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Neurología (English Edition)
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Inicio Neurología (English Edition) Consumption trends for specific drugs used to treat dementia in the region of Ma...
Neurología, founded in 1986, is the official scientific Journal of the Spanish Neurology Society (Sociedad Española de Neurología, SEN). It is edited by Dr. Jorge Matías-Guiu and is indexed in the most important international data bases, such as Science Citation Index or Index Medicus/MEDLINE. The Journal accepts works on basic as well applied research on any field of neurology.
MEDLINE, EMBASE, Web of Science, Science Citation Index Expanded, Alerting Services and Neuroscience, Neuroscience Citation Index, ScienceDirect, SCOPUS, IBECS, MEDES
Vol. 30. Issue 7.
Pages 416-424 (September 2015)
Lee este artículo en Español
DOI: 10.1016/j.nrleng.2014.02.005
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Consumption trends for specific drugs used to treat dementia in the region of Madrid (Spain) from 2002 to 2012
Evolución del consumo de fármacos específicos para la demencia en la comunidad autónoma de Madrid durante el periodo 2002-2012
M.C. de Hoyos-Alonsoa,
mcanto.hoyos@salud.madrid.org
, E. Tapias-Merinob, C.M. Meseguer Barrosc, M. Sánchez-Martínezd, A. Oterod
a Servicio Madrileño de Salud, Centro de Salud Pedro Laín Entralgo, Alcorcón, Madrid, Spain
b Servicio Madrileño de Salud, Centro de Salud Comillas, Área Centro, Madrid, Spain
c Servicio Madrileño de Salud, Subdirección General de Compras de Farmacia y Productos Sanitarios, Consejería de Sanidad, Comunidad de Madrid, Spain
d Departamento de Medicina Preventiva y Salud Pu¿blica, Universidad Auto¿noma de Madrid, Madrid, Spain
Table 1. Changes in consumption of specific drugs to treat dementia (cholinesterase inhibitors and memantine) in the region of Madrid between 2002 and 2012, in defined daily doses.
Table 2. Age distribution of consumption of cholinesterase inhibitors and memantine in the region of Madrid in 2012.
Table 3. Age and sex distribution of consumption of specific anti-dementia drugs (cholinesterase inhibitors and memantine) in the region of Madrid in 2012.
Analysing drug consumption in large population groups lets us observe consumption trends and compare them between different settings.
To analyse the time trends for consumption and costs of specific drugs used to treat dementia in the region of Madrid (Spain) and compare trends by sex and age cohort.
Descriptive study of cholinesterase inhibitors (N06DA) and memantine (N06DX01) dispensed in Madrid between 2002 and 2012 and covered by the Spain's national health system. Consumption was calculated by analysing changes in DDD (defined daily doses) to find total and yearly increases. The cost was estimated based on DDD price. To compare consumption rates by age and sex, we calculated DDD per 100 inhabitants/day.
Between 2002 and 2012, consumption of drugs used to treat dementia increased sixfold. During this period, cholinesterase inhibitors accounted for 76.70% of the drugs consumed and memantine, 23.30%. The estimated cost rose by a factor of 5.7 over 11 years (or by a factor of 4 taking into account the use of generic drugs).
In 2012, 2.42% of the patients aged 65 or over consumed cholinesterase inhibitors (women 2.82%, men 1.83%) and 0.90% consumed memantine (women 1.10%, men 0.61%). Consumption increased in age cohorts up to 86 to 90 (5.84% for cholinesterase inhibitors and 2.33% for memantine) and declined thereafter.
Consumption of cholinesterase inhibitors and memantine gradually increased, but consumption in 2012 did not reach levels equivalent to dementia prevalence figures. Pharmaceutical expenditure restraint measures may temporarily slow the cost increase temporarily but if the same trend of consumption persists, costs will rise.
Memantine
Drug utilization
El análisis del consumo de fármacos en grandes grupos poblacionales permite ver tendencias de consumo y comparar diferentes ámbitos.
Analizar la tendencia temporal de consumo y costes de fármacos específicos para la demencia en la comunidad autónoma de Madrid (CAM) y comparar por grupos de edad y sexo.
Estudio descriptivo, seleccionando anticolinesterásicos (N06DA) y memantina (N06DX01) dispensados en la CAM del 2002 al 2012 con cargo al Sistema Nacional de Salud. El consumo se calculó analizando la evolución de las dosis diarias definidas (DDD), con incrementos totales y anuales. El coste se estimó por precio de DDD. Para comparar el consumo por edad y sexo, se calcularon las DDD por 100 habitantes-día.
Del 2002 al 2012 se multiplicó por 6 el consumo de fármacos para la demencia. El 76,70% de los fármacos consumidos en este periodo fueron anticolinesterásicos y el 23,30% memantina. La evolución del coste estimado se multiplicó por 5,7 en 11 años (por 4 considerando utilización de fármacos genéricos).
En 2012, el 2,42% de los mayores de 65 años consumió anticolinesterásicos (2,82% mujeres, 1,83% hombres) y el 0,90% memantina (1,10% mujeres, 0,61% hombres). El consumo aumentó hasta los 86-90 años (5,84% en anticolinesterásicos; 2,33% en memantina), disminuyendo posteriormente.
El consumo de anticolinesterásicos y memantina aumentó progresivamente, sin alcanzar en 2012 cifras equivalentes a la prevalencia poblacional de demencia. Las medidas de contención de gasto farmacéutico pueden frenar el aumento del coste, aunque este volverá a crecer si persiste la misma tendencia temporal de consumo.
Anticolinesterásicos
Memantina
Farmacoepidemiología
Uso de fármacos
Dementia prevalence is approximately 6.4% in patients older than 65 years, and it increases with age, from 0.8% in patients aged 65 to 69, 10% in patients older than 70 years, and 25% to 54% in the group of patients aged 90 or older.1–3 Alzheimer disease (AD) is the most frequent type of dementia and the main cause of disability among elderly patients. It places a significant burden on caregivers and generates social costs which increase as the disease progresses.4,5 Researchers estimate that some 600,000 people have dementia and 400,000 people have AD in Spain.2 According to the ECO study,6 the average monthly cost per patient is 1425 euro. Almost 88% of the cost of illness corresponds to informal care, which is borne by the patient's own family. This percentage is higher than the European average, which is about 56%.7 Healthcare costs include pharmacological treatments, as well as diagnostic tests, office visits, hospitalisation, and institutionalisation.
Since there is no curative treatment for dementia, treatment approach is focused on treating cognitive impairment symptoms, as well as behavioural and psychological symptoms. Its target is also to prevent complications and functional disability, and manage comorbidities. Acetylcholinesterase inhibitors (AChEI) are indicated as specific treatment for mild to moderate AD.8–10 These include donepezil (marketed in Spain since 1998), rivastigmine (since 2000), and galantamine (since 2001). Memantine, a non-competitive N-methyl-d-aspartate (NMDA)-receptor antagonist, was authorised in 2003 for use in mild to severe AD.8–10 AChEI and memantine can be administered in combination, but studies yield contradictory results.8,10–12 In addition to AD, both drugs can be used to treat vascular dementia, and diseases with Lewy bodies (dementia with Lewy bodies and Parkinson's disease), but they are not indicated to treat frontotemporal dementia.8,9
Their effects are modest and temporary and not all patients respond to treatment.13 However, according to clinical practice guidelines,8 treatment with these drugs should be started as soon as AD is diagnosed, considering that previous identification of patients who will respond to treatment is not possible.14 Spanish regulations establish that every first or maintenance prescription should be authorised by the medical inspection service after a neurologist, gerontologist, or psychiatrist issues the initial report confirming the disease and the treatment indication. There is no consensus on when to suspend treatment with these drugs,15–17 but some Spanish regions have established rules regarding use and continuity.18 The cost-benefit ratio of these treatments is currently being debated. Although several studies indicate that starting drug treatments, especially in mild-moderate stages, can delay disease progression, institutionalisation, and associated costs, results remain uncertain.19–21 Therefore, they should be interpreted considering those differences between public health systems that would influence cost distribution.14
Consumption of AChEI and memantine has increased progressively since they were introduced to the market,22–26 and they are listed among the 35 most expensive active ingredients for the Spanish Health System.27 This increase, which may be partly due to the increased prevalence of dementia caused by population ageing, also depends on the higher percentage of dementia patients treated since these drugs began to be indicated habitually. Thus, a study performed in a primary care setting simultaneously with our own showed that the percentage of dementia patients treated with these drugs had increased from 23% in 2002 to 41% in 2011.28
Regarding pharmacoepidemiological studies, quantitative studies of the consumption of drugs using prescription invoicing data and/or sales turnover figures show the actual consumption trends of the drugs in large populations. They also provide an overview of the actual costs of the disease and permit comparisons between different settings or populations.29
The aim of our study is to analyse time trends of consumption and costs of cholinesterase inhibitors (AChEI) and memantine (specific drugs used to treat dementia) in the region of Madrid between 2002 and 2012. Consumption profiles by age and sex were also compared to one another.
