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Developing a clinical trial budget can be a confusing exercise for sponsors and CROs. There are too many cost variables to account for.This post covers the key cost drivers for medical device clinical trials. If you are a researcher or financial analyst working in clinical trial space or simply curious about clinical trial costs, this post will serve you well.So let’s get started.1. PATIENT GRANTPatient grant costs are broken down into screening, baseline and follow-up visits and medical imaging costs.A. SCREEN FAILURESClinical trial protocols have inclusion and exclusion criteria to qualify patients. Strict inclusions and exclusion criteria reduce the available patient pool for trial enrollment. Clinical sites spend physician and site coordinator time to screen for potential patients.During the budgeting process, map out the complete patient screening workflow. Speak with a few clinical sites to understand how many patients they would have to see in order to find one qualified patient. For example, a site may need to screen four patients to find one qualified patient. Understand how many hours the site is spending on screening activities and reimburse accordingly. It is not unusual to reimburse sites anywhere between $50 to $250+ per screen failure.B. BASELINE/INDEX PROCEDURE AND FOLLOW-UP VISITSDepending on the clinical trial design, data is collected at baseline/index procedures and follow-up visits. The site coordinator is generally responsible for entering the data in the case report form. Sites are reimbursed for the time spent to collect clinical trial data.Based on number and type data fields you are collecting, you’ll want to estimate the site coordinator time needed to collect and input trial data. Multiply the estimated coordinator time by the hourly bill rate to obtain the fair market value for each patient visit.In some cases, sponsors may choose to reimburse patients. Reimbursement for patients can include paying for their participation, reimbursement for travel, meals or overnight hotel stays.C. NON-STANDARD OF CARE TESTSMedical device trials may require non-standard of care tests such as medical imaging scans. These costs are generally not reimbursed by insurance companies or medical care agencies and should be budgeted as part of the clinical trial cost.D. PROCEDURE COSTSIf the clinical trial procedure is reimbursed, you don’t need to budget for the procedure cost. Insurance or medical care agencies will pay for the procedure. In case a brand new procedure where no reimbursement available, budget for the procedure costs.2. SITE COSTSA. START-UP FEESClinical sites spend significant time to initiate a new clinical trial. Sites are responsible for site specific informed consent development, Ethics Committee (EC)/ Investigational Review Board (IRB) submissions, staff training including participation in investigator/ site coordinator meetings and site initiation visits and execute a clinical trial contract. It is typical for sponsor to pay anywhere between $2000 – $5000+ in site start-up fees.B. EC/IRB FEESEC/IRB fees are in addition to site start-up fees. These fees cover the time spent to by EC/IRBs to plan and conduct review of the clinical trial protocol and other associated materials. Many EC/IRBs update and publish their rates annually.C. CLOSE-OUT FEESClose-out fees include time spent by site staff to reconcile clinical trial data, finances and regulatory documents during study closure. Not all sites require this payment but has started to become a more common practice in recent years.D. STORAGE FEESGovernment regulations require that clinical trial data be stored after study close-out. The duration for storage can range from 2-years to permanent storage. It is not uncommon for sites to have boxes of regulatory paperwork that needs to be stored once a clinical trial ends. The storage fees vary by country and site.Some sponsors make arrangements for site to send trial documents to an offsite storage location. Due to country specific regulations, a site might be unable to move documents outside their country.E. ADMINISTRATIVE OVERHEADClinical sites may require as much as 30% administrative overhead in addition to per patient grant amount. This cost covers management and legal resources needed to provide clinical research oversight and legal review of clinical contracts respectively.F. SITE MANAGEMENT ORGANIZATION (SMO)In certain countries such as Japan, data entry and collection tasks are outsourced to SMOs. For post approval studies, sites do not research coordinator support. Sponsors are expected to hire SMOs to support the site or pay the sites to hire their preferred SMOs.3. NON-PATIENT COSTSA. CLINICAL EVALUATION COMMITTEE (CEC)Adverse event and endpoint data is adjudicated by a non-biased, independent CEC. CEC is generally composed 3 or more physicians. CEC members review adverse events