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Blues musician Buffalo Nichols precedes the opening of the Drive-By Truckers show at the Smalls Theater on Friday, October 15th. Pittsburgh City Paper About music, tours, and the inspiration behind his latest project. Don’t be fooled by the simplicity of his answer, Nichols’ music is rich in the history of the black blues musicians who came before him.
His hit “Lost & Lonesome” has attracted the attention of musicians. With a light and deep sound and smoky vocals, Nichols’ songs are sure to please you while reflecting. His next self-titled album will be released on October 15th.
1. What kind of music do you listen to when you are not making your own music?
I try to listen to everything. There’s a lot of music in the world, and I’ve done it all.
2. What was the driving force behind your latest project?
3. Do you think you created it yourself during the tour? If so, is it just music or will it be creative in other media?
I often write and practice other instruments during the tour. In general, in my experience I don’t have much time for other media.
4. What are you most looking forward to on this tour?
The simple act of taking a tour is the most exciting part for me. We had a long break from the tour and are looking forward to the mundane parts of the road.
5. Been to Pittsburgh?
I don’t think I have one. This is my first visit and hopefully not the last.
Buffalo Nichols drive bite lacquer.. Door Smalls Theater at 7 pm. 400 Lincoln Avenue, Milbert. $ 30. 21 or more. mrsmalls.com
5 Questions with Buffalo Nichols | Music | Pittsburgh
Source link 5 Questions with Buffalo Nichols | Music | Pittsburgh


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Sherlock Holmes and the Disappearing Diamond
Welcome to Baker Street Academy, a school with a curious cast of characters. There’s the exuberant and clever Martha, the bookish and excitable John Watson, and the insightful and overbearing Sherlock Holmes. John becomes fast friends with Sherlock and Martha (and Baskerville the hound as well!), just in time to discover a mystery at a local museum. When the Alpine Star goes missing, the young trio sets out to find the lost gem…after homework is done, of course.
A delightful reimagining of the Holmes canon as the signature characters navigate the social perils of school while engaging in some amateur sleuthing, Sherlock Holmes and the Disappearing Diamond is a fun and visual take on the canon, both updating it for the modern world (John writes on a tablet now) and scaling it for school-age readers.
Although some of the references to the classic canon will be lost on new readers, any parents reading along will no doubt enjoy the sly references to other characters and events in the original stories. I do hope Hearn expands the cast of characters, if only to meet more of the students at Baker Street Academy and offer him more fodder for tongue-in-cheek callbacks.
|Page Count||176 pages|
|Amazon||Buy this Book|

domain: artistic


It is reported that Samsung will launch the Galaxy A series smart phones in the coming weeks. The upcoming Galaxy A series including the SM-A300, SM-A500 and A700 will feature the metal-framed design found on the Galaxy Alpha.
Today, one of the Galaxy A series smartphones, namely the Samsung SM-A3000 has been certified for sale in China by TENAA, the FCC equivalent in China.
The Samsung SM-A300 is expected to be a mid to low-end device as it sports a 4.5 -inch 960 x 540 (qHD) display. The processor is listed as a quad-core 1.2GHz SoC, and it has 1GB of RAM as well, According to TENAA listings.
Other Specs of the SM-A300 confirmed by TENAA listings includes: 8 GB of internal storage, 8MP Rear Camera, 5MP front Camera and Android 4.4.4 OS. The handset measures 130.1×65.5×6.9mm and weighs 112g.
Samsung SM-A300 handset specs roundup:
Display: 4.52-inch OLED qHD 960 x 540 pixel panel
CPU: 1.2 GHz -Quad Core Qualcomm Snapdragon 410
GPU Qualcomm Adreno ™ 306
RAM : 1 GB
Internal Storage: 8 GB
External Storage: Micro SD (Up to 64G)
Rear Camera” 8MP
Front Camera” 5MP
Video: FHD (1920 x 1080)
The new Samsung Galaxy A3 series smart phone is expected to be launched in select market in Q4 2014.
For Your reference, here is the list of Samsung Galaxy A3 model variants known so far:


Ford automobile enthusiasts have come to expect a certain level of dependability when driving their Gran Torino around town. You bought your Gran Torino because its reliability and long-lasting quality agreed with your nature; so why would you be okay with second best when it comes to the highest quality auto parts? Car aficionados appreciate the a brand you can trust built into each Ford, and know that only the highest quality replacement Gran Torino parts will suffice when maintenance needs to be done. Obviously, you bought your Gran Torino because you understood you would be getting horsepower and value both rolled up into one vehicle.
An important factor in fuel efficiency is the appropriate mix of air and fuel. Your Ford Gran Torino uses a paper or cloth air filter to remove dust and debris from the air stream before it enters the intake manifold, mixes with your fuel, and gets detonated. If your engine did not have an air filter or air cleaner, your fuel would be filled with particulates from outside. This will plug up your injectors and rob your engine of fuel; making it difficult for your engine to generate power. And unless your Ford Gran Torino air filter is replaced regularly your engine will be robbed of the necessary air flow needed to maintain optimum fuel efficiency. Clearly, replacement air filters are a necessity for everyone.
Bring your Gran Torino back to life with the best replacement parts from the experts at Car Parts Discount. Don't let a Air Filter & Cleaner repair bring about the demise of your car, truck, or SUV, and don't risk lowering its resale value by installing anything but the best replacement parts. Given all the hassles associated with fixing broken parts on your car or truck, let www.carpartsdiscount.com be the number one store you go to make purchasing it easy. Need 1976, 1975, 1974, 1973, 1972 Ford Gran Torino Air Filter & Cleaner parts? We've got them right here.