A population-based descriptive study of the consumption of specific drugs used to treat dementia was performed between 1 January 2002 and 31 December 2012 in the region of Madrid. Our data source was the system for information and analysis on prescriptions and pharmaceutical services of the region of Madrid (Farm@drid), which serves as the database of official medical prescriptions dispensed by pharmacies in the region of Madrid and invoiced to the Spanish Health System.
We selected cholinesterase inhibitors belonging to the chemical subgroup N06DA and identified the active ingredients donepezil (N06DA02), rivastigmine (N06DA03), and galantamine (N06DA04). We selected memantine (N06DX01) from the N06DX subgroup but excluded ginkgo biloba (N06DX02) as it is not used specifically to treat dementia.
As variables associated with treatment, we analysed year of consumption, sex, and age group (in 9 categories: 51-55 years, 56-60 years, 61-65 years, 66-70 years, 71-75 years, 76-80 years, 81-85 years, 86-90 years, and older than 90 years).
To analyse drug consumption, we used the parameters 'defined daily dose' (DDD) and 'daily dose per inhabitant' (DDI) for each active ingredient.
DDD corresponds to the daily maintenance dose for a drug used for its main indication in adults and given by a specific route of administration.30 We adhered to the DDDs defined by the World Health Organization: donepezil 7.5mg, rivastigmine 9mg (9.5mg transdermally), galantamine 16mg, and memantine 20mg.31
We assessed trends in drug consumption during the study period by calculating the total number of DDD based on the total number of packages dispensed every year. To do this, we converted commercial formats in milligrams or grams to DDD. We analysed consumption trends for the DDD of each active ingredient and therapeutic chemical subgroup, the ratio between the end and the beginning of the period, and the yearly and total increase in DDD. To calculate the percentages of total increase for 2012 compared to the beginning of the study, we used the formulaΔ2012–2002=([DDD2012−DDD2002]/DDD2002)×100 for AChEI, and % Δ2012–2003=([DDD2012−DDD2003]/DDD2003)×100 for memantine (marketed since 2003).29
Annual cost increases for each active ingredient were estimated by multiplying the number of DDD consumed each year by their sales price, calculated according to figures from the Nomenclátor Digitalis drug database.32 In our cost estimation, we considered commercial formats of maintenance doses exclusively. The price per milligram for each package format was obtained to later calculate the mean price per year of the different formats. Calculated DDD prices were between 4.39 and 4.04 euro for donepezil, 3.58 and 3.24 euro for rivastagmine, 3.84 and 3.53 euro for galantamine, and 3.8 euro for memantine. We performed an additional estimation after generic forms of donepezil became available in 2011 (DDD at 1.75 euro) and rivastigmine solution in 2012 (DDD at 2.65 euro). This estimation assumed that only generic drugs were used.
Daily dose per inhabitant refers to the mean number of inhabitants receiving daily treatment with a given drug.30 DDI corresponds to the DDD typically calculated for 1000 inhabitants. In our study, we decided to use a DDI per 100 inhabitants to draw comparisons with dementia prevalence in the population, and with other prevalence studies on consumption of these drugs.23,28
We used DDI to analyse consumption by age group and sex in 2012. We calculated DDI for both sexes and each age group, and for patients older than 60, 65, or 70 years, using the following formula: number of DDI2012=(number of DDD2012/population2012)×(1/365)×100. Only DDDs consumed by patients older than 50 years were considered. Populations used in calculating this rate were obtained from Farm@drid, according to health card holder records. Data were limited to patients older than 50 years since they constitute the reference population for these drugs. We calculated confidence intervals for both sexes and each age group.
Data extracted from the Farm@drid digital record did not include variables that could identify patients; therefore, our study preserves data confidentiality.
Data were analysed with the SPSS statistical software, version 19.0; Excel® version 12.3.0 (110427); and Epidat 3.0.
Consumption of the specific drugs used to treat dementia, cholinesterase inhibitors (AChEI) and memantine, increased by a factor of 6 between 2002 and 2012 in the region of Madrid. This meant a total increase in DDD of 507%. In this period, 76.7% of the drugs consumed to treat dementia were AChEI, with 23.3% corresponding to memantine (Table 1).
Changes in consumption of specific drugs to treat dementia (cholinesterase inhibitors and memantine) in the region of Madrid between 2002 and 2012, in defined daily doses.
All anti-dementia drugs
Δ (%)a
%TDDb
2002 2037210 100 NM 2037210
2003 2656311 30.39 90.29 285712 9.71 2942024 44.41
2004 3331106 25.40 82.87 688464 140.96 17.13 4019571 36.63
2005 3877923 16.42 80.17 959370 39.35 19.83 4837294 20.34
2006 4449169 14.73 77.36 1302078 35.72 22.64 5751247 18.89
2010 7766068 10.28 74.80 2616482 13.99 25.20 10382550 11.19
2011 8497908 9.42 73.31 3094222 18.26 26.69 11592130 11.65
2012 8969820 5.55 72.54 3396356 9.76 27.46 12366176 6.68
Total 2002-2012 60073025 340.30 76.70 18248068 1088.73 23.30 78321093 507.02
Beginning/end ratioc 4.40 11.89 6.07
DDD, defined daily dose; NM, not on the market.
Δ(%), increase in the annual percentage with regard to previous year. Total reflects cumulative increase for 2012 with regard to the initial period (2002 for cholinesterase inhibitor-TDD, and 2003 for memantine).
%TDD, percentage of the total for anti-dementia drugs (cholinesterase inhibitor+memantine).
2012/2002 ratio for cholinesterase inhibitors-TDD; 2012/2003 ratio in the case of memantine.
Half of the AChEI prescriptions filled during the study period were for donepezil. Galantamine consumption increased progressively up to 2008, when platformed off. Beginning in 2009, rivastigmine consumption increased until it made up 30% of all AChEI prescriptions in 2012. The increasing trend in consumption was more homogeneous for donezepil and memantine throughout the 11-year study period (Fig. 1).
Changes in consumption of specific anti-dementia drugs (cholinesterase inhibitors and memantine) in the region of Madrid between 2002 and 2012, given as defined daily doses. DDD, defined daily dose.
(0.1MB).
In 2012, 12.3 million DDDs of specific drugs used to treat dementia were consumed, 10.3 million more than in year 2002 (Table 1). Estimated costs increased by a factor of 5.7, from 8.2 million euro in 2002 to 47.6 million in 2012. If we consider prices for generic drugs only, the final cost amounts to 34 million, 4 times higher than at the beginning of the study period. Annual cost savings due to the use of generic drugs amounted to 12 million in 2011, and 13 million in 2013 (Fig. 2). Total costs during the 11-year period would be 300 million euro for brand-name drugs only or 275 million euro considering the generics that became available in 2011 and 2012.
Estimation of cost changes for specific drugs used to treat dementia (cholinesterase inhibitors and memantine) in the region of Madrid between 2002 and 2012. AChEI_Difference_Price brand/generic, price difference between brand name and generic drug.
(0.17MB).
After adjusting 2012 consumption data by age and sex, 2.42% of patients older than 65 years (95% CI, 2.39-2.45) consumed AChEI, and 0.90% took memantine (95% CI, 0.88-0.92). Consumption increased for both drug groups in patients between 65 and 90 years old; 5.84% consumed AChEI (95% CI, 5.68-6.00), and 2.33% took memantine (95% CI, 2.23-2.43). Consumption decreased in patients older than 90 (Table 2 and Fig. 3).
Age distribution of consumption of cholinesterase inhibitors and memantine in the region of Madrid in 2012.
DDD-AChEI
DDD-memantine
51-55 years 400388 15368 6412 0.01 <0.01
56-60 years 330706 60865 32648 0.05 0.03
61-65 years 305295 158585 66324 0.14 0.06
66-70 years 258342 362895 145866 0.38 0.15
71-75 years 203281 827404 306450 1.12 .41
76-80 years 192145 2026917 703456 2.89 1.00
86-90 years 81317 1733167 692378 5.84 2.33
>90 years 40147 450817 194378 3.08 1.33
Total >70 years 659550 7735406 2867096 3.13 1.16
Total >60 years 1223188 8256885 3079286 1.85 0.69
DDD, defined daily dose; DDI, defined dose per 100 inhabitants per day; AChEI, cholinesterase inhibitors.
Distribution of cholinesterase inhibitor and memantine consumption in the region of Madrid in 2012, by age group and sex. DDI, defined dose per 100 inhabitants per day; AChEI, cholinesterase inhibitor.
Consumption was higher in women than in men. In the group of patients older than 65 years, 2.82% of the women (95% CI, 2.78-2.87) consumed AChEI versus 1.83% of the men (95% CI, 1.79-1.87). Memantine was consumed by 1.10% of the women (95% CI, 1.07-1.12) versus 0.61% of the men (95% CI, 0.59-0.64). We found significant differences between sexes in patients older than 65 years regarding consumption of AChEI, and of memantine in patients older than 71 years. Increased consumption with age and decreased consumption in patients older than 90 years was observed both in men and women (Table 3, Figs. 3 and 4).