and trial endpoints in a team setting or independently.A sponsor can hire physicians to serve as the CEC and reimburse them at fair market value rates. It is more cost effective for sponsor to contract with physicians directly. However the sponsor has to assign its own resources to manage the CEC.The other option is for the sponsor to outsource management and conduct of CEC activities. This option is more expensive because you are hiring professionals to manage the CEC.CEC is a very important component of medical device clinical trial. Adjudicated adverse event data is highly regarded by regulatory agencies and the physician community. In many cases, it is a requirement to have adjudicated adverse event data in order to get the product on market.B. DATA SAFETY MONITORING BOARD (DSMB)DSMB is also known as the Data Monitoring Committee (DMC). According to IMARC research, the purpose of the DMC is to advise the sponsor on continuing safety of the trial subjects and those yet to be recruited and provide continuing validity and scientific merit of the study.For budgeting purposes, it is important to know that DSMB is required during trial enrollment phase and in some cases till all patients have reached their primary endpoint. The decision of whether or not to conduct DSMB meetings after the primary endpoint is reached, is up to the sponsor.C. PHYSICIAN CONSULTINGPhysicians are consulted during all phases of a clinical trial. Physician guidance is needed to develop clinical trial strategy, enrollment plan, final data analysis and publication plans.Depending on the physician’s medical expertise and geographical location, consulting costs can be anywhere between $150 – $600+ per hour. If a clinical trial is interesting to the physician, he or she may be willing to provide consulting services at no cost.D. INDEPENDENT CORELAB ANALYSISMany medical device trials collect imaging data such as angiograms, CT scans and X-Rays. Since this data comes from multiple sites, variability is expected. An independent corelab standardizes the collection and analysis of imaging data.Corelab costs can add up quickly. Costs depend upon the number of images analyzed per patient, the time it takes for the corelab to analyze the data, and the duration of the trial.Corelabs usually hire analysts to collect and calibrate data from different sites. The final analysis is usually done by a physician. Given the complexity of imaging data collection and analysis combined with the importance of corelab data to regulatory agencies, it is important that adequate and accurate budget is allocated for independent corelab analysis.E. MEDICAL DEVICE COSTOnce you are ready to enroll patients in the clinical trial, you’ll need to ship medical devices to the sites. Most sites will expect to receive these devices for free. The only exception is when conducting post approval trials for commercially available devices.Medical device manufacturers conduct trials for indication expansion. For example, a stent company may conduct a trial to get their heart stent approved for use in a different anatomy. For such expansion trials, sponsors may need to provide commercially available devices to sites at no cost.Whether or not you want to provide devices at no cost is a business decision. When investigational medical devices are provided at no cost, sites enroll faster and have a much stronger, collaborative relationship with the sponsor.4. LABOR COSTSIn order to conduct a clinical trial, you need to hire people that have expertise in clinical research and clinical trial management. Depending on the size of the trial and the number of trials conducted, resource allocations vary. Therefore amount of labor needed to run a study also varies.A. CLINICAL RESEARCH ASSISTANTS OR ASSOCIATES (CRAS)CRAs are primarily responsible for monitoring clinical trial data that is collected during the course of the study. They visit clinical research sites to ensure data is collected in a compliant manner.B. PROJECT MANAGER (ALSO KNOWN AS CLINICAL TRIAL MANAGER OR STUDY MANAGER)A project manager’s responsibilities can vary from one organization to another. Project managers are like “general contractors.” A project manager is responsible for managing the clinical trial budget, resources and timelines. The core function of a project manager is to resolve or escalate issues that come up during the course of a clinical study.C. DATA MANAGERA data manager’s job is to address data discrepancy issues by generating queries to sites. Data managers may also be responsible for implementing electronic data capture system or paper case report forms needed to collect trial data.D. SCIENTISTThe scientist is primarily responsible for developing the clinical strategy for a trial. Individuals with Ph.D. or M.D. degrees are usually the right fit for this role. In some organizations, the project manager also play the role of the scientist.E. BIOSTATISTICIANA