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[WTSIM] – Field Salad with filled mushrooms and sprouts
Andrew of Spittoon Extra is in charge of hosting this months WTSIM.
It’s been a long time since I last had time to participate in this wonderful event. And I missed a lot of great themes Andrew, Johanna and Jeanne came up with in the past… I truly hope to be back on a more regular schedule when it comes to participate in food blog events… *cross fingers*
Andrew chose “salads” has theme. I have to admit it was a rather challenging one for me as salads i like are related to more summerly times for me… most of the “winter” salads I would know are very heavy as they always have lots of mayonnaise… and I don’t like it too much.
Well, it’s the end of February and I am longing for spring – for milder weather and the first flowers, so I decided to do a light salad.
Field salad with filled mushrooms and sprouts
1 package of field salad
6-8 big mushrooms
1 small carrot finely grated and chopped
some radish sprouts
some lentil sprouts
some olive oil
Wash mushrooms carefully and remove the stems. Chop the stems and the carrot finely. Season with salt and pepper, sprinkle with fresh thyme.
Fill mushrooms with carrot/Mushroom filling and cover with cheddar. Bake in oven at 200°C for approx. 10 minutes.
Arrange field salad on a plate. Sprinkle with sprouts. Set warm mushrooms on top and drizzle with olive oil and balsamic cream.
The salad pampered my winter-afflicted soul and I was very happy with it. Thank you Andrew for this great idea!


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Plastic waste and oceans of opportunity (Day 151)
25th October 2014
I've been travelling extensively over recent weeks in Australia, Malaysia and Singapore.
Like many people, I use online news media to keep in touch with what is going on at home and around the world.
Scanning the UK news headlines earlier this week there was lots of stories of interest to chemical engineers; fires at power stations, new bills to allow the use of untested drugs, the introduction of charges for plastic carrier bags; and the growing Ebola problem.
The story about plastic bags may seem the least 'serious' of these stories, but it has been a problem for many decades and it may be the most difficult to solve in the long-term.
Many of us see, every day, rubbish in our environment. Of that, plastic is a huge offender and examples of the environmental impact are often reported. One of the main issues, which many of us do not see, is ocean pollution.
Over the last couple of days, I found out about an organisation called The Ocean Cleanup set up by a young engineer Boyan Slat. I accept he’s not a chemical engineer but reading about the work that his group are doing, I can see many opportunities for the application of chemical engineering principles.
Like many of the problems that chemical engineers address, prevention is better than cure, however, we need to address what has already happened.
Every year, millions of tonnes of plastic enter the world’s oceans. On a small scale some gets washed up on beaches and local communities work to clean it up.
In the UK we have Beachwatch, a national scheme for beach cleaning. But on a global scale, much gets caught up in ocean currents and accumulates. Over time, this does break down through mechanical action of winds and waves, but also through UV degradation.
The Ocean Cleanup group published a feasibility study outlining the problem and solutions to this. A team of engineers have proposed a strategy of floating barriers and a platform to extract the plastic from the ocean. This comes with a bold statement of scale, 7,900 times faster, 33 times cheaper than conventional methods. They are working towards a large-scale pilot to operate within the next three or four years.
The team of scientists and engineers include those doing computational fluid dynamics, modelling and simulations of the booms. This is applied across many science and engineering disciplines but is a fundamental part of the chemical engineering skill set.
The project also proposes to process the plastic; reusing the materials. The recycling of mixed plastics that undoubtedly will contain contaminants can be costly if cleaning and separation are required.
Chemical engineers are already working in the area of mixed waste plastic. Some processes involve cleaning and mechanical processing to produce composite materials. Others use chemical recycling through hydrolysis and pyrolysis. These two methods allow recovery of chemicals and fuels from the waste plastic.
Examples of this work are present in many areas of the world. Cynar plc installed its first full scale pyrolysis plant in Ireland in 2008. The original work involved SITA UK, but this is global and SITA Australia is also working on this.
Another example of this is Recycling Technologies Ltd who recognises the environmental and economic case for this work. This spin-off company involves many chemical engineers and makes fuel from mixed plastic waste.
In the future, every single person on the planet should have a duty of care to their environment. Each one of us can inflict needless ham. Thankfully, with the careful disposal of waste like plastic, chemical engineers have the skills and knowledge to turn environmental dangers into valuable and re-usable commodities.

domain: chemistry


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Thanks for the info Andrea. When I get to my computer with the photos on it, I'll send some updated ones of Wrigley. He's a very sweet dog - real mellow & gentle. He follows me around everywhere, & thinks he's a lap dog.
At almost 2 yrs old now, he's about 59 lbs, but he is sooooo tall. He's got those long poodle legs & everyone who sees him can't believe how big he is. I get stopped all the time when I'm walking him by strangers asking what kind of dog he is and complimenting on how beautiful he is.
I hope you are doing well.
Breeding for Quality, Health and Temperament since 2001

domain: pet


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$4.49 per 1 lbs
Bright green, slender pods that add versatility and nutrition to many dishes. Also, Indian Okra is rich in vitamin C and can be eaten raw, marinated in salads, deep-fried, or used in soups and stews.
Out of stock
Copyright 2020 Online Super Market. All rights reserved

domain: agronomy


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Windsor Smith, founder and creator of Windsor Smith Home, Windsor Smith Home Collection and Windsor Smith Room in a Box is widely known as a force in the design industry.
Her elegant interiors are infused with a modern sensibility and are frequently featured in shelter magazines. In fact, Windsor was honored by Veranda magazine as one of the top 25 design influencers in their 25-year history.
Windsor has a signature collection with Kravet, and has upcoming lines with Century Furniture and Arteriors Home. Windsor’s design intuition comes from an organic internal instinct and desire to have a life filled with color, texture, style and purpose.
Through her newest venture “Room in a Box,” clients are able to receive Windsor’s custom interiors through an online process that caters directly to their needs as if they were meeting with Windsor in person!
About Room in a Box
Those who know me know that I have always believed that everyone deserves to have beautifully designed rooms. More than ever, our homes are evolving into elevated versions of our offices, where we eat, where we workout and even spa. It is important to us for them to beautifully represent who we are as well as how we aspire to live. The era where having the same living room, offered by big catalogue stores, as several of your friends is coming to a close. Bespoke design is the new paradigm in how rooms are conceived and created. Henceforth, WSRoominabox.com!
Using new technology coupled with the creation of this amazing innovative strategy for design, you can have access to glamorous, publication worthy rooms! My design team and I will carefully curate and scale products tailored to your very specific likes and desired functionality. I am thrilled to be able to offer you a gorgeous and professional bespoke experience similar to what you would hope to achieve through traditional design services for a fraction of the cost. Whether one room at a time or tackling the whole house, we will create your very own unique spaces that you will enjoy and share with your family and guests for years to come!
About Room in a Flash
The incredible response to WSRoominabox.com prompted us to develop and bring to you our newest concept in immediate design gratification. For those who still want luxurious design but at a lower price point and with shorter lead times, we proudly introduce Room-in-a-Flash , an online selection of masterfully designed rooms with products handpicked, curated and edited by me and my team and available to you. Our stunning renderings depict the spaces as I envision them and without leaving our site, you can buy one piece, for the flavor of my signature style, or you can purchase all of the elements that make up the entire room. From the color story and fabrics to furnishings, lighting and art you too can have a Windsor Smith inspired home. Access to the transformative beauty of design has never been this easy.

