $2,500 per unit, plus maintenance.5,51 A room-sized, fully immersive system, such as a CAVE, can be much more expensive, with low-end systems priced in the tens of thousands of dollars and high-end systems in the hundreds of thousands of dollars.31,53,54 An expenditure this size may be beyond the budget of some research or academic institutions.31 Attrition also causes the value of VR equipment to decline rapidly when newer technology makes older equipment obsolete.5 Often, a system is expected to retain only minimal value three years after its purchase.5
Lower-cost VR systems have become available as prices have decreased over time.1,9 Smartphone-based systems are now available starting at $600, and VR HMDs that tether to a computer have been available for around $400 since 2016.11 However, there is a caveat with this increased affordability, as there is evidence that the efficacy of VR therapy is at least partially dependent on the quality of the equipment used.3,4 For example, one review identified two clinical studies in which the use of low-cost HMD visors and off-the-shelf VR software to treat burn patients did not achieve significant differences in self-reported pain measures or anxiety.4,23,55 Further investigation is needed to determine the association between higher-end hardware or software and clinical efficacy.4 Still, the decline of prices to what could be considered a reasonable expense may allow VR systems to become routinely available in health care settings, such as pharmacies and doctors' offices.11 Decreasing prices could also allow VR to be used for patient self-care, both in the hospital and at home.3,4 Despite the expenses associated with VR, it is still generally considered to be an effective and efficient tool within the areas it has been studied, compared to many traditional medical approaches.3
Although it is difficult to predict whether health insurance will pay for VR medical applications, some companies may do so, seeing the model is consistent with many existing health care plans.51 For example, plans that focus on preventive medicine and a healthy lifestyle may reimburse for VR equipment or treatment sessions.51 Important health care issues, such as the high prevalence of diabetes and the rapid rise of obesity (both of which can be prevented through education and behavior modification using VR sessions), have become a national focus.51 The Patient Protection and Affordable Care Act has also strongly oriented the health care system toward preventive care and the avoidance of hospital readmission.51
In the past, VR systems were difficult to set up and would frequently malfunction, creating a barrier to their use.9 Although the usability of VR technology has improved, the possibility of glitches and malfunctions still exists, creating a potential disadvantage for clinicians and patients.5,9 Technical difficulties and the need for in-depth training to achieve technical proficiency remain the primary obstacles to VR use.5,48 VR equipment should be considered as a tool that requires users to be properly trained to resolve possible malfunctions so that clinical care is not interrupted.5,9,48 Vendors that sell systems for VR therapy often offer Internet-based training as well as onsite instruction.9 This training generally includes information regarding the rationale for incorporating VR into patient care; troubleshooting glitches; and contacting the vendor.9 It is expected that the more widespread the medical application of VR becomes, the more proficient users will become.48
Another impediment interfering with usability is the adverse physical effects that can occur with VR, such as dizziness, nausea, headache, and eyestrain, i.e., "cybersickness."5,50 HMDs can also be heavy and cumbersome, which may be a problem for patients with limited head or neck mobility resulting from injury or a medical condition.5 Furthermore, most current VR applications are not usable for patients with visual or cognitive disabilities, because of difficulties interacting with the VR interface.5 High-end HMDs are tethered to a computer, which can be a tripping hazard or distraction, especially for elderly patients.5 Elderly patients may also have difficulty using VR software because of a lack of computer or video-game literacy.5 Prolonged exposure to an HMD screen, which is just a few centimeters away from the user's eyes, leads to eyestrain and headaches.5 An educational lecture can last hours, and some users cannot comfortably use VR equipment for more than 10 minutes.56 This issue may improve as the technology advances; however, the length of time a patient engages with VR during a health care application may need to be constrained.50,56
It is important to discuss these limitations with patients in advance, especially those participating in long-term clinical studies.5 In addition, most VR research has taken place in clinical settings, so there is much that needs to be determined regarding in-home applications of VR.5 There are common considerations regarding the in-home use of any technology, such as the learning curve, logistics, and technical support.5 However, some additional challenges are associated with VR, such as the need for dedicated space and the potential for interference, especially by pets or children.5 Room-scale VR systems require at least 5 ft2 of dedicated space in a patient's living environment, which may interfere with the usability of the space for other purposes.5 VR-system cables may also create tripping hazards, and infrared sensors can interfere with other electronic devices, such as TV remote controls.5 The motion-tracking calibration of VR equipment is also very sensitive and can be easily disturbed by moving the equipment.5 Despite these disadvantages, users in home, clinical, or educational settings often remain enthusiastic to participate in VR studies or treatment.1,5,9,48
Technical Capabilities
The technical capabilities of VR systems are currently limited, as the systems are not responsive to input delivered by the user's voice.11 This capability is necessary for implementing teach-back exercises during educational use.11 Another ideal feature for systems is the incorporation of data from other devices, such as wearable technologies that track weight, exercise, diet, blood glucose levels, and other factors.11 Ideally, a VR system could analyze these data comprehensively and make associations with the patient's state of health, as well as positive and negative projections regarding whether certain behaviors and habits (e.g., smoking, caloric intake, medication adherence) are maintained or changed.11 With the increasing use of electronic health records and patient portals, these tools may eventually be used as an access point through which VR systems can collect patient data.11 Ultimately, technological advancements in medicine may make it possible to collect data through biosensors used for monitoring during medical procedures.2