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The world’s attention over the last few weeks has been focused on the football team who became trapped in a cave in Thailand after sudden rains caused flooding which blocked the entrance.
As I write, the good news is that all 12 young boys and their coach have now been rescued after this harrowing ordeal. Sadly, one rescuer lost his life in his heroic attempts to help those trapped.
Natural disasters and tragic events like these cause us to ponder the fragility of our human existence. How easily and simply we can be caught in a situation where we are helpless, frightened and need others to assist.
The accounts of this tragedy and the successful rescue of the team is worth reading and understanding. In it are lessons for us all. We should never take for granted what nature can throw at us and we should never assume that since it hasn’t happened here it probably won’t.
We have caves and so, whatever lessons can be gleaned in terms of safety, security and avoidance as well rescue and recovery, should it come to that, is absolutely necessary. In fact, we experienced the tragedy of a cave-in some years ago and we know the pain of loss of life when these events occur.
These disasters tend to happen with very little notice or none at all. And when they do happen, we have to draw upon our and others expertise and experience to help get through them. The true kindness of humanity was witnessed in Thailand when people from several nationalities and backgrounds came together to find a way out for the footballers. It brought together people in a world that is so often chided for its divisions. The call for prayers for those trapped was heeded by all the faiths represented in Thailand and I was pleased to see the media highlighting the prayers as they happened in the places of worship in that country. Christian, Buddhist, Muslim and others all participated in praying for a successful outcome.
Every year, the Caribbean region is warned to prepare for the hurricane season. It is one of the most impacting natural disasters we face in this part of the world. 2017 was one of those worst years for hurricanes affecting the islands. Now, in 2018, we are once again in the midst of the hurricane season and cautioned to adequately prepare. It is often argued that until one experiences the horrors of a hurricane or any other natural disaster, then one will not always heed this advice seriously.
Having spoken to several persons who were affected by last year’s hurricanes, it is a fact that we can take things for granted if we don’t have the experience. Let us all hope and pray we don’t get the experience but at least, let us be prepared. I spoke recently to a Barbadian who was living in Tortola when hurricanes Irma and Maria tore through that tiny island in the British Virgin Islands. It is not something one would wish on their worst enemy. With the house almost totally destroyed, the only refuge was the bathroom walls. She suggested that the hurricanes were perhaps stronger than the strongest possible which is a Category 5. Unimaginable if one has never felt such natural forces at work.
The horrifying accounts out of Dominica were no different. Shell-shocked best describes the state of people on the island after the hurricane. Almost everything was destroyed or damaged. Until today, many have not yet recovered from the devastation.
And while we can never be 100 per cent ready for a natural disaster, we must at least try to be as ready and secured as we can. Making ourselves, families, communities and our country ready reduces the impact of such natural disasters. Government and non-governmental organizations all have their role to play in helping to reduce the effects of natural disasters. The present government addressed the subject of Preparing for Natural Disasters in its manifesto and so we hope that those plans get put into place.
It is interesting that one of the challenges facing rescuers in Thailand was the inability of the young boys to swim. That was a challenge because even though they were trapped in a cave underground, getting out required swimming and diving. We live on an island and we should all know, to some degree, how to swim. I was pleased to hear calls for swimming to be given prominence in the lives of our young people from the campaign platforms of the Barbados Labour Party. On page 27 of the BLP manifesto, under the caption Bajan Youth as Global Citizens it states: “The BLP will ensure that all Bajan youth will be multi-skilled and excel at home and abroad: By giving every young person the opportunity to speak a second language, learn to swim, learn basic first aid…”
Learning to swim and learning basic first aid is a perfect fit in reducing the impact of natural disasters, so I hope these promises are realized in some meaningful way. I remember at primary school having to go weekly to Pebbles beach to learn to swim. I am not sure if this is still on the school curriculum but I hope it is. Some families can afford to send their kids to swimming lessons. But there are others who can’t and so governmental and non-governmental agencies should find ways to ensure that every young person is exposed to swimming in some form.
Equally I agree with learning first aid and making that learning accessible to all citizens. Unfortunately, in recent times, there seems to be a reluctance to helping others in a distressed situation for apparently different reasons. It seems more people would rather take out their smart phones and record than actually step in and help. So all aspects of helping others should be taught including the legal ramifications if that is of concern.
I pray Barbados continues to be safe from such disasters and I hope we are ready should we have to face such calamities. Blessings on all those who helped in the rescue of the Thailand footballers. Humanity is at its best when we can be of benefit to others who we don’t even know.
(Suleiman Bulbulia is a Justice of the Peace, Secretary of the Barbados Muslim Association
and Muslim Chaplain at the Cave Hill Campus, UWI.
Email: [email protected]

domain: news


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Veggies fruit and fortified seeds.
Fresh clean chlorine free water.
Change toys often when broken.
Shower with mist of water. Household temperature should not drop under 65*F.
Their talking may be annoying but if you talk you can barely hear them.
A 10 to 20 gallon aquarium large tank.
A hide box with moist moss is needed so the gecko can shed skin. Many people use plastic storage boxes as housing.
The best way to heat up the gecko is to use an undertank heating pad. Mealworms or crickets
If you want to give your pet a treat, then give it wax worms or super worms.
Information was taken from, www.reptilesmagazine.com

domain: hobby


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Tucker Carlson’s Full Interview with Donald Trump Available on X
Tucker Carlson, the popular conservative commentator, recently conducted a full interview with former President Donald Trump. The interview has now been posted on a platform called “X” and is available to watch for free.
In the interview, Carlson and Trump discuss a range of topics and issues. It is unclear what specific topics were covered in the interview, but given Carlson’s and Trump’s past statements and positions, it is likely that they discussed current events and political issues.
The interview is sure to generate interest and discussion among political observers and the general public. Those interested in watching the full interview can do so by visiting platform X and accessing the video.
Watch the Full Interview for Free on Platform X
It is not often that former presidents give in-depth interviews, so this is a unique opportunity to hear directly from Donald Trump about his thoughts and opinions on various issues.
As more information becomes available about the content of the interview and any potential impact or reactions, we will continue to provide updates on this developing story.
Ep. 19 Debate Night with Donald J Trump pic.twitter.com/ayPfII48CO
— Tucker Carlson (@TuckerCarlson) August 24, 2023


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By Megan Faure
Delivering an easy-to-follow solution to deal with a toddler throughout the first 12 months, The Babysense mystery explains tips on how to learn a baby's physique language and indications, in order that mom and dad can know the way their child is feeling and what he/she desires. With convenient at-a-glance charts that exhibit mom and dad what to do in the course of the evening while their child is crying inconsolably, circulate diagrams to figure out precisely what their child is making an attempt to inform them, and the easiest easy methods to aid, The Babysense Secrethelps mom and dad simply determine how their child is feeling and the way top to reply.
By Neil Short
Операция Валькирия - самая известная и наиболее изученная попытка госпереворота. С немецкой тщательностью продуманная, но не учитывающая обычные человеческие слабости
By Unknown Author
This Elibron Classics booklet is a facsimile reprint of a 1863 variation via F. A. Credner, Prag.
By Rick Steves
You could expect Rick Steves to inform you what you really want to grasp while touring in Germany. This guidebook takes you from fairy-tale castles, alpine forests, and old fashioned villages to the lively Germany of this day. Get the main points on cruising the romantic Rhine or summiting the Zugspitze. Have a calming soak at a Black woodland mineral spa or take a thrilling summer time bobsled journey within the Bavarian Alps. Flash again to Berlin’s turbulent prior at Checkpoint Charlie; then rejoice the rebirth of Dresden and its wonderful Frauenkirche. Rick’s candid, funny suggestion will consultant you to good-value lodges and eating places. He’ll assist you plan the place to move and what to work out, looking on the size of your journey. You’ll examine which attractions are worthy a while and cash, and the way to get round Germany via educate, bus, carand even boat. greater than simply stories and instructions, a Rick Steves guidebook is a journey advisor on your pocket.
By Wolf Lepenies
In the course of the Allied bombing of Germany, Hitler was once extra distressed through the lack of cultural treasures than through the leveling of houses. Remarkably, his propagandists broadcast this truth, confident that it's going to show no longer his callousness yet his sensitivity: the destruction had did not overwhelm his artist's spirit. it really is very unlikely to start to make feel of this pondering with out realizing what Wolf Lepenies calls The Seduction of tradition in German heritage. This interesting and weird ebook tells the tale of an arguably catastrophic German habit--that of valuing cultural fulfillment specifically else and envisioning it as a noble replacement for politics. Lepenies examines how this tendency has affected German historical past from the past due eighteenth century to this day. He argues that the German choice for paintings over politics is key to realizing the abnormal nature of Nazism, together with its aesthetic attract many Germans (and others) and the truth that Hitler and lots of in his circle have been failed artists and intellectuals who appear to have practiced their politics in its place kind of paintings. In a chain of ancient, highbrow, literary, and creative vignettes instructed in an essayistic variety filled with compelling aphorisms, this wide-ranging publication can pay precise consciousness to Goethe and Thomas Mann, and likewise comprises tremendous discussions of such diversified figures as Novalis, Walt Whitman, Leo Strauss, and Allan Bloom. The Seduction of tradition in German background is anxious not just with Germany, yet with how the German obsession with tradition, experience of cultural superiority, and scorn of politics have affected its kin with different nations, France and the U.S. specifically.
By Christopher Duffy
Lines the lifetime of the Russian Czar, targeting his accomplishments as an army chief.
By Katherine E. Stoner
Utilizing Divorce Mediation is the great handbook you have to comprehend the total divorce mediation processfrom discovering the precise mediator to writing your ultimate payment. Encouraging and simple, it solutions all of the questions humans have approximately divorce mediation. Written via Attorney-Mediator Katherine Stoner, utilizing Divorce Mediation promises a valid, more and more renowned substitute for resolving your divorce matters with out spending a fortune.
By Canoy, J.R.
This e-book examines the complicated and paradoxical courting among authoritarian policing and the social and financial modernization of postwar Germanys biggest and such a lot traditionally real kingdom, as Bavaria joined the remainder of the Federal Republic in a passage from postwar obstacle to customer prosperity.
By Shelly Vaziri Flais
Prepare for the coming in their twins
Survive the 1st few days and weeks with suggestion on sleep schedules, feeding offerings, and discovering support
Develop ideas to aid effectively deal with (and enjoy!) the 1st 12 months in their twins’ lives
Negotiate the baby years, together with potty education, language improvement, big-kid beds, budgets, and discipline
Understand the realm in their twins as they turn into preschoolers, together with socialization in and out the kin, encouraging individualism, self-discipline and sleep issues.