Age and sex distribution of consumption of specific anti-dementia drugs (cholinesterase inhibitors and memantine) in the region of Madrid in 2012.
DDI donepezil
DDI rivastigmine
DDI galantamine
DDI AChEI
DDI memantine
51-55 years 0.01 <0.01 <0.01 <0.01 <0.01 <0.01 0.01 0.01 <0.01 <0.01
56-60 years 0.02 0.03 0.01 0.02 0.01 0.01 0.05 0.05 0.03 0.03
66-70 years 0.16a 0.23a 0.12 0.13 0.07 0.06 0.34a 0.42a 0.13 0.18
71-75 years 0.44a 0.66a 0.32 0.38 0.18a 0.20a 0.94a 1.25a 0.31a 0.49a
76-80 years 1.19a 1.65a 0.81a 0.94a 0.51a 0.57a 2.51a 3.16a 0.79a 1.15a
>90 years 1.38a 1.73a 0.76 0.87 0.46a 0.63a 2.61a 3.22a 0.89a 1.46a
Total >70 years 1.21a 1.90a 0.78a 1.05a 0.53a 0.70a 2.52a 3.65a 0.84a 1.41a
Total >60 years 0.65a 1.15a 0.43a 0.63a 0.29a 0.42a 1.37a 2.20a 0.4a 0.86a
DDI, defined dose per 100 inhabitants per day.
Significant differences (P<.05) between men and women in this section.
Consumption of specific drugs used to treat dementia (cholinesterase inhibitors and memantine) in patients older than 65 years in the region of Madrid in 2012. Sex distribution of dose per inhabitant and day. DDI, defined dose per 100 inhabitants per day.
The most widely used active ingredient in 2012 in both men and women of all ages was donezepil; the least used was galantamine. Rivastigmine was the drug with the least pronounced sex difference; differences in use by sex were only identified in patients aged 76 to 90.
Overall consumption of specific drugs used to treat dementia in the region of Madrid increased by a mean of 50% annually between 2002 and 2012. Mean annual increase during the first 6 years (2002-2007) was 48% versus 15% for the last 6 years (2007-2012). Compared to similar periods, the consumption increase in the region of Madrid was higher than that reflected by other studies performed in Spain using the same analysis methods. For example, DDD consumption around Madrid increased by 25% annually from 2004 to 2008, while in Castille-La Mancha this increase reached 11.5% (in a study which included ginkgo biloba23). Likewise, the annual increase between 2006 and 2011 was 20% in the region of Madrid, versus 12% in the Basque country during the same period, as reported by a study in patients older than 60.24
Donepezil was the most widely used active ingredient in the region of Madrid throughout the study period, a tendency that was also observed in other Spanish studies22,23,28,33,34 as well as in international studies.26,35,36 This trend has been linked to the drug's ease of use and low rate of adverse effects.14 However, the literature shows considerable variability in the proportions and consumption trends for these drugs.23,24,34,37
The standstill in galantamine consumption in the region of Madrid coincides with the increase in the use of rivastagmine. Increased use of rivastagmine during the past few years was also observed by other consumption studies24,26 and may be explained by the marketing of rivastigmine transdermal patches in 2008.
The indication of memantine for moderate to advanced dementia suggests that the prescription profile might show a use curve tending more towards advanced ages than is the case for AChEI. However, as in other studies of overall consumption,28 the memantine consumption profile by age group was similar to that of AChEI in 2012. This might indicate that memantine could be used in the same progression stages of dementia, whether in combination treatment or as sole treatment in cases of moderate dementia with a contraindication of AChEI. Testing this hypothesis would require a different study design.
In the last year of our study period (2012), AChEI consumption per inhabitant and day among patients older than 65 years was 2.82%, versus 1.10% in the case of memantine. Considering that combined treatment is used some patients, we have to assume that less than 3.92% of patients older than 65 consume specific anti-dementia drugs (consumption prevalence). Despite progressive increases in consumption, this percentage is lower than might be expected if we compare it to prevalences of AD (4.6%) or of dementia (5.8-7.6%)38,39 in patients older than 65, as reported by other population studies conducted in nearby settings. This difference is more pronounced if we consider only those patients older than 70, since consumption of AChEI (3.13%) and memantine (1.16%) indicate that 4.29% of all patients older than 70 consume these drugs. Meanwhile, the prevalence of dementia in that age group is much higher.2
Women older than 65 consume more AChEI and memantine that men, which may be explained by the higher prevalence of dementia among women. Likewise, consumption increases with age, since prevalence of dementia displays the same tendency. However, consumption tapers off at more advanced ages, a trend that has also been observed in other studies in the general population28,40 and in institutionalised patients.41,42 The reason may be that dementia prevalence no longer increases exponentially in patients older than 90 years; the tendency may also result from decisions to limit treatment (due to comorbidities, potential toxicity, very advanced dementia), and therefore withdrawal and/or reduced use of these drugs in this age group.3,17
Consumption of different active ingredients varies according to sex and age, which seems to indicate a sex-related prescription profile, as also observed in other studies.28,40 Confirming sex differences in how these drugs are prescribed will require further studies of consumption among patients with dementia to determine whether differences persist after adjusting by dementia subtype and stage of progression. Either one of these circumstances may determine which of the active ingredients is the most appropriate.
Costs of AChEI and memantine have been increasing since they were first marketed due to the progressive increase in consumption, considering that prices have remained relatively stable. These drugs' share of the pharmaceutical expenditure on prescriptions dispensed in the region of Madrid43 also increased from 1.31% in 2003 to 3.04% in 2010 according to our results. This was in line with findings from the Basque country.24 In the region of Madrid, this percentage has been increasing since 2011, despite expenditure have been contained by the appearance of generic versions of these drugs. Therefore, considering a total prescription expenditure amounting to 1.057 billion43 in 2012, we estimate that 4.50% would correspond to these drugs (3.23% if we consider generic drugs). In return, appropriate use of AChEI and/or memantine could help reduce the indiscriminate use of other drugs used to treat cognitive impairment and dementia (such as ginkgo biloba, piracetam, or citicoline), which have shown no benefits for controlling symptoms in patients with dementia.
This study presents some inherent limitations. Firstly, data regarding AChEI and memantine consumption refer to the total population, without mentioning patients with a confirmed diagnosis of dementia.
Since we do not have data regarding combined treatment (AChEI with memantine), only an estimated prevalence of patients treated with specific anti-dementia drugs (AChEI and/or memantine) in the region of Madrid could be obtained, unlike in other studies.
The study does not include prescriptions given by private practices or within the framework of special healthcare programmes such as the general Spanish civil service mutual insurance company, general mutual insurance scheme for the judiciary, and the social insurance institute of the armed forces. These groups make up such a small percentage of the population living in the region of Madrid (0.87%) and covered by the Spanish Health System that they do not impact the validity of our data whether in terms of the number of prescriptions or in population figures.44
Using DDD in our study involves the limitations inherent to this kind of indicator, considering that it is a technical unit of measurement that does not necessarily reflect the true prescribed dose.30,31 However, since these drugs are only indicated for dementia and are used according to an established protocol, data reflect consumption quite reliably.
Yearly cost estimations were performed assuming similar consumption of all available commercial formats (capsules, solution, and patches). However, there is probably a tendency towards using one type more than others. The very low variation in the price of DDDs for each active ingredient during the 11-year period, before generic drugs became available, justifies our method.
Data regarding AChEI and memantine dispensed by pharmacies upon presentation of official prescriptions do not fully ensure treatment compliance among patients. However, since these drugs must be prescribed by a specialist and authorised by the medical inspection service, the statistics provide information about consumption that is quite reliable. This fact, in addition to having the consumption data for all drugs covered by the Spanish Health System and finding coherent results, lets us state that data accurately reflect consumption tendencies for specific drugs used to treat dementia in the region of Madrid.
The appearance of generic formats of these drugs beginning in 2011, approval of different regulations to rationalise drug use and thus control pharmaceutical expenditure (for example, prescribing active ingredients rather than brand names under Legislative Royal Decree 9/201145), and the changes applied to the reference price system in 2013 are all measures able to temporally reduce costs and slow the progressive increase in expenditure.
However, an increase in the number of dementia patients due to population ageing is to be expected, together with gradual growth in the percentage of dementia patients receiving treatment.28 Both situations lead us to believe that the trend found by our study, i.e. increasing consumption of cholinesterase inhibitors and memantine, will continue. This being the case, it is also foreseeable that expenditure on these drugs will also increase in the next few years. It is therefore important to continue performing cost-benefit studies analysing the role of AChEI and memantine in the control of symptoms in different dementia stages. These studies should assess how these drugs contribute to reducing use of neuroleptics and to delaying disease progression and institutionalisation.
This study has not received funding from any sources.
The authors have no conflicts of interest to declare.
Directorate General for Pharmacy and Healthcare Products, Region of Madrid.
Juan José de la Cruz Troca, Universidad Autónoma de Madrid.