There is also a need to improve the virtual participants and environments depicted in VR systems.48 At present, avatars in VR applications are not especially realistic, which may adversely affect the ability of clinicians and patients to fully immerse themselves in a patient-care scenario.49 Facial expressions, physical gestures, and visual cues may not seem authentic; these limitations in nonverbal communication may reduce VR's effectiveness in role-playing scenarios and as a replacement for face-to-face meetings.48,49 The efficacy of pain relief achieved with VR has also been shown to be correlated with the technological capabilities of the equipment or system.4,8,23,55 The more advanced the equipment, the greater the sense of presence in the virtual world, a factor that has been identified as necessary for alleviating pain.3 With time and investment in further technological development, the equipment is likely to become more sophisticated, with the inclusion of speech recognition and more realistic avatars with authentic physical gestures and facial expressions.49
In spite of increasing awareness regarding VR in the medical and pharmacy community, whether and how to apply this technology in everyday clinical practice remains unclear.1 The extent to which patients will accept VR also remains to be seen.1 During many clinical studies, most subjects found VR to be a pleasant and positive experience, which at a minimum provides a distraction from the anxiety and distress associated with illness.1,5 Most subjects state that they would opt to use VR again, should the opportunity arise.1 It is also true that younger patients, generally speaking, tend to be more willing and able to use VR than older patients.1 Some patients also find the equipment to be confusing, uncomfortable to use, or difficult to operate1, and some occasionally describe VR experiences as having an unclear benefit.1 With regard to using VR in education, students and teachers may prefer traditional instructional approaches, creating a barrier to implementation.48 Having to design lessons that utilize VR could place a burden on teachers to create learning exercises that fulfill specific teaching goals.48 For these reasons, support may be required to encourage teachers to move away from traditional instructional methods and explore VR as a new approach to teaching and learning.48
Although it is still novel, the application of VR in pharmacy has significant potential.4 With further research, more data will become available regarding its efficacy in this arena, as well as other advantages and disadvantages.1 As the technology improves, costs and other obstacles will be reduced, likely increasing VR's influence as a viable and helpful instrument in clinical, research, educational, and patient-counseling practices in pharmacy.4
Figures and Table
Significant Events in the Development and Clinical Application of VR
The Reality–Virtuality Continuum
Barriers to Using VR in Pharmacy
VR: virtual reality; HMD: head-mounted display; EHR: electronic health record
- Spiegel BM. Virtual medicine: how virtual reality is easing pain, calming nerves, and improving health [published online May 21, 2018]. Med J Aust 2018;209;(6):245–24.
- Chirico A, Lucidi F, DeLaurentiis M, et al. Virtual reality in health system: beyond entertainment. A mini-review on the efficacy of VR during cancer treatment. J Cell Physiol 2016;231;(2):275–287.
- Li L, Yu F, Shi D, et al. Application of virtual reality technology in clinical medicine. Am J Transl Res 2017;9;(9):3867–3880.
- Dascal J, Reid M, Ishak WW, et al. Virtual reality and medical inpatients: a systematic review of randomized, controlled trials. Innov Clin Neurosci 2017;14;(1–2):14–21.
- Garrett B, Taverner T, Gromala D, et al. Virtual reality clinical research: promises and challenges. JMIR Serious Games 2018;6;(4):e10839
- Grand View Research. Augmented reality (AR) and virtual reality in healthcare market analysis by component (hardware, software, and service), by technology (augmented reality, virtual reality), and segment forecasts, 2018–2025 May 2017; Available at: https://www.grandviewresearch.com/industry-analysis/virtual-reality-vr-in-healthcare-market. Accessed March 19, 2019
- Mobach MP. The virtual pharmacy, 3D becomes reality?. Pharm World Sci 2005;27;(4):271–272.
- Riva G, Baños RM, Botella C, et al. Transforming experience: the potential of augmented reality and virtual reality for enhancing personal and clinical change. Front Psychiatry 2016;7:164
- Maples-Keller JL, Bunnell BE, Kim SJ, Rothbaum BO. The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harv Rev Psychiatry 2017;25;(3):103–113.
- Ratamero EM, Bellini D, Dowson CG, Römer RA. Touching proteins with bare hands: visualizing protein-drug complexes and their dynamics in self-made virtual reality using gaming hardware [published online June 7, 2018]. J Comput Aided Mol Des 2018;32;(6):703–709.
- Fox BI, Felkey BG. Virtual reality and pharmacy: opportunities and challenges. Hosp Pharm 2017;52;(2):160–161.
- Electronic Visualization Laboratory (EVL). The CAVETM virtual reality theater Available at: https://www.evl.uic.edu/cave. Accessed March 19, 2019
- Milgram P, Kishino F. A taxonomy of mixed reality visual displays. IEICE Trans Inf Syst 1994;12;(12):1321–1329.
- Wiederhold BK, Soomro A, Riva G, Wiederhold MD. Future directions: advances and implications of virtual environments designed for pain management. Cyberpsychol Behav Soc Netw 2014;17;(6):414–422.
- University of Washington Human Photonics Laboratory (HPL). Virtual reality pain reduction Available at: www.vrpain.com. Accessed March 19, 2019
- van Twillert B, Bremer M, Faber AW. Computer-generated virtual reality to control pain and anxiety in pediatric and adult burn patients during wound dressing changes. J Burn Care Res 2007;28;(5):694–702.
- Schmitt YS, Hoffman HG, Blough DK, et al. A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns [published online August 7, 2010]. Burns 2011;37;(1):61–68.
- Hoffman HG, Patterson DR, Seibel E, et al. Virtual reality pain control during burn wound debridement in the hydrotank. Clin J Pain 2008;24;(4):299–304.
- Patterson DR, Jensen MP, Wiechman SA, Sharar SR. Virtual reality hypnosis for pain associated with recovery from physical trauma. Int J Clin Exp Hypn 2010;58;(3):288–300.
- Li WH, Chung JO, Ho EK. The effectiveness of therapeutic play, using virtual reality computer games, in promoting the psychological well-being of children hospitalised with cancer [published online June 8, 2011]. J Clin Nurs 2011;20:2135–2143.
- Carrougher GJ, Hoffman HG, Nakamura D, et al. The effect of virtual reality on pain and range of motion in adults with burn injuries. J Burn Care Res 2009;30;(5):785–791.
