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Hypocrisy At Google Camp By A-Listers
By: Denise Simon | Founders Code
Google Camp? Yes, at a fine resort in Sicily, Italy. Can you take your private yacht or airplane to The Verdura Resort?
Scores of A-list celebrities arrived in Sicily, Italy this week for the annual "Google Camp" to discuss the threat of climate change while communing with some of the wealthiest tech entrepreneurs in the world to a posh, seaside resort.
The event is hosted by Google co-founders Sergey Brin and Larry Page, who reportedly intend for the camp to be a "meeting of the minds" between technology giants, powerful business owners, and others who are known to be global thought leaders.
Many guests, rumored to include former President Barack Obama, Leonardo DiCaprio, Katy Perry, Bradley Cooper, Mark Zuckerberg, Prince Harry and Meghan Markle, are said to be arriving to the multi-day fest and climate discussion via private jets and mega yachts. Others are anticipated to arrive via helicopter from the Italian mainland. More than 114 private jets were reported to have been expected at nearby Palermo airport, where camp guests would be transported to the resort by van. Mega yachts docked at a nearby beach were reported to belong to designer Diane Von Furstenberg, German pharmaceutical giant Udo J. Vetter, Google's Eric Schmidt, New Zealand tycoon Graeme Hart, and American billionaire David Geffen.
We are told by Beto O'Rouke and Alexandria Ocasio-Cortez we only have 10-12 years left before earth implodes due to climate change. Perhaps a few months less now that these A-Listers just added more nasty and deadly carbon to the atmosphere, right?
Here these mega-rich celebrities are discussing for three days how to make the world better, protecting privacy, and human rights. Google is paying big bucks to host this confab where the parking lot and the marina will be full of Maserati SUV's, speed boats, and yachts worth more than $400 million powered by 2300 horse-powered diesel engines. Swell gig, eh?
Meanwhile, the entire resort staff all had to sign non-disclosures and additional security has been hired to roam the grounds of the resort.
Meanwhile, will any of these attendees challenge Google on their exploitation of privacy as that is one of the topics being discussed? How about the attendees asking Google about using only renewable energy alternatives to power their own DataPlex(s)? Take a look and consider the massive use of power.
With this elite global resort gathering, are the A-Listers and Google competing with the Davos Economic Forum or in cadence to set the power and policies of ruling the world? These titans are part of a password-protected Google site that has the agenda and the scheduling of the fun stuff like golf, sailing, tennis, the spas, meal planning, and party events.
Check the Instagram feeds, betcha some of these celebrities will boast about their fun in the sun.
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About THETA
Team & Community
Health Modeling and Health Economics
Health Policy and Ethics
Publications & KT
KT Events
THETA Rounds
ClinEpi Rounds
HTA Related Courses
HTA for Decision Making
R Course Series
HTA courses
HCV Utility Pilot Study
We have identified two important knowledge gaps in understanding the burden of Hepatitis C Virus (HCV):
The utilities of Chronic Hepatitis C (CHC) patients who have late stage liver disease (decompensated cirrhosis (DC) and Hepatocellular Carcinoma (HCC)) are poorly understood.
Most costs studies and utility studies have been conducted in tertiary care clinics. There are no studies on patients receiving care in the community.
We propose to measure the patient burden of HCV. This includes Health-related Quality of Life (HRQL) and health utilities in patients across CHC disease stages. It also includes the effect of HCV on workplace productivity, and costs borne by patients and families across different health care settings. This information will be useful for patients, doctors, and policy makers to make decisions on the new CHC treatments. Our results will have significant impacts on drug reimbursement policies and on guidelines for population screening.
What are patients' burdens of HCV, including HRQL and health utilities, across CHC disease stages?
Design and Methods
This is a multi-centre cross-sectional study, employing 7 self-reported questionnaires. The study cohorts will be selected from CHC-infected individuals attending tertiary care clinics or inpatient units of the University Health Network (UHN), or attending one of the 3 community clinics of the Toronto Community Hepatitis C Program (TCHCP) at Regent Park Community Health Centre, South Riverdale Community Health Centre and Sherbourne Health Centre. The tertiary care clinic patients are mostly middle class whereas most community clinic patients are from high-risk populations such as the homeless and intravenous drug users. We predict that their utilities will also differ.
Patients diagnosed with CHC without cirrhosis or HCC; or CHC with cirrhosis (compensated or decompensated); or CHC with HCC.