domain: artistic


Sen. Mike Brubaker (R-Lancaster), Chair of the interstate Chesapeake Bay Commission, hosted a briefing Tuesday for House and Senate members on the status of Pennsylvania's efforts to comply with the Chesapeake Bay Watershed cleanup mandate.
At the briefing, John Hines, Executive Deputy Secretary for Programs for the Department of Environmental Protection, announced DEP will be taking the next step in the cleanup process by releasing a draft Chesapeake Bay Watershed Implementation Plan for public comment on December 15.
Video of the briefing is available online featuring these speakers:
-- Sen. Mike Brubaker (R-Lancaster), Chair of the Chesapeake Bay Commission, provided introductory and closing remarks.
-- Jeff Corbin, Special Advisor to the Administrator, U.S. Environmental Protection Agency, provided an overview of the Chesapeake Bay mandate.
-- John Hines, Executive Deputy Secretary for Programs, DEP, provided an outline of Pennsylvania's efforts to comply with the mandate.
-- Andy Zemba, Director of DEP's Interstate Waters Office, provided details on Pennsylvania's response.


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- A creative Minecraft player builds a fully playable game of Tetris within the sandbox game using only redstone.
- The impressive Tetris game is a fully functioning version of the popular puzzle game, featuring a working score counter, collision detection, and automated line clearing.
- Redstone has often lent itself to some of Minecraft’s most creative builds, using the technological block to power new games within Minecraft and helpful in-game contraptions.
An inventive Minecraft player has crafted a fully playable Tetris game within their in-game world, using Redstone to power the automated mini-game. The sandbox world of the massively popular game from developer Mojang offers players a wide variety of things to do within its enormous procedurally-generated worlds. Minecraft has regularly added new content to the game, introducing more animals and enemies for players to encounter, new types of biomes, and a variety of new items and objects to find. However, one of the game’s mechanics offers a unique kind of creativity.
Redstone has served as one of Minecraft‘s most popular items due to the wide array of uses for the powdery ore. Redstone allows players to add automated functions into their in-game world, used to create powered rails for mine carts or acting as a power source for items like redstone lamps. Redstone has often been used to craft stunning and unique automated…
Please check out the original article at Source link

domain: entertainment


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What is the best part of Miami to stay in?
South Beach. Art deco buildings along Ocean Drive in South Beach (photo: travelview / Shutterstock) Brickell. Brickell is in the southeast corner of downtown Miami. Coconut Grove. North Beach. Coral Gables. Key Biscayne. Homestead. North Miami Beach.
Is it better to stay in South Beach or downtown Miami?
While Downtown Miami is ideal for anyone seeking events, festivals, and the like, South Beach is the place to go for exciting nightlife. If you want to get the most out of a night out in Miami, then you must do it in South Beach.
What is the safest area to stay in Miami?
Coral Gables. One of the cities in Miami that people love and consider to be very safe to live in is Coral Gables. Coconut Grove. Kendall. Pinecrest. Aventura. Bal Harbour. Sunny Isles Beach. Key Biscayne.
Where can I stay in Miami without a car?
Downtown Miami is the best Miami neighborhood to stay in if you’re looking for a central location with easy access to public transportation. The area is home to plenty of restaurants, bars, and shops, and it’s also close to attractions like the FTX Arena and Bayfront Park.
How many days in Miami is enough?
While some come here for just a day or two, we recommend spending at least 3 days in Miami and Miami Beach area to see the most popular tourist attractions including South Beach, Wynwood Wall, and Vizcaya Museum and Gardens.
Is there a difference between Miami Beach and South Beach?
South Beach is a section of Miami Beach (the most famous section) at the you guessed it south end of the island. So there you have it South Beach is a neighborhood of Miami Beach. So if you’re staying in South Beach, you’re also staying in Miami Beach.
What part of Miami is walkable?
Coral Gables Coral Gables is one of the most walkable small cities in Florida. It has its own downtown, and if you’re in walking distance, you can dine out, do your shopping, and experience some great entertainment without going far from home. The city also has a trolley.
What is the main strip in Miami called?
Ocean Drive is the quintessential Miami boulevard think cute cafes, beachgoers, art deco digs, and booming all-night gigs. The avenue runs parallel to the Atlantic Ocean, with a row of busy venues on one side and the beachfront Lummus Park on the other.
What month is best in Miami?
The best time to visit Miami is between March and May. During these months, you’ll be able to enjoy daily temperatures in the 70s for non-peak rates, while the rest of the country is still defrosting.
What should I be careful of in Miami?
Don’t assume that Miamians party all the time. Don’t be on time. Don’t skimp on sunscreen. Don’t go to the Everglades in the summer. Don’t drive. Don’t surf during a hurricane. Don’t wander Wynwood’s borders at night. Don’t say to a local that Miami Beach is Miami.