- Kipping B, Rodger S, Miller K, Kimble RM. Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial [published online February 18, 2012]. Burns 2012;38;(5):650–657.
- Morris LD, Louw QA, Crous LC. Feasibility and potential effect of a low-cost virtual reality system on reducing pain and anxiety in adult burn injury patients during physiotherapy in a developing country [published online December 21, 2009]. Burns 2010;36;(5):659–664.
- Das DA, Grimmer KA, Sparnon AL, et al. The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries: a randomized controlled trial. BMC Pediatr 2005;5;(1):1
- Clinicaltrials.gov. Immersive virtual reality intervention for non-opioid pain management: a randomized, controlled trial. NCT02887989 September 2, 2016; Available at: https://clinicaltrials.gov/ct2/show/NCT02887989. Accessed March 20, 2019
Gromala D, Tong X, Choo A, Karamnejad M. The virtual meditative walk: virtual reality therapy for chronic pain management. Proceedings of the 33rd Annual Association for Computing Machinery Conference on Human Factors in Computing Systems New YorkNew York: Association for Computing Machinery. 2015;521–524. Available at: https://dl.acm.org/citation.cfm?id=2702123. Accessed March 20, 2019
- Garcia-Palacios A, Herrero R, Vizcaíno Y, et al. Integrating virtual reality with activity management for the treatment of fibromyalgia: acceptability and preliminary efficacy. Clin J Pain 2015;31;(6):564–572.
- Hoffman HG, Richards TL, Coda B, et al. Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. Neuroreport 2004;15;(8):1245–1248.
- Thomas DA. Virtual reality research continues to progress at the National Institutes of Health. Cyberpsychol Behav Socl Netw 2014;17;(6):334
- National Institute on Drug Abuse. Overdose death rates January 2019; Available at: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed March 20, 2019
- Richardson A, Bracegirdle L, McLachlan SI, Chapman SR. Use of a three-dimensional virtual environment to teach drug-receptor interactions. Am J Pharm Educ 2013;77;(1):11
- Wiederhold MD, Wiederhold BK. Virtual reality and pharmaceuticals: enhanced synergy to improve clinical care. Cyber-Therapy & Rehabilitation Magazine 2013;1:10–12. Available at: http://vrphobia.eu/files/cr-611.pdf. Accessed March 20, 2019
- Garcia-Palacios A, Botella C, Hoffman H, Fabregat S. Comparing acceptance and refusal rates of virtual reality exposure therapy vs.
in vivoexposure by patients with specific phobias. Cyberpsychol Behav 2007;10;(5):722–724. 10.1089/cpb.2007.9962
- Beck JG, Palyo SA, Winer EH, et al. Virtual reality exposure therapy for PTSD symptoms after a road accident: an uncontrolled case series. Behav Ther 2007;38;(1):39–48.
- Wilson J, Onorati K, Mishkind M, et al. Soldier attitudes about technology-based approaches to mental health care. Cyberpsychol Behavior 2008;11;(6):767–769.
- Shiban Y, Pauli P, Mühlberger A. Effect of multiple context exposure on renewal in spider phobia [published online November 11, 2012]. Behav Res Ther 2013;51;(2):68–74.
- Bordnick PS, Carter BL, Traylor AC. What virtual reality research in addictions can tell us about the future of obesity assessment and treatment. J Diabetes Sci Technol 2011;5;(2):265–271.
- Hone-Blanchet A, Wensing T, Fecteau S. The use of virtual reality in craving assessment and cue-exposure therapy in substance use disorders. Front Hum Neurosci 2014;8:844
- Riva G. Virtual reality for health care: the status of research. Cyberpsychol Behav 2002;5;(3):219–225.
- Ferrer-García M, Gutiérrez-Maldonado J. The use of virtual reality in the study, assessment, and treatment of body image in eating disorders and nonclinical samples: a review of the literature [published online November 25, 2011]. Body Image 2012;9;(1):1–11.
- Ferrer-García M, Gutiérrez-Maldonado J, Riva G. Virtual reality based treatments in eating disorders and obesity: a review [published online June 25, 2013]. J Contemp Psychother 2013;43;(4):207–221.
- Koskina A, Campbell IC, Schmidt U. Exposure therapy in eating disorders revisited [published online November 29, 2012]. Neurosci Biobehav Rev 2013;37;(2):193–208.
- Wiederhold BK, Riva G, Gutiérrez-Maldonado J. Virtual reality in the assessment and treatment of weight-related disorders. Cyberpsychol Behav Soc Netw 2016;19;(2):67–73.
- Aresti-Bartolome N, Garcia-Zapirain B. Technologies as support tools for persons with autistic spectrum disorder: a systematic review. Int J Environ Res Public Health 2014;11;(8):7767–7802.
- den Brok WL, Sterkenburg PS. Self-controlled technologies to support skill attainment in persons with an autism spectrum disorder and/or an intellectual disability: a systematic literature review [published online May 22, 2014]. Disabil Rehabil Assist Technol 2014;10;(1):1–10.
- Liu XH, Wang T, Lin JP, Wu MB. Using virtual reality for drug discovery: a promising new outlet for novel leads. Expert Opin Drug Discov 2018;13;(12):1103–1114.
- Ensembl January 2019; Available at: http://www.ensembl.org/index.html?redirect=no. Accessed March 20, 2019
- Gustafsson M, Englund C, Gallego G. The description and evaluation of virtual worlds in clinical pharmacy education in Northern Sweden [published online August 21, 2017]. Curr Pharm Teach Learn 2017;9;(5):887–892.
- Fertleman C, Aubugeau-Williams P, Sher C, et al. A discussion of virtual reality as a new tool for training healthcare professionals. Front Public Health 2018;6:44
- Aungst T. Digital realities could find a place in the pharmacy classroom. Pharmacy Times March 8, 2018; Available at: https://www.pharmacytimes.com/contributor/timothy-aungstpharmd/2018/03/digital-realities-could-find-a-place-in-the-pharmacy-classroom-. Accessed March 20, 2019
- Nuffer W, Smith SM, Trinkley K. Integrating virtual reality to expand the public health role of community pharmacists. J Am Pharm Assoc 2013;53;(2):152–158.
- Birckhead B, Khalil C, Liu X, et al. Recommendations for methodology of virtual reality clinical trials in health care by an international working group: iterative study. JMIR Ment Health 2019;31, 6;(1):e11973
- Miller SA, Misch NJ, Dalton AJ. Low-cost, portable, multi-wall virtual reality.
Presentation at IPT/EGVE 2005: 9th International Workshop on Immersive Projection Technology, 11th Eurographics Workshop on Virtual Environments Aalborg, Denmark 2005Available at: https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20050240930.pdf. Accessed March 20, 2019
- Gaudiosi J. Dassault Systèmes uses HTC Vive to replace CAVE virtual reality tech. Fortune January 8, 2016; Available at: https://fortune.com/2016/01/08/dassault-systemes-htc-vive/. Accessed March 20, 2019
- Kipping B, Rodger S, Miller K, Kimble RM. Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial [published online February 18, 2012]. Burns 2012;38;(5):650–657.
- Kuehn BM. Virtual and augmented reality put a twist on medical education. JAMA 2018;319;(8):756–758.