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Drugs, 72 (2012), pp. 789-802
M. Bond, G. Rogers, J. Peters, R. Anderson, M. Hoyle, A. Miners, et al.
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Health Technol Assess Winch Engl, 16 (2012), pp. 1-470
I. Villar Fernández, M.J. Rabaneque Hernández, J. Armesto Gómez, E. García Arilla, M. Izuel Rami.
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Please cite this article as: de Hoyos-Alonso MC, Tapias-Merino E, Meseguer Barros CM, Sánchez-Martínez M, Otero A. Evolución del consumo de fármacos específicos para la demencia en la comunidad autónoma de Madrid durante el periodo 2002-2012. Neurología. 2015;30:416–424.
This article has not been submitted to any other Spanish or international journals. Our results have not been published either totally or partially. Part of this study was presented at the 18th annual meeting of the Spanish Psychogeriatric Society, held in Madrid in October 2011 (partial data as of 2010). Part of this study was also presented at the 34th Congress of the Spanish Society of Primary Care Doctors (SEMERGEN) in September 2012 (partial data as of 2011).
Copyright © 2013. Sociedad Española de Neurología
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baseball Leagues » Middle School Baseball Live Pitching/Hitting League 2021
The Live Pitching/ Hitting League provides the pitcher, catcher and batter with a live-game situation without the mess of the whole team Each week teams compete in a six inning game (or hour and 30 minute time limit) with an umpire. Pitchers will be on pitch counts early and will be monitored closely. The goal is for each pitcher to throw two consecutive innings. Pitchers will only be able to throw fastballs and change-ups. A game will consist of 24 batters faced so we encourage each team to have a minimum of three pitchers per game.
Four players bat every inning and points are awarded for each position: catcher, pitcher and batter. For example, line-drives hit into designated area of the net, strike outs, walks, passed balls and dropped third strikes. At the end of the last inning, the team with the most points wins.
The Live Pitching/ Hitting League creates a situation where a player can practice under "Semi-pressure" situations. Six at-bats per game against a live pitcher and umpire….What's more important than that?
Each team should consist of 4-6 players that must include 3 pitchers and a catcher. Only four players will hit per inning.
Players must be currently in 7th or 8th grade
Pitchers will be pitching from 60 ft
LEAGUE DATES:
Winter Session: Saturdays, January 16 – February 13, 2021
Division: Middle School (7th and 8th grade)
Times: Game start times will be between 12:00pm-9:00pm
**Saturday February 17th will either be a playoff week or a makeup week**
Cost: $400 for a team of 4-6 players
$100 for "Free Agents"
**League Limited to 8 teams so register early
**Team Registration: Simply fill out the team registration below. There is no charge to fill out a team registration, and we will contact you for payment details after registering.
Date & Times: Saturdays, 01/16/21 - 02/13/21 • Varies
Full Schedule - ALL DIVISIONS
Scores Week 1
$100.00 $400.00 Register through eSoft »
Print »

redpajama_set_name: RedPajamaCommonCrawl


Amir Khan headlines in Las Vegas in his welterweight showdown with Devon Alexander with hope that victory will earn him a meeting with Floyd Mayweather Jr.
Khan v Alexander is available to watch live on Sky Sports 1 with the broadcast scheduled to get underway at 02:00am (GMT) on Saturday, 13 December.
December, Khan v Alexander - we've been here before, haven't we? A meeting between these two was initially put forward this time last year before the showdown was shelved. Khan's camp instead decided to push for a clash with Mayweather in May but the Bolton-born fighter was overlooked in favour of Marcos Maidana, despite winning an online fan poll to determine his next opponent.
Khan instead settled for a spot on the undercard, dominating Luis Collazo to extend his record to 29-3. Since then, the 28-year-old has been vocal in his desire to take on the best the weight class has to offer, while a long-awaited meeting with his old adversary Kell Brook has also been mooted, although the IBF world champion's stabbing in August delayed such plans.
Under the guidance of Virgil Hunter, Khan's resurgence following those back to back defeats to Lamont Peterson and Danny Garcia has been impressive. While some continue to question the legitimacy of his attempts to become the welterweight division's king, a win over Alexander will certainly heighten calls for the showdown with Mayweather he is so desperately seeking.
While he has not ruled out signing a contract extension, Mayweather has just two fights left remaining on his current Showtime deal and has openly discussed the possibility of retiring in September 2015. Given that timescale, Khan cannot afford to slip up at the MGM Grand on Saturday.
While a victory for 28-year-old Alexander (26-2) may not be enough to earn him a ticket for a showdown with the five-weight world champion, it will once again elevate him into the upper echelons of the welterweight division. His loss to Shawn Porter by a unanimous decision last year cost him his place at that level but the Missouri-born fighter is more than capable of reclaiming it in Vegas this weekend, perhaps at the expense of Khan.
Khan: "Winning this fight [against Alexander] could lead to a massive fight but I'm not looking past it because I know it's a dangerous fight.
"I've made the mistake before with fights I should have gone in and won. I'm 28 today and I'm still learning and I'm still hungry and I just have to pace myself and take my time.
"I think every fighter in the welterweight division wants that big fight against Floyd and as a hungry fighter you want to fight and beat the best.
"Some styles cause problems for Floyd and some styles are made for him. You never want to leave boxing thinking 'what would have happened if I'd fought someone like Floyd?'."
Alexander: "He's a good fighter, but I just don't see anything special that Amir Khan does. From me you're going to see versatility, power, speed, movement - all of it. I'm going to be ready. I'm excited.
"There's going to come a time in the fight when I'll put pressure on him and rough him up a bit," he said. "I know he doesn't like that.
"We've been working with a lot of sparring partners where I've had to go in and go for the body. I don't think he likes body shots either."
Khan's improvement under Virgil Hunter coupled with his unwavering motivation to earn a meeting with Mayweather should see him secure victory, but Alexander will take rounds off the Brit. Khan win via split decision.


You know the drill, let's do this!
Really enjoyed reading this series. I really want to know what happens after all this has played out. I thought it was quite an intriguing world that Charbonneau created.
Two of my many, many unread classics. I promise to read them all o ne day.
Started, but never finished. I was one of the nerdy girls that translated all the weird symbols (above or at the bottom of the page). That was the funnest part for me. I just remember not liking the story. Perhaps I should give it another try and then decide whether to unhaul it or not.
I love these books. They're on my soon to reread-list. I know some people prefer the first two books, or just the last. I don't remember that I did. I think when I read them, I loved them all equally. It's been a while though, so I'll figure that out once I've reread them.
Do you see any of your favorites here?
Hunger Games is a favorite!
I've read Wife of Bath Prologue and Tale by Chaucer for school and ended up enjoying the tale more than the prologue!


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Free Trade Deal With Europe a Serious Cause for Concern for Canadian Space Industry
Marc Boucher December 14, 2016 Earth Observation, News, Policy Leave a comment
Prime Minister Justin Trudeau, European Commission President Jean-Claude Juncker and European Council President Donald Tusk sign the Comprehensive Economic and Trade Agreement (CETA) during the European Union-Canada Leaders' Summit in Brussels, Belgium. Credit: Government of Canada.
Free trade agreements are by their very nature a means of increasing trade between two or more countries. In the case of the Canada-European Union Comprehensive Economic and Trade Agreement (CETA), the deal Prime Minister Trudeau signed in Brussels on October 30th could have a significant negative effect on Canada's domestic space industry. Industry sources SpaceRef Canada spoke to are very concerned, with one saying the deal appeared lopsided.
A One Way Deal (It seems)
The problem is that suppliers in the European Union (EU) will have access to the Canadian civil space tendering process for goods and services, while there is little to no reciprocal access for Canadian companies. EU suppliers will be limited to goods and services related to satellite communications, earth observation and global navigation satellite systems.
And it's important to point out that Canada is entering an agreement with 28 nations that make up the EU, including countries like Germany, France, and Italy, all with strong space sectors and suppliers eager to expand foreign market share.
Global Affairs Canada told SpaceRef Canada that "Canadian suppliers can bid on contracts put out by EU Member State space entities that are covered under the CETA Government Procurement Chapter."
However if you examine the list of Ministries and agencies under the market access schedule for the EU, there is no mention of the German Aerospace Center (DLR), Germany's national space agency, nor the French national space agency, the Centre national d'études spatiales (CNES), nor the Agenzia Spaziale Italiana (ASI), Italy's space agency, the three largest space agencies in the EU which account for over 2/3 of all EU space expenditures. Since they are not listed this presumably means Canadian suppliers don't have the ability to bid on their respective tenders.
With respect to Italy, the ASI operates under the Ministry of Education, University and Research which is on the market access schedule but it's unclear if Canadian suppliers would have access since ASI itself is not listed.
In going through the market access schedule for the EU, SpaceRef Canada could find no EU member state national space agency listed other than the very small Sweden National Space Board which is not a national space agency, but an agency under the Ministry of Education and Research.