domain: library


Together for Dance Gala
Join us for THE dance event of the season.
Date: Sunday 9 October 2016
Venue: Novello Theatre, Aldwych, London, WC2B 4LD
Tickets: £20, £35, £50, £75, £100 +£2.25 booking fee.
Artistic Director, Mara Galeazzi
A shimmering constellation of dance stars comes together at the stunning Novello Theatre in London’s West End, for a breath-taking one-off evening of world class dance in support of One Dance UK.
This will be an unforgettable event with an exciting array of performers, including special guest artists, a world premiere, and a few surprises!
Together for Dance features some of the finest dancers in the UK including artists from BalletBoyz, Company Wayne McGregor, English National Ballet, Impact Youth, Jaivant Patel Dance, The Urdang Academy, Namron, Sonia Sabri Company together with Gary Avis*, Zenaida Yanowsky*, Edward Watson*, Tommy Franzen & Xena Gusthart, Mara Galeazzi and a few surprises!
Featuring a stellar line-up, Together for Dance is designed to raise much-needed funds towards One Dance UK’s programmes supporting dancers’ health, a diverse range of artist and art form development, and projects for children and young people.
Special VIP Tickets* at £200 now available
*VIP Tickets include entry to pre-performance reception, premium seats, interval champagne, and after-show black-tie dinner at the Waldorf Hilton alongside a number of artists taking part in the show.
Unable to attend? Consider making a donation to One Dance UK to support the dance sector.
Proceeds from the Together for Dance Gala will go towards One Dance UK’s work for children and young people. We believe that dance changes and enriches young people’s lives.
Together for Dance Auction
Our auction, raising funds alongside our Together for Dance Gala, in support of our work for dancers’ health, a diverse range of artist and art form development, and projects for children and young people, is NOW LIVE.
This year’s prizes include exclusive outings, gorgeous limited edition photographs, and fabulous holiday getaways.
Visit the online auction site to start bidding. Good luck!


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At almost literally the 11th hour in the FY20-21 budget process in late June, the legislature included a provision in the conference committee’s version of the budget bill which provides a much easier route for certain township residents to move from one school district to another. This provision, which had originally been included in the House-passed version of the budget, removed by the Senate and then subsequently added back during the conference committee process, allows residents of a township that is located in more than one school district to vote to move their property from one school district to another.
Whereas existing Ohio law required the State Board of Education to approve the transfer of any territory from one school district to another, the newly enacted legislation allows any number of residents of a township which is located in more than one school district to file a petition with the county board of elections proposing the transfer, with a vote at the next primary, general or special election. The only requirement of the petition is that 10% of the petitioners must have voted in the most recent general election. Crucially, only the petitioners would be allowed to vote at the election on whether the territory transfer should be approved, with a majority “yes” vote required for approval. Other township residents and residents of the school districts that the territory would be transferred from or to are not allowed to vote on the territory transfer.
Additionally, the newly enacted legislation does not establish a minimum number of petitioners required, which means that a single person could successfully file a territory transfer petition so long as they voted in the most recent general election. Furthermore, in the event that there is more than one petitioner, there is no requirement that the petitioners live adjacent to one another, meaning that the territory to be transferred can be a series of unconnected parcels. Imagine a street where residents in every other home wish to be transferred to a different school district. A petition that has each of these houses included would be valid (so long as at least 10% of the signers voted in the last general election), and only those in the proposed transfer area would be allowed to vote.
Two territory transfer petitions were filed in time for the 2020 Primary Election and both would impact the Plain Local School District in Stark County. One petition was filed by a group of eight homeowners located on a cul-de-sac in the Plain District. They have petitioned for their properties to be transferred to North Canton City Schools. However, the first petition filed was by a small group of residents of the Village of Hills and Dales. These petitioners have requested that their territory be transferred from Plain Local school district to the Jackson Local school district. Plain Local, which stands to lose over $600,000 as a result of the territory transfer, has filed suit in a federal court to block the action on the basis that the new process denies them due process and also that it could increase segregation and undermine students’ rights to an equal education.
The fact that the residents of Hills and Dales were the first to exercise their rights under the new law should be no surprise as the State Board of Education blocked a previous attempt by more than 100 Hills and Dales residents to transfer from Plain Local to Jackson Local in 2005. This decision was later upheld by the Ohio Supreme Court. More recently, Hills and Dales village council minutes from February 2018 record the village’s desire for an alternative to the existing territory transfer process.
Finally, the newly enacted law could have a much larger impact statewide. There are 1309 townships in Ohio with a 2010 collective population of almost 5.7 million people – nearly half the state. Furthermore, according to Policy Matters Ohio, over 500 school districts in Ohio share a township with another district, which would make them eligible for the new transfer process. In fact, it has been reported that twelve different petitions have been filed by residents wishing to transfer from the Bowling Green City School District in Wood County.
Based on the above description, it would be difficult to find another piece of legislation passed in Ohio in recent memory as undemocratic as the new territory transfer provision. A Federal Court decision notwithstanding, the only real solution to a law which enables a small minority of voters to unilaterally choose their school district in contradiction to more than 60 years of legally established territory transfer practice is to repeal it. Recognizing the severity of this precedent, the Ohio House recently amended Senate Bill (SB) 89 to place a sunset provision on the new territory transfer law. The sunset provision would effectively repeal the new territory transfer provision on September 1, 2020. However, SB 89 was also tied to the EdChoice voucher debate, and differences between the House and Senate versions of the bill had not been resolved when the legislature recessed in late March in the midst of the Coronavirus health emergency.
Even if SB 89 were passed, the September 1 date still allows those interested in filing petitions for transfer the opportunity to meet the deadlines necessary to be on the November 2020 ballot. Without legislative action, currently, the only other prospect for eliminating this territory transfer provision lies with the fate of the Plain Local federal court case.