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Who we are
Ugene Laboratory Services is a leading Industrial Microbiological Testing Laboratory. Since our founding in 1997, we have dedicated ourselves to providing clients with Quality Industry Testing and serving as a reliable partner in maintaining their business activities at the highest standard possible.
Accredited by SAC-SINGLAS and a key member of AOAC and the National Restaurant Association amongst others, Ugene Laboratory Services offers the most innovative tests and services including diagnostic test for general food products, traditional Chinese medicinal products, water/environmental analyses and much more.
At Ugene Laboratory Services, we have a dynamic and dedicated team of leading experts and technicians in the field of microbiology who are always available to provide valuable insight and firsthand experience in their consultations and analytical testing. This team has been the determining factor in establishing our industry-wide recognition and solid reputation over the years.
Under the slogan "Professional Services with a Personal Touch", we are committed to meeting all our clients' demands by delivering our services in an ethical, cost-efficient, prompt and timely manner.
- Responsibility and Performance
- Accuracy
- Efficiency and Precision
- Innovation and Continuous Improvement

subset: commoncrawl


text:
Learn something new every day
More Info... by email
Kirschenmichel is a type of German bread pudding that uses day-old bread. Simple ingredients including eggs, sugar and milk are used to create a souffle-like texture when the pudding is baked in an oven. The addition of tart cherries either inside the batter or on top of the dish makes it unique, as can spices such as cardamom and cloves. Some recipes put almonds or hazelnuts into the pudding, while variations can include cocoa powder, vanilla icing, lemon zest or a sprinkling of flavored liqueur when the dish is done cooking. The finished pudding can be eaten as a main course or as a dessert served with ice cream, whipped cream or custard.
The first step in making kirschenmichel is to prepare the bread. The recipe requires dried bread, so a loaf that is a few days old is good. Alternately, fresh bread can be dried out in an oven and used. This is because too much moisture in the bread could ruin the consistency of the kirschenmichel, leaving it a mushy soup-like concoction.
Eggs are separated and the yolks are mixed with more eggs, butter and sugar until smooth. Additional spices — such as cloves, cardamom, cinnamon, vanilla or lemon zest — can be added at this point. The bread and tart cherries are combined with the egg yolk mixture and stirred until each piece is coated and the cherries are evenly dispersed. Some recipes allow the mixture to sit for a period to allow the bread to fully absorb some of the liquid.
The egg whites are whisked with a pinch of salt until they form peaks. The stiff egg white mixture is then folded into the main kirschenmichel batter. Folding involves gently incorporating the whites so they do not lose the air they contain and collapse, so somewhat delicate movements with a spatula are key. The addition of the egg whites ensures kirschenmichel will have some height and volume after baking.
The entire mixture is placed in a large ramekin, casserole dish or other oven-safe baking dish. If the cherries were not added with the bread earlier, then they can be poured or placed on top of the uncooked batter. Some small pieces of butter can be put on top to help promote browning. The mixture is placed in an oven and allowed to cook until it has set and the top of the kirschenmichel has browned.
The finished kirschenmichel can be served hot, cold or at room temperature. It goes well with sweet side dishes such as ice cream or sweetened whipped cream. Thick vanilla cream sauces or icing can be drizzled over the top, or it can be garnished with chocolate powder or chocolate shavings.
One of our editors will review your suggestion and make changes if warranted. Note that depending on the number of suggestions we receive, this can take anywhere from a few hours to a few days. Thank you for helping to improve wiseGEEK!


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Following the success of its website, which takes visitors to old news items as if they were recent events, the BBC has decided to randomise all news coverage, with old events appearing alongside new.
'The BBC believes in challenging itself', a spokesman said. 'The licence-fee payer deserves a service which is distinct from that offered by other news outlets – CNN, Al Jazeera etc. One question we asked was : why does news have to be so new? What's wrong with classic news?
'The result is a sea-change in our style of reporting. If viewers or listeners just want to know about things which are happening now, they can switch to commercial radio or television. With the BBC they will hear about present events and past events at the same time. We're planning an exciting series of vox pop interviews about the sinking of the Titanic, followed by 'live' coverage of its launch.
'The possibilities are endless. The fall of Singapore, that cat being run over by a fire wagon, Jimmy Savile's OBE. Taking events out of sequence puts a completely fresh slant on what we mean by 'current affairs'. Our guiding principle will be 'no hindsight'. So, for example, coverage of every England football match since 1966 will be optimistic and dismissive of other nations.
'Our racing tipsters are particularly excited about the prospect of getting it right occasionally. The next step will be reporting of future events. This might need a bigger licence fee'.


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Graduate from your old push mower to a new 100 Series riding lawn mower. Engineered for level terrain and ideal for homeowners with up to 2 acres of land, these riding lawn mowers range from 17.5 HP to 25 HP and feature mower decks ranging from 42- to 54-inches. Visit our store today for a test-drive or Request a Quote below.
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Waist high in water
They swim a dark cold shore house
Lights burst from afar.
(Photo by Susan, New Orleans)
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text:
Home Renovation Ideas for Better Exterior and Interior
Many people try to find some home renovation ideas. It is sometimes due to the old age, the house needs some renovations or remodeling in order to make it still in a good shape. House is practically a kind of investment; whether we are going to live in it or we just want to rent […]Continue Reading


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By Zelda Montoya | Published October 9, 2019 | Posted in Articles | Comments Off on September, 2019- Painter Can't Cover up Lack of Enforceable Contract
An employee of a sub-subcontractor on a project at Buckley AFB in Aurora, Colorado, filed a breach of contract claim against the painting subcontractor. He claimed he had a contact directly with the subcontractor under which he would be paid the sub-subcontractor's profit on the project. The subcontractor was represented by Karl Berg. After a Read MoreRead More
After an extremely difficult 2+ year project at Fort Lewis College in Durango, Colorado, on a new science building, a mechanical contractor pursued a lost labor productivity claim against the general contractor, Jaynes Corporation of Colorado. The mechanical contractor claimed Jaynes' failure to properly schedule, coordinate and manage the project caused it significant damages. In Read MoreRead More
In an August, 2019, trial Murray Weiner and Jessamyn Jones successfully defeated contract and other claims against the Firm's client. The damages sought exceeded $3M. At the conclusion of trial, the Pueblo County District Court entered judgment dismissing all claims because of the plaintiff's fraudulent conduct. The Court found that the contracts were procured by Read MoreRead More
The El Paso County District Court has ruled in favor of a local church represented by Murray Weiner. In the case, the international denomination to which the local Church belonged sought to take control of the Church sanctuary building and other assets in Colorado Springs. After trial, the Court determined the Church building and other Read MoreRead More
Litigation over possession and occupancy of a greenhouse in Pueblo, Colorado was successfully resolved by Murray Weiner in favor of the firm's client who received a $850,000 settlement. The case involved more than ten parties each of which had asserted various claims, counterclaims and cross-claims. The settlement was reached shortly before the case was to Read MoreRead More
David Slays Goliath– In September, 2018, Murray Weiner successfully resolved a multi-million-dollar Civil Racketeering Action against his clients which was pending in Federal Court in Denver. After more than a year of hard-fought litigation, and the assertion of Counterclaims against the Plaintiff insurance company, the Plaintiff dismissed all of its claims against Mr. Weiner's clients with Read MoreRead More
A family-operated greenhouse farming venture received more than they hoped for after obtaining a special use permit to build a greenhouse in the Black Forest area. A local advocacy group challenged the issuance of the special use permit El Paso County District Court. Represented by Murray Weiner and Joe Kinlaw II, the farming operation received Read MoreRead More
On April 7, 2016, the El Paso County District Court entered judgment after trial in favor of the firm's client in an easement dispute. Murray Weiner and Joe Kinlaw of the firm obtained a permanent injunction from the Court prohibiting the defendant from continuing to block access or otherwise interfere with an easement across defendant's Read MoreRead More
At the conclusion of a one day trial, the Court dismissed the owner of a four-plex's breach of contract claim against a roofing contractor represented by Karl Berg. Although the owner claimed that the roof began to leak shortly after it was replaced, the court did not find the owner's, or his unlicensed roofing expert's, Read MoreRead More
After a two day trial, the court entered a defense verdict for a home seller on a fraudulent misrepresentation claim arising out of the sale of a high-end home in the Broadmoor area. The seller was represented by Karl Berg. The home had experienced significant structural movement ten or more years ago which the seller Read MoreRead More