domain: geography


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Economic evaluation of aclidinium bromide in the management of moderate to severe COPD: an analysis over 5 years
Authors Karabis A, Mocarski M, Eijgelshoven I, Bergman G
Received 20 November 2013
Accepted for publication 16 January 2014
Published 5 April 2014 Volume 2014:6 Pages 175—185
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 2
Andreas Karabis,1 Michelle Mocarski,2 Indra Eijgelshoven,1 Gert Bergman1
1Mapi HEOR and Strategic Market Access, Houten, the Netherlands; 2Forest Research Institute, Jersey City, NJ, USA
Purpose: Aclidinium bromide is a long-acting muscarinic antagonistic used in maintenance treatment of chronic obstructive pulmonary disease (COPD). A model-based health economic study evaluated the cost-effectiveness of aclidinium 400 µg bid as an alternative to tiotropium 18 µg od for this indication in the US.
Patients and methods: Patient characteristics in this model reflect those in the aclidinium clinical studies: age > 40 years, stable moderate-to-severe COPD, current or ex-smokers (>10 pack-years), post-salbutamol forced expiratory volume in 1 second (FEV1) ≥30% and <80% of predicted normal value, and FEV1/forced vital capacity <70%. The model consists of five main health states indicating severity of COPD and the level of utility, resource use, and costs. Treatment efficacy over 5 years was modeled using FEV1% predicted; a network meta-analysis comparing aclidinium and tiotropium was used to estimate disease progression during the first 24 weeks, and results from the UPLIFT trial were used for time points after 24 weeks. Quality of life was assessed using utility scores in US patients from the UPLIFT trial. Cost-effectiveness was assessed as the incremental cost per quality-adjusted life year (QALY) gained.
Results: Over 5 years, QALYs were 3.50 for aclidinium versus 3.49 for tiotropium; life years accumulated were 4.52 for both. In this economic model, aclidinium versus tiotropium showed marginally fewer exacerbations (3.364 versus 3.390, respectively) and mean total health care costs (US$126,274 versus US$128,591, respectively). In all scenario analyses performed (discount factors of 0% and 6% for benefits and costs; time horizon of 1 year; mapping St George's Respiratory Questionnaire to European Quality of Life–5 Dimensions; excluding pharmacy costs, COPD-related cost only; cost of exacerbations; including ACCORD II trial in the network meta-analysis), aclidinium was associated with lower costs and marginally greater QALYs versus tiotropium.
Conclusion: Aclidinium is potentially cost-effective compared with tiotropium for maintenance treatment of moderate-to-severe COPD.
Keywords: chronic obstructive pulmonary disease, cost-effectiveness, model, tiotropium
Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease characterized by persistent airflow limitation that is usually progressive.1 It arises as the result of a modified inflammatory response in the respiratory tract to chronic irritants in noxious particles or gases, most commonly from tobacco smoking. The effects on lung function are irreversible; symptoms include dyspnea, cough, sputum production, wheezing, and chest tightness. Patients are susceptible to COPD exacerbations characterized by worsening of symptoms that may necessitate a change in medication, unscheduled health care utilization, or hospital stay.2
COPD is associated with considerable morbidity and mortality.3 COPD was estimated to be the eleventh leading cause of disability-adjusted life years in high-income countries, rising to seventh place by 2030, according to the WHO (World Health Organization) Global Burden of Disease and Risk Factors project.4 COPD accounted for 672,000 hospital discharges in the US in 2006.5 It is the third leading cause of death in the US; in 2005, there were 126,005 deaths with COPD as the underlying cause in people over the age of 25, reflecting an increase of 8% from the year 2000.6 COPD also poses a major economic burden in terms of health care costs and resource utilization. The total (direct and indirect) annual cost of COPD to the US was estimated by the National Heart, Lung, and Blood Institute to be US$(2005)38.8 billion, with more than half (US$21.8 billion) constituting direct costs.7 Direct costs of COPD typically include medication, general practitioner and specialist visits, and inpatient and outpatient hospital visits, and may also include the cost of pulmonary rehabilitation. Management of comorbidities contributes to additional health care spending.
In consideration of the significant economic and humanistic burden of COPD, therapeutic decisions should be based on an evaluation of the costs and benefits of available treatments. Bronchodilator medications are central to symptom management in COPD and are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms.1 Long-acting bronchodilator medications are more convenient and produce more sustained relief than short-acting bronchodilators. In particular, long-acting muscarinic antagonists such as tiotropium bromide act by blocking the effect of acetylcholine on muscarinic receptors.8 Tiotropium has been shown to reduce exacerbations and related hospitalizations, improve symptoms and health status,9 and improve the effectiveness of pulmonary rehabilitation.10 Aclidinium bromide is a long-acting muscarinic antagonist indicated for long-term maintenance treatment of bronchospasm associated with COPD, including chronic bronchitis and emphysema, and has shown efficacy and tolerability among patients with COPD.11 From an economic perspective of the health care system, the cost-effectiveness of aclidinium should be assessed as a potential alternative to tiotropium.
A model-based health economic study was conducted to evaluate the cost-effectiveness of using aclidinium bromide 400 µg twice daily (bid) versus tiotropium bromide 18 µg once daily (od) in the maintenance treatment of COPD patients. As the analysis was performed from the perspective of the payer in the US health care system, only direct medical costs were considered.
Material and methods
The patient population used in this model was in line with the licensed indication of aclidinium bromide 400 µg bid. The intention was to reflect patients enrolled in the aclidinium clinical studies. Therefore, the model assumed patients to be >40 years of age with stable moderate-to-severe COPD, current or ex-smokers with more than 10 pack-years, and have a post-salbutamol forced expiratory volume in 1 second (FEV1) ≥30% and <80% of predicted normal value and FEV1/forced vital capacity <0.7.
The age and sex characteristics used to inform the model were in line with the pivotal trial ACCORD I (AClidinium in Chronic Obstructive Respiratory Disease I),12 which was conducted solely in North America (Table 1).
For this analysis, a cost-utility model was developed using Microsoft Excel® 2010 (Microsoft Corporation, Redmond, WA, USA), based on a time-in-state model structure. The model structure was similar to that of a Markov cohort model, with five main health states: mild, moderate, severe, and very severe (reflecting the severity of COPD) and a state for death (absorbing state). However, instead of using transition probabilities to determine movement between health states, the model calculated the proportion of patients in each health state according to the estimated FEV1% predicted values.
A schematic representation of the model structure is shown in Figure 1. Severity of COPD is depicted in line with the GOLD 2010 classification (Global initiative for chronic Obstructive Lung Disease [GOLD] Guidelines 2010).13 Although this classification has been modified in the updated GOLD 2011 guidelines,1 (and remained unchanged in the more recent 2013 update of the guidelines) the model was created according to the previous classification, as utilities, costs, and exacerbation rates in all available publications are reported according to the GOLD 2010 document. There were no research publications as of this analysis that quantified the utilities, costs, and exacerbation rates according to the severity classifications in the GOLD 2011 guidelines.
Figure 1 Basic concept of the model indicating health states in chronic obstructive pulmonary disease.
Each disease severity health state in the model reflected the risk of experiencing a severe or non-severe exacerbation, as well as the corresponding level of utility, resource use, and costs. Regardless of the patient’s level of disease severity, it was possible for that patient to experience either a severe or non-severe exacerbation. The model used a 1-month cycle length. At the end of a cycle, patients could remain in the same state or move to another state, according to the estimated post-bronchodilator FEV1 value. The model uses the mild state for extreme cases, in which a patient began the model being marginally in the moderate state (eg, FEV1 =49% of predicted normal value), and after a short period of treatment, an improvement in FEV1 percentage of predicted normal value was achieved such that the patient moved to the mild state for a number of cycles. For the lower extreme FEV1 values, the very severe state was used for those patients whose lung function deteriorated beyond the severe stage.
Most published models for the economic evaluation of COPD treatments (for example, Price et al14 and Rutten-van Mölken and Lee,15) are based on individual patient data (IPD) from head-to-head clinical trials. Using the IPD, transition probabilities from health states can be calculated. In the current study, the trials on aclidinium that were of sufficient duration for consideration in this model were versus placebo; therefore, the calculation of transition probabilities from IPD was not feasible.
To bypass the lack of IPD and direct comparison with other drugs, this model used the FEV1% predicted to measure the progress of the disease and the treatment effect by the following method: first, a baseline FEV1 predicted value was calculated at the starting point of the model (as post-bronchodilator FEV1/FEV1% predicted) using data from the clinical trial ACCORD I,12 which was conducted primarily in the US. Thereafter, a (linear) decline of this value with time (age) was considered. The slope of this FEV1 predicted graph was derived from published data for FEV1 regression analysis.16 Next, the change from baseline (CFB) for the post-bronchodilator FEV1 at 12 and 24 weeks was estimated. This estimation was based on the assumption that CFB for post-bronchodilator FEV1 was equal to CFB for FEV1 trough (ie, the use of a short-acting β2-agonist for the postbronchodilator measurement would not affect the CFB FEV1 values). The CFB values for FEV1 trough for each arm were estimated with a network meta-analysis (NMA).17 Finally, the FEV1% predicted was calculated at 12 and 24 weeks as the ratio of post-bronchodilator FEV1/predicted FEV1. The value of FEV1% predicted at the starting point was taken from ACCORD I.12
A linear interpolation was used to estimate the FEV1% predicted values between these three time points. After 24 weeks, the results of the UPLIFT (Understanding Potential Long-term Impacts on Function with Tiotropium) study18 were used to extrapolate the FEV1% predicted estimation for both arms. The rate of decline used for both arms was the same. A schematic representation of this approach is given in Figure 2.
Statistical testing has demonstrated that empirical data for FEV1% predicted does not significantly deviate from a normal distribution,19 with a standard deviation of 19.9%. Therefore, this model assumed that at each time point, the FEV1% predicted is normally distributed, with a mean value given by the three-step procedure described above and a standard deviation of 13.35% (baseline of ACCORD I study),12 which does not change over the time. This standard deviation is lower than in Hoogendoorn et al’s study,19 as only patients with moderate and severe COPD were included. With this assumption, we can estimate the percentage of patients in each health state. At the end of each cycle, the percentage of patients who had died was estimated. The model assumed that patient age followed a normal distribution, with a mean of 64.3 years and a standard deviation of 9.4 (baseline of ACCORD I study).12
Short-term changes in trough FEV1
Efficacy was modeled using values for FEV1% predicted. The estimation of FEV1% predicted was based on trough FEV1. The results of an NMA for the CFB trough FEV1 endpoints at 12 and 24 weeks were used in the economic model to estimate the decline of the FEV1% predicted during the first 24 weeks of the time horizon as a result of the efficacy of treatments (short-term changes in trough FEV1). NMA results of the comparison between aclidinium 400 µg bid and tiotropium 18 µg od were taken from a larger NMA that also compared aclidinium 400 µg bid and tiotropium 5 µg od;17 however, since tiotropium 5 µg od is not a relevant comparator in the United States, a scenario analysis was performed comparing only aclidinium 400 µg bid and tiotropium 18 µg od, and these latter results were used to populate the present model. NMA results were used, as no long-term studies have been conducted comparing aclidinium and tiotropium.20 The inclusion of data from the shorter studies (2 weeks and 6 weeks) comparing aclidinium and tiotropium would require substantial extrapolation of the trial data, which would increase uncertainty in the outcomes of the analysis.
The LAS-MD-38 (ACCORD COPD II) study was excluded from the NMA because of a high risk of bias due to an imbalance in patients’ baseline characteristics, including COPD severity, which occurred despite randomization.21 The aclidinium bromide arm included a more severe COPD population than the placebo arm at baseline, reducing the apparent treatment differences in this study. The impact of including this trial on the NMA results was evaluated in scenario analysis, which in turn has been evaluated in the economic model.
Long-term changes in trough FEV1
The estimation of the long-term evolvement of trough FEV1 (after 24 weeks) was based on long-term data from the UPLIFT study, a 4-year randomized controlled trial comparing tiotropium versus placebo in patients with COPD.18 This study showed that after a 30-day period, tiotropium did not significantly reduce the rate of decline in trough FEV1 compared with placebo. Therefore, the assumption used in our economic model was that the annual decline in trough FEV1, after an initial treatment-specific improvement, was the same for both interventions; this is −0.04 mL (standard error 0.01), extracted from the UPLIFT publication graph.18
The treatment effect at 12 and 24 weeks (NMA result) as well as the common annual decline after 24 weeks (based on UPLIFT study data) are demonstrated in Figure 3.