domain: law


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Donosti@ b&b offers an intimate atmosphere, comfort and a great location: 2 blocks from the Beach. The best restaurants, shopping centers, and nightclubs are nearby (less than 5 minutes walking).
DBB - Donosti@ B&B
- Amazing breakfast included in the price!
- Private rooms with shared bathroom.
- Big chill out area .
- Free Hair dryer & iron
- Free Internet WIFI and also computer available
- Free TV, DVD, and TV
- Free Security Box in each room
- Information board, books & guides
+ Please contact us if you need a triple room and is not available in the web site. Most of our double rooms have the possibility to add an extra bed
+ Only >18 years. If you are travelling with kids, please contact us. We are not able to offer comfort to children. All our rooms share bathrooms.
Non smoking b&b (we don't allow to smoke in the common areas, in the rooms and also in the balconies)
* Cancellations must be made at least 48hrs prior to arrival time! Thank you.
* Check-in is after 14:00 hours (at least to leave your luggage).
Check-out is before 12am.
Please call us or send us an e-mail with your estimated time of arrival.
We hope you enjoy your stay and look forward to meeting you !
FRom Amara The Bus Station:
By foot: a 15 min walk. In the Concha beach direction, you should follow Sancho el Sabio street, and continue along Urbieta street up to the Buen Pastor Cathedral. Cross the San Martin street and after 2 blocks we are in a corner in front of the San Martin Shopping Center, the entrancy is around the corner in San Marcial street Nº33 5th-A.
By bus: Bus N.28-26. Get off the bus at the Buen Pastor Cathedral, and cross the street. After 1 block we are in a corner in front of San Martïn Shopping Center the entrancy is around the corner in San Marcial street Nº33 5th-A.
There´s a public parking in front our building, the price is between 15-20€ per day.
To principal entrance to the parking is located in Urbieta street.
We also can show you in a map different places to park for free in San Sebastian, one of them is the University parking, that is 15 min. from the property.

domain: travel


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Poke means “chopped up” and it is a very popular dish from Hawaii! I love poke and honestly I can eat it for every meal! What I love about poke is that you can really customize it to your liking. I am going to break it down for you so you can add whatever you like! I will also include one of my favourite homemade poke recipe. Here we go!
- white rice
- brown rice
- mix green lettuce
- zucchini noodles or any veggie noodles you like
Veggies (Pick as many as you like):
- pickled ginger
- bell peppers
- green onions
As you can see, the possibilities are endless!
- Sushi grade salmon or tuna
- Regular cooked salmon, tuna, or whatever fish you like
- Thinly sliced beef
- If you are vegetarian, you can use tofu or just load it up with more veggies!
- Imitation crab meat
- Spicy mayo (mayo + sirarcha)
- Basic soy (Light soy sauce + sesame seed oil + Rice vinegar)
Give it a try and see what combination you like best! You can never get bored of poke because every bowl can be different!