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There is something special about walking into a home with such interesting architectural elements. We're faced with details we've never seen before. Such was the case with this home in Morris, Ill. The 12-month complete renovation required VF Interiors to preserve as much of the character of the original home as possible while still creating a beautiful and functional home for its new owners.
Though the project itself resulted in a new look that took advantage of the original architecture, we consider the highlight of this project as the kitchen. We completely opened the space and added all new cabinets as well as the stunning accent color on the island. To create this look, we chose granite countertops, sleek, modern lighting and created a large open breakfast area. The living space and bathrooms also resulted in some stunning looks. We worked closely to execute the clients' vision.


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Investment Management Solutions Manager Senior Advisor
Rob Jackson is the senior advisor of platform consulting at 1st Global, where he is responsible for the ongoing growth and development of the Investment Management Solutions (IMS) and Retirement Management Solutions (RMS) platforms. He has been with the company since 2004, and in his role, he helps to ensure the platforms are in line relative to advisor needs and the competitive landscape, and he also serves as a platform subject-matter expert, providing advisors and internal staff members with education and training on investment management and platform-related topics.
Rob received his Bachelor of Business Administration degree in marketing from the University of North Texas and his Master of Business Administration degree in finance from the University of Dallas. He has a passion for helping people achieve their goals, which gave him the desire to enter the financial services industry so that he could channel that drive to creating a lasting impact on those seeking to obtain their financial objectives. He enjoys being able to provide the necessary tools and resources for clients to reach their investment-related goals and assisting advisors and staff members be better to those individuals they serve on a daily basis. He has passed his FINRA Series 7, 24, 63 and 66 exams as well as his Texas Life and Health Insurance exam.
Investment Management Consultants Association is the owner of the certification mark, "CIMA®," the service marks "Certified Investment Management Analyst℠," Investment Management Consultants Association℠," and "IMCA®." Use of CIMA® or Certified Investment Management Analyst℠ signifies that the user has successfully completed IMCA's initial and ongoing credentialing requirements for investment management consultants.
Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and federally registered CFP (with flame logo), which it awards to individuals who successfully complete initial and ongoing certification requirements. CFA® and Chartered Financial Analysts® are registered trademarks owned by CFA Institute.


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Carolina Jasmine
I have two Carolina Jasime plants that are planted in Very Large pots 25 " deep. The plants themselves are approx 7' tall and growing on a tripod of bamboo. The pots and plants are too large to bring indoors for the winter. I live in Charlottesville, VA Zone 7, I believe. How can I care for them over the winter months. Should I prune them back, if so how far. And should I cover them for the winter months? If so, what would you recommend I use. Would wrapping them in sheets be sufficiant?
I think the plant you're referring to is Carolina Jessamine, Gelsemium sempervirens (some people do call it Carolina Jasmine, but it's not a true jasmine). This plant is winter-hardy in zone 7, so it should do fine. It is not recommended to cover them for the winter, because the leaves are semi-evergreen and will still be photosyntheiszing in the winter. Placing a wind screen near them is a possibility. They will also be protected if they are near trees or shrubs that break the wind.
This plant can be pruned if desired, but the best time for pruning is just after they've finished flowering. They won't benefit from pruning in the fall.
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Medical Tourism in Thailand
Thailand is one of the most popular destinations for medical tourism in the world because of their well-developed medical infrastructure, highly-trained medical professionals, advanced medical technology and competitive medical costs. Many procedures can cost 40-60% less than in other Western countries.
With a population renowned for its hospitality, it's no wonder Thailand is a hub for many tourists seeking medical attention as well. The country is home to the highest number of internationally accredited hospitals in Southeast Asia which specifically cater to medical tourists. Some hospitals are built to give patients utmost comfort and convenience. As such, it's not unusual to chance upon a hospital that looks like a shopping mall or a five-star hotel.
Accounting for about 40% of the global tourism market, Thailand is poised to dominate the market with the government's continued commitment and support in the healthcare sector.
But before traveling to Thailand for any medical treatment, it is best to do an extensive research to find qualified doctors and registered medical establishments. It is also recommended to stay in the country for a while to avoid any post-surgical risks. Some medical establishments offer surgery tour packages which includes an examination, the surgery and recovery time.


