This is a 1947 Garwood runabout in great condition. This boat was originally a 16' Garwood Ensign design that was stretched to 20' by professional boat builders using 20' planks. Bottom is epoxied. This boat has a completely rebuilt 350 Mercruiser 260 hp that has been balanced and rebuilt with all new parts. Such as, new oil pump, water pump, pulley, new manifolds, risers, new intake manifold, marine carburetor, fuel lines, new electric fuel pump, new gas tank. Complete new steering system, complete new electrical system including new alternator, new electronic ignition, new custom gauges by Classic Instruments, complete new closed cooling system, new flushing system. Upholstery is in excellent condition. New custom built tandem axle trailer with loading guides. This boat runs strong and rides well. Boat has been winterized and stored in garage with boat cover.


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Settlement is the novel I didn't plan to write. It's the sequel to Displacement. I thought I'd told all of Rachel and Jack's story but readers of Displacement told me no. They insisted there was more to tell. And they were right. I loved spending time with these characters again and although the book is a sequel it can be read as a standalone – but of course I'd love it if people read both.
The background to Displacement comes from my own experience of living for many years in the Scottish Hebrides and from my long association with Israel-Palestine. The latter is rooted in my friendship with an Israeli woman which began when we were schoolgirls in Edinburgh in the 1970s. Her father came to Edinburgh University to do his PhD and he brought his family with him. I volunteered to look after the new girl in class. After a year she returned home, but our friendship has endured. And because of that friendship I've visited Israel several times and I'm both fascinated and frustrated by this amazingly complex and beautiful country.
It's never too late to fall in love, but the past can get in the way of a happy future.
From the Scottish Hebrides to the Middle-East, Displacement is an intense, contemporary love story where romance and realism, and the personal and the political, meet head on.
Divorce, the death of her soldier son and estrangement from her daughter, leave Hebridean crofter, Rachel Campbell, grief stricken, lonely and lost.
Forced retirement due to a heart condition leaves former Edinburgh policeman Jack Baxter needing to take stock and find a new direction for his life.
After the two of them meet in dramatic circumstances on a wild winter's night on the island of Skye, a tentative friendship develops between them, despite their very different personalities. Gradually, however, their feelings for each other go beyond friendship.
But Rachel is about to go to Israel-Palestine where she plans to explore her Jewish heritage and to learn more about this contested land. And Jack is already in what is, for him, the ideal relationship – one where no commitment or fidelity is required.
Will they be able to overcome the obstacles that lie in the way of their deepening love?
Can Rachel find a way forward and let herself love again?
Can Jack trust himself not to hurt her?
For readers who enjoy mature, romantic, and thought-provoking fiction.
Change of Life is my first book. I began writing it after being diagnosed with, and recovering from, ovarian cancer. Although it was a difficult time in my life, having a brush with my own mortality helped me to stop procrastinating and take my writing seriously. In the book, one of the main characters has breast cancer and other significant disruptions in her life. And although her experiences aren't the same as mine, the book does deal with what it's like to have to cope with enormous upheaval and change and how you come out the other side.
When she hits a teenage boy with her car, her life explodes into uncharted territory. The boy is Robbie – and Rosie discovers he is part of a terrible secret that Tom has kept for seventeen years. Then Rosie is diagnosed with breast cancer. Rosie leaves home and begins the fight for her life. Meanwhile Tom, is forced to learn what it means to be a husband and father. He struggles to keep his family together and strives to get his wife back.
For readers who like mature main characters, heartwarming romance and an uplifting take on some difficult issues.


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New 2023 Mazda CX-7 Release Date, Changes, Review
New 2023 Mazda CX-7 Release Date, Changes, Review – Apparently, based on the motor trend site, the actual 2023 Mazda CX-7 is within the works. The brand new SUV must obtain some modest improvements and also changes. First, we could count on a far more eye-catching design exterior and within, and in all likelihood, the newest foundation.
From whatever we listened to, this portable SUV ought to trip with a changed Toyota Worldwide Design C-Program, and it also may possibly discuss a hybrid set up with all the Toyota Venza in addition to Toyota RAV4 designs. If you did not know, this well-known SUV was an immediate strike quite a while again. It's extremely lightweight and a lot small compared to the CX-9. Any predicted selling in the new design can happen during the new year, commencing around $30,000.
The most up-to-date 2023 Mazda CX-7 will likely make use of the exact same design vocabulary because of the CX-5 and CX-9 types. Generally, all seek the exact same, using a front-end that dominates. The most up-to-date records suggest the CX-7 will embrace any Toyota New International Structure C-System.
Nevertheless, it is unclear whether it will implement a comparable boxy form as the forerunner or expose many sharper collections. Incidentally, the brand's unique KODO design words will certainly exist, but we do not learn how very different it will likely be when compared to the designs CX-5 in addition to CX-9.
The particular cabin from the 2023 Mazda CX-7 must continue being neat and present. Generally, we do not assume considerable changes compared to the outbound product. Mazda will prove to add much more top-quality components and attempt to keep very competitive inside the class. The design will most likely stay the same, presenting a place in the back end for 3 travelers having a foldable heart armrest. The chairs may be broken up straight down, supplying a massive freight capability entry.
Regarding common capabilities, their list ought to be near CX-9 products. So, assume a 10.3-inches touchscreen display, Android mobile phone Car, Apple CarPlay, some sort of half a dozen-lecturer stereo system, two USB 2 . 0 plug-ins, Wireless Bluetooth, plus a Wi-Fi warm location. Aside from that, the company could increase the number of drivers' bits of help, causing this SUV to be a lot more tempting.
As said before, the forthcoming 2023 Mazda CX-7 will probably trip in the different Toyota's TNGA-C foundation. It also would use exactly the same hybrid setup as the Toyota Venza and Toyota RAV4 designs. This engine will be aspirated using a 2.5-liter inline-4 Atkinson-routine fuel-driven engine mated to 2 electric-powered engines.
Because of this setup, the Mazda CX-7 needs to supply 219 horsepower maximum result with fuel and electric power merged. On the flip side, we anticipate the all-tire-travel to become regular. All previously mentioned must convert to some merged city/road fuel economy connected with 39 miles per gallon.
This release date in the different 2023 Mazda CX-7 will occur at some point in the new year, in line with the motor trend website. Apart from far more exterior originality, the forthcoming SUV must present a lot more ease and comfort within.
The newest SUV could feature a hybrid setup, in contrast to the present version, which utilizes a new 2.5-liter inline-4 or perhaps a 2.3-liter turbocharged inline-4. It should start at $30,000 for your entrance-level product when a higher clip can get to 50,000.

redpajama_set_name: RedPajamaCommonCrawl


In her professional life, Soraya Denis serves as a senior program coordinator with the NYC Department of Correction (DOC), focusing on juvenile re-entry issues in the Youthful Offender Programming Division. It's rewarding work, she said, but like many ambitious John Jay alumni, it's only one part of her commitment to giving back to those groups that helped put her where she is today. Denis is also the founder of Dlo Pou Viv, a non-profit that advocates for clean water and personal hygiene for school-aged children and women in Haiti, and co-founder of Women Who Inspire Women (WWIW), a collective of professional women that promotes sisterhood and mentoring.
Those commitments earned her a spot on the Star Network's "40 Brooklyn Stars Under 40" ranking this year, an award that honors those who exemplify leadership skills not only in their chosen fields, but in their communities as well.
That includes having a multi-cultural background. Born in Brooklyn to Haitian parents, Denis lived in her ancestral country for several years before returning at the age of 6. She developed an interest in law early on, and attended both The High School for Legal Studies and Sheepshead Bay High School. As an undergrad at John Jay, Denis majored in legal studies and took courses in the Thematic Studies Program, but eventually found herself torn between pursuing law school or going into law enforcement, for which she had begun preparing by participating in a co-op program with the U.S. Marshall Service.
Today, Denis works in the DOC, opening up pathways to employment for young adults between 18 and 21 as they try and return to society after being incarcerated. This involves teaching them the soft and hard skills needed to get decent jobs upon release, as well as providing individualized support services and links to community-based organizations. "What's rewarding about this work is that I am able to follow up on the young adults who leave DOC custody through our partnerships," she said.
Still, the 34 year old has never forgotten her roots. A visit to Haiti in 2008 convinced her to launch Dlo Pou Viv, Haitian Creole for "water to live", which has held fundraising drives and conducted on-the-ground field work in an effort to bring international relief to the country's water crisis. At the same time, she's played a leading role in WWIW, which hosts an annual women's history month event to highlight everyday women making strides in their communities.
Both of these positions resulted her inclusion on the 40 under 40 list, a distinction she's not taking lightly. "It serves to remind me that the little girl who moved back to Brooklyn from Haiti at 6 years old lived up to her childhood dreams," she said.