domain: food


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Real estate brokerage Franklin Street is on the move — and the latest data on South Florida office space suggest it’s not alone.
When the lease on its 2,500-square-foot office in Plantation expires in December, Franklin intends to double or nearly triple its space to accommodate up to 100 employees. Its brokers are at work ferreting out 6,000 square feet of Class A space for the company whose primary business is trading investment-quality real estate.
“That’s happening throughout Broward” County, said Greg Matus, the brokerage’s regional managing partner for South Florida. “A lot of people are looking to get into premium space and solidify long-term deals.”
Across the region last year, tenants relocated across hundreds of thousands of square feet of offices as developers, who had mostly focused on residential projects in the rebounding economy, delivered limited new office options.
In Broward County, the office market finished 2015 with 763,691 square feet of net absorption, primarily by software publishers, insurance carriers, legal services and business support firms, according to data from CBRE Inc.
Tenants in Palm Beach County leased 1.7 million square feet last year, a 38 percent increase over 2014, for 419,888 square feet of net absorption driven by organic growth as companies moved to “right size” their staff after downsizing, Cushman & Wakefield of Florida Inc. reported in its quarterly office snapshot.
In Miami-Dade County, net absorption neared 1.2 million square feet in 2015, nearly triple the previous year’s tally of 441,367 square feet.
The desire for higher quality space fueled rising rents in most markets where limited supply, especially for larger tenants, shifted the markets in favor of landlords.
“It’s great news for owners; tougher news for tenants who have fewer options and less negotiating leverage,” Cushman & Wakefield director Mark Pateman said.
Construction forecasts suggest the trend is likely to continue well into 2016.
In Broward, Cushman & Wakefield reported developers “remained reluctant to break ground on office inventory,” delivering only one project in the fourth quarter: Pembroke Pointe, Duke Realty’s 143,535-square-foot Class A building in the southwest Broward submarket.
“We’re starting to see the potential of new construction that we haven’t seen in many years,” Cushman & Wakefield executive director Deanna Lobinsky said.
But for now, most new construction still focus on multifamily, industrial and retail, pushing up development costs and making new office space a less feasible option.
Nowhere in the region is the preference for other asset types more noticeable than in Palm Beach County, where no new office projects have been built since 2011. None were under construction by the end of 2015, according to Cushman, despite a push by some city governments to encourage new Class A projects.
Trophy assets remain in high demand by investors as price leaders like Phillips Point, Esperante Corporate Center and CityPlace tower — a 2008 development that was the first Class A office tower built in West Palm Beach in more than 20 years — remain at about 95 percent occupancy.
“The buildings are actually full, and space is really tight,” Pateman said. “There are still blocks of space in creative-class spaces, but it’s getting harder and harder to accommodate the class of clients we’re seeing.”
In West Palm Beach, a city moving to create a financial district to attract wealth managers looking to escape state taxes in other parts of the U.S., the biggest need is for new premium office space for small tenants used to paying high rents for prime finishes, concierge services and other amenities.
The good news for landlords: Palm Beach County rents climbed 5.3 percent to about $37.45 per square foot for premium space as vacancies dipped and occupancy tightened to about 90 percent in most buildings in core markets, Cushman reported.
Brokers like Pateman hope this velocity will encourage new projects, especially with major infrastructure investments like All Aboard Florida’s Brightline passenger rail service under construction in all three South Florida markets.
But that could take time.
“We’re going to see a slowdown in leasing, not because there’s lack of demand but because of lack of supply,” Pateman said.
That lack of supply prompted some office users to take action.
“One of the things our brokers noticed is tenants wanting to build their own space instead of leasing,” Cushman & Wakefield senior research analyst Valerie Tatum said.
One such tenant, 3Z Telecom, leases about 4,000 square feet in Miramar and purchased land to build a 34,000-square-foot owner-occupied office building as its new headquarters.
The telecom company operates in a submarket where vacancy shrank to 9.3 percent in 2015 from 10.9 percent a year earlier — on total inventory of 1.9 million square feet.
As vacancy dipped, average asking rents moved in the opposite direction, climbing to $29.67 per square foot last year from $27.72 in 2014.
“Now with Class A space limited and rents going up, Class B is starting to push their rents too because they can,” Tatum said.
Meanwhile in Miami, investors are fueling the region’s most active construction pipeline.
Developers are on track to deliver 600,000 square feet of office space this year, primarily in projects offering less than 100,000 square feet, according to Marcus & Millichap Real Estate Investment Services broker Alex Zylberglait. They on schedule to complete another 412,000 square feet in 2017.
CBRE’s count put the projected development for 2017 to 2019 at about 3.3 million square feet of office space.
But Zylberglait said the new projects won’t satisfy escalating demand, resulting in private capital investors redeveloping and repositioning infill properties, including several in the Biscayne corridor.
Older buildings in Miami’s central business district have been among the key beneficiaries, attracting attention from both developers and renters drawn by rental rates sometimes about 50 percent below those of neighboring high-rises in Brickell’s financial district.
One investor, Moshe Mana, has been especially active, accumulating more than 30 downtown infill sites as part of an undisclosed investment strategy.
“It’s an area in transformation,” Marcus & Millichap senior vice president Douglas Mandel said of the central business district. “It hadn’t been heavy on trade from an investor perspective, but now we’re seeing some real velocity. The focus and attention had been on Brickell, but now we’re starting to see some larger transactions taking place downtown.”
In February, Mandel helped broker the $33.85 million sale of a renovated Miami office building at 200 SE First St. The property last sold for $21 million in a foreclosure sale in May 2014. Less than two years later, seller Integra Investments made a gain of more than 61 percent in a deal that brought new capital to the market. Mandel said the buyer, a fund linked to New York-based private equity investor Brickman, was a first-time Miami investor.
“We’re seeing continued, really great appetite for product in South Florida,” Blanca Commercial Real Estate CEO Tere Blanca said. “We’ve had tremendous new-to-market activity in the last five years. It’s become so significant that it’s worth noting.”
Analysts say the office forecast is positive across South Florida with employment growth buoying occupancy and rental rates.
Broward added more than 27,000 jobs last year, including 11,700 white-collar positions in professional and business services.
Palm Beach County’s efforts to attract financial services firms appeared to be paying off. Its unemployment rate dipped 60 basis points to end the year at 4.9 percent, with business and financial services, information technology, aviation and manufacturing among the top industries driving expansion.
In Miami-Dade, the employment rate strengthened 1.6 percent with the majority of new hires in hospitality, trade and education.
Job growth helped push Florida’s net absorption of office space to nearly 6.5 million square feet in 2015 — about 3.8 million more than the previous year, CBRE reported.
South Florida submarkets like Kendall and Coral Gables joined Aventura, Miami Beach and Miami’s Coconut Grove with single-digit vacancies in 2015. And in the fourth quarter, Miami-Dade office tenants executed 132 leases for 615,000 square feet.
Of 156,407 square feet of net absorption in Palm Beach County, about 68 percent was in Boca Raton. Technology firms and legal and financial services accounted for 39 percent of that activity, according to CBRE.
In Broward, leasing activity was concentrated in suburban submarkets like Plantation, where one tenant, Magic Leap, signed a 256,737-square-foot lease in a former Motorola building on West Sunrise Boulevard.
But brokers in submarkets with concentrations of lower quality buildings say big transactions aren’t as likely.
In Cypress Creek, for instance, asking rents fell in the last year as vacancy rose. Much of that submarket’s 4 million square feet is Class B or C space. For triple net leases, which include taxes, insurance and maintenance costs with the base rent, average asking rents were $23.46 per square foot, down from $24.44. And overall vacancy rose to 14.7 percent in 2015, up from 12.3 percent a year earlier.
“We have a lot of competition in that product-type up here,” Sperry Van Ness president and CEO Keith Kidwell said. “A lot of the tenants have upgraded to nicer space.”
Kidwell, a 25-year Broward broker, said he fielded dozens of calls after a client bought the nearly 70,000-square-foot vacant building at 2200 W. Commercial Blvd. and started a million-dollar upgrade to increase rental rates and attract new tenants.
“That office market is still soft, and we continued to be approached by owner-users looking to purchase the property for their own use,” he said.
For tenants on the move like Franklin Street, the competition is fierce for premium space.
“Because there are limited options, tenants aren’t necessarily going to have a lot of options,” Lobinsky said. “They’re going to have to make a decision on product type or size of space.”


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Sometimes, drug use disorders co-occur with mental health issues due to the reasons below:
- Certain illegal drugs can make addicts experience one or more signs of a mental health condition
- Mental health conditions can occasionally cause alcohol or drug use, as some people with these conditions may abuse these substances as a form of self-medication.
- Genetic vulnerabilities, early exposure to stress or trauma, and changes in brain structure are some of the shared underlying causes of both mental and substance use problems.
In Indianapolis,Detox to Rehab offers the miller care groupsegments and their treatment services, which are based on a mixture of drug abuse and mental health.
Substance Use Disorders
Disorders related to substance use or dependency are referred to as substance use disorders.
Substance use disorders symptoms may include:
1. Behavioral changes, e.g.
- Drop in attendance and also a performance at school or work
- Often getting into trouble like fights, accidents, or illegal activities
- Using drugs in physically hazardous situations e.g., while driving cars or while operating any machine
- Engaging in secretive/suspicious behaviors
- Changes in appetite
- Changes in sleep patterns
- Unexplained change in attitude or personality
- Sudden mood swings, angry outbursts, or irritability
- Periods of unusual agitation, hyperactivity, or giddiness
- Lacking motivation
- Appearing very anxious, dreadful, or paranoid, with any reason
2. Physical changes, e.g.
- Bloodshot eyes and also abnormally sized pupils
- Sudden weight loss/weight gain
- Deterioration of physical look
- Uncommon smells on breath, dress, or body
- Slurred speech, tremors, or impaired coordination
3. Social changes, e.g.
- Sudden changes in hobbies, friends, and favorite hangouts
- Legal problems concerned with drug use
- Unexplained need for urgent money or financial problems
- Using drugs even though may cause problems in relationships
Recovering From drug use and mental health problems
A person who has both a mental health condition and a substance use disorder must address both conditions. Treatment options for both substances use disorders and mental health issues may include talk therapy, support groups, medication, and rehabilitation.