biostatistician is responsible for developing a statistical analysis plan (SAP). The SAP documents on the data will be analyzed during the course of the study. A statistician or statistical programmer is also responsible for programming data tables that are incorporated in the final clinical study reports.F. QUALITYClinical research is a regulated industry. Quality plays an important role in ensuring sponsors, CROs, and clinical sites are conducting the trial in a compliant manner. A quality associate or manager helps an organization create and implement standard operating procedures (SOPs).Salaries for these roles can vary by geography and experience. The above list is not comprehensive. However it should give you an idea of the core resources needed to conduct a medical device clinical trial.5. SITE MANAGEMENTA. PRE-STUDY VISITSPrior to inviting any site to participate in a clinical trial, you want to conduct pre-study visit, also know as the site assessment visit. This visit becomes even more important if you don’t have any prior experience working with the site in a clinical or commercial setting.Although sites don’t charge for this visit, the sponsor will need to pay for travel and CRA labor costs.B. SITE INITIATION VISITS (SIV)Once the site has received Institutional Review Board (IRB) approval and the trial contract has been signed, it’s time to activate the site for patient enrollment.A SIV is conducted once you are ready to activate the site. SIV involves training the site on the clinical protocol and any other study-specific requirements.Similar to the a pre-study visit, the sponsor will need to pay for travel and CRA labor costs.C. MONITORINGOnce patients are enrolled in the study, you want to ensure data is collected in a compliance with regulations and the clinical study protocol. This is when monitoring comes into play.A CRA, sometimes known as the site monitor, visits clinical sites at regular intervals to ensure compliance.In recent years, due to push for reduction in clinical trial costs, several sponsors have started to monitor remotely rather than conducting an in-person monitoring trip.D. CLOSE-OUTOnce all patients at a site have completed their follow-up visits, it’s time to conduct a close-out visit. Any open items related to study conduct are addressed during the close-out visit.Although it’s always nice to have in-person close-out visits, it’s acceptable to close trials via remote close-out calls.6. MISCELLANEOUSA. INVESTIGATOR MEETINGSInvestigator Meetings usually serve to kick-off a new clinical trial. Investigators and research coordinators participating in the study are invited to participate in a 1-2 day meeting. The purpose of these meetings is to educate site personnel on the clinical trial protocol and any other specific trial requirements.These meetings can be quite expensive as airfare, hotel and meals are usually provided by the sponsor.B. TRAVELPlan and budget for adhoc travel. Since clinical trials are heavily regulated, you may need to visit a site to address a compliance issue or help them prepare for an audit. In other cases, you may want to visit a site to motivate them to enroll patients. Whatever the case may be, it’s always good to have some money set aside for travel.C. DOCUMENT TRANSLATIONSDocument translations costs can increase significantly depending on the countries in which the clinical trial is conducted. Sites where English is not the primary language, you may receive request for translation of key documents such as the protocol and site specific informed consent in the local language.Also if the adverse event source documents from non-English speaking sites are in their native language, additional costs will incur to translate documents into English for event adjudication purposes.D. TECHNOLOGY SOLUTIONSClinical Trial Management System (CTMS), Electronic Data Capture (EDC), Electronic Trial Master File (eTMF), Interactive Voice/Web Response System are a few common technology solutions implemented when conducting a clinical study. These systems are needed to manage site contact information, collect clinical data and maintain clinical trial records. There is a monthly or annual license fee associated with these systems. Additionally staff is needed to manage and maintain these systems.E. REGULATORY FILING FEESRegulatory filing fees should not be overlooked as these can run into thousands of dollars. Depending on the class of medical device, different applications need to be filed with regulatory agencies, competent authorities and notified bodies.7. OTHER FACTORS:A. PROTOCOL AMENDMENTSDue to unforeseen circumstances, a clinical protocol amendment may be necessary. A protocol amendment has many downstream effects that can increase the cost of a clinical trial.A protocol amendment usually leads to additional IRB/EC fees, site costs, regulatory re-submissions and more.B. INFLATION, VALUE ADDED TAX (VAT) AND FOREIGN EXCHANGEInflation should be factored in for multi-year clinical trials. In the US, a minimum 3% inflation is expected.Sites in countries such as Australia and Europe, add VAT for the research services. VAT can be upwards of 12% on all research services.For trials conducted in multiple countries, paying attention to foreign exchange rates. At a minimum, annual review of exchange rates is advised. Clinical trial cost projections should be adjusted based on exchange rates.C. TRIAL ENROLLMENT DELAYSEnrolling in trials is tricky business. It takes longer to complete enrollment and initial projections are overly optimistic. Account for these delays when you develop your clinical trial budget.