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Cost-effectiveness and value of information analysis of NephroCheck and NGAL tests compared to standard care for the diagnosis of acute kidney injury
Elisabet Jacobsen1,
Simon Sawhney2,
Miriam Brazzelli3,
Lorna Aucott3,
Graham Scotland1,3,
Magaly Aceves-Martins3,
Clare Robertson3,
Mari Imamura3,
Amudha Poobalan4,
Paul Manson3,
Callum Kaye5 &
Dwayne Boyers1
Early and accurate acute kidney injury (AKI) detection may improve patient outcomes and reduce health service costs. This study evaluates the diagnostic accuracy and cost-effectiveness of NephroCheck and NGAL (urine and plasma) biomarker tests used alongside standard care, compared with standard care to detect AKI in hospitalised UK adults.
A 90-day decision tree and lifetime Markov cohort model predicted costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) from a UK NHS perspective. Test accuracy was informed by a meta-analysis of diagnostic accuracy studies. Clinical trial and observational data informed the link between AKI and health outcomes, health state probabilities, costs and utilities. Value of information (VOI) analysis informed future research priorities.
Under base case assumptions, the biomarker tests were not cost-effective with ICERs of £105,965 (NephroCheck), £539,041 (NGAL urine BioPorto), £633,846 (NGAL plasma BioPorto) and £725,061 (NGAL urine ARCHITECT) per QALY gained compared to standard care. Results were uncertain, due to limited trial data, with probabilities of cost-effectiveness at £20,000 per QALY ranging from 0 to 99% and 0 to 56% for NephroCheck and NGAL tests respectively. The expected value of perfect information (EVPI) was £66 M, which demonstrated that additional research to resolve decision uncertainty is worthwhile.
Current evidence is inadequate to support the cost-effectiveness of general use of biomarker tests. Future research evaluating the clinical and cost-effectiveness of test guided implementation of protective care bundles is necessary. Improving the evidence base around the impact of tests on AKI staging, and of AKI staging on clinical outcomes would have the greatest impact on reducing decision uncertainty.
Acute kidney injury (AKI) incidence among the adult general population is estimated at about 150 per 10,000 per year [1]. Hospitalised patients are at greater risk following cardiac surgery (ranging from 8 to 40%), abdominal surgery (13.4%), and major trauma (21 to 24%) [2,3,4,5].
Early diagnosis and treatment can prevent AKI progression, which may reduce the risk of chronic kidney disease (CKD), and mortality [1, 6,7,8]. Patients who develop AKI in hospital are more likely to require renal replacement therapy (RRT) or intensive care unit (ICU) admission for kidney organ support and have longer length of stay (LOS). Cost implications to health services in England may be as high as £483 million per year [6].
In current standard care, AKI detection relies on monitoring changes in serum creatinine and urine output [9]. However, serum creatinine levels are not a precise indicator, and can take days to rise leading to delays in AKI recognition [2]. Novel biomarkers are intended to help detect AKI earlier, allowing initiation of prompt treatment with a care bundle to protect the kidneys, thereby improving outcomes and reducing healthcare costs. However, clinical and cost-effectiveness evidence for different biomarker tests is sparse, especially prior to admission to critical care [10,11,12,13]. This study uses a decision model to estimate the cost-effectiveness of four diagnostic biomarkers from a UK National Health Service (NHS) perspective. Value of information (VOI) analyses identify areas of greatest uncertainty where future research should be prioritised.
The modelled population was UK hospitalised adults, at risk of AKI, who were having their kidney function monitored. The modelled population was designed to conform to the National Institute for Health and Care Excellence (NICE) assessment of diagnostic tests for AKI [14]. At model entry the cohort had a mean age of 63, and 54.3% were female, based on a published study of AKI incidence in a UK population [1].
Interventions and comparators
Four biomarker tests were evaluated [14]. The NephroCheck test (Astute Medical) measures two biomarkers (tissue inhibitor of metalloproteinase 2 [TIMP-2] and insulin-like growth factor binding protein 7 [IGFBP-7]) in urine to calculate an AKI risk score. The threshold used for the NephroCheck test results to assess the risk of AKI was 0.3. The ARCHITECT urine NGAL assay (Abbott) is a chemiluminescent microparticle immunoassay to measure NGAL in human urine. The BioPorto NGAL test (BioPorto Diagnostics) is a particle-enhanced turbidimetric immunoassay to determine NGAL in either human urine or plasma (considered as two different tests). No restrictions were placed on the threshold for assessing the risk of AKI for the NGAL test results (see the Diagnostic accuracy section for more details). All tests were assessed in addition to standard clinical monitoring (e.g. serum creatinine and urine output monitoring), compared to standard clinical monitoring alone. The reference baseline levels of serum creatinine are defined according to current clinical criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE), Kidney disease: Improving Global Outcomes (KDIGO) and Acute Kidney Injury Network (AKIN)).
Model structure
A decision tree combined with a Markov cohort model was developed in TreeAge Pro (TreeAge Software, Williamstown, MA, 2019). The model structure (Fig. 1) was adapted from Hall et al. [10], who shared access to their model files under a 'creative commons' licence. The model structure was validated with clinical experts in nephrology and intensive care medicine.
Decision tree (up to 90 days)
The decision tree described the diagnostic accuracy and short-term health outcomes (admission to ICU, need for RRT, hospital LOS, and mortality) up to 90 days after test initiation. Tests may be true positive (TP), false negative (FN), true negative (TN) or false positive (FP). Biomarker tests may be beneficial if they can promptly and accurately identify AKI to enable appropriate early initiation of a protective care bundle which in turn can prevent further kidney damage. The benefits of prevention or a reduction in AKI severity (KDIGO stage) include reductions in LOS, need for RRT, ICU admission, development of CKD and the risk of mortality. All test positive patients are modelled to receive the care bundle but only those with a TP test result receive early treatment benefits. AKI prevention means keeping patients in the "No AKI" model pathway. It is assumed that FN tests incur the same risks as standard care, assuming that all positive AKI cases will eventually be identified using serum creatinine monitoring. Due to a lack of evidence, no negative effects of FP tests were assumed for the base case analysis but we recognise that identification and kidney support in AKI may not be risk free [15]. Scenario analyses explored an increased mortality risk associated with unnecessary removal of nephrotoxic treatments.
Markov model (lifetime horizon)
The Markov cohort model described CKD progression from early to subsequent end-stage renal disease (ESRD), need for dialysis, transplant, and mortality over a lifetime horizon from day 90 to death. The surviving cohort (at 90 days) enter the Markov model in either the "CKD (1-4)" or "No CKD" state. The cohort then transition between six health states: "No CKD", "CKD (1-4)", "ESRD", "Post ESRD + dialysis", "Post-transplant" and "Death" in annual model cycles, according to a set of transition probabilities. A half-cycle correction is applied. It was assumed that reversion to milder states (e.g. "No CKD") was not possible. Those that had a failed transplant returned to dialysis, after which a subsequent transplant was possible. Other than the initial CKD risk, health state transitions are independent of 90-day AKI status. An annual mortality risk was modelled according to disease-specific [16,17,18] and age, and sex-adjusted general population risks [19].
Full details of all model parameters (transition probabilities, relative risks, costs, and utilities) are provided in Additional file, Table 1.
Diagnostic accuracy
Test sensitivity and specificity were obtained from a systematic review and random-effects meta-analysis where possible. This model was chosen because of the heterogeneity across studies regarding different threshold values used for a positive NGAL test and variation in the classification systems used to determine AKI (KDIGO, RIFLE and AKIN). Table 1 describes the pooled diagnostic accuracy estimates obtained from 22 studies.
Table 1 Sensitivity and specificity data obtained from the systematic review
Clinical parameters
AKI incidence and severity were based on KDIGO staging (peak AKI status during hospitalisation), obtained from a 2012 cohort of people admitted acutely to hospital in the Grampian region of Scotland [1].
The impact of early delivery of a KDIGO care bundle on AKI was assumed to be that obtained from Meersch et al., a German trial of 276 NephroCheck positive patients, which reported a 16.6% (95% CI: 5.5 to 27.99%) absolute risk reduction in 72-h AKI for patients treated with a KDIGO care bundle compared to standard care [20]. The study also provided data to enable calculation of the impact of the care bundle on AKI severity (KDIGO staging). No comparable data were available for NGAL tests. Clinical expert advice indicated that NGAL may not detect kidney stress before damage occurs. It was therefore conservatively assumed that NGAL may reduce severity but could not prevent AKI.
The modelled hospital and post-discharge health outcomes associated with changes in AKI severity (need for ICU, 90 day mortality, hospital length of stay) were obtained from a re-analysis of published observational data from N = 17,630 patients admitted to Grampian (Scotland) hospitals in 2003, who were having their kidney function monitored through a blood test, and assumed to be at high risk of AKI [18, 21, 22]. Those with AKI, and those classified as having more severe AKI were more likely to need ICU care, had longer hospital LOS, and had a higher 90-day mortality risk. For those with AKI, the probability of developing CKD was calculated using hazard ratios from a recent systematic review and meta-analysis [23].
The modelled effect on outcomes of averting or reducing the severity of AKI through testing may be confounded with patient underlying characteristics. Therefore, based on clinical expert advice, and the published literature [20, 23, 24], we assumed that AKI mitigation/prevention leads to the full observed impact on CKD risk reduction obtained from the Grampian cohort data [23], some improvement (half the observed effect) in the need for ICU and hospital LOS and no improvement (none of the observed effect) in 90-day mortality [20, 24]. The extent to which observed associations are causal remains uncertain. Therefore, the proportion of the effect size applied in the model is varied in scenario analyses.
For the Markov cohort model, the proportion starting in the CKD state was calculated based on CKD prevalence (11.05% from the Grampian dataset) and hospital AKI severity. The remaining cohort with no initial CKD experienced an ongoing risk of developing CKD in the following cycles [10]. The remaining transition probabilities were obtained from a Swedish multi-centre cohort study, the SHARP trial, Scottish registry data and the UK Renal Registry [17, 25,26,27].
NHS perspective costs include the costs of test kits, staff time, hospital resource use up to day 90 (this included total number of days in hospital ward and ICU from the point of index admission up to day 90), hospital resource use after day 90 (including longer term hospital costs post discharge from hospital ward/ICU) and long term costs of CKD over a lifetime horizon.
Biomarker test costs included analysers, equipment, maintenance, consumables, staff time and training. Costs were based on manufacturer provided data, clinical expert opinion and unit costs for staff time (Additional file, Table 2). An additional three days of a preventative KDIGO care bundle was given to all test positive patients. This consisted of the avoidance of nephrotoxic agents, discontinuation of certain medications (ACE inhibitors and ARBs), regular monitoring of serum creatinine and urine output, steering clear of hyperglycaemia, avoiding radio contrast and intense hemodynamic monitoring. This was costed at £106.36, based on NICE guidelines for preventing AKI and included the costs of nephrologist and pharmacist time, intravenous fluids and clinical review of medications including those for blood pressure (ACE inhibitors, ARBs) [9]. Costs of LOS on a hospital ward, ICU, and RRT delivery were based on NHS reference costs [28].
Markov health states costs for those without CKD, included outpatient follow-up, as an average of those who had and had not received ICU care as part of their index admission [25]. The remaining health state costs were obtained from the SHARP trial, including outpatient, day-case and inpatient admissions [17]. Additional medication costs (immunosuppressant for a transplant patient, ESA for dialysis patients and blood pressure medications for dialysis patients) were obtained from the literature, NICE guidance and the BNF [16, 29,30,31]. All costs were incorporated in 2017/18 values, and inflated where necessary using the Cochrane and Campbell economic methods group online tool [32].