domain: psychology


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Your Evening Briefing
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All the countdowns have reached zero and a new clock has been set, with Donald Trump sworn in as the 45th U.S. president. The country, though, is anything but united. The Republican takes office with historically low approval ratings. Protesters smashed windows and set fires in Washington and massive demonstrations are planned for multiple cities.
In his inaugural address, Trump vowed to unseat the Washington establishment and called for unity: "When America is united, America is totally unstoppable." Read on for what's next for the new president, his critics, and the rest of America. –Emily Banks
Here's what to expect from an unexpected president. Trump's team has been tight-lipped about details, but clear about his intent: he’ll start on Inauguration Day, and the pace will pick up next week. Here are some likely priorities in his first few days: tightening immigration, repealing Obamacare, and nominating a Supreme Court justice.
Now what? From the Bloomberg View editorial board: "The critics are correct that Trump possesses troubling characteristics for a president. But the shortsighted response some have chosen–boycotting the inauguration and declaring him an 'illegitimate' president–only weaken the foundation of democracy: the peaceful transition of power. That could have disastrous consequences down the road."
Warren Buffett said he “overwhelmingly” supports Trump’s cabinet choices who currently face Senate confirmation hearings. “I feel that way no matter who is president," said the billionaire Berkshire Hathaway chairman and CEO, who backed Hillary Clinton in the election and scolded Trump for not releasing his tax returns.
George Soros says Trump will fail and markets will slump. It's tough to be gloomier than this billionaire who said America has elected a would-be dictator as president, the EU is disintegrating, U.K. Prime Minister Theresa May won’t last long, and China is poised to become an even more repressive society.
A travel boom to India is sending tourists home with superbugs. Doctors in North America, Europe, and Australia have observed a decade-long pattern: Travelers who spent time in India have an especially high risk of returning home with unwanted germs. With a record 3.77 billion air passengers worldwide last year, new disease-causing microbes have never traversed faster.
Trying to cultivate ties with Vladimir Putin doesn't always pay political dividends. No politicians have managed to get the better of the Russian president. Here's a quick guide to those who tried to do business with him, who failed—and some who succeeded.
The most peaceful place on earth is in the middle of Tokyo. The new Hoshinoya Tokyo offers ample unwinding smack in the middle of the frenetic Otemachi financial district. It's billed as the city’s first “luxury ryokan.” For the uninitiated, a ryokan is a traditional Japanese-style inn that offers an immersive cultural experience. Staying at a ryokan usually means sleeping on a futon bed on a tatami (straw mat) floor, bathing in a communal hot-spring bath, and eating a multi-course kaiseki-style meal while wearing a kimono.

domain: politics


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Freedom—July 3, 2020—The Marine Patrol’s job is to help keep things safe on state waters like Ossipee Lake. When our lake is crowded with holiday boaters, Marine Patrol’s job is more difficult. This year the task is even more onerous due to the social distancing guidelines established for boaters as a result of the pandemic.
As the long holiday weekend begins and the lake fills with boats, the State Police’s Marine Patrol unit yesterday asked boaters “to assist them” by complying with the state’s rafting rules.
Rafting laws are “designed to limit the concentration of boats on a sandbar by creating minimum distance requirements between boats, the shoreline, and rafts,” according to the state’s tweeted message. The primary aim is boater safety, but there can be other factors as well.
Ossipee Lake is one of a handful of state lakes with enforceable rafting rules that target specific areas. In our case, it’s the sandbar where the channel from the big lake enters Broad Bay at the junctions of Cassie Cove, Turtle Cove and Spindle Point.
The sandbar was the focus of state rule-making in 2001 after years of complaints by lake property owners and members of the boating community who said crowds at the site had created a public nuisance and safety hazards.
A state hearing on the matter resulted in Saf-C 407.04, which limited “rafts” at the sandbar to 10 boats that must stay 50 feet from the main navigation channel and be gone by sunset.
The regulation ended the debate but satisfied few. By one interpretation of the rule, there can be no more than 10 boats at the site. But another interpretation posits that there can be any number of “rafts,” each consisting of 10 boats.
In any event, the sandbar rule has rarely been enforced, and it’s so old that many boaters who congregate there are unlikely to be aware of it. But COVID-19 may change that, because rafting is at the heart of the state’s social distancing guidelines for boaters.
“No Rafting—Keep Your Distance on the Water” is a key tenet of the guidelines, as seen on posters at marinas, boat ramps and other places where boaters gather. Additionally, the state has asked that boat passengers be limited to household members.
“NO GUESTS ON YOUR BOAT,” the poster also reads, in all caps.
Like most weekends, this weekend will bring rafting to a number of spots around the lake. But all eyes will likely to be on the sandbar, where the state’s 2001 rafting rule and its 2020 social distancing guidelines will combine to test whether boaters cooperate with the state’s request for cooperation, or whether the state will take action if the cooperation doesn’t materialize.


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According to Canadian Blood Services’ current policy, this arm could not belong to a sexually active homosexual male.
In the mid-1980s at the height of the AIDS scare, nations around the world banned blood donations from gay men. At the time, this made sense: people didn’t know much about how HIV/AIDS spread or what could be done to stop it. One of the things they knew for certain was that gay men — along with prostitutes and intravenous drug users — were contracting the virus at much higher rates than the general population.
Almost 30 years later, though, we live in a very different world. We now know how the virus spreads and how to safeguard against infection. Testing has been refined such that certain types of tests, namely Nucleic Acid Tests, can detect HIV within two to three weeks. There is no need for the kind of blanket donor ban that focuses on a person’s innate characteristics, like sexuality, rather than how safe his or her behaviours are.
Simply put, people’s sexual orientations have no bearing on whether or not they are likely to have HIV.
What puts gay men at higher risk of HIV infection is that anal sex is significantly more likely to lead to the spread of infection from one partner to the other. However, condom use is about 79 per cent effective in preventing HIV infection during anal sex, and medication can reduce the likelihood of transmission by as much as 99.9 per cent.
With figures like this, it becomes clear that the focus should be on excluding donors who do not practice safe sex rather than on all gay men.
Canadian Blood Services still has a ban in place on donations from any man who has had sex with another man since 1977; this is, for all intents and purposes, a lifetime ban on gay men giving blood. It is homophobic and misplaced. While it is true that homosexual men make up the largest portion of HIV-infected Canadians, it is not true that gay men are inherently more likely to have the virus.
Bowing to pressure from gay rights groups, Blood Services has considered changing this policy: allowing men to donate if they have not had sex with another man in the past five to 10 years. This is effectively the same as a lifetime ban for gay men, but disguises itself as a more progressive policy. It should be scrapped in favour of a rule that actually targets the behaviours that put people at risk of HIV infection.
It is well known that sharing needles for drug injection and engaging in unprotected sex are the two most common ways of passing the HIV/AIDS virus on. Organizations like Blood Services rightly screen for people who have used intravenous drugs or had unprotected sex in the past year, and excludes them from donating.
But the key difference here is that these people are not banned forever. Someone who has neither had unprotected sex nor used needle drugs in the last year is free to donate blood, because Blood Services assumes — rightly — that any infections they have will be detected by the rigorous screening process every single donation is subjected to.
Meanwhile, all gay men are assumed to be as risky to the community as people who share needles and have unprotected sex. Or, to be more precise, all gay men who are sexually active. To request that someone forgo sex, an integral aspect of a healthy adult life, in order to donate sorely-needed blood is ludicrous and backward, and Canadians should hold their institutions to a higher standard.
Photo: European Parliament/Flickr

domain: medical


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February is Black History Month, and for 40 years, members of the Woods Hole community have come together to remember, commemorate, and celebrate with speakers, art exhibits, films, musical groups, and other events culminating in the annual “Harambee,” a potluck feast celebrating people of every race and ethnicity.
In 2021, Woods Hole Black History Month honors “The Black Family: Representation, Identity, and Diversity.” Due to COVID-19 restrictions, we will gather online this year, with a schedule of panels and discussions and a Virtual Harambee celebration. Although nothing can fully replace sharing a meal in person, we will come together online to celebrate global cultures and food, share our stories, and celebrate our diversity in community.
Please join us throughout the month by sharing your recipes, trying out new dishes, and sending us photos of your culinary creations! Email your recipes & pictures to firstname.lastname@example.org to have them added to the collection. Be sure to check out the rest of the schedule, and visit Eight Cousins on Main St. in Falmouth, Market Street Bookshop in Mashpee Commons, and the Falmouth Public Library to view their Black History Month displays.