Figure 3 Change in FEV1% predicted over 5 years.
In the model, severe exacerbations were defined as exacerbations that required hospitalization, while non-severe exacerbations were those that required a change in medication and/or contact with a health care provider. The estimation of treatment differences in terms of the reduction in rate of exacerbations was challenging due to variation in the definitions used across the randomized controlled trials. Furthermore, the trials reported relatively low rates of exacerbations as a result of short follow-up periods. Therefore, the probabilities of experiencing severe and non-severe exacerbations in each modeled health state were derived from published literature.22 The values used in the analysis are presented in Table 2.
Table 2 Values used for each of the parameters in the model
Both treatment regimens (aclidinium 400 µg bid and tiotropium 18 µg od) had acceptable safety profiles. No adverse events were included in the analysis, on account of the lack of data on utility loss and costs related to adverse events.
No mortality benefit was assumed with either treatment. Disease-specific mortality, estimated using the hazard ratio of COPD mortality versus natural mortality reported in the UPLIFT study (hazard ratio =1.8),18 was equal for both arms. Estimations of natural mortality were based on a US-specific life table.23
Quality of life
Rutten-van Mölken et al24 assessed the quality of life of COPD patients using the European Quality of Life–5 Dimensions (EQ-5D) for COPD severity stages and concluded that an increase in severity of COPD was associated with a decline in utility scores. In their analysis, data on a subset of 1,235 patients from the UPLIFT trial (out of a total of 5,993 patients) were used. A substantial proportion (34.5%) of patients lived in the US. The EQ-5D was completed at the randomization visit and prior to start of study medication. Utility scores were reported for three GOLD-defined COPD severity stages (moderate, severe, and very severe) for the UK (derived in 1990) and the US (derived in 2002). For the current evaluation, the US dataset was used. As the utility value for mild COPD was lacking, it was assumed that the utility value for moderate COPD was applicable to mild COPD as well.
In a recently published US cost-effectiveness study, Earnshaw et al25 used a utility multiplier for moderate and severe exacerbations of 15% and 50% utility loss, respectively; the utility multipliers were derived from Oostenbrink et al.22 In the current analysis, these same utility multipliers (15% and 50% reduction in utility score for mild/moderate and severe exacerbations, respectively, applied to the cycle length) were used.
Additionally, Pickard et al26 demonstrated that the St George’s Respiratory Questionnaire (SGRQ)27 provides a greater capacity for discrimination between different levels of COPD severity stages compared with the use of generic measures such as the EQ-5D. Therefore, for the US model, the SGRQ total score was mapped to utility values using the algorithm developed by Starkie et al.28 The SGRQ data by COPD severity at baseline from the ACCORD I trial was used as the basis for the mapping. The utility value for exacerbations did not change, as it was not possible to quantify this due to the lack of SGRQ data at time of exacerbation. This set of utility values was evaluated in a scenario analysis.
Due to a lack of quantifiable resource use data, a lump sum cost per severity stage for COPD management and exacerbations was used in the model (Table 2).25,29–31 Costs from Yu et al31 were used for the base case results, while the cost of exacerbations was varied using data from Earnshaw et al25 and Oba29 in our scenario analysis.
As Yu et al31 did not report the COPD management cost by disease stage, the all-cause cost in 2008 for patients not having an exacerbation (US$4,672) was assumed to be applicable for the moderate COPD stage. In addition, a multiplier was used to estimate the COPD management costs for the severe (1.37) and very severe (1.90) stages, as suggested by Rutten-van Mölken et al.32
The drug costs are US$7.25 and US$8.03 per day for aclidinium and tiotropium, respectively (Table 2). All prices have been indexed to 2012 using the consumer price index33 (2008–2012 costs multiplied by 1.076, and 2006–2012 by 1.15). As the model uses a 1-month cycle length, the COPD management quarterly cost31 was converted to a monthly cost.
In accordance with the recommendations of the American Society of Health System Pharmacists,34 the third-party payer perspective was taken. For the base case, the willingness to pay threshold was set at US$50,000. Costs and health benefits were discounted yearly, after the first year, at a rate of 3%.34
At the start of treatment, all patients were considered to be in the moderate or severe health states, reflecting the characteristics of patients in the aclidinium pivotal trials.
Although COPD is a chronic disease, suggesting that a lifetime horizon should be applied, long-term efficacy and safety data are not available for aclidinium, as the longest double-blind, placebo-controlled trial was of 24 weeks’ duration. Additionally, our approach assumed that the FEV1 benefit incurred during the first 24 weeks of treatment will not be lost over the course of time, or in other words, that the slope of lines describing lung function decline will remain parallel between treatment groups. This assumption can be supported clinically by studies like TORCH (TOwards a Revolution in COPD Health) (3 years)18 and UPLIFT (4 years) but has not been demonstrated in life-long studies. Thus, the authors decided not to extrapolate to a lifetime horizon, as it introduced assumptions that cannot be supported by clinical evidence. Therefore, our analysis was based on a time horizon of 5 years. Longer timeframes would require substantial extrapolation of 24-week trial results. Many other published economic models in COPD support this approach (1 year,22 3 years,35 and 5 years15,32,36).
The model compared the benefits expressed in quality-adjusted life years (QALYs) and costs with aclidinium versus tiotropium by taking into account efficacy, safety, health-related quality of life, mortality, medical resource use, and costs over 5 years. The costs were broken down into drug costs and medical costs. Uncertainty in the modeled outcomes was evaluated using a probabilistic sensitivity analysis (PSA). The primary estimate for cost-effectiveness was the incremental cost per QALY gained.
Over 5 years, 4.52 life years were accumulated for both aclidinium and tiotropium, while the QALYs were slightly lower for tiotropium (3.49) than for aclidinium (3.50) (Table 3). The mean total health care costs were lower for aclidinium (US$126,274) versus tiotropium (US$128,591), arising from the lower drug cost and lower cost of COPD management for the former (Table 4). Aclidinium showed a marginal benefit compared with tiotropium in terms of QALYs, reflecting a marginally better treatment efficacy (Figure 3), which in combination with the lower costs, resulted in a position of dominance (Table 5). Fewer exacerbations were seen with aclidinium compared with tiotropium over the 5-year time horizons (Table 6).
Table 3 Life years and QALYs with the upper–lower bound estimation from PSA (over 5 years)
Table 4 Total health care costs (in USD) (over 5 years)
Table 6 Number of exacerbations over 1-year and 5-year time horizons
To address uncertainty in the evaluation, a PSA was performed to quantify the uncertainty in the model outcomes based on the uncertainty of the input parameters. The parameters included in the PSA together with the distributions are presented in Table 2. The results of the PSA for 1,000 stochastically sampled iterations are presented on the cost-effectiveness plane (Figure 4). Incremental QALYs (QALYAclidinium – QALYTiotropium) and incremental costs (CostAclidinium – CostTiotropium) are represented by the x and y axes of the graph. As the number of exacerbations is the key driver for both costs and QALYs, the incremental costs are (negatively) correlated with the incremental QALYs (eg, as the number of exacerbations for aclidinium increases, the incremental costs increase, and the incremental QALYs decrease). Although the difference in QALYs is low, 84% of the iterations fall in the lower right quadrant (Figure 4), demonstrating the robustness of the base case results (Table 5).
Figure 4 Probabilistic sensitivity analyses – incremental cost-effectiveness plane.
As the incremental benefit in QALYs is low, the results are driven by cost, and even small changes in the input values can have an impact on the incremental cost-effectiveness ratio.
For the base case analysis for the COPD management cost, the all-cause medical costs were used. Since the all-cause medical costs for patients not having an exacerbation also included pharmacy costs and we modeled daily-use drugs (tiotropium and aclidinium separately), a scenario was tested excluding the pharmacy costs reported31 from the all-cause medical costs. In addition, a scenario was tested using only the COPD-related cost, although this was expected to be an underestimation of the true COPD-related medical costs due to coding inconsistencies in medical claims from which these values were derived.31
Furthermore, scenario analyses using discount factors of 0% and 6% for benefits and costs were performed; a scenario for a time horizon of 1 year, scenarios on the cost of exacerbations, a scenario using estimation of utilities by mapping SGRQ to EQ-5D, and a scenario including the ACCORD II trial on the NMA results were evaluated. In all analyses, aclidinium was associated with lower costs (US$–2,458 to US$–444) and marginally greater QALYs (0.0041–0.0072) compared with tiotropium for each of the parameters assessed (Table 7).
The current study evaluated the cost-effectiveness of using aclidinium 400 µg bid versus tiotropium 18 µg od in the treatment of patients with moderate-to-severe COPD in the US. The findings suggest that aclidinium 400 µg may be expected to provide comparable accrued health benefits as tiotropium 18 µg, but at a lower treatment cost. Cost savings are expected due to the lower price of aclidinium 400 µg compared with tiotropium 18 µg.
The modeling approach used is largely in line with previously published models in COPD, although some differences should be noted. Most of the previously published models have used patient level trial data as source data. In the current model, the use of aggregated level data was forced by the lack of comparative trial data versus tiotropium. Hence, comparative data were generated by means of indirect treatment comparison techniques. This increases the number of assumptions and complication of the model, as the lack of IPD does not allow for the estimation of transition probabilities. One limitation related to the use of the indirect treatment comparison is that variables may be listed differently in the hierarchy of endpoints for the different studies compared. For instance, in some studies used in the indirect comparison, exacerbations were listed as an additional efficacy endpoint, whereas in others they were listed as a secondary endpoint.
Inconsistencies in the reported data and the lack of reported data presented a challenge in parameterizing the model. Trough FEV1 formed the key treatment clinical source data, but only short-term comparative data were available. Hence FEV1 data from the long-term UPLIFT trial were used to extrapolate the findings beyond the trial period; this had to be assumed applicable for both treatments compared. Pronounced differences in accrued health benefits were therefore not expected.
A final limitation of this study was the use of health states (COPD severity states) that are in line with a previous (2010) version of the GOLD guidelines. This was due to the lack of published research quantifying utilities, costs, and exacerbation rates according to the new severity classification.
The cost-utility analysis described in the present paper suggests that the use of aclidinium is potentially cost effective compared with tiotropium in the maintenance treatment of moderate-to-severe COPD patients in the US. The precision of this estimation is limited mainly due to the lack of long-term head-to-head trials between the treatments under consideration.
All authors participated in the design and conduct of the study, as well as drafting and revising the manuscript. All authors have provided final approval of the submitted manuscript.
The authors would like to acknowledge Shamika de Silva (Medical Writer, MAPI Consultancy) for assistance in drafting the manuscript as well as thank Prescott Medical Communications Group, Chicago, USA for additional editorial support. Financial assistance to support these services was provided by FRI.
This study was conducted by Mapi HEOR and Strategic Market Access on behalf of Forest Research Institute, Inc. (FRI), a wholly owned subsidiary of Forest Laboratories, Inc., which funded the study and the preparation of this manuscript.
Michelle Mocarski is an employee of FRI. Andreas Karabis is an employee of Mapi and served as a paid consultant to FRI during the conduct of this study and the preparation of this manuscript. Indra Eijgelshoven and Gert Bergman worked for Mapi during the conduct of the study but are currently employed by AbbVie and Roche Diagnostics, respectively. AbbVie and Roche Diagnostics were not associated with this study.
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text:
A plane flying from Europe to the United States has been diverted after a cryptic note hinting at a bomb was reportedly found scrawled on the wall in the aircraft's bathroom.
There were 214 passengers and crew on board.
They also confirmed that the plane and all the passengers are now being searched.
Flight 971 was en route from Rome to Chicago when it diverted to Shannon around 1:44 pm local time.
The airline said on Twitter that the flight was now canceled and would depart for Chicago on Tuesday.
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A United Airlines flight from Rome to Chicago has been diverted to Ireland's Shannon Airport after a message perceived as a potential security concern was discovered on board, Irish police and airline officials said.
The message made reference to a bomb on the plane, a source with knowledge of the investigation told Reuters.
A United spokeswoman said on Monday that passengers and baggage would undergo more security screening before the flight resumes.
Gardaí are carrying out examinations of handwriting samples gathered from passengers while all hand luggage has also been screened.