[1][1][1][1]To summarize, you should now have a solid understanding of these factors that impact clinical trial costs:Patient grant amount such as screen failure costs, data entry costs and travel reimbursementSite costs such as site start-up fees, EC/IRB fees, close-out and storage feesNon-patient costs such as core labatory fees, clinical events committee and data safety monitoring boardLabor costs – clinical research employee salaries or contractor paymentsSite management costs such as pre-study, site initiation, monitoring and close-out visitsMiscellaneous costs such as travel, technology solutions and regulatory filing costsOther factors such as value added tax, inflation, protocol amendment and delays in enrollmentFootnotes[1] Ultimate Guide to Clinical Trial Costs - Clinical Trial Podcast[1] Ultimate Guide to Clinical Trial Costs - Clinical Trial Podcast[1] Ultimate Guide to Clinical Trial Costs - Clinical Trial Podcast[1] Ultimate Guide to Clinical Trial Costs - Clinical Trial Podcast

It depends…live in a box, don’t spend any money, and it’s cheap. Instead of trying to guess how you’ll spend yourself, here are some pros and cons, good and bad points, and general info about living in Las Vegas from someone who has lived here a little while and lived throughout the world (Germany, Italy, Korea, Belgium), the US (Florida, Georgia, Texas, California, Nebraska, Mississippi) and the desert southwest (Arizona).EmploymentI’m on my third employer since moving to the Las Vegas valley. With the idea that the lower cost of living as compared to California comes lower corporate cost of living indexes as compared to the rest of the US, so national employers don’t always have the best compensation packages here. I’m fortunate, my current employer is based on the east coast (NoVA) and doesn’t adjust wages for out-of-market locations as there are so few of us there, so I’m pretty happy with that, but the other two companies did not have market adjustments based on “ground truth” but only large-scale economic factors such as housing costs (see below) and some basic generic living expenses. It’s easy to find work if you’ve got either the education or the experience in what companies out here look for. Check the job boards for what’s hot here before moving out thinking you’ll work a gaming table and make $500K a year off of tips because you’re a great comedian or your bust should be in the Louvre.HousingHome prices are reasonable, but the market is volatile. Depending on the part of town, cost per square foot can fluctuate wildly, and even within similar parts of the town, being in a planned community can significantly increase the costs - but also leads to (hopefully) more stable resale values. There are substantial portions of town that are gated, master planned communities. This restricts your ability to drive around and see the neighborhoods without a realtor or coordinating with an individual seller. There are many areas with custom multi-million dollar homes, especially on the west side/north west inside the CC-215 beltway, where this is not a problem, but variable zoned land, lack of HOA rules, and utility and drainage issues lead to some interesting home clusters. There are quite a few horse ranches as well, and while Las Vegas doesn’t have a huge problem with flies and mosquitoes, the more livestock, waste, and standing water, the more of a problem you’ll have.Figuring out what houses really cost can be a problem. There are still more foreclosures in Las Vegas than the national average and there is still a lot of foreclosed inventory that banks are releasing slowly in order to keep the market from getting thrown out of whack. (Finally, the banks do something smart.) So when you see housing cost averages, make sure they don’t include foreclosed or short-sale properties as those could radically lower the average home price and lead to sticker shock when you first show up.The foreclosures and housing bubble were real here in Las Vegas. Pull up the history of a home on Zillow and for new construction between 2003 and 2008, you’ll see the vast majority had at least one “sale to bank” between 2010 and 2012. Homes in my area sold new in 2005 for around $500K. They’re just now hitting the