domain: sociology


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The spa will offer a range of luxurious treatments with essential oils
Beauty brand Aromatherapy Associates has launched its range of products and treatments at St Pancras Spa at St Pancras Renaissance Hotel, London.
The brand, which is renowned for being a leading expert in aromatherapy, will be offering spa clients a range of luxurious treatments incorporating hand-blended essential oils to transform physical and mental wellbeing. The Renaissance Hotel is the latest in more than 400 spa partners of the brand, which is stocked in boutiques, hotels and retailers worldwide.. . .
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Executive summary of HTA journal title
Health Technol Assess 2009;13(41):1–358
The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation
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J Picot,* J Jones, JL Colquitt, E Gospodarevskaya, E Loveman, L Baxter and AJ CleggSouthampton Health Technology Assessments Centre, University of Southampton, UK
The prevalence of overweight and obesity among people in England and Wales is increasing. Associated serious health consequences in adults include Type 2 diabetes, cardiovascular disease, musculoskeletal disorders, certain cancers and increased mortality. Childhood obesity is associated with a higher chance of premature death and disability in adulthood. Obesity imposes a considerable economic burden on society. Weight loss improves obesity-related comorbidities and may have a mortality benefit. The intensity of intervention depends on the degree of obesity and presence of comorbidities. Management begins in primary care, but moves to the specialist setting when initial measures have failed and surgery is being considered. Bariatric (weight loss) surgery is increasing, but is not uniformly available across the country and a significant proportion is funded privately.
To assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity.
Seventeen electronic resources, including MEDLINE, EMBASE and Cochrane, were searched from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references.
Titles and abstracts were screened for eligibility by two independent reviewers. Inclusion criteria were defined a priori and applied to the full text of retrieved papers by two independent reviewers using a standard form. The inclusion criteria were as follows:
- Intervention Open and laparoscopic bariatric surgical procedures in widespread current use.
- Comparators Surgical procedures in current use in comparison with one another; open surgery compared with laparoscopic surgery for the same procedure; surgical procedures in current use compared with non-surgical interventions (medical management, usual care or no treatment).
- Population Adult patients fulfilling the standard definition of obese [body mass index (BMI) of 30 or over] and young people who fulfil the definition of obesity for their age, sex and height.
- Main outcomes At least one of the following reported following a minimum of 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness [reporting outcomes as either life-years or quality-adjusted life-years (QALYs)].
The study types that were eligible for inclusion were:
- Systematic review of clinical effectiveness Surgery versus surgery – randomised controlled trials (RCTs); surgery versus non-surgical procedure – RCTs, controlled clinical trials and prospective cohort studies (with a control cohort).
- Systematic review of cost-effectiveness Full cost-effectiveness analyses, cost–utility analyses, cost–benefit analyses and cost–consequence analyses.
Data extraction and quality assessment
Data extraction was undertaken by one reviewer and checked by two reviewers. Two reviewers independently applied quality assessment criteria. Differences in opinion were resolved through discussion at each stage.
Studies were synthesised through a narrative review with full tabulation of the results of all included studies.
The analysis was developed for three patient populations covered by studies included in the clinical effectiveness review:
- patients with morbid obesity BMI ≥ 40 undergoing adjustable gastric banding (AGB) or gastric bypass (GBP)
- patients with moderate-to-severe obesity (BMI ≥ 30 and < 40) with significant comorbidity at baseline (Type 2 diabetes) undergoing AGB
- patients with moderate obesity (BMI ≥ 30 and < 35) undergoing AGB.
A model developed previously was used for patients with morbid obesity (BMI ≥ 40), with updated assumptions on costs, diabetes incidence, permanency of diabetes remission following surgery, and on the impact of BMI on health-state utility.
A new model, including cardiac heart disease and stroke was applied in the analysis of AGB for moderate-to-severely obese (BMI ≥ 30 and < 40) patients with Type 2 diabetes and for moderately obese (BMI ≥ 30 and < 35) patients. The analysis was initially undertaken for the period of the trial follow-up only, but also included extrapolations up to 20 years following surgery.
Quantity and quality of studies
A total of 5386 references were identified. Twenty-six studies (reported in 52 publications) were included in the review of clinical effectiveness. Three RCTs and three cohort studies compared surgery with non-surgical interventions; 20 RCTs compared different surgical procedures. Two studies focused on patients with a lower BMI (< 35 or < 40). The risk of bias of most of the trials was uncertain, only nine of the RCTs reported adequate sequence generation and only five reported adequate allocation concealment.
Summary of clinical effectiveness
Surgery versus non-surgical interventions
The evidence indicates that bariatric surgery is a more effective intervention for weight loss than non-surgical options. Surgery led to a greater reduction in weight in all six studies and the difference was statistically significant in five studies reporting a statistical comparison. In the two RCTs that reported outcomes at two years, mean per cent initial weight loss in the surgical groups was 20% and 21.6%, whereas the non-surgical groups had lost only 1.4% and 5.5% of their initial weight. In the two cohort studies reporting outcomes at two years, per cent weight change ranged from a weight loss of 16% to 28.6% in the surgical groups, but the non-surgical groups had gained weight with per cent weight change ranging from 0.1 to 0.5%. A large prospective cohort study [Swedish Obese Subjects (SOS) study] found that weight loss was still apparent 10 years following surgery, whereas patients receiving conventional treatment had gained weight. One RCT and one of two cohort studies assessing QoL found greater, and statistically significant, improvements after surgery on some measures, but not others. Two RCTs found that significantly fewer people had metabolic syndrome in the surgical group, and one found significantly higher remission of Type 2 diabetes following surgery. The SOS study found a statistically significant reduction in the incidence of three out of six comorbidities assessed at 10 years follow-up after surgery compared with conventional therapy.
Comparison of surgical procedures
Of the available surgical options assessed by RCTs there is evidence that GBP is more effective for weight loss than vertical banded gastroplasty (VBG) and AGB. Five of the seven included RCTs reported greater weight loss following GBP than VBG with per cent excess weight loss at one year ranging between 62.9% and 78.3% for GBP, and ranging between 43% and 62.9% for VBG. In two studies there was no statistically significant difference in 'success rate' or 'per cent ideal body weight'. One RCT found per cent excess weight loss of 66.6% was significantly greater up to five years following laparoscopic GBP than following laparoscopic AGB, which led to per cent excess weight loss of 47.5% (p < 0.001). Evidence from one RCT shows laparoscopic isolated sleeve gastrectomy to be more effective than AGB with greater excess weight loss up to three years (median per cent excess weight loss 66% versus 48%, p = 0.0025). GBP and banded GBP led to similar weight loss up to 24 months follow-up among patients with BMI > 50 (57.2% and 64.2%, p = ns) in the single RCT making this comparison. Comparisons of GBP and laparoscopic sleeve gastrectomy (LSG), and of VBG and AGB produced equivocal results. One RCT found slightly greater per cent excess weight loss with LSG (69.7%) than GBP (60.5%, p = 0.05) at 12 months, but no statistically significant difference in mean BMI or mean weight loss. Three RCTs found that measures of weight loss at one year follow-up favoured VBG over AGB, but longer-term results were conflicting. All the comparisons of open versus laparoscopic surgeries (GBP four RCTs; VBG one RCT; AGB one1 RCT) found that both groups lost similar amounts of weight.