Quality adjusted life years (QALYs)
QALYs combine length (accounting for mortality) and quality of life into a single measure for use in decision-making. Utility data were obtained from an updated version of the systematic review published by Hall et al. [10]. For the acute decision tree phase, no new utility studies were identified. Therefore, utilities from Hall et al. were used. The review identified several health state utility values for the post discharge time period [33], CKD [34], ESRD [34] and dialysis [35] states. Where several utility studies were available, we prioritised those that used EQ-5D with a UK value set and larger sample sizes. All utilities used in the model were age and sex adjusted to allow quality of life to reduce naturally over time and to reconcile source study characteristics with the characteristics of the modelled cohort [36, 37].
The decision model was analysed probabilistically using Monte Carlo simulation, with 1000 random draws. Costs and QALYs accruing beyond the first year were discounted at 3.5% per annum [38]. Incremental cost-effectiveness ratios (ICERs) were calculated for each test compared to the next best alternative, excluding those that were more costly and less effective than an alternative (dominated). Uncertainty was illustrated using cost-effectiveness acceptability curves (CEACs) and a comprehensive range of scenario analyses were carried out to explore the impact of key assumptions on the ICER. Subgroup analyses were conducted to explore the cost-effectiveness by parameterising the model using diagnostic accuracy data from several pre-defined subgroups (critical care only, post cardiac surgery only) (see Additional file, Table 5 and 6).
Expected value of perfect information (EVPI) and the expected value of perfect parameter information (EVPPI) were calculated for the model comparison of NephroCheck vs. standard care using the Sheffield Accelerated Value of Information (SAVI) tool [39, 40]. In this case, EVPI helps establish the economic value of future research (for example a new randomised trial) that could help inform the cost-effectiveness of NephroCheck vs. standard care by comparing the decision value under current and perfect information. Given a positive EVPI indicating that future research is worthwhile, we then used EVPPI analysis to identify research areas, specifically model parameters, where future research should be prioritised to have the greatest impact on reducing decision uncertainty [39]. To complete the EVPI and EVPPI calculations the target population size was assumed to be the number of AKI episodes in England in 2018 (564,738) [26], and the duration of time where the technology is relevant was assumed to be 10 years [39].
The base case analysis showed that none of the tests achieved an ICER <£20,000 per QALY gained compared to standard care (Table 2). Amongst the testing strategies, NephroCheck was the most promising test due to its potential ability to avert AKI.
Table 2 Base case cost-effectiveness results
Scenario analyses show that there is substantial residual uncertainty around the results. Full details of all scenario analyses are provided in the Additional file, Tables 3 and 4. Results are most sensitive to assumptions about the impact of AKI prevention on health outcomes. The extent to which preventing or reducing severity of AKI through early test guided protective KDIGO care bundles can truly reduce the risk of ICU admission, 90-day mortality, hospital length of stay and CKD risk is a major driver of model uncertainty. Assuming that the full observed relationship between AKI and these outcomes can be achieved through early detection and prevention (Scenario 1), NephroCheck is the most likely test to be cost-effective (98.5% probability if society is willing to pay £20,000 for a QALY gain). However, assuming none of the benefits in health outcomes can be achieved (Scenario 2), means none of the tests are cost-effective, demonstrating that it is not sufficient to prevent AKI, unless that prevention can definitively improve health outcomes.
Several scenario analyses increase the probability of NephroCheck being cost-effective (at a threshold value of £20,000 per QALY gained): including a daily excess AKI cost to patients in hospital ward/ICU over and above the hospital ward/ICU daily cost (Scenario 4, 98.8%), applying long-term costs and mortality risks that depend on whether the patient entered ICU or not (Scenario 6, 97.2%), assuming a lifetime excess CKD risk for AKI patients (Scenario 7, 55.5%), and applying a higher AKI prevalence (Scenario 10, 63.1%). On the other hand, some scenario analyses reduce the probability of the NephroCheck test being cost-effective: including removing RRT costs (Scenario 5, 27.7%), increasing the number of times a test is conducted to two (Scenario 11, 9%), and applying an additional mortality risk (RR = 1.5) to all FP test results (Scenario 12; 0%).
Given that our model base case assumes that NGAL cannot avert AKI, the probability of cost-effectiveness tends to be lower for the NGAL test strategies than NephroCheck across the scenario analyses. However, an analysis assuming that NGAL can also avert AKI, results in the BioPorto urine NGAL test being the optimal strategy (Scenario 3, 43.5%), though evidence to support the validity of this assumption is weak.
Subgroup analyses showed similar cost-effectiveness results for the critical care subgroup but low probabilities of cost-effectiveness in the cardiac care subgroup. Any suggestion of differences in cost-effectiveness across subgroups should be interpreted cautiously due to sparse diagnostic accuracy data in each subgroup, and due to a lack of subgroup specific data to inform downstream costs, utility and event probability parameters.
Value of information analysis
The EVPI was £11.62 per patient and approximately £66 million at the population level over a ten-year time horizon, indicating that there is substantial value to be obtained from future research (such as well-designed randomised trials) to investigate the cost-effectiveness of NephroCheck vs. standard care (Fig. 2). Among individual model parameters, the EVPPI value was highest for the impact of early treatment on AKI prevention (£5.05 million) and the impact of AKI prevention on 90-day mortality (£3.66 million), indicating that research funding allocated to addressing these research questions would have the greatest impact on reducing decision uncertainty. The group population EVPPIs were £19.29 million for baseline probabilities, £8.98 million for costs and £0 for the utilities. This indicates there is adequate information available on utilities, but more research is required on overall AKI disease progression, downstream clinical events following AKI and its resource use implications.
Prioritised areas for future research
Interpretation of findings
This economic model compared the cost-effectiveness of four biomarkers NephroCheck, ARCHITECT urine NGAL and BioPorto urine and plasma NGAL to identify AKI in a UK hospital setting. The optimal, most cost-effective strategy was unclear, driven predominantly by the lack of clinical trial evidence of the impact of the biomarker tests on direct health outcomes such as ICU need, hospital LOS, development of CKD and mortality. Under base case assumptions, none of the biomarker tests were cost-effective. However, when exploring alternative analyses around uncertain parameters, the NephroCheck test had the greatest potential to achieve cost-effectiveness. That is because of NephroCheck' s theoretical ability to pre-empt kidney damage and because the only evidence available to support an impact of a positive biomarker test guided implementation of an AKI care bundle is for NephroCheck [20].
The VOI analysis clearly shows that future research to resolve this decision uncertainty is worthwhile and that future research effort should be prioritised towards determining the clinical-effectiveness of novel biomarker tests in terms of AKI prevention through early intervention and 90-day mortality risks. Currently, clinical evidence points to some mitigation or aversion of AKI [20]. The observed data demonstrate that people with AKI (and more severe AKI) have poorer health outcomes than those without AKI (and with less severe AKI). However, it is not clear if averting AKI, or reducing its severity can fully remove the observed increased risk of adverse health outcomes associated with it. For example, Meersch et al. showed that early test guided application of a protective care bundle reduced AKI incidence and severity, but no beneficial effect on health outcomes was demonstrated. Similarly, an RCT of an early warning electronic alert system for AKI to trigger a renal consultation showed no evidence of a mortality benefit [24]. Hence, limited direct evidence exists to support an impact of biomarker tests on other health outcomes. Several trials are currently being conducted that are comparing NephroCheck guided initiation of a KDIGO care bundle to standard care (e.g. BigpAK1 trial, NEPHROCAR trial and a clinical trial in sepsis patients) [41]. These studies will report outcome data on AKI, 90-day mortality, need for RRT, ICU LOS, and hospital LOS. The data provided from these studies will be a valuable resource from which to inform future economic evaluations.
Current literature
Hall et al. [10] also developed an economic model comparing different biomarker tests to assess the risk of AKI in ICU patients. The results for the biomarker tests in this study are less favourable to those reported in Hall et al. for several reasons. Our study scope focused on people not in ICU who could be considered for critical care rather than ICU patients where critical care is already being delivered. Therefore, the AKI prevalence is lower than in Hall et al. The higher the prevalence, the more likely the tests are to be cost-effective, as shown in our scenario analysis. This implies that careful consideration should be given to identifying subsets (e.g. post-major surgery) of those in hospital who would be most likely to benefit from testing and could be targeted in future trials. Furthermore, there were differences in test accuracy data between the reviews, with our review showing lower sensitivity for NephroCheck. This may be because new studies have become available since Hall et al. and the broader setting considered in our model. Finally, the approach to the estimation of costs is different; our analysis does not include an excess daily AKI cost for patients while in hospital, due to concerns about double counting costs already captured through AKI staging. An additional excess daily cost was added in scenario analysis. We also do not differentiate between the follow-up costs of ICU and non-ICU patients in the longer-term, though we explored this in scenario analyses.
A key strength is that the economic model is built on the basis of a comprehensive evidence synthesis to identify the diagnostic accuracy of the biomarker tests. The economic model was populated using both trial and real-world clinical registry data ensuring a high degree of external validity for the model inputs. The results are policy relevant and the VOI analysis in particular can help guide future research prioritisation and hence help avoid future research waste.
Our analysis was limited to the scope of the research question. For example, our results are only relevant to testing for AKI in a hospital setting. In addition, we recognise that NephroCheck and NGAL are two biomarkers among many. AKI biomarkers differ in what their measurement represents, across spectrums of inflammation, damage, and function loss at different time points. It may be that either a panel of biomarkers or sequential use of tests would be more clinically useful. However, it was not possible to evaluate these uses in our study. Additionally, given the broad heterogeneity of AKI causes, it is possible that further research will be able to delineate specific clinical circumstances or subsets of people in which biomarkers have the greatest potential to provide a cost-effective use of resources. Although our study had no ethnic restriction on inclusion criteria, future studies, especially clinical trials, should ensure diverse recruitment across ethnic and demographic populations. Furthermore, a separate analysis would be needed to assess the potential for stepping down care among those whose sole requirement for critical care is for kidney support.
This model did not account for CKD regression (i.e., a subset of people who have improving kidney function over time) [42] but used the conventional model for CKD where the majority are stable and a minority progress through CKD stages accumulating higher costs and worse outcomes, in line with previous kidney disease models [10]. It is unclear how this may or should influence mortality outcomes, or health care resource use. Furthermore, our model does not capture regression or progression between CKD stages (but applied average hospital care costs and utilities for this patient group) with a very small chance of progressing to CKD 5. Therefore, the impact of incorporating regression on cost-effectiveness findings is uncertain.