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|M.Sc Student
|Hirshberg Netta
|Utilization of Saccharomyces cerevisiae for production of
Valuable Chemicals
|Department of Biotechnology and Food Engineering
|Professor Ayelet Fishman
|Full Thesis text
Biocatalysis is the execution of chemical reactions using biological systems. Having a broad substrate acceptance and being inexpensive, readily available, fast growing and easy to use, places Saccharomyces cerevisiae among the most popular biocatalysts. This work describes two model reactions targeted for the pharmaceutical and food industries, catalyzed by S. cerevisiae whole-cells or enzymes.
(S)-4-chloro-3-hydroxybutanoic acid ethyl ester ((S)-CHB) is an important chiral building block used in the synthesis of chiral pharmaceuticals which can be produced by S. cerevisiae. However, previous studies using non-modified S. cerevisiae for (S)-CHB production reported a non-satisfactory enantiomeric excess (ee) of 92%. Attempts for overcoming this drawback have shown only partial success or suffer from high complexity.
The objective of this part was to use classic genetic introgression for combining complex multi-component traits from two parents in a single strain. Lately, natural yeast strains, isolated from Mount Carmel were characterized as resistant to environmental stress. Nevertheless, these strains showed relatively low ee values, while a laboratory strain, Y103, exhibited both the highest specific activity (1.88 µmol/min/mg protein) and the highest enantioselectivity of (98%). The enantioselective lab strain was crossed with Ye-519, a multi-stress resistant isolate (93%) to obtain, after selection for both characteristics, a haploid offspring of backcross-1, C242, exhibiting both multi-stress resistance and high enantioselectivity (98%). Introducing osmotic (1 M NaCl), oxidative (0.6 mM H2O2) and thermal stress (44°C) to growing cultures of the enantioselective parent, resulted in a decrease of 24-32% in specific activity, while the enantioselectivity of the stress-resistant parent decreased by 4-12%. Unlike its original parental strains, the new hybrid strain maintained both parameters constant.
2-phenylethanol (PEA) is an aromatic alcohol with a rose-like odor widely
used in the fragrance and food industries. Although the vast majority of this
commercial compound is produced chemically,
increase in consumers' preference for natural flavors, and economical considerations,
motivate the design of high PEA-producing microorganisms. S. cerevisiae naturally transforms phenylalanine (L-Phe), to
PEA via the "Ehrlich Pathway". However, competitive pathways, and the inhibitory effect of
PEA on cell growth, limit the productivity of the bioprocess. Attempts for
improving the production yields focused mainly on in-situ product
removal (ISPR). The aim of this part was to clone and
overexpress in E. coli the
three genes responsible for converting L-Phe to PEA as an alternative approach. Cloning of Aro8, Aro10 and Sfa1
separately in E. coli resulted in overexpression of each gene, and a 5-fold, 2.5-fold, and 4-fold increase
in initial activity rate of the respective
enzymes. Future cloning of those genes as a cluster will form a clone, solely dedicated to PEA production and free of the
S. cerevisiae limitations.
The aromatic aminotransferase from S. cerevisiae is expected to have a broad substrate acceptance and therefore may be suitable for industrial purposes. This enzyme was successfully purified by an affinity column and is in the process of structural and biochemical characterization.
In summary, two genetic approaches were used in this work for improving the S. cerevisiae performance as an industrially oriented biocatalyst. The classic genetic introgression technique allowed the combination of two complex traits (enantioselectivity and stress- tolerance) affected by multiple components, while modern genetic engineering showed promising results for the improvement of a well known and defined metabolic pathway.


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The Fall Elk Rut In Estes Park
During fall in the high country, the haunting bull elk bugle marks the beginning of the elk "rut," or mating season. The bugling starts high-pitched, like a shrill whistle, and slides into a grunt that echoes across the valley. It comes from the gut, signaling that a bull and his harem are in the area


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Lauren & Daniel // Mottram Hall Wedding Film
Why did you choose to celebrate your day at Mottram Hall?
We've always loved Mottram Hall and the grandeur of the front is amazing!
Why do you want your day filmed & why did you choose In Love Wedding Films?
So we can look back on every moment we might miss as we're wrapped up in our day! We saw you on Instagram and loved what we saw of your work!
You guys – what do you do, what is important in life? etc…
We run a business together, we love holidays and the most important thing in our life is our 3 year old son, Leo
How did you meet? What was the first date?
We met at work, first date was cinema and chicken (cringe) haha!
The Proposal … tell me everything … even the soppy stuff
Dan proposed to me after being together just 9 months, he invited all our close friends and family round to the house on my birthday and got down on one knee whilst everyone was singing happy birthday and on the cake it said "will you marry me?" I was a mess!
What experience do you want your guests to have on the day?
We're a very fun & laid back couple so just lots and lots of fun!
Lauren & Daniel would also like to thank all the other amazing suppliers who helped create their day, including: Paul Martin Flowers & Planters, Antonias Cakes, Sophie Nicola MUA, Chloe Whitehead of Jessica Rose Salon, Shane Webber Photography, Hipswing Entertainment, the wonderful dress by Riki Dalal supplied by the White Gallery in Ramsbottom and the guys suits by Slaters Manchester.


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L-Carnitine assists in the metabolic process of shuttling fatty acids across cell membranes into the mitochondrial matrix where energy is processed. Being more efficient in this process helps the body produce natural energy more readily.
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Total Serves per Package: 31
Serving Size: 1 Tablespoon (15g)
Amount Per Serving
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1,000 mg
250 mg
|L-Carnitine L-Tartrate
250 mg
Other Ingredients/Information
Purified Water, Natural Flavor, Malic Acid, Phosphoric Acid, Sucralose, Acesulfame-K, Potassium Sorbate, Sodium Benzoate
NOTE: The Nutritional Information & Ingredients is for Mixed Berry flavour. These may slightly vary depending on different flavours.
As a dietary supplement, adults take 1 serving (one tablespoon) of L-Carnitine twice daily, or as directed by a licensed healthcare professional. L-Carnitine LS3 can be used on its own or in combination with other iSatori weight loss supplements. Shake well before use. Refrigerate after opening.
KEEP OUT OF REACH OF CHILDREN. Not intended for individuals under the age of 18 unless instructed by a doctor. Do not use this product if you are pregnant, nursing, or contemplating pregnancy. Consult a physician or healthcare professional before using this or any other dietary supplement or before beginning an exercise program. Consult with your primary physician prior to use if you have any pre-existing medical conditions, or if you are taking any prescription or over-the-counter drug(s). Discontinue use and consult a medical doctor if you experience any unusual symptoms. Discontinue use two weeks prior to surgery.
Earn 50 Z points by submitting your own product review!
iSatori Liquid L-Carnitine LS3 1500 473mL Reviews
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100 Day Returns
100 Day Returns!
• Easy and hassle free
• You can return both opened and unopened product (see below for details)
For up to 100 days from the day that you place your order, you can take advantage of our returns, even if you just change your mind!
Please note, this policy does not relate to items that are damaged in transit, lost or incur an issue beyond your control. In situations like these, we will either refund, credit or send a replacement to you without delay. Our 100 day returns is for your peace of mind if you don't like the product, or simply change your mind.
For any unopened product, just ship the item back and we will refund or replace that item! You can obtain a refund, store credit or product exchange to the same value. Just let us know within 100 days from the date of your order.
For any opened product (Club Z members only), we understand that trying new supplements sometimes carries some uncertainty. Perhaps you're not sure about a new flavour, or you just bought the wrong product. So if you're not happy with your purchase within 5 scoops (or 5 serves) and 30 days from the date of purchase, you can send it back for a full money-back guarantee! The purchase must have been made when you had an active Club Z membership.
Please note that if your item was purchased as an advertised discounted shortdated item, the above time frames are limited to 14 days. Shortdated items are heavily discounted items due to a sooner expiry date.
If however there was any issue in receiving your order (for example, if your order was lost or damaged in transit) - don't stress! Just contact us and we'll fix things up for you.
Simply contact us by email, phone, chat or visit us in-store to arrange a return. Our returns policy is subject to our standard terms and conditions.
Other Returns
Whenever a problem is incurred that is not your fault, we will be happy to arrange return shipping (if applicable) and the shipment of any replacement goods to you to avoid any further cost and inconvenience. All you need to do is contact us so we can jump on it as quickly as possible.
Here's what we will do in certain situations:
- Your item has been damaged/lost in transit (we'll replace it)
- Incorrect goods received (although rare, we'll ship off the correct item)
- A problem with the actual product or anything else (we'll do what is necessary to fix things for you!)
So we can fix things quickly for you, please let us know of any issues within 48 hours of receiving your goods. In certain situations we may ask for a photograph (for example if the product is damaged in transit, so we can take it up with the delivery company to avoid future issues).
If you do receive an incorrect product, please do not open the actual product so we can arrange a resolution quickly.
In a nutshell, we work really hard on keeping you happy. So if a problem arises, just contact us and we'll do our very best to fix it!