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text:
Our friend Allan was the Sherriff of Galilee. At least that’s what we called him. In actuality he was a commander in the border police and was often called on to settle disputes between Israeli and Jordanian farmers whose land abutted the Jordan river. He lived in one of the most beautiful spots in Israel, Kfar Kish. The Moshav (a cooperative community of farmers) in the eastern end of the Jezreel Valley, faced Mount Tabor. As Bible readers may remember, Mount Tabor is believed to be the place where Jesus began to radiate light and talk to the prophets Moses and Elijah. It is also the site of a battle between the Israelite army and the Canaanites. (the Israelites won after God intervened by sowing panic among the Canaanites). In those days, the drive up to the Church of the Transfiguration at the top was quite perilous but you were rewarded with a magnificent view of the Jezreel Valley and the fabled site of Armageddon.
Once when visiting Allan and his wife, Maxine, we were introduced to a neighbor who was a beekeeper. His honey produced from wildflowers was renowned and we often took some home.
Motti, the beekeeper, was in his mid-forties, very fit, completely bald and had piercing blue eyes that gazed with intensity. He was soft spoken and amiable. After he left, Allan asked me what I thought of him.
“He looks like a killer,” I replied.
“During the Lebanese war which was started to eradicate the Palestinian Liberation Organization (PLO), soft- spoken Motti and few of his commando friends commandeered a Jeep and drove right into the heart of western Beirut where the PLO had their stronghold. They toured around the neighborhood taking photos. They were totally fearless.”
“Once,” he continued, “A friend was having an issue with the harassment of his girlfriend so he and Motti visited the guy to ask him to desist. The guy took one look at Motti, who didn’t say a word, and turned white and forever disappeared.”
From then on, his honey tasted better.
My first job in Israel was selling high-quality Danish furniture. The store was called Danish Interiors and was owned by a South African. It was a great place to work because the staff were mainly ex-pats like myself, young, educated and interesting. Some of my best friendships started in “Danish,” as we called it. This was a time (early seventies) when there was a large emigration from the west and as most of us were ex-pats, making new friends was really important.
It was also a great pick-up place; a good percentage of the clientele were wealthy Israeli women whose husbands were often somewhere else.
One day an Israeli man approached me and placed an order for a large quantity of furniture. It was a special order and I explained that it would take four months to arrive.
“Is this a guaranteed time frame?” He asked.
“Yes.” I replied, “We do this all the time and four months is highly accurate.”
He looked me in the eye, held out his hand, and said, “I work in the diamond trade and shaking hands is the only guarantee we need.”
I clasped his hand and shook it.
I placed the order and about once a month, I called him advising him of the progress of his order.
In the third month, I phoned and told him that the order was booked to be loaded in a container the following week and it would arrive on schedule in Haifa Port.
That week, the Yom Kippur War broke out. All ships and their containers scheduled for Israel were commandeered by the defense forces and used to transport urgent materiel for the war effort.
I called my customer and of course he understood as he himself was just leaving for the front.
Not being an Israeli citizen, I was not conscripted so my wife and I volunteered to work in a kibbutz in the north where we had the mind-numbing, all-day job of sorting apples by size.
The war over, I was recalled to “Danish” to resume my job. As many of the staff were still in the army, I became a delivery man, a furniture assembler and a trouble-shooter before I returned to my sales job.
I received word that my client’s shipment was finally on the water. I called him.
“It’s on the way. The boat will dock on Tuesday, it will take a couple of days to unload and sort and we are planning to deliver the order sometime next week.”
He thanked me for the good customer service and said that he would recommend me to his friends. This was great as I worked on commission.
The boat docked in Haifa and the unloading began. In those days, containers were lifted off the boat using the kind of large cranes you often see in docks. While transferring my container, the chain snapped and the whole box dropped into Haifa bay.
The final phone call was not easy.
The drive to the Sinai was magical. The road that parallels the Dead Sea is particularly beautiful in the early morning when the sun illuminates the Negev desert as it rises above the Jordanian mountains to the east. This was 1972 and Israel, at that time, controlled the Sinai Peninsula so travel into the desert was easy. We had been living in Israel for about a year when we decided to visit Sinai for a few days during the Yom Kippur holiday. (Yom Kippur is the holiest day for religious Jews.)
Passing through Eilat we continued south until we reached Nuweiba on the Gulf of Aqaba. It was there that we set up our tent and sleeping bag. Nuweiba is now a small town but back then, it consisted of a couple of makeshift shacks run by local Bedouins selling basic foodstuffs and swimming gear. After an al fresco dinner, we went for a swim in the crystal-clear waters of the Gulf and settled down to watch the sunset turn the hills of Saudi Arabia orange, pink and blood red. We stayed in Nuweiba for a couple of days, doing nothing more than swimming, eating and talking to other Israelis and Bedouin. We then packed up our gear and moved south to Dahab which was as desolate as Nuweiba. Dahab has wonderful coral reefs and we did do some snorkeling. There was a Bedouin camp nearby where we bought water and food. We often chatted with some of the tribesmen and found them to be very friendly and inquisitive.
This, our first vacation since we moved to Israel, was idyllic. The vast expanse of the desert, the colors, the light and the waters of the gulf all conspired to calm and seduce us.
As a child, in my bedroom at night in cold, rainy Glasgow, I would read stories about exotic places like the Sinai, dreaming of visiting them someday and now, here I was, living that adventure.
We drove home on Yom Kippur taking the more westerly road through the Negev. We were, with one exception, the only car on the road. The journey was quite long as we were about 250 miles from home but the lack of traffic made it go quickly.
When we approached Yavne, a small town south of Tel Aviv, the road narrowed as we entered the town center. Our car was a Triumph Herald convertible and we drove with the windows down. The car had no air conditioning and it was too hot during the day to open the roof. Up ahead, we saw a crowd of people. This was odd as, until that point, the countryside and towns had been deserted. As we got closer, we saw that the crowd consisted of young, orthodox teenagers. They started to yell and as we passed, a deluge of stones hit us. Some were quite big and we managed to roll up the windows before any came inside. Then a large rock landed on one of the side windows, breaking it. Many others left dents on the sides of the car. Shocked and frightened, we continued driving trepidatiously hoping to avoid a repeat performance. We made it home and vowed never to venture out again on Yom Kippur.
The following year, as a safety measure, we stayed home. Food was bought and some friends stayed over. We awoke to the sounds of tanks rumbling by; it was 1973 and the Yom Kippur war had just started.
Header image: view from Mount Tabor, Israel. Courtesy of Wikimedia Commons/Zairon.