low-to-mid $300K’s in recovery; most were under $200K as foreclosures in 2011. The good news is the dry weather keeps the homes in excellent condition. Bonus: there’s not really a termite problem to speak of unlike many desert locations - even termites have trouble surviving here. Anecdotally, homes are going for $10K-$15K minimum over the “Zestimate” on the Zillow site - it just can’t keep up with the market here.Schools (K-12)They suck. Look it up. Bloated administration, apathy running deep with administrators, teachers, and students. Sports > academics. Heck, everything > academics. If you can, put your kids in a private school. If not, work hard to show them that there’s a payoff to independent study, reading, and developing a strong work ethic.Schools (vocational/community college)There are some good nursing schools, The College of Southern Nevada (CSN) has several conveniently located campuses, and there are vocational and service industry academies. The situation with this level of learning isn’t too bad.UNLVThe local high school students have nicknamed it “U Never Leave Vegas”. They’re opening up a medical school and are one of two accredited 4-year institutions that offer degrees in hotel and restaurant management (Northern Arizona University is the other) and this may be dated information, but last I heard it was only these 2.CrimeWell, if the students aren’t motivated, the criminals are. I think all but one ZIP code (Summerlin?) had crime rates above the national average for 2015. We were on track early this year for 11 homicides per 100,000, but that’s leveled off to a more respectable 6/100,000 or so, helped by our record-setting 16 days this July/August without a homicide. Drugs are right there if you need them, opiod abuse is rampant, and there are enough random acts of violence that you just never know what’s going to happen in specific parts of town. Here’s a tip: if you see a street sign that says “Maryland”, you’re where you shouldn’t be. (It’s almost a joke to side bet on the over/under when there’s a homicide to see how many blocks it is from Maryland Parkway between I-515 and the Airport.)The good news is the Las Vegas Metro PD keeps The Strip and Fremont Street areas very, very safe. They also have a very high solve rate on homicides and violent crime. So yeah, you might get killed, but odds are they’ll figure out who did it. So you’ll have that going for you.PotThe good news is that all of this crime will magically disappear because you can now buy recreational marijuana if you’re 21. (There have been 29 attempted burglaries, burglaries, robberies, or assaults on marijuana “dispensaries” in the last 12 months.) If you live here, cool, you can mellow out in your domicile. But you won’t, most likely, because the prices are higher than on the street (or so I’m told) and they’re in the crap areas of town. But you could, you know, if you wanted to. And if your employer let you. And if your wife didn’t give you that look when you mention it.SportsThe NHL decided one failing franchise in the desert (Phoenix Coyotes) wasn’t enough and thus the Las Vegas Golden Knights were born. They have the dumb name because the owner is a former US Army alumnus who wanted to name them after the Army’s parachute team, the Black Knights, but thank God the US Army said, “No, thank you, we own the copyright on that.” I love ice hockey, so I’ll go, but only for single games so I can deconflict with other major events on the strip as they will play in the T Mobile area smashed between I-15 and The Strip (Las Vegas Blvd).The NFL, not wanting to be left out, voted to let the Oakland Raiders move to Las Vegas. We’re crazy enough to be Raiders fans, but I don’t know that there’s going to be enough of the 2 million or so people who will be crazy enough to pay for season tickets. My gut feeling is 1/2 the stands will be full of the visiting team’s drunk/hungover fans who are combining a Vegas trip with a road game experience. More Backpage ads between September and January, I suppose. Traffic will be just short of apocalyptic on NFL game days.There’s NASCAR and NHRA tracks, the NBA Summer League, boxing, MMA, and there’s talk of bringing Formula 1 to the valley as a road circuit. That I would pay to see…like book a room in a resort hotel on the Strip, do the parties, spend the week just soaking it in. Fingers crossed.UtilitiesResidential natural gas for cooking and home heating is cheap; gas for your car is not. And while natural gas and (oddly enough) residential water prices are low, electricity rates are high unless your only other comparison is California or an overseas country, which is bizarre given that solar and hydroelectric power comprise the majority of of residential power sources. There are some that attribute this to the opening up of power utilities and the large casino corporations have been paying “exit fees” to the state-run utility in order to purchase power