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Weekdays 07:30 to 17:30 Saturdays 08:00 to 12:00
(When agents are available)
Why do you build me up (build me up) Buttercup, baby
Just to let me down (let me down) and mess me around
And then worst of all (worst of all) you never call, baby
When you say you will (say you will) but I love you still
I need you (I need you) more than anyone, darlin'
You know that I have from the start
So build me up (build me up) Buttercup, don't break my heart. The Foundations.
Oh flowers! They have been the subject of songs, poems, paintings and even inspiration forclothes! In case you didn't know NetFlorist is South Africa's largest online flower market to turn towhen you want to buy flowers online! Basically, wetake the hassle out shopping for flowers, no more having to trek around themalls and lame flower shops. Nope, when youchoose to shop with NetFlorist, you can sit back, pour yourself a cup of tea orcoffee, put your feet up and buy flowers online in South Africa!
When you think about it, there are always going to occasions that call for you send flowers to a friend or loved one. For instance the gift of sympathy flowers are traditionally sent when a person passes on. You send these flowers as a show ofsolidarity, and support and prayer that the grieving family will be ok aftertime. Other occasions at will call for you to buy flowers online are a person's birthday, an anniversary, to say get well and even as housewarming flowers. But what we're trying to get at here with these musings and ramblings is that NetFlorist is the best, the only and the most awesome place to turn to when you want to buy flowers online in South Africa.So what are you waiting for? Log on now and buy flowers online for your nearest and dearest!
NetFlorist.co.za is the best online flower shop in South Africa to turn to when you want flower ideas because we have flowers of any and every kind that you could possibly ever want! We floral fairies here at NetFlorist do nationwide, same day and next day flower delivery . This means that you can order flowers online in South Africa and we'll deliver your flower gift for any occasion faster than the Flash could hope to run!
Cactus Plants
Bonsai Trees
Black Roses
Flowers Online
Plants Online
Red Roses


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how much do you know about the Great River Road – specifically, the network of more than 70 interpretive centers that tell visitors about the Mississippi River region's history, culture and heritage?
Answer correctly for a chance to win $500!
August 29, 2014
how much do you know about the Great River Road – specifically, the network of more than 70 interpretive centers that tell visitors about the Mississippi River region's history, culture and heritage?
Answer correctly for a chance to win $500!
August 21, 2014
Five bike trails for everyone
Fall is the ideal time for a biking getaway. The cool weather and wonderful scenery make pedaling a pleasure. These five trails are suitable for every rider.
Middleton's award-winning community trail system is the perfect destination for a fall ride. The system consists of a network of bike paths, bike lanes and sidewalks. It connects bicyclists to parks and businesses throughout the community. During the fall, the best scenery can be found in the Pheasant Branch Conservancy. Ponds throughout the conservancy attract migrating ducks, geese and wading birds. The conservancy's forests dazzle with autumn color. A 3.5-mile loop around the entire conservancy is a great fall ride.
Throughout Vilas County, you'll find more than 50 designated trails, including rugged mountain biking trails and smooth paved bike paths. The St. Germain Bike and Hike Trail is a paved, level trail running through forests and along lakes. For 12 scenic miles, you'll have a chance to see towering white pines set against a canvas of colorful leaves. The trail connects with a system of paved trails that stretches across the county, providing many miles of riding.
The Bearskin State Trail runs for 18 miles from Highway K near Tomahawk to Minocqua. The semi-paved, crushed-granite trail surface is suitable for most kinds of bikes. You'll pass several lakes, including Bearskin Lake, Little Bearskin Lake and Lake Minocqua. If you're looking for a level trail appropriate for beginning riders, this is it.
The Crystal Lake trail is part of Boulder Junction's outstanding network of trails that includes 45 miles of trails running throughout Vilas County. If you're looking for great fall color, the Crystal Lake Trail is the place to ride. The trail runs from downtown Boulder Junction past Trout Lake and the Crystal Lake Campground. Crystal Lake is just as advertised – clean, clear and shimmering. The autumn-hued trees reflecting off the lake's surface are a sight to behold.
The Mississippi River Valley is stunning in the fall. The tree covered bluffs and flocks of migrating waterfowl combine to create a visual display unlike any other. The Great River State Trail follows the Mississippi River for 24 miles, and a fall bike ride along this crushed-limestone trail is the perfect way to experience the sights and sounds of the fall season.
August 21, 2014
These trails are perfect for enjoying the autumn hues
When summer gives way to fall and the leaves are set ablaze with color, it's time to put on your walking shoes and hit the trail. Here are five of the state's best places for a fall stroll.
Located in the center of Middleton you'll find a natural oasis. This 550-acre nature conservancy offers miles of trails, including a 3.5-mile trail that encircles the entire nature area. In addition to fall color, the conservancy offers an opportunity to see migrating birds.
West Bend's location at the southern end of the Kettle Moraine State Forest's Northern Unit makes it the perfect jumping-off point for exploring the forest's hills and valleys this fall. The New Fane trail system provides 7.7 miles of scenic walking.
The Schmeeckle Reserve protects 280 acres of woodlands and wetlands. Enjoy a fall hike along five miles of trails through a diverse habitat. See migrating waterfowl on Lake Joanis. Boardwalks lead you over marshes and river-bottom forests.
The Holmboe Nature Trail is ideal for people looking for an easy, scenic walk in the woods. The trail runs for just under a mile through old growth forest along the banks of the Pelican River. Keep your eyes peeled for white-tailed deer and other creatures that thrive in this protected natural area.
At 0.5 miles, the Awassa Nature Trail is the shortest of our five trails. It's also the easiest to use; the level trail is wheelchair accessible. The mature forest presents a spectacular color show in the fall. It's a beautiful place to experience the wonder of the fall season.
August 7, 2014
Win big with the Wisconsin Travel Best Bets $500 Fall Giveaway! One lucky fan will start the fall off $500 richer! Use it to plan your own perfect Wisconsin getaway!