The results of the base case analyses should be interpreted cautiously because of the heterogeneous nature of the diagnostic accuracy studies in terms of NGAL threshold levels, timing of the sample collection, time of AKI diagnosis, definition of AKI, prevalence of AKI and definition of the population. Moreover, the clinical-effectiveness review identified no direct evidence about the incremental benefit of biomarker tests on clinically important and patient relevant health outcomes. We had to rely on a linked evidence approach, which contributed substantial decision uncertainty regarding cost-effectiveness.
Current evidence is inadequate to support the cost-effectiveness of general use of biomarker tests. To minimise uncertainty about the cost-effectiveness of biomarker tests future research should be prioritised towards high quality randomised trials that target select patient subsets and assesses the added value of test guided use of AKI care bundles on clinically important and patient relevant health outcomes, in particular 90-day mortality.
No new individual patient data were generated in support of this research. All cost-effectiveness and valuation of information model parameters are reported within the article and additional supplementary materials.
ACE:
Angiotensin-converting enzyme
ARBs:
Angiotensin receptor blockers
AKI:
AKIN:
BNF:
British National Formulary
CEAC:
Cost-effectiveness acceptability curve
CKD:
EQ-5D:
EuroQol five dimensional measure of quality of life
ESRD:
End-stage renal disease
EVPI:
Expected value of perfect information
EVPPI:
Expected value of perfect parameter information
FN:
False negative
FP:
ICER:
Incremental cost-effectiveness ratio
ICU:
IGFBP-7:
Insulin-like growth factor binding protein 7
KDIGO:
Kidney Disease: Improving Global Outcomes
LOS:
MVN:
Multi-variable normal distribution
NHS:
NICE:
National Institute for Health and Care Excellence
QALY:
Quality adjusted life year
RCT:
Randomised controlled trial
RIFLE:
Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease
RRT:
SAVI:
Sheffield accelerated value of information tool
SHARP:
Study of Heart and Renal Protection
TIMP2:
Tissue inhibitor of metalloproteinase 2
TN:
True negative
TP:
True positive
VOI:
Value of information
Sawhney S, Robinson HA, van der Veer SN, Hounkpatin HO, Scale TM, Chess JA, et al. Acute kidney injury in the UK: a replication cohort study of the variation across three regional populations. BMJ Open. 2018;8(6):e019435.
Bell S, Lim M. Optimizing peri-operative care to prevent acute kidney injury. Nephrol Dial Transplant. 2019;34(5):757–9.
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Hall PS, Mitchell ED, Smith AF, Cairns DA, Messenger M, Hutchinson M, et al. The future for diagnostic tests of acute kidney injury in critical care: evidence synthesis, care pathway analysis and research prioritisation. Health Technol Assess. 2018;22(32):1–274.
Shaw A, Chalfin D. Economic impact and cost-effectiveness of urine neutrophil gelatinase-associated lipocalin following cardiac surgery. Crit Care. 2010;14(1):1.
Parikh A, Rizzo JA, Canetta P, Forster C, Sise M, Maarouf O, et al. Does NGAL reduce costs? A cost analysis of urine NGAL (uNGAL) & serum creatinine (sCr) for acute kidney injury (AKI) diagnosis. PLoS One. 2017;12(5):e0178091.
Petrovic S, Bogavac-Stanojevic N, Lakic D, Peco-Antic A, Vulicevic I, Ivanisevic I, et al. Cost-effectiveness analysis of acute kidney injury biomarkers in pediatric cardiac surgery. Biochem Med. 2015;25(2):262–71.
National Institute for Health and Care Excellence. Tests to help assess risk of acute kidney injury for people being considered for critical care admission (ARCHITECT and Alinity i Urine NGAL assays, BioPorto NGAL test and NephroCheck test) Diagnostics guidance [DG39]. 2020. Available at: https://www.nice.org.uk/guidance/dg39/history. Accessed 3 Nov 2020.
Wilson FP, Martin M, Yamamoto Y, Partridge C, Moreira E, Arora T, et al. Electronic health record alerts for acute kidney injury: multicenter, randomized clinical trial. BMJ. 2021;372:m4786.
UK Renal Registry. UK Renal Registry 21st Annual Report - data to 31/12/2017 [online]. Bristol, UK: UK Renal Registry. Available from: https://www.renalreg.org/publications-reports/. Accessed 24 Oct 2019.
Kent S, Schlackow I, Lozano-Kühne J, Reith C, Emberson J, Haynes R, et al. What is the impact of chronic kidney disease stage and cardiovascular disease on the annual cost of hospital care in moderate-to-severe kidney disease? BMC Nephrol. 2015;16(1):65.
Sawhney S, Marks A, Fluck N, Levin A, Prescott G, Black C. Intermediate and long-term outcomes of survivors of acute kidney injury episodes: a large population-based cohort study. Am J Kidney Dis. 2017;69(1):18–28.
Office for National Statistics. National life tables: UK [Online]. Newport, Wales: Office of National Statistics. 2019. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/datasets/nationallifetablesunitedkingdomreferencetables. Accessed 31 Oct 2019.
Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, et al. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;43(11):1551–61.
Sawhney S, Mitchell M, Marks A, Fluck N, Black C. Long-term prognosis after acute kidney injury (AKI): what is the role of baseline kidney function and recovery? A systematic review. BMJ Open. 2015;5(1):e006497.
Sawhney S, Tan Z, Black C, Marks A, Mclernon DJ, Ronksley P, et al. Validation of risk prediction models to inform clinical decisions after acute kidney injury. Am J Kidney Dis. 2021;78(1):28–37.
See EJ, Jayasinghe K, Glassford N, Bailey M, Johnson DW, Polkinghorne KR, et al. Long-term risk of adverse outcomes after acute kidney injury: a systematic review and meta-analysis of cohort studies using consensus definitions of exposure. Kidney Int. 2019;95(1):160–72.
Wilson FP, Shashaty M, Testani J, Aqeel I, Borovskiy Y, Ellenberg SS, et al. Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial. Lancet. 2015;385(9981):1966–74.
Lone NI, Gillies MA, Haddow C, Dobbie R, Rowan KM, Wild SH, et al. Five-year mortality and hospital costs associated with surviving intensive care. Am J Respir Crit Care Med. 2016;194(2):198–208.
UK Renal Registry (UKRR). UK Renal Registry Acute kidney injury (AKI) in England – a report on the nationwide collection of AKI warning test scores from 2018. 2020.
Rimes-Stigare C, Frumento P, Bottai M, Mårtensson J, Martling C, Walther SM, et al. Evolution of chronic renal impairment and long-term mortality after de novo acute kidney injury in the critically ill; a Swedish multi-Centre cohort study. Crit Care. 2015;19(1):221.
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Joint Formulary Committee. 2019. British National Formulary [Online] London: BMJ Group and Pharmaceutical Press. Available from: https://bnf.nice.org.uk/medicinal-forms/sodium-chloride.html#PHP76736. Accessed 25 Oct 2019.
Scotland G, Cruickshank M, Jacobsen E, Cooper D, Fraser C, Shimonovich M, et al. Multiple-frequency bioimpedance devices for fluid management in people with chronic kidney disease receiving dialysis: a systematic review and economic evaluation. Health Technol Assess. 2018;22:1–138
Cochrane and Campbell economic methods group. CCEMG – EPPI-Centre Cost Converter [Online]. 2019; Available at: London: Institute of Education, University College London. https://eppi.ioe.ac.uk/costconversion/. Accessed 24 Oct 2019.
Cuthbertson BH, Roughton S, Jenkinson D, MacLennan G, Vale L. Quality of life in the five years after intensive care: a cohort study. Crit Care. 2010;14(1):R6.
Nguyen NTQ, Cockwell P, Maxwell AP, Griffin M, O'Brien T, O'Neill C. Chronic kidney disease, health-related quality of life and their associated economic burden among a nationally representative sample of community dwelling adults in England. PLoS One. 2018;13(11):e0207960.
Liem YS, Bosch JL, Hunink MM. Preference-based quality of life of patients on renal replacement therapy: a systematic review and meta-analysis. Value Health. 2008;11(4):733–41.
Ara R, Brazier JE. Populating an economic model with health state utility values: moving toward better practice. Value Health. 2010;13(5):509–18.
Ara R, Brazier JE. Using health state utility values from the general population to approximate baselines in decision analytic models when condition-specific data are not available. Value Health. 2011;14(4):539–45.
National Institute for Health and Care Excellence. Guide to the methods of technology appraisal 2013. 2013; Available at: https://www.nice.org.uk/process/pmg9/chapter/foreword. Accessed 3 Nov 2020.
Briggs A, Claxton K, Sculpher M. Decision analytic modelling for the evaluation of health technologies. Oxford: Oxford University Press; 2006.
Strong M, Oakley JE, Brennan A. Estimating multiparameter partial expected value of perfect information from a probabilistic sensitivity analysis sample: a nonparametric regression approach. Med Decis Making. 2014;34(3):311–26.
NIH U.S. National Library of Medicine. Clinicaltrials.gov. 2021; Available at: https://clinicaltrials.gov.
Liu P, Quinn RR, Lam NN, Al-Wahsh H, Sood MM, Tangri N, et al. Progression and regression of chronic kidney disease by age among adults in a population-based cohort in Alberta, Canada. JAMA Netw Open. 2021 Jun;4(6):e2112828.
We are grateful to Thomas Walker and Rebecca Albrow at NICE for their thoughtful comments on earlier versions of the economic model and to the NICE Diagnostic Committee for their critical review of our identified evidence. We are also grateful for the advice and clinical guidance received from the NICE Specialist Advisory Group for DG19 and to Peter S Hall and Alison F Smith (on behalf of the team) for providing early versions of their economic model that was instrumental in the development and structuring of the model used in this study. A big thank goes also to Lara Kemp for her secretarial support and patience throughout the study.
The results presented in this paper have not been published previously in any academic journals, nor have they been submitted elsewhere. This work has informed the development of NICE guidance for diagnostic testing for AKI (https://www.nice.org.uk/guidance/dg39) and a full report to the funder describing the totality of this work will be published in the NIHR, HTA monograph series in due course.
The findings presented in this manuscript are part of a broader research project funded by the National Institute for Health Research (NIHR) and commissioned through the NICE Diagnostic Assessment Programme (project no 12/88/97). The views expressed are those of the authors and not necessarily those of NICE, the NHS, the NIHR or the Department of Health. The Health Economics Research Unit and the Health Services Research Unit, University of Aberdeen, are funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.
Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
Elisabet Jacobsen, Graham Scotland & Dwayne Boyers
Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, UK
Simon Sawhney
Health Services Research Unit, University of Aberdeen, Aberdeen, UK
Miriam Brazzelli, Lorna Aucott, Graham Scotland, Magaly Aceves-Martins, Clare Robertson, Mari Imamura & Paul Manson
Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
Amudha Poobalan
NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK
Callum Kaye
Elisabet Jacobsen
Miriam Brazzelli
Lorna Aucott
Graham Scotland
Magaly Aceves-Martins
Clare Robertson
Mari Imamura
Paul Manson
Dwayne Boyers
EJ (Research Fellow) developed the economic model, conducted the economic evaluation and wrote this manuscript. DB (Research Fellow) developed the economic model, supervised the economic analysis, and critically reviewed the paper. MB (Reader) oversaw the Diagnostic Evidence Synthesis on which the economic model is based and reviewed this manuscript. MA-M, CR, MI (Research Fellows) and AP (Senior Lecturer) reviewed the clinical effectiveness evidence of the biomarker tests and reviewed the paper. LA conducted the statistical analyses of the clinical effectiveness evidence. PM (Information Specialist) conducted the literature searches. GS (Reader) provided senior advice on the development of the economic model. CK (Consultant in Anaesthetics and Intensive Care Medicine) and SS (Clinical Lecturer in Nephrology) provided clinical guidance. All authors provided comments on this manuscript and approved its final version.
Correspondence to Elisabet Jacobsen.
Additional file 1: Supplementary Table 1
. Model parameters. Supplementary Table 2. Test costs. Supplementary Table 3. Scenario analyses description. Supplementary Table 4. Scenario analyses results. Supplementary Table 5. Sensitivity and specificity data obtained from the systematic review for the subgroup analysis. Supplementary Table 6. Results of the subgroup analyses.
Jacobsen, E., Sawhney, S., Brazzelli, M. et al. Cost-effectiveness and value of information analysis of NephroCheck and NGAL tests compared to standard care for the diagnosis of acute kidney injury. BMC Nephrol 22, 399 (2021). https://doi.org/10.1186/s12882-021-02610-9
Cost-effectiveness
Economic evaluation
Markov model