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For starters, I told you I'd be back with more cake batter recipes and here I give you CHOCOLATE CAKE BATTER COOKIES! (a major nephew hit) I came across a cake batter cookie recipe over at Chef in Training that included a special ingredient, pudding. The only problem was it called for vanilla and I only had chocolate fudge on hand. I thought what the heck, might as well give it a try. Me oh my what a good try because now I have chocolate cake batter cookies! Can you say YUM!
CHOCOLATE CAKE BATTER COOKIES
- 1 1/2 sticks butter
- 3/4 c brown sugar
- 1/4 c sugar
- 1 package chocolate fudge pudding mix (dry)
- 3/4 c yellow cake mix (dry)
- 2 eggs
- 1 tsp vanilla
- 1 tsp baking soda
- 2 1/4 c flour
- 1/2 tsp salt
- LOTS of sprinkles
- Preheat oven to 350 F
- Mix together flour, baking soda, and salt
- In another bowl cream butter and sugars together. Beat in pudding and cake mix. Add eggs and vanilla, mixing until smooth
- Gradually add in flour mixture
- Mix in LOTS of sprinkles
- Roll into balls onto greased baking sheet. Bake for 10-12 minutes
My nephew may just be the pickiest of picky eaters. In his world there are three food groups: chicken nuggets, chips, and cookies. I'll admit I give into the cookie category a little too much but hey I'm the aunt, I'm allowed to. Anywho, I'm always thinking of what I can make that he is actually going to to eat or how can I make something so he will eat it. This brings me to M&M PANCAKE SHAPES. Simply whip up your favorite pancake mix (thank you aunt jemima complete for only having to add water), add m&ms, throw on the griddle, use cookie cutters to make into fun shapes. Ta-Dah, he loved them!
Dinner Time My sister and niece came over to join us for dinner. My niece is not as picky as my nephew but still pretty picky. Then you got my sister who's a vegetarian. Great, now what could I make that everybody is going to eat? When in doubt, make mac & cheese. I stumbled across this homemade mac & cheese recipe from Chef in Training (such great food over there) that I happened to have all the ingredients minus the broccoli. To go along with it, I whipped up some of my cheesey garlic biscuits!
HOMEMADE MAC & CHEESE
- 14oz box of pasta noodles
- 1 tsp butter
- 1/3 c bread crumbs
- 3 tbsp parmesan cheese, divided
- 2 1/2 c milk
- 1/3 c flour
- 1/2 c chopped onions
- 1 c cheddar cheese
- 1 tsp dijon mustard
- 1 1/2 tsp salt
- 1/2 tsp pepper
- Preheat oven to 375 F. Coat a shallow 2-quart baking dish with cooking spray.
- Cook pasta according to package; drain and return to pot.
- Meanwhile, in a large saucepan, melt butter over medium heat; add bread crumbs and cook, until light golden.
- Remove from heat and transfer crumbs to a small bowl; stir in 1 tablespoon of Parmesan cheese and set aside.
- In same saucepan, whisk together milk and flour until blended; add onion. Bring to a boil over medium-high heat, whisking frequently. Reduce heat to low and simmer until thickened, about 2 minutes.Remove from heat and whisk in cheddar cheese, mustard, salt, pepper and remaining 2 tablespoons of Parmesan cheese.
- Pour over cooked, drained pasta; toss to mix and coat. Transfer to a baking dish; sprinkle with bread crumbs. Bake 20-25 minutes.
CHEESEY GARLIC BISCUITS
- 2 c biscuit mix
- 2/3 c milk
- 1/3 c shredded mozzarella cheese
- 1/3 c shredded cheddar cheese
- 3 tbsp melted butter
- 1/8 tsp garlic powder
- Preheat oven to 450 F
- Stir together biscuit mix, milk, & cheeses. Drop by spoonfuls onto ungreased cookie sheet.
- Bake 8-10 minutes. Melt butter; stir in garlic powder; brush on top of warm biscuits.
Sunday morning, the sun was shinning, the birds were chirping, and I had us some Banana Peanut Butter Muffins in the oven. Mmmmmm...
BANANA PEANUT BUTTER MUFFINS
- 1 1/2 c flour
- 1 tsp baking soda
- 1 tsp baking powder
- 1/2 tsp salt
- 2 bananas, mashed
- 3/4 sugar
- 1 egg
- 1/3 melted butter
- 1 tsp vanilla
- 1 tsp cinnamon
- 1 tsp nutmeg
- 2/3 peanut butter
- 1/3 c brown sugar
- 2 tbsp flour
- 1/4 tsp cinnamon
- 2 tbsp butter
- 1/3 c chopped peanut butter chips
- Preheat oven to 375 F, line 10-12 muffin cups with muffin papers
- Mix together flour, baking soda, baking powder, and salt. In another bowl, beat together bananas, sugar, egg, melted butter, vanilla, cinnamon, nutmeg, and peanut butter. Stir in flour mixture until all combined; spoon into muffin cups.
- Mix together all topping ingredients until mixture resembles coarse cornmeal; sprinkle over muffins.
- Bake 18-20 minutes
These turned out way yummy I had to share (although I could have kept them all for myself). I packed a few of them up and gave them to my grandma & grandpa. =)
Moving on to the Crafting, First project-- recycled crayons. These are pretty neat to make; my nephew had a fun time breaking up the crayons and was fascinated by how they turned out!
Easy peasy-- break up old crayons, fill them in foil lined muffin tins (I used a mini muffin tray), bake 8 minutes on 275 F. Let them cool, pop them out, & get to coloring again!
Last but not least, my favorite of the weekend & I think my nephew would agree-- SALT DOUGH HAND PRINTS:
- 1 c flour
- 1/2 c salt
- cold water
- Mix together flour and salt; add enough water to form a consistency like play dough
- Roll into balls and flat out with a rolling pin on greased cookie sheet
- Push that little hand down to form a hand print (I also added their names)
- Bake at 250 F for 2 hours; let them completely cool (I let it cool over night)
- PAINT and let dry!
These measurements gave enough dough for two hand prints with a little extra dough left over. We used the leftovers and made shapes out of them-- train for my nephew, heart for my niece
|Little Hands at Work|
Now that's what I call a weekend! Enjoy =)