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The Aetos hoist is a very nice product, maybe most significant new product for yearsLars Berge Multitechnic AS, Norway
Leg to Leg Clamp DoubleCatalog number: SM-ACC-CLP-02 - Item code: 115500005
The Leg-to-leg clamps connects 4 legs, connecting the StageDex to a safely connected system. The clamp can be mounted without the need for tools. This clamp absorbs the horizontal as well as the vertical forces on the stage floor and guarantees a close fit of the decks.


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Haunted mansion
My epic Disney tattoo
Sister tigger/Pooh
Sister Disney balloons
Hula girl from it's a small world
Figment tattoo
Remember the Magic
Little mermaid
Love of Disney
Tink watercolor
Mickey Mouse, Jack skellington Haunted Mansion
I just can't wait to be king
Mickey tattoo
Dream It Quote
Disney heartbeat Castle
Beauty and The Beast
Cinderella's castle
Up! Up! and Always
Ursula Disney Villan
Squirt. Memorial tattoo for my mom
Slave 1 in a bottle
Disney World/DVC/DCL
Alice in winderland
Remember who you are
Narnia lamp with other destinations.
Genie sketch watercolor
Bambi and Thumper
Mickey mouse
Tinker bell
Sorcerers apprentice Mickey
The Dark Side
Captain hook
My daughters name
Mickey Firefighter
Beauty & The Beast
Disney love
We Have Everything We Need
Part of my Frozen leg sleeve
Star Wars lightsaber
Zero from nightmare before Christmas
Hidden Mickey
Minnie aladdin mashup
May the mouse be with you
"Walt Sent Me"
Hello Ewok
I had a kitty named simba and I lost him...
Alice in wonderland flowers
Bippity Babbitt boo/ under the see
Zurg Infinity
Pirates Coin
My Disney
Soaring Mickey. Disney fan and aviation professional.
Peter Pan
My Disney Family
The Rose from Beauty and the Beast
Mother and Daughter Mickey tattoos
Daddy/daughter first tattoo
Mickey Heartbeat, Practically Perfect in Every Way, watercolor splash
Kingdom hearts
I love THE MOUSE AND HIS GIRL!
Disney/Lion King
Huey, Dewey, and Louie Quicksand
Disney Pirates
Haunted Mansion Stitch
the talking pirate skull before the drop
Ariel - the little mermaid
Main Street Electrical Parade Tattoo
Hakuna Matata
Have Courage...
Mickey Swirl
Punk rock Peter Pan
Anna and Elsa
My Cheshire Cat
Minnie wrist
Tiana tattoo
Tattoo contest
Cinderella's Castle
Broadway's Beast
Pixie dust with Tink
Stylistic Tomorrowland with hidden Mickey
Mickey flags
Disneyland Paris castle in a Mickey head
Can you find the Ewok?
Space Ranger Logo
My Disney Tattoo
Pinup Belle-Beauty and the Beast
Hidden initials Minnie
Cinderella's Castle
Adventure is out there
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- Safe & Confidential - Call 24/7
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There are 11 Drug and Alcoholism Recovery Centers and Resources in Greenville, South Carolina
Miracle Hill Ministries - Renewal for WomenGreenville, SCMiracle Hill Renewal Program uses a Christian adaptation of the 12-Steps to help free women from their life-dominating addictions. The...
Miracle Hill Ministries - Overcomers CenterGreenville, SCMiracle Hill Overcomers for Men has a Christian curriculum that also implements the 12-step model. The program has four phases,...
Pavillon Greenville Outpatient ServicesGreenville, SC
United MinistriesGreenville, SC
PavilionGreenville, SC
Greenville Intergroup OfficeGreenville, SC
Alano ClubGreenville, SC
Serenity PlaceGreenville, SC
Pavillon InternationalGreenville, SC
Greenville County CommissionGreenville, SC
Greenville Metro Treatment CenterGreenville, SC
Cities Near Greenville, SC
How to Choose the Best Addiction Rehab Greenville, Offers
If you know what amenities you'll want, you can locate Greenville residential recovery programs that suit nearly any requirement. From professional treatment for businessmen and women to VIP recovery programs, your city offers many choices, both cost-conscious and upper end.
How Long Should Recovering from Drug and Alcohol Addiction Take?
Depending on the kind of dependency and severity, you or someone close to you may require anything from a 1-month in-patient drug or alcohol treatment program all the way up to a 3-month or longer one. Some drugs can be treated with outpatient programs while severe cases may require longer-term treatment services. However, you can find a Greenville treatment facility to fit just about any personal budget.
How Much Does a Rehab Treatment Center Cost and Is Insurance Accepted?
In estimating the price of rehabilitation in Greenville, , you first have to look at the amenities the center delivers and its location relative to your own preferences. The price varies quite a bit for rehabilitation facilities. Many can take private insurance, so either check with your provider to see if the cost can be partially covered through your PPO or HMO, or dial our hotline, toll-free for a discreet insurance check.
Ready to Get Help and Change Your Life for Good?
Whether you need help getting rid of a drug or alcohol addiction or live with a family member who does, our phone line is ready to take your call, anytime, and is answered by friendly advisors, there to discuss the highest-quality inpatient alcohol, illicit and prescription drug addiction recovery centers Greenville, South Carolina offers. You can review the specifics of one month abuse treatment clinics versus 2 or 3-month ones and make sure the treatment clinic you decide on is going to give you or your family member all you need to be successful.


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The Life and Music of Eugene Ettore
June 2nd 2011 would have been the 90th birthday of Eugene Ettore. In honor of his birthday, I have updated the website with photos of his many distinguished awards and honors which he received over the years. All of these prestigious awards are on a wall in his home in Livingston, NJ . where his daughter, Carol, and family still live. Carol kindly loaned me these awards, and in scanned form are now included here for you to see.
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