There is a minimum threshold in goods and services contract value that must be reached before an EU supplier can bid on a Canadian contract. That threshold, SDR 130,000, is defined using Special Drawing Rights (SDR), a weighted average of various convertible currencies, and in this case, a negotiated rate which is adjusted every two years for currently fluctuations. The current rate would mean SDR 130,000 is equivalent to $221,400 according to a spokesperson at Global Affairs Canada.
As an example, if Canada decided to move forward with a follow-on to the current RADARSAT Constellation Mission (RCM) and build additional satellites for the constellation, an EU supplier would be able to bid on it. The caveat being in this example, if the satellites have a military component, Canada could invoke a national security exception that would rule out an EU supplier bid. However, RCM as it stands now has Department of National Defence funding, but was tendered under the civil space program. So if a follow-on program was initiated, RCM2 would be fair game for EU suppliers.
The RCM example and other similar questions are being asked by industry to Global Affairs.
The Liberal government supposedly "gets it" according to multiple sources with respect to the importance of Canada's space program and through the new Innovation Agenda is expected to make meaningful moves to encourage innovation, including in the space sector. However, while the government may make moves to grow the civil space program, allowing access to foreign suppliers could undermine their own efforts.
The Clause
The details regarding access to Canada's civil space program is found in Annex 19-A – Market access schedule of Canada subsection 19-1 – Central government entities and Note 1 of Notes to Canada's Annex 19-1.
1. For the Canadian Space Agency (CSA), the procurement of covered goods and services is limited to those related to satellite communications, earth observation and global navigation satellite systems. This commitment is in effect for a five-year period following the entry into force of this Agreement. The calculation of the five-year period includes the period of provisional application, if any. Before the end of the five-year period, Canada may notify the European Union that it is removing the temporary commitment. The notification takes effect at the end of the five-year period. If Canada does not provide such notification, the temporary commitment will become permanent.
This asymmetrical clause was added by Canada to limit access to the civil space program. But if Canadian suppliers are shut-out on bidding for the principal EU member states contracts, why even include Canada's civil space program in the trade agreement?
According to the spokesperson at Global Affairs Canada who responded to SpaceRef Canada queries "the reason Canada did not negotiate reciprocal access is due to the unique way in which the EU space sector is structured and operates."
They then provided the following funding numbers, keeping in mind that CETA has been in negotiations for several years, and these were the funding amounts at the time.
"According to 2011 data provided by the CSA, total European space funding (7.6 billion euros) was divided in the following way:"
a) 3,316M euros (43.6%): European Space Agency (ESA – not covered by CETA)
b) 3,313M euros (43.6%): EU Member States (National Programs)
c) 977M euros (12.8%): European Union (EU)
"Given that the (European Space Agency) ESA is an international organization outside of the EU, its procurement is not covered by CETA. Furthermore, since many EU Member States' national space programs include defence-related procurement (which is not covered by CETA), a significant portion of the European funding for space activities will not be subject to the CETA Government Procurement Chapter. When Canada explained to EU negotiators our concerns about the lack of clarity/precision regarding what entities are precisely covered and the benefits that Canadian suppliers in the space industry would receive from the CETA Government Procurement Chapter, the EU agreed to Canada's conditions as stipulated in Annex 19-1."
While the clause will limit EU supplier access to the areas outlined, for Canadian suppliers there is still serious cause for concern and there still exists a lack of clarity as to what benefits, if any, Canadian suppliers in the space industry will have.
It should be noted that Canada does have very limited access to ESA optional programs as a cooperating member. However, for Canadian suppliers to participate in these programs Canada has to contribute to their budgets.
The CSA told SpaceRef Canada that "since the 2008 ESA Council Meeting, Canada has contributed to the following programs. The funding indicated next to each program has already been allocated towards Canadian organizations. ESA operates on the principle that the proportion of contracts under a particular programme awarded to companies from Canada is in proportion to the funding that Canada has contributed to the programme."
Advanced Research in Telecommunications Systems (ARTES): 13.8 Million euros
Earth Observation Envelope Program (EOEP): 14.0 Million euros
Global Monitoring for Environment and Security (GMES) Space Component: 6.4 Million euros
Earth Watch: 1.9 Million euros
European GNSS Evolution Program: 650K euros
General Support Technology Program (GSTP): 3.5 Million euros
Aurora (inc. ExoMars): 4.5 Million euros
ELIPS: 5.5 Million euros
European Transportation and Human Exploration Preparatory Activities Program: 3.5 Million euros
The CSA recently increased its contribution to ESA with an additional 30 million euros to ESA's Advanced Research in Telecommunications Systems (ARTES) program.
So in essence, while Canada can participate in a limited way in some ESA programs, it's pay to play.
It's not a Surprise
The ramifications on the Canadian space industry should not come as surprise. Negotiations concluded in mid-2014 and Prime Minister Harper signed the agreement on September 26, 2014 setting the current stage.
Around the same time, the CSA Audit and Evaluation Directorate was tasked to create a report evaluating the international market access in relation to the European Space Agency. That report, "Evaluation of the International Market Access Program (Comprising the European Space Agency Contribution Program) of the Canadian Space Agency", was released in July 2015.
The reports first recommendation was as follows: "The CSA should communicate the implications of the Canada-EU Free Trade Agreement to the Canadian space industry and encourage the industry to prepare in order to be better able to compete with European firms."
According to SpaceRef Canada sources, some within industry, have known about the issue for a couple of years, and have for at least the last year, been asking questions and seeking answers to what market access Canadian suppliers will have and still don't have a clear answer.
The agreement could still be scrapped and still must be ratified by the EU parliament and the 28 member nations of the EU. However, once the EU parliament approves the agreement, which may only take months to happen, much of the agreement will take effect provisionally, pending ratification by EU members.
The agreement will certainly provide benefits to both parties, however for the Canadian space industry, the agreement as it stands now, appears to be one sided.
Tags Canadian Satellite Constellations CETA Earth Observation RADARSAT Constellation Mission Satellite Constellations
Previous The CSA is Interested in Hosting a Sub-surface Ice Sounder on NASA's NeMO Orbiter
Next Short Cuts: Free Trade with EU a Problem for Industry, GHGSat Celebrates Milestone and More
Euroconsult Says Satellite Demand to Quadruple and Concentrate in a Few Key Players
Canada Elects Not to Renew CETA Trade Agreement Space Related Section
Three new GHGSat microsatellites operational, doubling capacity


That is why I love to take collagen when I'm training. But what in the world does collagen do for your joints? Well, let me tell you what I have found out!
Collagen actually improves skin and hair, repairs joints, helps leaky gut, boosts metabolism, strengthens teeth and nails, helps detox, and reduces cellulite and stretch marks. As we age, our natural collagen production actually slows down. Say hello to wrinkles, saggy skin, weaker joints as well as a whole long list of other issues!
NeoCell has released some new products such as Move Matrix. And the Move Matrix Advanced Joint Hydrator actually has tumeric in it; which helps to reduce inflammation. Imagine the amount of inflammation going on after a long run!
Move Matrix helps to promote healthy joints by supporting joint flexibility and range of motion with Collagen Type 2, Tumeric, and Hyaluronic Acid.
NeoCell's Joint Bursts are another one of the newer products. They give your joints the fluidity and lubrication with a delicious chew rather than a pill.
They come in the Tropical Tang flavor which I really like! They are also gluten free, soy free and NON GMO.
I've been in the habit of taking one of these after every run. If I want to continue to run well into my 80's, I need to make sure I enter my 40's taking care of myself right? Actually, I should have been taking care of myself all along, but it doesn't hurt to amp it up now with some added collagen! Thanks, NeoCell!!!
Derma Matrix Collagen Skin Complex is another new product by NeoCell. This lovely powder is SO easy to use. I just add it to my shakes in the morning.
Then just shake, drink and enjoy. The Derma Matrix focuses in on the skin those wrinkles and fine lines that creep up on you (well, me) as I age.
ugh ugh ugh.... I'm aging!!!!
It actually improves elasticity in the skin, slows down hair loss, repairs connective tissues for improved elasticity, improves circulation, helps to build lean muscle and helps burn fat while you sleep. Now you can see why collagen is so important!
With NeoCell in my corner, I can slow down this aging skin thing and keep my body/joints happy! I think you should check out NeoCell!


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HomeSportCAF President, Ahmad Tests Positive For COVID-19
CAF President, Ahmad Tests Positive For COVID-19
November 1, 2020 admin_edu Sport 0
Confederation of African Football (CAF), Mr Ahmad Ahmad
The President of the Confederation of African Football (CAF), Mr Ahmad Ahmad, has tested positive for COVID-19.
CAF disclosed this in a statement via its official website on Friday.
"the president after his arrival to Cairo on Oct. 28, presented mild flu symptoms and submitted to the COVID-19 protocol.
"Today, the test results are positive, and the president immediately self-isolate for at least the next 14 days at his hotel.
"All those who have come into contact with Ahmad over the past seven days, especially during his trip to Morocco for the Confederation Cup, have been informed and requested to take the necessary measures," the statement read.