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PulseLive.ug
A 36-year-old New York lawyer who makes $270,000 says he lives off rice and beans so he can save 70% of his salary — and he's part of a growing movement pinching pennies to retire early
Hillary Hoffower
Maskot/Getty Images
A Manhattan corporate lawyer earning $270,000 a year told Suzy Weiss of The New York Post he lives on rice and beans so he can retire early.
He's one of an increasing number of millennials trying to join the FIRE community , Weiss wrote.
Successful early retirees have told Business Insider they stayed on track for financial independence by living on less.
Frugality is the key to building wealth .
Visit BusinessInsider.com for more stories.
Some people will do anything to escape the rat race.
Just ask 36-year-old Daniel, a Manhattan corporate lawyer earning $270,000 a year, who told Suzy Weiss of The New York Post that he lives in New Jersey to avoid city taxes, lives on rice and beans, owns one patched-together suit per weekday for work, and layers up during the winter instead of turning the heat on all so he can save 70% of his salary and retire early.
It's working: He's saved more than $400,000 and is set to retire in three years, Weiss wrote.
Other six-figure earners Weiss talked to have similar goals and are pulling out all the stops to reach them, from banning buying drinks out to wearing shoes that are falling apart.
They all hope to join the Financial Independence Retire Early (FIRE) movement , which was first popularized when " Your Money or Your Life " was published 20 years ago. It's nothing new but more millennials are becoming interested in the community, according to Weiss.
Read more : What 8 people wish they knew before retiring in their 20s and 30s
Living on less helps early retirees stay on track
Being content with less and refusing to succumb to lifestyle inflation are the tickets to staying on track to retire early.
J.P. Livingston , who runs a personal finance blog called The Money Habit , built a nest egg of more than $2 million before retiring at 28. Livingston worked in Manhattan's finance industry and earned $100,000 in her first post-grad job, she previously told Business Insider .
But, determined to retire early, she tucked 70% of her take-home pay away. In an effort to be more frugal, she bought furniture from Craigslist and chose a living situation more modest than one she could have afforded with a roommate in a three-floor walk-up on the Upper East Side for $1,050 a month (reasonable rent in a New Yorker's eyes).
Even those not working in traditional high-salaried careers make do with a frugal lifestyle. Consider Joe and Ali Olson , who quit their jobs as public school teachers in their early 30s with $1 million in the bank. They saved 75% of their income and lived in a 400-square-foot home, keeping their annual expenses to about $20,000, Business Insider previously reported .
Read more : A day in the life of a 34-year-old early retiree who lives in NYC, grew his net worth to $1.25 million in just 5 years, and wakes up at 7:30 a.m.
Frugality is the key to building wealth
Regardless of early retirement goals, frugality is the key to building wealth.
Look no further than Warren Buffett, who still lives in the modest home in Omaha, Nebraska, that he bought for $276,700 (in today's dollars), or Richard Branson , who is famously frugal when it comes to buying luxury items.
Frugal lifestyles help millionaires get rich in the first place, according to Sarah Stanley Fallaw, the director of research for the Affluent Market Institute and an author of " The Next Millionaire Next Door: Enduring Strategies for Building Wealth ," in which she surveyed more than 600 millionaires in America.
During her research, she studied the characteristics most predictive of net worth and found that six behaviors, which she called " wealth factors ," were related to net-worth potential, regardless of age or income. One of those is frugality : a commitment to saving, spending less, and sticking to a budget.
"Spending above your means, spending instead of saving for retirement, spending in anticipation of becoming wealthy makes you a slave to the paycheck, even with a stellar level of income," she wrote.
Read the full article at The New York Post
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I'm a millennial who went from earning $30,000 a year to earning $30,000 a month by launching my own business. Here are the 5 steps I took to bring my income to the next level without fancy marketing.
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50% of millennials have left a job for mental-health reasons, a new study found and it speaks to some of the biggest problems plaguing the entire generation
SEE ALSO: A woman who retired at 38 says 4 strategies can help anyone save big without pinching pennies
DON'T MISS: 5 people explain how their life unexpectedly changed after retiring early
Author: Hillary Hoffower Source: Business Insider USA
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Ruhi Singh Wiki, Biography, Age, Husband, Family, Net Worth
Ruhi Singh is an Indian actress, former Miss India and model who primarily appears in Hindi films and television. Singh has appeared in Emmy-nominated documentary The World Before Her and acclaimed web series Chakravyuh and Runaway Lugai. She was recently spotlighted among the top 10 of The Times' '50 Desirable Women of 2020' list.
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Ruhi Dilip Singh is an Indian actress, model, and former Miss India. She began her acting career by starring at the drama film Calendar Girls (2015).
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text:
Q: Android_Chronometer pause I want to pause chronometer and after I click the button I want to continue chromoneter to count... I search but couldn't a function related this.. how can do it?