on the open market, thus reducing the subsidies for residential power costs. (When I first lived here it wasn’t unusual for your kWH price to drop every quarter or so. Nothing like that over the past few years.)TaxesThere isn’t an income tax, but there are two annual taxes that come as a surprise to some folks: the GST and the Supplemental GST. The GST, or General Services Tax, and it’s supplemental cousin, are assessed annually when you register or renew a vehicle registration. The assessment is based off of the (depreciated) MSRP of your vehicle and the depreciated value itself. For a 2015 BMW 3 series, with an MSRP of around $44K when new, this was $711 the first year, still in the mid $600’s last year. Some people see this as a vehicle registration fee, but vehicle registration is only $32…but you can’t register without the GST/S-GST, unless…Veteran’s Benefits/CareThe Southern Nevada VA Health Care system is pretty good. There are 6 or 7 primary care clinics in the Las Vegas/Henderson area, a brand-new VA hospital was built in northern North Las Vegas, very accessible from the highway, and the SNVA works with Veteran’s Choice in the event they can’t provide the care in a timely manner.For veterans with individual ratings that mathematically add up to 100% - not using the VA’s combined rating chart - Nevada offers a tax credit towards either property or the GST/S-GST that is collected when vehicles are registered or renewed. For the current fiscal year (the fiscal year starts on 1 July in NV) this was $1,365. You have the option of applying towards one or the other tax, but not both. I applied the entire amount to the GST/S-GST and so paid less than $100 to register 3 late model vehicles.For veterans with a combined rating of 100%, you are entitled to two (2) Disabled Veteran license plates that permit parking in disabled/handicapped parking spaces, the tax credit, and free parking at all paid public parking locations - including McCarran Airport.Dining & FoodThe vast majority of the non-strip restaurants are national chains and even the mom & pop places can be total crap. (I have yet to find good Italian food off the strip, if you know where to find it, please message me. Same for excellent legit Asian massage - if you know, message.) There’s chain restaurant after chain restaurant with 1 or 2 diamonds in the rough. One high point is that all of the Nevada-Style Taverns (read: local gambling spots with video poker and slots, a restaurant, and bar) are open 24/7, so you can always get food, and it’s not bad food, it’s just more “American” style or comfort food. Now, for Asian food? Jackpot. Las Vegas’ Chinatown and concentrations/clusters of Korean, Japanese, Vietnamese, and Thai restaurants, supermarkets (fresh giant prawns even!), and shops are a Godsend. It’s no Koreatown or Chinatown in LA or SFO, but it’s pretty damn good, and very reasonably priced. There are also some smaller markets and butcher shops, but given the volume of what’s brought into Las Vegas and the way the city is arranged most of the food will be at higher-volume retailers. (Yes, there’s good Mexican food, it’s Nevada.) Strip restaurants can be hit or miss depending on whether they’re serious (Wolfgang Puck) or kitsch (Guy Fieri). It’s hard to trust the reviews because so much of it comes “baked in” with the overall experience most tourists are having. Myself, I now just pick one, order what I like, and hope for the best…and it’s usually excellent. (I’ve lived in Seoul, Korea; Germany, Italy, & Belgium; Monterey, CA, and other places with pretty good dining, Las Vegas holds up - on the strip and for Asian food.) Russian and Balkan food can be more difficult to pin down. There’s an excellent no-kidding German-run German bakery with 2 1/2 locations (one is pickup only).ShoppingWhat you can’t get locally you can order and odds are it’ll be shipped from a local fulfillment center. The lack of decent indoor malls is odd given the weather, but the open-layout centers are quite nice. If you do need the “mall” experience, the one on the strip has just about everything and many stores have local discounts. Even the “premium” outlet malls now have Local’s Night with gifts, free valet parking, and coupon books. There are really nice high end and ultra high end shops in the major hotel resort casinos. The Shops at the Forum (Caesar’s Palace) and The Shops at the Venetian (The Venetian) are superb.Yeah, there are brothels outside of Clark Count on the other side of the Spring Mountains. Google it, I’m not going into it here as that kind of shopping’s not my thing.TrafficThere’s an almost-beltway for Las Vegas. The Air Force base and some mountains in the north east prevent extending a loop from I-515 to the new CC-215 highway, but it’s close enough with US 95 and the Summerlin Parkway that you can avoid the downtown and strip traffic if you don’t mind a few extra miles at regular speed as opposed to