I Lost 2 Pregnancies In SARS Custody – Teacher Tells Lagos Judicial Panel
NUC Lists Obstacles To Nigeria Achieving E-Learning Education System


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Springport, Michigan
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Sentences forSpringport, Michigan
M-99 heads north through farmland to the village of Springport where it turns eastward along Main Street as it passes through the town.M-99 (Michigan highway)-Wikipedia
The station broadcasts from a tower near Springport, Michigan.WWDK-Wikipedia
Springport Mid-Michigan Speedway is a 3/8th mile, high-banked, oval short track located northwest of Springport, Michigan.Springport Mid-Michigan Speedway-Wikipedia
The James M. Jameson Farm is a farmstead located at 10220 North Parma Road near Springport, Michigan.James M. Jameson Farm-Wikipedia
Lightner and her family live in Springport, Michigan.Sarah Lightner-Wikipedia
Springport High School is located on the western edge of Jackson County in Springport, Michigan.Springport High School-Wikipedia
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Programme for Government 2020-21: not a normal PFG
September 2, 2020 SPICe Economy & Finance, Health, Parliament & Government Comments Off on Programme for Government 2020-21: not a normal PFG
On Tuesday 1 September 2020, the First Minister set out the new Programme for Government (known as "the PFG"), Protecting Scotland, Renewing Scotland, in a statement to the Parliament.
With an election in May 2021, this final PFG of the session only officially covers the seven-month period from September 2020 to dissolution, around the end of March 2021. However, as would be expected for the final year of the session, a lot of the policies highlighted in the PFG are either already in train, or will only be completed some years into the future, and beyond the next election.
Of course, the PFG is dominated by the implications of the COVID-19 pandemic, and the policy and fiscal response.
This blog provides a summary of the PFG, and picks out areas that will be of particular interest to MSPs and the Parliament over the next seven months. It is not a comprehensive summary.
The PFG contains a significant range and scale of financial commitments across all areas. Many of these commitments are over multiple years and/or have been previously announced. Committees will have an opportunity to scrutinise these commitments in detail through the budget process in the coming months.
At the time of last year's PFG (see our blog from September 2019), the main themes were a "Scottish Green Deal" and the constitution. Much has changed since then, and a number of pieces of legislation from the previous PFG, including on gender recognition and a "tourist tax", were either paused or cancelled earlier this year because of the pandemic.
Alongside the overarching focus on the pandemic, the PFG includes a range of policy proposals across other areas. The number of new pieces of legislation is very low compared to previous years. This is not surprising as there is limited parliamentary time between now and dissolution to pass legislation. In addition, the Parliament will be dealing with the twin pressures of COVID-19 and a raft of Brexit-related legislation over the coming months.
COVID-19: "our most immediate priority"
The forthcoming election is expected to go ahead as planned on 6 May 2021 although in light of the pandemic, the Government is "working with the Electoral Management Board to explore options for running the election in circumstances different to the norm, if required."
In her statement to Parliament, the First Minister said that:
[…] this is not a normal, business-as-usual programme for government. Today's programme is clear that suppressing Covid is our most immediate priority and will remain so for some time.
However, despite highlighting the difficulties caused by the pandemic across all areas of Government policy, the First Minister also stressed that in her view "this is a time to be ambitious" and that the pandemic should be treated "not as a brake on our ambitions, but as an accelerant."
COVID-19: health and social care
The PFG re-states and highlights the ongoing policy response to the pandemic. Much of the new proposals are focused on dealing with what the PFG calls "a global economic crisis". In terms of policy developments in health and social care, the PFG includes:
A commitment to suppress, and "preferably eliminate" COVID-19.
A review of adult social care, including consideration of a "national care service", to report by January 2021. However, this might be a challenging timescale for a "comprehensive and fundamental review".
The introduction of a new "proximity app" later this month, Protect Scotland, to assist (but not replace) the ongoing Test and Protect scheme. MSPs will no doubt want to closely follow the roll-out of this app, given issues with apps faced in other countries.
COVID-19: economic response
Aside from health and social care, a major theme of the PFG is the response to the economic crisis caused by the pandemic. To that end, the PFG launches the Government's "new national mission to help create new jobs, good jobs and green jobs." "Good jobs" are defined as "paying fair wages and complying with high standards," and in terms of the "green recovery", the PFG states that:
It is imperative that our economic recovery is a green recovery – not just because it is the right thing to do in the face of the climate crisis, but also because it provides opportunities for new work and growth in today's challenging global market.
Many of the policies in this area are either already being implemented or were announced in previous PFGs or other publications. Some areas that MSPs and committees may wish to explore include:
The stated focus on a "green recovery", including details around the £2 billion "Low Carbon Fund", previously highlighted in the 2020-21 Budget. This £2 billion is over the next parliamentary session, so will total around £400 million per year. There are a range of announcements in this area, and it is not entirely clear from the PFG which of these are included in the £2 billion, and which are additional to it. However, the new PFG does include further announcements on a £100 million "green jobs fund", although again this is over five years.
The previously announced plans for road building are unchanged. While there is a commitment to "new funding of £500 million" over the next five years for "active travel", this is not an increase on the £100 million funding in place for 2020-21.
The range of policies aimed at tackling youth unemployment, including a £60 million "Youth Guarantee", so every young person aged between 16 and 24 will be guaranteed one of the following: an opportunity at university or college, an apprenticeship programme, employment including work experience, or participating in a formal volunteering programme. This will be backed by additional funding for apprenticeships and the new Job Start Grant. The implementation plan is expected to be published "shortly".
A focus on "digital adoption" and to get more people online.
Establishing "a national network of world-class start up incubators, 'Tech Scalers'", with the aim of creating and supporting between 300 and 500 high quality start ups over the next 5 years, which comes off the back of the Logan Review.
A number of new plans and strategies, including a new Infrastructure Investment plan, to be published in September, covering the next five years. In addition, there will be an update of the Climate Change Plan, which the Cabinet Secretary for Environment, Climate Change and land Reform has stated will "articulate a "green pathway to recovery that is in line with our Climate Change targets, including reaching net zero by 2045".
Independence, Brexit and the constitution
The previous PFG contained a focus on the constitution, including a commitment to undertake the necessary work" to update the 2014 white paper, "Scotland's Future", ahead of another referendum on independence. Much of this work was paused due to the pandemic. But the new PFG states that a "draft Bill" will be published before the end of this session, which would set out the Government's preference for both the question to be asked and the timescale in which a referendum should take place in the next session.
The Referendums (Scotland) Act 2020, which sets the framework for any referendum held in Scotland and which is within the competence of the Scottish Parliament, was passed by the Parliament earlier this session. But to put a referendum on independence beyond legal challenge, the Scottish Government has maintained that a "Section 30 Order" would be required – and that means the UK Government cooperating on an independence referendum.
Brexit is specifically referenced on a number of occasions in the PFG. With the UK set to leave the transition period at the end of 2020, all eyes are on whether the terms of a future UK-EU relationship can be agreed to come into force at the start of 2021. The Scottish Government uses the PFG to reiterate its view that Brexit and the end of the transition period will cause significant economic damage for Scotland and the UK more widely.
The PFG also refers to the UK Government's internal market proposals, which it has argued are necessary to protect the UK's "internal market" after Brexit. The PFG highlights the Scottish Parliament's vote to oppose the proposals in August 2020 and states the Scottish Government's view that the proposals are "the most significant threat to devolution since the creation of the Scottish Parliament in 1999". As a result, the PFG indicates that it will not recommend that the Scottish Parliament gives legislative consent to such proposals.
Other policy areas
As mentioned in the introduction to this blog, while COVID-19 and Brexit will likely dominate parliamentary time and debate from now until dissolution, the Government has also set out its policy intentions in a range of other areas. Some of these could lead to significant changes and MSPs and committees will have the opportunity to scrutinise these areas closely in the months to come:
First, the PFG confirms the introduction of the United Nations Convention on the Rights of the Child (Incorporation) (Scotland) Bill. This is potentially significant legislation and will enable children and young people to take public authorities to court to enforce their rights. It's worth highlighting that many of the policies and commitments in this PFG focus on supporting young people.
Other significant bills to be progressed include the Hate Crime and Public Order (Scotland) Bill, currently under detailed consideration by the Justice Committee; and a Bill to "advance the existing legislative protections for those most at risk of domestic abuse, including the ability to ban suspected perpetrators from their homes."
The PFG makes a number of cross-portfolio commitments on minority ethnic communities in response to the impact of COVID-19 and the Black Lives Matter movement. For example, on employment, the Government plans to publish "a recruitment toolkit designed to support employers in recruiting more people from minority ethnic backgrounds" in September. On health, the Government plans to make ethnicity a mandatory field in health databases, and there is commitment to a review of past and current initiatives to tackle systemic racism.
In addition, an "independent expert group" will be charged with looking at museum collections with a view to making recommendations on how to reflect Scotland's colonial and slavery history in collections, and ensure that people are aware of this history.