domain: food


text:
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SHANGHAI, July 21. /TASS/. Investment projects screening for BRICS New Development Bank (NDB) will start by the end of this year, NBD Vice President from Russia Vladimir Kazbekov told TASS on Tuesday.
"Certainly, each country has its portfolio of projects. I think serious screening will start already by the end of the year," Kazbekov said.
"Neither articulated screening criteria nor a scoring system is available so far," Kazbekov said. "A highly intensive process of preparing all the criteria required for screening and appraisal of projects and assessment of credit risks will start now," he added.
NBD expects to present the five-year development strategy of the bank not later than the end of this year.
The agreement on establishing BRICS New Development Bank was reached on July 15, 2014 in Brazil’s Fortaleza. The bank will have a starting capital of $50 billion and the capital may be later increased to $100 billion. The Shanghai-headquartered bank has been set up to finance infrastructure projects and projects for sustainable development of BRICS and other developing countries.


text:
Vallery Jean | Mark Davis, Getty Images Fat Joe is wearing his heart on his sleeve…
- Posted on Nov 12th 2007 5:00PM by Christina Lang
'Lake Michigan,' by Rogue Wave
Rogue formed the Oakland-based quartet after losing his job in the 1990s dot-com bust, and since then the group has released albums on two record labels -- Sub Pop and, more recently, Jack Johnson's Brushfire Records. Chosen for Zune's advertising campaign and as November's Ignition Artist, this is not the first time Rogue Wave have lent their music out. The soundtrack to 'Napoleon Dynamite' featured a live version of 'Every Moment,' from thefoursome's 2003 release 'Out of the Shadow,' and 'Eyes' was featured on two episodes of NBC's hit sci-fi drama 'Heroes.'
Watch the video for 'Lake Michigan'
Buy it on iTunes
Can't find the name of that song? Send the commercial, movie or TV show to us at firstname.lastname@example.org.