a shorter trip with some stop-and-go and slowdown. (It takes the same amount of time in most cases, so you’re balancing frustration vs. distance.)Right now, I think just about every single major highway or intersection is under construction. Maybe it just feels like it, but it’s a bit of a mess as things are re-routed to help the flow of traffic. It’s supposed to be much better when they finish…just in time for the NFL’s Raiders to get here and they’ll start all over.When there is traffic, it sucks. Las Vegas has some of the most aggressive drivers I’ve ever encountered, police presence on the highways is minimal, and almost every accident is litigated, which, as my insurance company explained to me, is why my rates doubled when I moved here.Oh, and with the high winds that are a part of the NV weather, there’s usually a fair bit of debris all over the roads. What doesn’t crack your windshield will puncture your tire.WeatherIt’s really not that bad. Okay, there are 4 months, June - September, that can just be incredibly miserable if you need to be outside, aren’t used to the heat, don’t have shade, and don’t have water. If that happens, you’ll not have to worry about it too long, because you’ll die.The reason it’s only 4 months of near-blast furnace temps and wind is because of both the elevation (most of Las Vegas is at or above 2,000 ft altitude) and the mountain range to the west. (I could be full of crap on the reasons, ask a meteorologist friend. What you don’t have one? Well, neither did I.) As the days grow shorter, the more time the city spends in the shadow of Mt. Charleston (11,916 ft) and the Spring Mountains. Oh, and the mountains, for the most part, appear to have been stripped of all soil, so there’s very little to hold the heat in once summer’s over, however, Las Vegas doesn’t experience the high diurnal temperature fluctuations that the northern part of the state does.One surprise for new residents is how cold the cold feels in the winter. While the lows may only be in the high 30’s or low 40’s, the cold, combined with the winds, lack of heat retention, and darkness will have you breaking out your old winter gear your 2nd or 3rd winter here. It’s not Scottsdale, Arizona. You’re not going to swim in November without a heated pool and it’s not a shorts-and-a-t shirt at 7 AM kind of place. There’s usually snow on Mt. Charleston from late October through late June, and this year, given the snow totals, into July.(Okay, the weather is really that bad, but only for those 4 months. 114 degrees F with a UV index of 9, 30+ MPH winds, and a sun that will cut through any amount of window tinting really sucks. But it’s only 1/3 of the year, and you do get used to it. Really, you do.)Non-Strip/Fremont Street Nightlife100’s of local places to hang out at, probably 1000’s. That’s not too bad…if you like your clothes smelling like 1,000 packs of cigarettes. Most places that are open late and cater to the nightlife crowd also have some slots, which means they can have indoor smoking. (All of the casinos have some indoor smoking, some have better ventilation systems than others.) I had forgotten how nice it was (even as a [now reformed, relax ma, I quit] smoker) to not have your clothes stink when you get home. Alas, if you go out here, you’re probably going to have to put up with it again.The good news is, there’s hiking, day trips, a park with stocked lakes, Mt Charleston recreation areas, and more than a few festivals, dining events, beer festivals, and same type of events other cities of 2+ million people have. Las Vegas is someplace I’ve spent more time outside as the sun’s going down (summer or not) grilling, swimming, and just plain relaxing than any other place I’ve lived.But, if you do want to dance to EDM until 5 AM, stay up bleary-eyed at a blackjack table all night, or take in pulsating neon and street performers, well, we have that, too, but you can read enough about that online. One thing The Strip and Fremont Street do is make it very easy to entertain guests, although 1/2 the time it’s the first time in a long time (or ever) that I’ve been to the same place I’m “showing” them.The town is seriously lacking in real museums, particularly art and history. Fly to NYC or drive to LA. But really, would it be so difficult to have at least one decent art museum that wasn’t in some casino shop backroom (really) or showing off old neon?TravelThe good news is that flights are cheap, plentiful, are rarely delayed, and the airport is conveniently located, both in relationship to where you want your guests to be (on The Strip) and where you live (it’s at the I-15/I-215 interchange).The bad news is, if you’re not flying there, you’re driving all damn day or several damn days, to get there. LA, Anaheim, and the beach cities are 5–7 hours away depending on traffic. You won’t go there as often as you think, mostly because the 2-lane sections of I-15 between Barstow, CA, and