On tourism, there are no major announcements, which is possibly surprising given the scale of the challenge for that sector. The existing tourism strategy, Scotland Outlook 2030, will form the framework for recovery and build on the existing Tourism Rural Infrastructure Fund
To gather data on student finance and the impact it has on students' education and experience at university, the "student income and expenditure in Scotland" survey will be carried out for the first time since 2007-08.
The PFG restated the commitment to fund additional university places following the decision to reverse SQA downgrading of teacher estimated grades, but no further detail on this is provided and questions remain about the number of places and level of funding required.
Measures in the Coronavirus Act that provide protections for eviction are to be extended. The 2020 Act temporarily extended the length of notice landlords needed to give tenants to end the tenancy. These measures will continue until end of March 2021, although the Government has announced that eviction grounds for antisocial behaviour will revert back to 1 month. This appears to be in response to concerns from stakeholders.
On agriculture, there is a commitment to set out some clarity on post-Brexit agricultural support schemes, though there is no commitment to bring forward a second Agriculture Bill.
There is also a new commitment to a Blue Economy Action Plan to "strengthen the resilience of our marine industries" and "support coastal communities".
The level of personal debt is likely to increase during the COVID-19 crisis. As a result, there have been calls for the Scottish Government to reform things like bankruptcy and protected trust deeds, to make them more accessible to those affected. The PFG does not contain any proposals for legislative reform. However, it does highlight funding for money advice.
The PFG states in a short chapter that it is "steered by the longer‑term vision in the National Performance Framework (NPF)." But the NPF is only referenced briefly in one other chapter. Links between the rich data in the NPF and the budgetary choices made by the Government will likely be a focus for committees in the forthcoming budget process.
The PFG also references the UN Sustainable Development Goals (SDGs), which are part of the NPF. MSPs may also look to scrutinise government policy through this sustainable development lens, in particular the relationship between SDG 8, which is about inclusive and sustainable economic growth, in the context of the pandemic and the move to net-zero emissions.
Edited by Allan Campbell, Head of Research and Financial Scrutiny. Contributions from senior researchers across SPICe.
Coronavirus (COVID-19)EconomyParliament and Elections
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The Acting Executive Secretary of the Commission, Tony Ojukwu Esq made this call in Abuja on Monday while reacting to confirmation by the federal government that 110 out of the total of 906 students in Government Science and Technical College in Dapchi, Yobe state were unacounted for, after the school was allegedly attacked by Boko Haram insurgents on February 19, 2018.
Mr. Ojukwu who also Heads the NHRC Human Rights/Humanitarian Assessment Team in the North East condemned what happened in Dapchi as "inhuman and degrading treatment which inflicts both physical and psychological torture on the innocent school girls and an affront on their fundamental rights and freedoms ".
The Acting Chief Executive Officer of the Commission therefore calls on security agencies to restructure the security architecture of the country and take adequate measures to protect all educational institutions in the country against any further attacks.
The Commission commiserates with the government and families of the victims of the Dapchi incident and urged that immediate steps must be taken to rescue the missing girls and prosecute the abductors.


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Theme Park & Ride Discussions
Roller Coaster Construction
Attractiepark Slagharen | Goldrush | Gerstlauer Infinity
Thread starter TilenB
TilenB
Atractiepark Slagharen has announced the retirement of their good old Thunder Loop (Schwarzkopf Looping Star) in order to make place for a new coaster in 2017. The park has cited the maintenance costs to be the main factor behind the removal. Thunder Loop is to operate till the end of this season, with the new coaster opening at some point in the Spring of 2017. The new ride will have at least one inversion, with more details about the project being released in the coming weeks.
Official announcement put through Google Translate said:
After years of speculation, the fans Attractie- & Holiday Slagharen - and amusement parks in general - look forward to a new roller coaster. The "thrill ride" will open in the spring of 2017, is quieter, higher and more spectacular than the current Thunder Loop roller coaster.
The legendary Thunderbird course, with the first loop of the Netherlands, this fall is broken. The icon "Thunder Run" or better known as "Looping Star" this season will drive its final laps. Millions of visitors to the park have a ride, including Dutch celebrities, such as Linda de Mol. The former Slagharen Pony Park was the first park in the Netherlands where you went over the top in a roller coaster.
The rollercoaster is on the site of the Thunder Loop and the lawn that lies ahead. The track is quieter, more and more spectacular than the current roller coaster.
Goodbye Thunder Run!
Did you know that ... Thunder Loop?
Designed by Anton Schwarzkopf
Designed as a mobile roller coaster for German fairs. could not stay behind the Netherlands after its introduction in Germany
when time Looping Star, was ordered in 1978
was completed in June 1979
when opened by Pieter van Vollenhoven
1st looping was in Netherlands
in 37 years, 1x completely disassembled
The plan was to put him in another place
which is now the entrance to Thunder Loop, was the starting
He has had over 4 different colors through the years ....
Why the Thunder disappears walk from the amusement park?
The maintenance of the Thunder Walk will rise in the coming years, which has made it economically interesting to invest in a new roller coaster. We can also offer visitors a new experience.
Can I still make a safe ride in the Thunder Loop?
Yes, certainly. Daily Thunder Run is checked by our technical service. There is also an extensive yearly audit by an independent inspection body.
When the Thunder disappears walk from the amusement park?
The Thunder Walk will be demolished in the fall of 2016 to make room on the same site for a new roller coaster.
How the new roller coaster will look like?
At the site of the Thunder Run is a new spectacular roller coaster with at least one inversie.Een inversion is a roller coaster where one element short time hanging upside down. Further details will be made public in the coming weeks, keep our newsletter and social media good eye.
When the new roller coaster will open?
The new roller coaster will open in spring 2017. An exact opening date is currently not known, like our newsletter and social media good eye.
#MissionWildWest
Follow us on Facebook for hints about our new rollercoaster through #MissionWildWest and stay tuned!
http://www.slagharen.com/nl/missionwild ... 3d&urlid=1
Mysterious Sue
Re: Atractiepark Slagharen to Build a New Coaster in 2017
That's so sad. I was literally just looking at this park and making a list of all the old creds in Europe that I still need to visit.
I know some people don't give two hoots about them and obviously these things are getting more and more expensive to upkeep so they are gonna go eventually. But I love the forces in the old circular loops and I'm not ashamed to be sad. Hope they get something good to replace it.
Martyn B
You're not alone Sue, I have a lot of love for these! In fact this coaster was the main draw for me to go here (as a part or a Dutch trip mind), so I'm gutted to hear this, especially as it's likely to be replaced by something generic.
Hang on though, wasn't it this place that was heavily rumoured to get an Intamin Mega lite a couple of years back?
That would be sweet as there are not nearly enough Megalites in the world, but the article that Tilen posted suggests an inversion so...
But I doubt the park can afford anything that decent.
Ahh this is sad. So sad in fact that I've just decided to pop in there in the morning to show it some goon-love.
(to be fair, was gonna pop into one of the parks between where I am now (Zwolle) and Bremen airport to get home ; its just won the vote over Hellendoorn's Tornado thats all)
Sad to see this coaster go, but Slagharen had quite some technical problems with it the last few years and I've heard it also had trouble getting through inspections. Hopefully its replacement will be good.
I've read on a dutch forum that some people from Slagharen (including the parks director Wouter Dekkers) have visited Tripsdrill (home of Karacho) a while ago.
Martyn B said:
Actually, the rumor was about an iSpeed clone. (which I think would have been awesome )
david morton said:
...I've just decided to pop in there in the morning to show it some goon-love.
And I did.
Was good, extremely slow lift hill though (slower than walking pace), perhaps thats the maintenance problems? The ride itself was good enough for a 37 year old thing though.
roomraider
Best Topic Starter
They were meant to get an Ispeed clone and then the park was bought out by Parque Reunidos and the whole thing dropped off the map.
I would imagine this new ride is something completely different though. If someone knows the park maybe they can say if the above plans are in the same area as the Looping Star.
Mysterious Sue said:
This park has ridiculous visitor figures though, something crazy like 8m a year (don't quote me on that, but it is certainly a lot higher than you'd expect from a park that just has two off the shelf coasters).
^I really doubt that since that would make it the second most visited park in Europe.
It's not even in the top 25 according to TEA.
Hope they do get an iSpeed clone, it's fab.
oriolat2
Lofty said:
I don't think a park that small could afford an Intamin clone of that size. Maybe a Gerstlauer launcher could fit the bill, plus they ride rather nicely...
TheCoasterCruiser
While I think a Gerstlauer Launcher is more likely, I don't think we are to say what the park can and can't afford.
The argument that "the park seems small", doesn't really hold up when we look at past investments from parks of similar size. Besides, this is just from our perspective, of course there is a lot to more to it on a business level.
Ireeb
I think something like Karacho (Gerstlauer Launched Infinity Coasters) would fit that park well. A rather small rollercoaster that is lots of fun and serves a pretty wide audience (I have a photo of me on Karacho and the age of the riders reached from about 40 to 12, which kinda proves that it attracts many different people.), and that's probably what a park that doesn't have too many rollercoasters yet wants.