A: The two other answers are identical, and work very well on the Chronometer's display, but they have one flaw: timeWhenStopped, as well as the value returned by getCurrentTime(), is negative.
Here is my suggestion, base on these two answers:
public class PausableChronometer extends Chronometer {

    private long timeWhenStopped = 0;

    public PausableChronometer(Context context) {
        super(context);
    }

    public PausableChronometer(Context context, AttributeSet attrs) {
        super(context, attrs);
    }

    public PausableChronometer(Context context, AttributeSet attrs, int defStyle) {
        super(context, attrs, defStyle);
    }

    @Override
    public void start() {
        setBase(SystemClock.elapsedRealtime() - timeWhenStopped);
        super.start();
    }

    @Override
    public void stop() {
        super.stop();
        timeWhenStopped = SystemClock.elapsedRealtime() - getBase();
    }

    public void reset() {
        stop();
        setBase(SystemClock.elapsedRealtime());
        timeWhenStopped = 0;
    }

    public long getCurrentTime() {
        return timeWhenStopped;
    }

    public void setCurrentTime(long time) {
        timeWhenStopped = time;
        setBase(SystemClock.elapsedRealtime() - timeWhenStopped);
    }
}

You've got to understand SystemClock.elapsedRealtime() as an indicator for "now". So when we (re)start the chronometer, we shall set the base N seconds in the past, N being the timer's current value (0 in case of first start).
Similarly, when stopping the chronometer, the time displayed by the chronometer is the time elapsed between the previously set base (getBase()) and now (SystemClock.elapsedRealtime()), hence the subtraction.

A: You are gonna need a variable that keeps track on the time that has passed since the Chronometer was started:
long timeWhenStopped = 0;

Update the value of the variable when you stop the chronometer like this:
timeWhenStopped = mChronometer.getBase() - SystemClock.elapsedRealtime();
mChronometer.stop();

We will also use this variable to adjust the chronometer before starting it:
mChronometer.setBase(SystemClock.elapsedRealtime() + timeWhenStopped);
mChronometer.start();

And finally if you have a way to reset your chronometer then you should remember to also reset the timeWhenStopped variable. Something like this:
mChronometer.setBase(SystemClock.elapsedRealtime());
timeWhenStopped = 0;

A: I made a PauseableChronometer class for this.
import android.content.Context;
import android.os.SystemClock;
import android.util.AttributeSet;
import android.widget.Chronometer;

public class PausableChronometer extends Chronometer {

    private long timeWhenStopped = 0;

    public PausableChronometer(Context context) {
        super(context);
    }

    public PausableChronometer(Context context, AttributeSet attrs) {
        super(context, attrs);
    }

    public PausableChronometer(Context context, AttributeSet attrs, int defStyle) {
        super(context, attrs, defStyle);
    }

    @Override
    public void start() {
        setBase(SystemClock.elapsedRealtime()+timeWhenStopped);
        super.start();
    }