Primm, NV, will drive you absolutely insane with the number of slow, open-mouth breathers parked in the left lane at 10 MPH under the speed limit and the other 95% of non-truck traffic which is rental cars weaving around hungover or drunk going to or from Vegas.Phoenix is 5–6 hours away, but no one has really found a good reason to go there yet. (I’m from there with family there and the drive on US-93 alternates between sheer boredom and sheer terror.)Even Grand Canyon NP is over 4 hours away. There’s what’s left of Lake Meade (1 hour), Zion NM (2 1/2 hours), Death Valley (3 hours), Sedona (4 hours), see where I’m going with this?You wanna leave Vegas? You’re going to fly, but it’s not going to cost you much. (SFO is 10–12 hours by car, have fun.)EntertainmentShows are cool, sometimes, and there are pretty good discounts for locals for most attractions. Concerts, however, are a different story. For example, I bought two tickets for The Weeknd’s show in Las Vegas, $340/each, open seating/floor (New Year’s Eve Eve, was worth it). If I had the time it would have been cheaper to fly to Phoenix, have a rental car, stay 2 nights in a hotel, see The Weeknd there ($30 cheap seats), and still have money left over. Concerts, because they’re a Big Deal when they’re in Vegas, can be over-the-top expensive. On the positive side, the venues are typically smaller, more personal and intimate, and the performers hit the city while they’re in town, and the clubs will usually announce if they’ve got a talent scheduled to be there. But holy crap are they expensive. Most of the reason taxes are low for residents is because everything tourist-related is taxed to the edge of discouraging tourists. (I’m good with that by the way.) Again, a positive note, everyone comes here, some headline for a while, and if you combine a concert with a family or friend visit, it’s pretty cool to actually “act like a tourist” in your own city.GamblingYeah, some locals are heavy into this. I was honestly surprised at first. I would have thought that the industry wouldn’t pee in its own pool (so to speak), but they’ll take it all if they can get it. I remember my first visit to a car dealership to have routine maintenance done on a Saturday. There was a TV on in the customer area, some coffee, couches, etc. (Audi, they do things right, it’s not a McDonald’s play area atmosphere like at a Toyota dealer.) I was watching the CBS national game and a guy walked up and said, “What’s the score?” I told him I wasn’t really paying attention and he commented on the spread, how much he had on what, what prop bets he had taken, etc. Then another customer chimed in with his bets, and so on. I couldn’t believe it. Now I have local casino apps on my phone giving me the to-the-minute money line on games. I don’t bet much, less than $100 a year, but I still have the information handy.MiscellaneousA one day class, background check, and $93 will get you a concealed carry permit for your pistol. No special additional checks needed otherwise. You can open carry just about anywhere. (Screw you, Buffalo Wild Wings and Levi’s Jeans.)The Clark County shooting range is the largest municipal range in the US. They even have a .50 cal range. On quiet Sunday mornings I can just barely hear muted “pop pop pop” coming from the range while having my coffee on the patio; it’s soothing.If that’s not your scene, jack up your 4 x 4 phallus extender so your bumpers don’t protect regular car owners and your headlights blind everyone and head out into the desert for a full day of off-roading. I hear it’s nice. Dirt bikes and ATV’s and Utes are out there as well.Fishing and boating on both Lake Meade and the Colorado River are popular pastimes as are hiking, photography, camping, and hunting.Being a local has almost unfair advantages over tourists when it comes to, er, “hooking up” with tourists. If you’re single, or if it’s just your thing, male or female, you’ll love the “dating” scene. Serious, more meaningful relationships are, as I’m led to believe by my coworkers, just not worth it. When you’re ready to settle down move away, then come back after you are. Their words, not mine.After a few years, you’ll yearn to see real, natural, lush, green vegetation. You’ll kill to see rivers flowing with regular banks of grass, trees, and dirt instead of the cold, dead, lifelessness of Lake Meade and the Colorado River. You’ll start to forget about those “hot” summer days by the pond when it was almost 90 (can you believe it?!?!) and you’re just relaxing in the shade of a tree.Then you’ll go stand in line in the air conditioning at the Venetian to ride a fake gondola around a chlorinated “canal” with a bunch of fat tourists wearing Crocs and talking about how they were this close to winning big the night before. You’ll smile - smile smugly inside - sit back and enjoy the artificial breeze before heading back home.(I’d leave, but Vegas just fits.)