In 2015, Attractiepark Slagharen had 997,000 visitors. To put that in perspective, Walibi Holland only had 860,000 visitors. A few years ago, Slagharen claimed to have a much higher amount of visitors (1.45 million in 2011), but those numbers were false. (New management of Slagharen acknowledged the false numbers)
A list of the top 50 attractions of the Netherlands in 2015 can be found here:
http://www.respons.nl/nieuws/top50-dagattracties-2016-efteling-blijft-meest-bezochte-dagattractie
_koppen
oriolat2 said:
I don't think a park that small could afford an Intamin clone of that size.
Bullcrap. Small parks make big investments all the time.
The park is owned by the same company (Parques Reunidos) as Mirabilandia is. Why couldn't they afford an iSpeed clone, when there is the original operating in their sister park?
^ Because not all parks are given the same budgets, even if they are owned by the same parent company. The budget for each park is defined on their attendance and gross income, not a cost spread out to all parks equally.
Mr CoasterForce 2016
But if Parques Reunidos wanted to boost Slagharens annual attendance figures and its gross income they could quite easily do so with a larger investment as they have the cash. Its how parks grow and reach new audiences.
See I said don't quote me on it :lol:


While I don't buy toys (much) anymore, my fan-boy tendencies run deep. I can't go to a Target (or Walgreens or CVS) without peeking at the toys.
This is the modern world of toys: Companies market toys to adult men for the sake of nostalgia.
These are guys my age, buying figures that are sold as "exclusive" in specific retailers such as Target. The most popular lines are often not even in stores and are available only through mail-in offers or at comic conventions.
Collectors chronicle it all in stunning detail on dedicated blogs. My favorite is Online Action Figure Entertainment (oafe.net).
The focus is on pop-culture franchises from the mid-1980s on and comic books and video games.
Star Wars is the most obvious and everyone has at least one friend who still collects Star Wars stuff. (I have several. Looking at you, Mike Seay).
G.I. Joe has seen its resurgence thanks to movie tie-ins and an updated animated series, while the Teenage Mutant Ninja Turtles have a new animated series on Nickelodeon -- and a toy line. Transformers never really disappeared.
Even Ghostbusters, which hasn't been a thing for 20 years, has a whole line of toys, including an almost 2-foot tall Stay Puft Marshmallow Man that's a coin bank and "perfect for displaying your entire Ghostbusters collection!"
I know this because I recently visited the Mattel store in Pomona. I was with my toy-freak friends. They entered with wide eyes and left with a full shopping cart, including that Marshmallow Man.
They should have read the online reviews first. Apparently the soft white foam turns yellow at the slightest hint of sunlight, then gets hard and cracks.
So they have theirs on display -- facing a wall.
This is my generation. We're grown ups out in the working world with discretionary income to blow on toys. As a bonus, we're now the ones designing and marketing the things, and we know what we want -- a Red Ninja figure with lots of articulation and some cool accessories.
That, and a giant Marshmallow man that won't crack.


Are you an employer trying to find warehouse workers in your area? It's a widely accepted understanding that trying to find warehouse workers in your area can often be a problematic experience. High amounts of strenuous labor combined with low wages can often times lead to high turnover rates – leading to wasted time and effort in recruiting. To help with your hunt, we would like to provide you with some tips on how to find warehouse workers in your area, and keep them for the long haul. These tips are a small collection of methods that we here at Continuum Consulting have used in the past, and we are happy to share them with you.
One way to find warehouse workers is to check out the local job boards.
The most popular job boards out there are swarming with candidates. Craigslist, for example, is great for finding high volume traffic at a great price per job post. The problem with Craigslist is that there are a lot of other competitive employers posting similar jobs, and candidates can pick and choose at their own discretion. Expect to fill your appointment book with loads of qualified candidates. However, at the same time, expect a lot of no-shows, and cancellations.
Another great job board is Monster. Unlike craigslist, the candidate traffic for Monster is not as high as other competitor boards. However, the candidates on Monster are typically more experienced and better qualified than many of the candidates on craigslist. Unlike Craigslist, however, employers should expect to pay a higher premium to use Monster.
Lastly, there is indeed.com. Like Craigslist, indeed.com has extremely high candidate traffic. In fact, indeed.com has the highest traffic volume compared to all the other job boards out there today. The website is also extremely user-friendly for both candidates and employers alike – only adding more to its popularity. They even have competitive pricing available. However, like craigslist, the board is full of other competitive employers posting similar jobs. The only way to make sure that your job postings achieve maximum results is by advertising your postings – which costs a pretty penny.
Posting job ads are great, but you can cover even more ground on your quest to find warehouse workers by checking out resumes that the candidates themselves have posted. Every job board I have mentioned before have keyword search tools to help narrow the parameters of your search. Typing in phrases such as "experienced warehouse worker", or "forklift certified" can filter the results shown. However, make sure to check the date of when these resumes were uploaded or updated. Some job boards have been known to have old resumes still in their databases for several years after they have been uploaded by the candidate. This may present a problem because you may end up code calling a bunch of candidates who already have a job they love and aren't looking for new employment opportunities – Leading to a huge waste of time.
Maybe the internet isn't really your thing when it comes to hiring. Maybe you prefer a more face-to-face approach to recruiting and hiring. Luckily for you, hosting job fairs can be a great alternative to finding warehouse workers in your area!
Job fairs can be hosted in a variety of places such as convention centers, libraries, unemployment offices, and even at your own location of business. We here at Continuum Consulting, for example, have teamed up with ARIZONA@WORK and have hosted many job fairs for those in dire need of employment. Many great candidates have been found at these events and have been placed in long-term employment thanks to this partnership. Make sure you get in touch with any work development programs in your state! Maybe both of you can come up with a mutually beneficial arrangement.
Finding great warehouse workers is one thing – keeping them is another issue that needs to be addressed. Often times, warehouses and distribution centers with high turn-over rates have internal problems such as poor safety procedures, and not having the proper tools to effectively get the job done. Other times, unforeseeable circumstances may arise and an employee who just started working in a new position suddenly needs to quit. Subsequently, hiring managers end up back at square one. To prevent that, here are a few tips we can share.
Sometimes, warehouses aren't the safest places to work. Needless to say, it's important for employers to stay on top of the most critical safety practices in the industry. Sometimes, Isles can be cluttered, dock doors can be open or exposed for extended periods of time, and environments can be hot or lacking sufficient ventilation. To check out our OSHA inspired safety checklist, click here. Workplace safety can play a vital role in keeping employee turnover rates low. Moreover, proper workplace safety can improve the relationship between your business and the community.
Are your employees working harder than they should be? Using the proper tools for the job can make work easier and play a huge role in employee retention. For example, Pallet jacks can make moving heavy loads across large surface areas a breeze for anyone – regardless of their physical strength. However, with so many to choose from in the market, how will you know which type of pallet jack to get for your warehouse workers? In a previous blog, we weigh in on some of your options to help make the buying process a little easier.
How Can Continuum Consulting Help You Find Warehouse Workers?
We know how much time it takes, and how hard it can be to find warehouse workers. Most importantly, we know how crucial it is to retain great warehouse workers.
There are many problems associated with having a high turn-over rate – particularly in the realm of unemployment insurance. High turn-over rates can actually affect the DES(Department of Economic Security) tax rates for your business. You can read more about it in a previous blog here.
If you're having difficulties trying to hunt down and keep workers, don't worry! We've got you covered.
Contrary to popular belief, there is a way to keep your employee turn-over rate low by partnering up with a staffing agency like us. Take advantage of our 90-day temp to perm services and test out the many qualified candidates in our pool. If you like the work they do, you can make them a member of your team! If it doesn't work out, we can rapidly place another. This also gives our pool employees the opportunity to test you out as an employer. So show them how great you can be by giving an awesome first impression!
Moreover, we know how long it can take to find a great team and hire them on. We also know how much of a burden it can be for hiring managers. We understand that some businesses don't have the amount of time or resources to effectively hire a great staff. Thankfully, we've developed a process that takes the hassle out of hiring, and we can quickly place a qualified individual within your ranks. Trust us when we say that we have everything you need. Every time you need it.
Finally, if you take advantage of our services, you won't have to worry about things such as workman's compensation coverage or payroll for the duration of the 90 days. Just submit the time our employees have worked for you at your job site to us. We will handle the rest.
It's not easy to find great and dependable warehouse workers. But, when you need rapid and hassle-free warehouse staffing options, count on Continuum Consulting. A staffing agency you can depend on.


FLAGSTAFF, Ariz. -- The National Park Service is floating a steep increase in entrance fees at 17 of its most popular parks, mostly in the West, to address a backlog of maintenance and infrastructure projects.
Visitors to the Grand Canyon, Yosemite, Yellowstone, Zion and other national parks would be charged $70 per vehicle, up from the current fee of $30 for a weekly pass. At others, the hike is nearly triple, from $25 to $70.
The proposal comes not long after many of the parks that charge entrance fees upped them. The rationale is the same this time around - to address a backlog of maintenance and infrastructure projects.
Click here for more stories about the National Park Service.