• Unable or unwilling to provide informed consent
• Psychiatric disorder impeding comprehension and completion of questionnaires
• Life expectancy of less than six months.
We have recruited 285 participants and have presented our preliminary findings in the 37th and the 38th Annual Meeting of the Society for Medical Decision Making and the 5th Canadian Symposium on Hepatitis C Virus. We are preparing the manuscript for publication.
Study Timeline
January 2015 – March 2017
William Wong, PhD
Murray Krahn, MD, MSc, FRCPC
Karen Bremner, BSc
Julie Bruneau, MD, MSc
Jordan Feld, MD, MPH
Zeny Feng, PhD
Samuel Lee, MD
Kate Mason, MHSc
Nicholas Mitsakakis, MSc, PhD
Robert Myers, MD, FRCPC
Petros Pechlivanoglou, PhD
Jeff Powis, MD, FRCPC
Valeria Rac, MD, PhD
Josephine Wong, MD
Yasmin Saeed, PhD (Candidate)
CIHR Operating Grant
Publications / Presentations
Saeed Y, Mason K, Chung S, Altenberg J, Powis J, Bruneau J, Feld J, Feng Z, Mitsakakis N, Myers R, Rac V, Bremner K, Krahn M, Wong W. Health utilities in marginalized chronic hepatitis C patients participating in a community-based hepatitis C program. 37th Annual Meeting of the Society for Medical Decision Making, October 17-21, 2015. St. Louis, MO, USA.
SIESTA Study: Diagnosis of Obstructive
Sleep Apnea with BresoDx® Study
SIESTA Study: Diagnosis of Obstructive Sleep Apnea with BresoDx®
The purpose of this study is to assess the clinical and cost-effectiveness of obstructive sleep apnea (OSA) diagnosis based on a home sleep study with BresoDx® portable monitor compared to diagnosis based on in-laboratory sleep study with polysomnography in patients being referred to sleep clinics with suggestive OSA symptoms.
How does the clinical diagnosis of OSA assisted by the home sleep study with BresoDx® in comparison with the clinical diagnosis assisted by the in-laboratory sleep study with PSG as the reference standard?
What is the agreement between the AHI from the home sleep study with BresoDx® and the in-laboratory sleep study with PSG?
What is the cost-effectiveness (cost per quality-adjusted life year) of the OSA after diagnosis based on home sleep study with BresoDx® in comparison with after diagnosis based on an in-laboratory sleep study with PSG?
Referral to a sleep clinic by a general practitioner or family physician with symptoms suggestive of OSA
Provide signed informed consent
At least 18 years of age
Ability to complete study questionnaires either on their own or with assistance
A history of chronic respiratory diseases (e.g., asthma, chronic obstructive pulmonary disease, lung cancer, cystic fibrosis and occupational lung diseases)
An existing diagnosis of other sleep disorders (e.g. periodic limb movement disorder)
A history of neuromuscular diseases (e.g., multiple sclerosis, muscular dystrophy)
A history of congestive heart failure
A history of stroke/Transient Ischemic Attack
Unable or unwilling to provide informed consent
The SIESTA Home Sleep Study is a pragmatic, multi-centre randomized single-blinded two arm trial. This study focuses on subjects referred to a sleep clinic with symptoms suggestive of OSA. Study subjects will be randomized by a ratio of 1:1 to a sequence of home sleep study with the BresoDx® PM followed by an in-laboratory sleep study with PSG (the PM-PSG sequence) or the PSG-PM sequence. The target sample size is 250 subjects from 3-4 sleep clinics over a 4-5 month period evenly allocated between the two arms.
The study started recruitment in March 2014 and finished in March 2016. The manuscript preparation is underway.
Mike Fitzpatrick, MD, FRCPI, FRCPC, D.ABSM
Valeria E. Rac, MD, PhD
Lusine Abrahamyan, MD, MPH, PhD
Steven Carcone, MSc
Suzanne Chung, BEd, CCRP
Petros Pechlivanoglou, MSc, PhD
MaRS EXCITE
2017 CADTH Symposium will be in Ottawa, Otario, from April 23, 2017 to April 25, 2017
Economic Evaluation of a Portable, Home-Testing Device (BresoDx) for Obstructive Sleep Apnea. Petros Pechlivanoglou
Diagnostic Accuracy of Level IV Portable Sleep Monitors Versus Polysomnography for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. Lusine Abrahamyan
SIESTA Home Sleep Study With BresoDx Portable Monitor for the Diagnosis of Obstructive Sleep Apnea: A Pragmatic Randomized Controlled Trial. Valeria Rac
Mapping MFSAF and MPN-SAF to EQ-5D
The purpose of this study is to develop a statistical model in order to map between Myelofibrosis (MF) specific Health Related Quality of Life instruments using the Myelofibrosis Symptom Assessment Form (MFSAF) and Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) and generic preference based utility instrument using EQ-5D. This will enable the estimation of utility values based on MFSAF and MPN-SAF data.