    @Override
    public void stop() {
        super.stop();
        timeWhenStopped = getBase() - SystemClock.elapsedRealtime();
    }

    public void reset() {
        stop();
        setBase(SystemClock.elapsedRealtime());
        timeWhenStopped = 0;
    }

    public long getCurrentTime() {
        return timeWhenStopped;
    }

    public void setCurrentTime(long time) {
        timeWhenStopped = time;
        setBase(SystemClock.elapsedRealtime()+timeWhenStopped);
    }
}

redpajama_set_name: RedPajamaStackExchange


text:
require_dependency "roadblock/application_controller"

module Roadblock
  class PermissionsController < ApplicationController
    before_action :load_permission, only: [:show, :edit, :update, :destroy]

    def index
      @permissions = Permission.ordered
    end

    def show
    end

    def new
      @permission = Permission.new
    end

    def edit
    end

    def create
      @permission = Permission.new(safe_params)

      if @permission.save
        redirect_to @permission, notice: 'Permission was successfully created.'
      else
        render :new
      end
    end

    def update
      if @permission.update(safe_params)
        redirect_to @permission, notice: 'Permission was successfully updated.'
      else
        render :edit
      end
    end

    def destroy
      @permission.destroy
      redirect_to permissions_url, notice: 'Permission was successfully removed.'
    end

    private

    def load_permission
      @permission = Permission.find(params[:id])
    end

    def safe_params
      safe_attributes = [:action, :subject_class, :description, :restricted]
      params.require(:permission).permit(safe_attributes)
    end

  end
end

redpajama_set_name: RedPajamaGithub


text:
Do you trust politicians? Well, depends on how you define trust says research
May 24, 2019 Case Studies No comments
Summary:For decades, political scientists have measured the public's trust in the federal government consistently, using measures that are largely unchanged since the 1960s — despite the momentous changes happening over the last five decades in the United States. The new research tested a definition of trust and revealed three assessments that lead to one trusting in the government.
There's more to trust than credence and faith, especially as it comes to politics. Research from Michigan State University and North Carolina State University presents new evidence to suggest that there are more layers to political trust than the public — and politicians themselves — previously thought.
For decades, political scientists have measured the public's trust in the federal government consistently, using measures that are largely unchanged since the 1960s — despite the momentous changes happening over the last five decades in the United States.
The new research, published in PLOS ONE, tested a vulnerability-centered definition of trust — meaning, defining trust as a willingness to be vulnerable to the actions of another. The results revealed three assessments that lead to one trusting in the government: whether it has the ability to do its job, the benevolence to care about its people and the integrity to generally do the right thing.
"We went beyond the question of, 'do you trust government?' to find out what the concept of trust really means. Our research presents new ideas for thinking about political trust and offers suggestions for how to refine it beyond what's been done in the past," said Joe Hamm, MSU assistant professor of criminal justice and lead author of the study. "Using previous trust measures, people view 'happiness with' and 'trust in' government interchangeably — which is something we wanted to break apart and dissect. This is critical for us to understand and consider, especially given shifts in what we perceive as trust in recent years."
Hamm — who collaborated with MSU political scientist Corwin Smidt and Roger Mayer, professor of leadership in North Carolina State University's Poole College of Management — recruited participants to complete an online survey about their perceptions of the federal government. Participants were asked about the extent to which they felt recent political scandals mattered, whether they felt as though the government positively affected the economy and the extent to which they believed government represented their interests.
"We then used a series of questions to specifically measure the three dimensions of ability, benevolence and integrity," Hamm said. "Unlike the trust surveys used for decades, our questions focused specifically on the characteristics of government and how those characteristics impacted one's comfort in allowing the government to have power over parts of their day-to-day lives."
These more specific questions allowed for greater insight into how and why big issues, such as the economy and political scandals, may impact trust, Hamm said.
Data from the survey largely supported the researchers' arguments, such that while prior measurements of trust are not necessarily inaccurate, context and nuance matter.
"We can do better in thinking more critically about the psychological nature of trust," Hamm said.
The current research seeks to the lay the groundwork to eventually refine how political think tanks, pollsters and campaigns measure trust, Hamm said, and it may prove especially relevant looking ahead to the presidential election.
"We shouldn't ask whether or not you trust a politician — it's how you trust him or her, and what you're willing to accept vulnerability for," Hamm said. "If you're a candidate looking ahead to the 2020 election, there are different things to consider to be someone constituents like versus one that they trust."
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If anyone here is using Koush's AllCast beta application, which allows users to stream on-device videos to almost all of their TV-connected devices, a newly updated beta application is available through Google Play. Since the old beta version is set to expire, you will definitely need to pick up this new version if you plan to continue using the service.
To download the new version, if you are not a tester, simply join this Google+ community and then download the apk from Google Play. So far, devices such as Roku, Apple TV, a few Google TV boxes, Xbox 360 and Xbox One units are supported. It's quite the service, so go check it out and start streaming if you haven't already.


text:
---
uid: SolidEdgeAssembly.AssemblyFeaturesHoles.Application
summary:
remarks:
---


text:
<!DOCTYPE html>

    <meta charset="utf-8">
    <meta name="viewport" content="width=device-width, initial-scale=1">
    <meta name="mobile-web-app-capable" content="yes">
    <title>Ars Arsenal</title>

ArsArsenal

      vigetlabs/ars-arsenal


Whenever you're working in New Hampshire, you might not legally document your tiny business brand in Maine, for case. Ultimately you realize that it can be no much longer possible perform it most and continue to grow your provider. When you begin a new business, among the first items to carry out is get the company name you is going to apply.
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text:
YG Rapper Net Worth
There are a lot of active artists out there in the music industry. It may seem weird to start off an article with just a statement of fact. But there are just so many artists out there making music for their respective audience. It's really hard to keep track of all of them. I am not really somebody who actually reviews music by these artists. For the most part, it's very hard to articulate my thoughts about each track of an album outside of "I like this song. This one, not so much." I don't have the kind of vocabulary you would often see in those kinds of reviews.
NEXT: Here's What You Can Do To Increase Your Net Worth
One of the genres I don't often listen to is rap. There's just not much in the genre that has gotten me hooked. I have listened to a few rap songs. But more often that not, it's usually the ones that get played a lot on the radio. Even then, I don't really remember much of those songs once they've finished playing. So whenever I find out about any artist that I am not familiar with, I am always a bit surprised when I find out that they've actually been industry for quite a few years. Case in point: the rapper YG.
Weirdly enough, I am more familiar with the Korean entertainment company YG Entertainment more than the rapper YG. Obviously, the entertainment company and the rapper have nothing in common other than those two letters. YG was roughly five years old when the Korean company was first founded. So they've both been in the world for a while. There isn't much about to know about his childhood other than he was born in Compton, California. There are of different notable personalities, largely African-American, who have either been born or raised in that city.
YG, like a lot of rappers, first started their music careers with a mixtape. At the time he started releasing music on his own, there were a few digital platforms where you could buy his music. For the most part, streaming platforms weren't the big thing that it was in 2010. The way artists would earn money from their works was through digital sales for the most part. I guess you could still sell physical copies of your music in stores. But the internet was sort of one of the best places to release stuff aside from the radio. His single "Toot It and Boot It" that he did with Ty Dolla Sign managed to get on the Billboard Hot 100 on the 67th spot.
He consistently released through under Pushaz Ink. Though it wasn't really an actualy record label. He attempted to start one with Ty Dolla Sign and DJ Mustard, who were the ones who wrote Toot It and Boot It, but the process of finding another label to distribute it didn't really work out. And some of the people in the roster for Pushaz Ink had parted ways with them. Still, the Pushaz Ink brand was still part of most of his mixtape releases. It was until he got signed to Def Jam that he started having a major label handling the marketing for his debut album My Krazy Life in 2014. Looking at his discography, YG has managed to get most of his major label releases on the Billboard 200 charts. Some of them also have certifications like platinum for My Krazy Life and gold for his later releases. He also has a few gold and multiple platinum certified singles.
Shortly after the release of his debut album under a major label, YG restarted his plans to have his own label. In August 2016, he started 4Hunnid Records. Even though YG was signed to Def Jam Records, the distribution for the albums released under 4Hunnid were handled by Interscope Records which, along with Def Jam Records, operate within the Universal Music Group. All of the releases he did soon after establishing his own label were in conjunction with his label deal. Though it seems that he and Def Jam parted ways in 2020. His soon-to-be released album I Got Issues is distributed by 4Hunnid and Epic Records. Even then, YG has managed to amass a net worth of about $2,500,000.
Although 4Hunnid started off mainly as a record label, it seems like they sort of expanded to also become a general lifestyle brand. Looking at the pieces that's on the website, it's mostly streetwear that's inspired by the community that he lived in. I did forget to mention that apparently YG was a gang member.
TRENDING: Be Rich Like the Rapper YG