QoL was assessed by only two RCTs. One RCT found that QoL was significantly better following GBP than VBG on some items. The other found that there was no significant difference in QoL following either open or laparoscopic GBP.
Changes in comorbidities after surgery were assessed by five of the 20 RCTs. In general, comorbidities improved in all groups with no significant differences in improvements observed between different surgical interventions.
The extent of reporting of adverse events varied between studies; few were compared statistically and none were powered to do so. Fourteen RCTs reported no deaths. Where deaths were reported separately for each RCT trial arm, mortality ranged from 2% (1/51 patients receiving Open GBP within the first 30 postoperative days) to 10% (2/20 patients receiving Open GBP, one on the fourth postoperative day, one after 13 months). The large SOS study reported mortality of 0.25% in the surgical cohort (5/2010 patients within 90 days of surgery). Adverse events from conventional therapy included intolerance to medication, acute cholecystitis and gastrointestinal problems. Major adverse events following surgery, some necessitating reoperation, included anastomosis leakage, pneumonia, pulmonary embolism, band slippage and band erosion.
Summary of cost-effectiveness
All modelled economic evaluations assessed in this report found that bariatric surgery was cost-effective in comparison to non-surgical treatment although the variability in estimates of costs and outcomes is large. The results of the economic evaluation alongside a clinical trial were inconclusive. However, because of the numerous methodological shortcomings and some poorly justified modelling assumptions the reported results are unlikely to be reliable and generalisable estimates of the incremental cost-effectiveness of bariatric surgery in comparison to non-surgical treatment.
Summary of economic model
Surgical management with GBP or AGB of morbid obesity (BMI > 40) was more costly than non-surgical management, but results in improved outcomes (in terms of QALYs) over the modelled 20-year time horizon. The incremental cost-effectiveness ratios (ICERs) ranged between £2000 and £4000 per QALY gained. The results were generally robust to changes in assumptions in the deterministic sensitivity analysis, and in all cases the ICERs remained within the range conventionally regarded as cost-effective from an NHS decision-making perspective.
Surgical management (with AGB) of moderate to severe obesity (BMI ≥ 30 and < 40) in patients with Type 2 diabetes was more costly than non-surgical management, but resulted in improved outcomes. The ICER reduced with a longer time horizon from £18,930 at two years to £1367 at 20 years. The results were generally robust to changes in assumptions in the deterministic sensitivity analysis. In the probabilistic sensitivity analysis the probability of surgical management being cost-effective (compared with non-surgical management) was 2.5% at a willingness-to-pay threshold of £20,000 per QALY and 50.6% at a willingness-to-pay threshold of £30,000 per QALY, for a two-year time horizon, and was 100% at both thresholds, for a 20-year time horizon.
Surgical management (with AGB) of moderate obesity (BMI ≥ 30 and < 35) was estimated to be more costly than non-surgical management, but resulted in improved outcomes, though the QALY gain at two years is small (0.08). The ICER reduced with a longer time horizon from £60,754 at two years to £12,763 at 20 years. There was considerable variability in results, in the deterministic sensitivity analysis, with ICERs above the range conventionally deemed acceptable in some scenarios even for longer time horizons. In the probabilistic sensitivity analysis the probability of surgical management being cost-effective (compared with an intensive medical programme) was 64% at a willingness-to-pay threshold of £20,000 per QALY and 98% at a willingness-to-pay threshold of £30,000 per QALY with a 20-year time horizon. In contrast, for a two-year time horizon, the probability of surgical management being cost-effective was zero at both thresholds.
Bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required, including:
- good-quality, long-term RCTs and cohort studies to provide detailed data on:
- patient QoL to inform on the gains in utility associated with reduction in BMI
- impact of surgeon experience on outcome of surgery
- late complications leading to reoperation
- more than one weight outcome measure with standard deviation about the mean reported to enable future meta-analysis
- duration of remission of comorbidities and factors affecting this
- resource use across the entire patient pathway to develop robust costings
- good-quality RCTs to provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.
- A core set of important adverse bariatric surgery outcomes should be identified so that a standardised approach to describing adverse outcomes can be developed and their impacts on patients' QoL determined.
Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation Health Technol Assess 2009;13(41).
NIHR Health Technology Assessment programme
The Health Technology Assessment (HTA) programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care.
The research findings from the HTA programme directly influence decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC). HTA findings also help to improve the quality of clinical practice in the NHS indirectly in that they form a key component of the 'National Knowledge Service'.
The HTA programme is needs led in that it fills gaps in the evidence needed by the NHS. There are three routes to the start of projects.
First is the commissioned route. Suggestions for research are actively sought from people working in the NHS, from the public and consumer groups and from professional bodies such as royal colleges and NHS trusts. These suggestions are carefully prioritised by panels of independent experts (including NHS service users). The HTA programme then commissions the research by competitive tender.
Second, the HTA programme provides grants for clinical trials for researchers who identify research questions. These are assessed for importance to patients and the NHS, and scientific rigour.
Third, through its Technology Assessment Report (TAR) call-off contract, the HTA programme commissions bespoke reports, principally for NICE, but also for other policy-makers. TARs bring together evidence on the value of specific technologies.
Some HTA research projects, including TARs, may take only months, others need several years. They can cost from as little as £40,000 to over £1 million, and may involve synthesising existing evidence, undertaking a trial, or other research collecting new data to answer a research problem.
The final reports from HTA projects are peer reviewed by a number of independent expert referees before publication in the widely read journal series Health Technology Assessment.
Criteria for inclusion in the HTA journal series
Reports are published in the HTA journal series if (1) they have resulted from work for the HTA programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors.
Reviews in Health Technology Assessment are termed 'systematic' when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.
The research reported in this issue of the journal was commissioned and funded by the HTA programme on behalf of NICE as project number 08/06/01. The protocol was agreed in June 2008. The assessment report began editorial review in January 2009 and was accepted for publication in April 2009. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
The views expressed in this publication are those of the authors and not necessarily those of the HTA programme or the Department of Health.
Editor-in-Chief: Professor Tom Walley CBE
Series Editors: Dr Aileen Clarke, Dr Chris Hyde, Dr John Powell, Dr Rob Riemsma and Professor Ken Stein
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