What is the mapping algorithm between two different types of instruments by using a simple linear regression method?
Patients with myelofibrosis from any English speaking countries including Canada, America, Australia, and England
Family members of myelofibrosis patients if patients are unable to participate the study by themselves
MF patients who can read, write, and speak English and complete the questionnaires
No specific exclusion criteria
The study is composed of three parts: a) a systematic review of regression methods previously used for mapping, b) design and conduct of a survey of Myelofibrisis patients (including challenges arisen during the study), and c) the analysis of the survey data and mapping using statistical regression methods, which is the main part of the study. Patients with myelofibrosis from English-speaking countries will be asked to complete questionnaires which include both MFSAF/MPN-SAF and EQ-5D. Patients will be recruited through two ways: 1) online survey system using Survey Monkey or 2) direct mail out. Patients can choose the method to be participated.
September 2013 - October 2015
Progress: Analyses are completed. A report was sent to Sanofi-Aventis Canada, the sponsor. Manuscripts are under preparation
Chang-Ho Lee, BSc Honours
Sanofi - Aventis Canada, Inc.
Lee CH, Bremner K, Grootendorst P, Ringash J, Krahn M, Mitsakakis N. Predicting utility scores for myelofibrosis patients: mapping the myelofibrosis symptom assessment form and myeloproliferative symptom assessment form to the EUROQOL-5D. 37th Annual Meeting of the Society for Medical Decision Making, October 17-21, 2015. St. Louis, MO, USA.
OSUN Study: Ontario Stroke Units
Comparison of acute stroke care received at stroke units (SUs) to the care received in general medical wards (GWs) (i.e. care not received at SUs), specifically evaluating cost-effectiveness and characteristics associated with stroke unit care.
The primary research questions are:
What are the characteristics of SUs in Ontario (i.e. frequently occurring, common characteristics)?
Are SUs effective, as currently structured in Ontario?
Are SUs cost-effective, as currently implemented in Ontario (i.e. what are the resources used and associated costs)?
What SU characteristics are associated with improved patient- and system-level outcomes?
The primary objective of the current research is to use a survey of hospitals in Ontario and data available from the Ontario Stroke Audit (OSA) to identify which specific characteristics of Ontario SUs appear to be (cost-) effective and are associated with improved patient outcomes, in comparison to GWs.
The characteristics of SUs in Ontario will be based on a telephone survey administered to all known SUs in Ontario. The comparative effectiveness and cost-effectiveness analyses will be based on the Ontario Stroke Audit (OSA) administrative database maintained by ICES.
January 2013 - June 2016
Progress: Data collection started in January 2013.The final report has been completed and submitted to Ontario Stroke Network (OSN). The preparation of manuscripts is in progress.
Mark Bayley, MD, FRCPC
Moira Kapral, MD, Msc, FRCPC
Luciano Ieraci, MSc
Gabrielle van der Velde, DC, PhD
Ruth Hall, BSc, MSc, PhD
Linda Kelloway, RN, MN, CNN(c)
Ontario Stroke Network (OSN)
Presentations/Publications
Rac VE, Sahakyan Y, Fan I, Luciano Ieraci, Ruth Hall, Linda Kelloway, Gabrielle van der Velde, Moira K. Kapral, Mark Bayley, Murray Krahn.The characteristics of stroke units in Ontario: a pan-provincial survey. BMC Health Services Research 2017 Feb;17:154. DOI 10.1186/s12913-017-2099-1
Sahakyan Y, Rac VE, Fan I, Ieraci L, Hall R, Kelloway L, van Velde G, Kapral MK, Bayley M, Krahn MD. Structure and function of stroke units in Ontario in 2013-2014. Presented at: Toronto General Research Institute (TGRI) Research Day, October 6, 2015; Toronto ON, Canada.