text:
Trust in a relationship my review here means you are opening up to your lover’s ability to end up being responsible and do the right element. It is the determination to take dangers in order to be available and genuine about their needs and expectations by another person. Nevertheless , sometimes it could also mean the difference between a loving relationship and one that is certainly destructive. Rely upon a relationship can make all the difference in the world among two people who would like to share a life jointly. So many times i will be smothered or perhaps smacked straight down by the partners since they avoid trust all of us enough to share us what exactly they are thinking. Just how is it in that case that we can have trust in a relationship and also flourish?
Trust is such a great thing. It delivers people along, allows these to see that at this time there aren’t any kind of differences between themselves every other, and allows these to have honest and available communication with each other. While not trust in a relationship, presently there simply is not any room; with no honesty, there is certainly nothing to talk about, no eye-to-eye contact, and no understanding. No one can actually take spins with which they you should with this sort of disregard designed for the others involved.
Now discussing assume to get a second that you know that you, like most couples, aren’t at the highest with this basic level of trust. Both you and your partner take even lands. Perhaps get been loyal to each other throughout the course of your relationship, or perhaps things have evolved, but if both you and your partner are certainly not at that same level, then simply what are you doing incorrect? What can you carry out to help?
Very well, one thing is to realize that when you are building trust in a relationship, you need to take turns with whom you tell your partner. If one individual is normally trustworthy, therefore trust in general will unfold across the face. If two people are the same, consequently building trust will probably be easier. However , if one person is certainly not trustworthy whatsoever, then you have to find a new partner.
In order to build trust in a marriage, it’s important to know who you will be trusting with in your life. It’s also important to realize that trust means different things different people. To a few, trust means having total openness. To others, trust means being very careful with what you say. Even now others believe that trust means being entirely genuine.
To sum up, the definition of self-trust is that you could have an equal degree of confidence in the ability to result in your own personal actions and you don’t will need another person to rely on to do something responsibly. Self-trust is an attitude towards your self. It is an frame of mind that allows you place yourself initial. It is not shades faith in someone else. (Fahkry, 2021). Self-trust is essential to building relationships and trusting other folks.
In order to guarantee that you just trust-build in your relationship, take turns with responsibilities. If someone in your home has a thing that needs to be performed, take transforms doing it. If your friend includes a chore which should be done, take turns choosing turns doing it.
To build healthier trust in a relationship, you will need to be honest with yourself. Be honest about your intentions, and become honest along with your spouse. You don’t have to always be perfect; try to be yourself. You should let your partner see your problems, and make sure that he or she understands these people and knows they not necessarily some thing dreadful. Have a tendency minimize your feelings and be extremely apologetic.
Rely upon a relationship can take in many different levels. At the most basic level, trust implies that you will be comfortable opening up to him or her about things which may be awkward to discuss. At most basic level, it implies that you two have a significant comprehension of each other and therefore are perfectly comfy communicating with each other on almost all levels.
Building trust in a relationship is easy when your partner cartouche you. Sadly, many romantic relationships don’t start that way. Therefore it’s important to work through any issues that you two could possibly be having to make sure that you build trust quickly and effectively. One of the most effective ways to do that is to focus on the goals of your romance. Focus on what you need to escape the relationship, and ask yourself should your partner stocks and shares that same goal.
There are numerous ways that you can improve your relationship. Trust is one of the most critical relationships in a person’s lifestyle, so it’s necessary to make sure that you build it well from the ground up. If you are having issues, seek advice from bonior Chi town personal injury attorneys. They may have many products and services that they can provide to assist you overcome virtually any obstacles you will be experiencing in this field.

domain: sociology


Dear Friends and Neighbors,
What does Phase 3 mean?
On Monday, March 22nd the entire state entered Phase 3 of the Roadmap to Recovery. This is possible because of the work of healthcare professionals to get people vaccinated and the work of everyone to decrease rates of transmission. If we continue to follow the guidance, mask up, and keep social gatherings small and distant, then we can all recover more quickly.
Phase 3 will be one more step on the Roadmap to Recovery and I want to share the initial, high level guidance. For a full and current description, please refer to coronavirus.wa.gov.
- First, the state will return to evaluating phases by county instead of by region.
- Sports spectators will be allowed to gather for events with limited capacity and following specific safety guidelines.
- Industries and indoor activities that were allowed in Phase 2 can increase capacity. This includes businesses like restaurants, gyms and fitness centers, and movie theaters, among others.
Again, please refer to coronavirus.wa.gov for the most up to date details. If cases in a county increase at a certain rate then that county may be moved to a previous phase and if statewide ICU capacity reaches greater than 90% then all counties will move to a previous phase in order to maintain enough beds for patients needing critical care.
I know we all want to return to doing the things we miss. We can get there faster if we follow the evidence-backed guidance to make sure we keep the virus under control while reopening safely.
988—a new lifeline for crisis response and suicide prevention
For most people in our community, the only number they know for emergencies is 911. When police or the fire department is needed, that’s the best number to call. But when the emergency is related to substance use, a mental health crisis, or a person at immediate risk of suicide, having a law enforcement officer arrive at their door may not be the appropriate emergency response.
Officers are not social workers, nor do they want to be. Without a comprehensive crisis response system, people in crisis can find themselves in standoffs with law enforcement when they should be in the care of a counselor. People with severe mental illness are far more likely to end up in jail or prison and are more likely to be involved in fatal police encounters.
An improved crisis response system would reduce reliance on emergency room services and the use of law enforcement response to crises. Last year, the bipartisan National Suicide Hotline Designation Act designated 988 as the new national suicide prevention and mental health crisis hotline number, paving the way for states to develop improved crisis response systems. The federal law requires the line be operational by July 16, 2022.
Last week, I was proud to vote for HB 1477 which would implement the 988 system here in Washington state. The vision of this bill and the 988 line is to create robust call centers to support people in crisis and ensure they receive the care they need, when they need it. These enhanced 988 services will coordinate with 911, EMT and law enforcement, and behavioral health systems to create a seamless system of care for those in crisis.
American Rescue Plan: What’s in it for Washington?
This month, Congress passed President Biden’s American Rescue Plan, a strong federal investment in communities to help us all get past the COVID-19 pandemic. Due to strong leadership at the federal level, Washington state residents will receive support in the form of economic impact payments, while state, county, city, and tribal governments will receive increased funding and access to vaccines and testing, boosts to school districts and higher education institutions, rental assistance and child care funding, and support for small business grants.
Washington state’s share of the funds that the Legislature will have control over is about $4.253 billion. While we do not know exactly where that money will be directed yet, we should have a better idea by the time the House and Senate approve an operating budget in late April. Like we passed in February with our Step One for Community and Economic Recovery Plan (HB 1368), I will support using these federal funds to provide assistance to Washington families and businesses who have been most impacted by the COVID-19 pandemic. That means direct support for struggling renters, small restaurants and other neighborhood businesses, school districts, uninsured and underinsured individuals, and Black and Brown communities, which have been disproportionately hurt during the pandemic.
As always, please reach out if you have questions, comments, or ideas.
All best wishes,
Representative, 45th District
Washington State Legislature