text:
The Future of Fair Use After Google Books
Jonathan Band · February 11, 2014
CopyrightFair UseGoogle BooksIntellectual Property
This weekend I participated in a panel about Judge Chin's decision in the Google Books case at the Copyright Society's mid-winter meeting. My debating partner was Jon Baumgarten, former General Counsel of the Copyright Office and partner at Proskauer Rose, where he represented publishers, among other rights holders. Jay Dougherty, a professor at Loyola Law School, acted as the moderator/referee. The discussion revealed profound disagreement on whether fair use jurisprudence is headed in the right direction.
After Professor Dougherty provided a quick overview of the case (eight years in five minutes!), I made four arguments why Judge Chin correctly concluded that fair use permitted Google's scanning of 20 million books into its search index.
First, in support of his finding that Google Books served the public interest, Judge Chin cited five times an amicus brief I helped write for the Library Copyright Alliance.
Second, the decision is consistent with "transformative use" decisions in the Second Circuit (Bill Graham Archives v. Dorling Kindersley, Authors Guild v. HathiTrust) as well as other circuits (A.V. v. iParadigms LLC, Kelly v. Arriba Soft Corp., Perfect 10 v. Amazon.com).
Third, to the extent that Jon Baumgarten might disagree with the transformative use jurisprudence generally, the Google Books decision fell within a subset of those decisions that involved digital technology. In these cases, although there was a large amount of copying in toto, that copying occurred "behind the curtain" in the course of creating a new product or service, and the end user generally could not see entire works. Thus, the use did not supersede the market for the works. Here, for example, Google displayed only three short "snippets" in response to each search query.
Fourth, even if one had doubts about these technological fair use cases, the Google Books case presented a unique set of circumstances that distinguished it from most other cases. In particular, because the Authors Guild did not seek preliminary relief, and did not insist that Google stop scanning during the lengthy negotiations and legal proceedings concerning the settlement, Judge Chin was confronted with a highly useful database containing 20 million books. Fashioning an appropriate remedy would be exceedingly difficult. Enjoining the use of the database until Congress develops a mass digitization exception, as the Authors Guild proposed in the HathiTrust case, was a completely unrealistic remedy. Thus, finding fair use may have been the best way forward given the facts on the ground.
Jon Baumgarten then explained why he thought Judge Chin decided the case incorrectly. Jon agreed with me that there was precedent supporting the decision, but argued that Judge Chin ignored other, more compelling, precedent. Jon's basic point was that Judge Chin compounded the errors that are the heart of many of the transformative use cases: rather than identify whether the expression is transformed, as Judge Leval originally intended, these cases simply ask if the expression is being used for a new, socially beneficial purpose. Jon is concerned that it will be too easy for clever lawyers to highlight a socially beneficial purpose, as my amicus brief did in this case. The emphasis on socially beneficial purpose changes the focus from the infringer's actions to uses made by third parties. It limits the ability of rights-holders to receive financial benefits from the use of their works. Analog works will become fodder for technology companies.
Jon added that although fair use is extremely important to the functioning of the copyright system, it should involve incidental activity, and not be conducted at the enterprise level. Under Judge Chin's analysis, Google is "too big to infringe."
Finally, Jon noted that Google's "Partner Program," under which it entered into licensing arrangements with publishers, indicated that there was a functioning licensing market, tilting the fourth factor against Google.
In my limited rebuttal time, I responded that while Google reached licensing agreements with some publishers with respect to some books, the copyright ownership of many of the books scanned by Google was unclear. The copyright might belong to the publisher, the author, or the author's heirs. The transaction costs involved in determining the ownership of these books' copyrights made licensing infeasible.
I added that reliance on fair use in this case, as well as in many of the other transformative use cases, was a function of the conflicts resulting from the interaction of a changing copyright system and evolving digital technology. On the one hand, the lengthening of copyright term and the abandonment of formalities as a condition for protection means that more works are covered by copyright than ever before – including many of the works at issue in this case. At the same time, the nature of digital technology means that users are making dramatically more copies in the course of their daily activities – turning on their computer, viewing websites with browsers, responding to and forwarding emails. During the course of the day, a user may make hundreds, if not thousands, of copies. Fair use is the theory that permits these activities.
Professor Dougherty asked the first question: was the Google Books decision consistent with the Berne three-step test? Jon Baumgarten said that it may well not be; how could the copying of millions of books be a "special case?" I replied that the three-step test applies to statutory exceptions a national legislature may adopt, so the issue would be whether fair use is compliant with the three-step test, not whether this application of fair use is three-step compliant. I noted that ever since joining the Berne Convention, the U.S. government has taken the position that fair use is three-step compliant, and as the world's only superpower, our position on this issue is dispositive. Further, the second and third steps ("do not conflict with a normal exploitation of the work and do no unreasonably prejudice the legitimate interests of the author") sounded like the first and fourth fair use factors ("the purpose and character of the use," "the effect of the use upon the potential market for or value of the copyrighted work").
A member of the audience asked whether the Google Books and HathiTrust decisions rendered the updating of section 108, as recommended by the Copyright Office, superfluous. I responded that while the exceptions in section 108 were extremely important to the operation of libraries, they probably were a bit out of date, as was the rest of the Copyright Act. Fortunately, fair use can provide some flexibility to specific exception. I mentioned my article published in the Journal of the Copyright Society where I argued that in situations where a defendant engaged in the sort of activity permitted by a specific exception, but ultimately did not qualify for a narrow technical reason, the court should consider the defendant's substantial compliance with the exception when applying the first fair use factor – the purpose and character of the use. I added that in a perfect world, Congress should update section 108, and the rest of the Copyright Act. But we live in an imperfect world, and given the availability of fair use, it made no sense for libraries and publishers to spend five years negotiating an update to section 108 that would be obsolete when completed.
Jon Baumgarten opined that my Copyright Society article was very scholarly, and dead wrong.
Another member of the audience made an impassioned statement that by pushing the fair use envelope, Google was in effect deciding unilaterally what the copyright law was, thereby forcing copyright owners to abandon their rights. Some audience members applauded at the conclusion of this statement.
I replied that it wasn't only Google that was relying on fair use. Some recent prevailing fair use defendants include Bloomberg, Thomson Reuters, and Reed Elsevier. I pointed out that Thomson Reuters and Reed Elsevier without authorization copied over a million briefs and other pleadings, which they incorporated into a commercial database product. When sued by a law firm, these publishers successfully argued that they had engaged in a transformative use.
Moreover, in many cases, plaintiffs are able to convince courts to reject assertions of transformative use. In the Salinger case, the Second Circuit found that a sequel to Catcher in the Rye was an infringing derivative work. Likewise, a district court found that a Harry Potter lexicon copied more expression than necessary to accomplish its purpose. In other words, courts are perfectly capable of distinguishing legitimate transformative uses from infringing derivative ones. They are readily equipped to find uses that will advance the public interest without diminishing an author's incentive to create.
After a panel of this sort, I always think of arguments I should have made, or more convincing ways to frame an argument I did make. A point I did not make is one I wrote about soon after the decision. I argued that for at least some of the Authors Guild members, this case has always been about the principle that no one should use their works without their permission. While they may agree with fair use in the abstract, they oppose it as applied to their works. The fact that the use is socially beneficial and does not harm them economically is irrelevant. They believe that creators should have complete control over copies. The positions Jon Baumgarten expressed this past weekend are consistent with this perspective.
This belief in complete control is based more on the Continental "author's rights" (droit d'auteur) tradition than on the Anglo-American utilitarian tradition. In the author's rights approach, copyright springs not from statutes but from natural law. By contrast, in the Anglo-American system, copyright is not a response to natural law, but rather is a matter of legislative choice directed at incentivizing the creation of works for the benefit of society. The Anglo-American utilitarian approach in theory provides only as much protection as is necessary to encourage creative activity, while the author's rights approach provides more robust protections of both economics and moral rights such as the rights of integrity and attribution.
However, in response to lobbying by right-holders, Congress has enacted certain features of author's rights systems – for example, the ever-increasing copyright term, referenced above. The first U.S. copyright act provided a term of 14 years, renewable for another 14 years, for a maximum total of 28 years. Now, the copyright term matches the European Union's term of life of the author plus 70 years.
The complete control over copyrighted works sought by the Authors Guild in this case is inconsistent with the public interest purpose of our copyright system. Fortunately, Judge Chin recognized that the objective of copyright is not to enrich rights-holders, but "to advance the progress of the arts and sciences."
Jonathan Band is a DC-based attorney whose clients include Internet companies, providers of information technology, universities, library associations, and CCIA. He previously guest-posted on DisCo about the impact of software infringement on manufacturing competitiveness.
The Internet enables the free exchange of ideas and content that, in turn, promote creativity, commerce, and innovation. However, a balanced approach to copyright, trademarks, and patents is critical to this creative and entrepreneurial spirit the Internet has fostered. Consequently, it is our belief that the intellectual property system should encourage innovation, while not impeding new business models and open-source developments.


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