Ieraci L, Pechlivanoglou P, Bayley M, Kapral M, Fang J, Li S, Krahn M. Real-world effectiveness of stroke units in Ontario. A matched cohort analysis. Presented at: 2015 Canadian Association for Health Services and Policy Research (CAHSPR) Policy Forum; March 24, 2015; Toronto ON, Canada.
Rac VE, Sahakyan Y, Fan I, Ieraci L, Hall R, Kelloway L, van der Velde G, Kapral M, Bayley M, Krahn M. Structure and Function of Stroke Units in Ontario in 2013-2014. Poster session presented at: 2015 Canadian Association for Health Services and Policy Research (CAHSPR) Policy Forum; March 24, 2015; Toronto ON, Canada.
End of Life Care Interventions (EOL):
End of Life Care Interventions (EOL): Economic Analysis
The annual cost of providing health care for patients in their last year of life is estimated to account for approximately 9% of the Ontario healthcare budget. Access to integrated and comprehensive pain and symptom management and comfort support for these patients appears to be inadequate and inequitable. We evaluated the cost-effectiveness of palliative care interventions to support policy development.
What is the cost-effectiveness of evidence-based interventions for end-of-life care?
Cost-effectiveness and cost-utility analyses from a health-care payer's perspective. Target population: patients nearing end-of-life (according to observed population-based setting-specific patterns of palliative services) over the last year of life (one-year time horizon) and their primary informal caregivers. Comparators: "usual care" with current provision of palliative services in Ontario, "in-home" palliative team care (service provision either at home or long-term care), "in-patient" palliative team care, and "comprehensive" palliative care by a single team with care coordination across settings.
We included health care costs (2013 Canadian dollars; including home care, long-term care, hospital care, outpatient services, drugs, and physician billing costs), and additional costs of private insurance, out-of-pocket expenses, and time lost from paid work. Effectiveness measures were days at home, percentage dying at home (base case analysis), and quality-adjusted life days (QALD; sensitivity analysis).
We developed a state-transition microsimulation model to simulate palliative care needs by the target population. Model inputs were obtained from an end-of-life cohort of Ontarian decedents (n= 256,284) assembled from linked health administration databases (2007-2009), systematic reviews of randomized controlled trials evaluating palliative team care, and published literature. We conducted one-way and probabilistic sensitivity analyses.
September 2014 – December 2014
Ba' Pham, MSc, PhD
Robert Fowler, MD, MS, FRCPC
Peter Tanuseputro, MHSc, MD, CCFP, FRCPC
Doug Manuel, MD, MSc, FRCPC
Nancy Sikich, MSc
Shamara Baidoobonso, PhD
Les Levin, MB, MD(Birm), FRCP(Lon), FRCPC
Murray Krahn, MD, MSc, FRCPC, on behalf of the Health Quality Ontario Expert Panel on End-of-Life Care, and the Toronto Health Economics and Technology Assessment Collaborative
Health Quality Ontario
Ba' Pham, MSc, PhD (c), Robert A. Fowler, MD, MSc, Peter Tanuseputro, MD, MHSc, Douglas Manuel, MD, MSc, Nancy Sikich, MSc, Shamara Baidoobonso, MSc, PhD, Petros Pechlivanoglou, PhD, Les Levin, MD, MSc and Murray D. Krahn, MD, MSc. Cost-Effectiveness Analysis of Palliative Team Care for Patients Nearing End-Of-Life.Presented at: 36th Annual Meeting of the Society for Medical Decision Making; 2014 Oct 18 - 22; Miami, FL, USA.
Prognosis for Canadians Infected with HEP C,
Prognosis for Canadians Infected with HEP C, 1986-1990
To estimate future treatment patterns with newly developed antiviral regiments for chronic hepatitis C (CHC) and update model predictions on long-term health outcomes in a Canadian hepatitis C compensation cohort.
How will the newly developed antiviral regimens affect long-term health outcomes associated with compensation claimants with CHC?
Canadians who have been approved for compensation because of their acquired CHC during the period of 1986 to 1990.
A physician survey will be designed to understand the impact of new antiviral agent on treatment patterns with CHC who have similar background with the compensation cohort. A systematic review will be conducted to estimate their efficacies and toxicity by previous history of antiviral therapy and HIV co-infection. We will also maximize the use of the claim cohort data to estimate model variables and modify model structure according to the estimated future treatment patterns. Microsimulation will be run with the updated prognostic model to project lifetime risks of liver-related complications and mortality in current surviving compensation claimants. Sensitivity analyses will be also performed to explore the impact of model variable data sources, treatment pattern, and treatment uptake timeframe on model prediction.
September 2013 - August 2014
Wendong Chen, MD, PhD
Qilong Yi, MD, PhD
The 1986-1990 Hepatitis Settlement Trust Fund
Bayesian Regression Models for
Disease-Specific Net Costs
Bayesian Regression Models for Disease-Specific Net Costs
EOL Care in Lung Cancer Patients
in the USA and Canada
EOL Care in Lung Cancer Patients in the USA and Canada
To investigate the application of a novel statistical approach for the estimation of net costs attributed to a disease or health condition when only aggregate data are available and provided as collection of sample means and standard deviations for a number of strata. The proposed method is based on the application of a Bayesian Gamma mixed effects model, where both sample means and standard deviations are participating as stochastic nodes in the Bayesian model. The method is evaluated and compared with two simpler Bayesian Normal models using a series of simulation experiments.
Does the proposed Bayesian Gamma mixed effects model offer an improvement for the estimation of net costs over simpler normal linear models, when only aggregate data are available?
This is a study of development of statistical methods, using a series of simulation experiments.
Oct 2010 – present (manuscript under revision)
George Tomlinson, MSc, PhD
in Prostate Cancer Patients
Androgen Deprivation Therapy in Prostate Cancer Patients
To describe patterns of use, type and indication of androgen deprivation therapy (ADT) in prostate cancer patients in Ontario, and determine costs of ADT and its side effects.
To determine the overall use and useof different types of ADT and its indications in the treatment of prostate cancer.
To estimate costs for various types of ADT used for each indication.
To estimate the incidence and costs of several of the most common side effects of ADT
The cohort will include Ontario Cancer Registry (OCR) patients assigned International Classification of Diseases-Oncology (ICD O) topography code C61.9 (cancer of the prostate) who had either bilateral orchiectomy or who received ADT pharmacotherapy for 3 consecutive months between January 1, 1995 and December 31, 2005, at age > 65.5 years, and who had no ADT therapy prior to January 1, 1995 or before age 65.5 years.
Exclusion critera are missing histology codes date of diagnosis the same as date of death, sex coded as female or missing, residence outside of Ontario, and no valid Ontario Health Insurance Number.
Analyses will be conducted at the Institute of Clinical Evaluative Science. We will link all patients to their health care administrative data and classify patients according to the type of ADT they received and its indication, using available data and algorithms. We will determine patterns of care (type and indications of ADT) over the years of the study. We will estimate one-year, five-year, and ten-year total costs for each type and indication of ADT. In addition, the known side effects of ADT will be identified and their costs also estimated.
April 2007 to December 2013
Shabbir Alibhai, MD, MSc, FRCPC
Padraig Warde
Gary Naglie, MD, FRCPC
John Trachtenberg
Audrey Laporte, MA, PhD
Paul Ritvo
Canadian Cancer Society Research Institute
New Drug Innovation Fund (Ontario Ministry of Health and Long-term Care)
Beyond Case Fatality Rate
To investigate potential methodological improvements in the estimation of the effect that uptake treatment increase of various treatments has on mortality as it is implemented in the IMPACT epidemiological model. The effect is measured by the number of deaths prevented or postponed. The method currently used in IMPACT model has data limitations, which could lead into biased estimates. This study proposes a probabilistic framework for the estimations in the IMPACT model, and presents how this framework allows naturally the application of the Potential Impact Fraction (PIF), a traditional epidemiological tool, for the estimation of the effect.
What is the magnitude of the bias introduced by the traditional methods of the IMPACT model in the estimation of the number of deaths prevented or postponed? Can the appropriate application of PIF reduce or eliminate this bias under different settings and assumptions?
This is a study of development of statistical and epidemiological methods. It includes application of methods to real data originally presented in a previous study (IMPACT 2).
Jan 2011 – present (manuscript published)
Harindra Wijeysundera, MD, FRCPC
Economic Policy Model for HEP C
To establish an economic model based on the best information available in the public domain on the natural history progression of hepatitis C to be used by Canadian Agency for Drugs and Technologies in Health (CADTH) to project long-term outcomes, costs and cost-effectiveness of interventions in treating hepatitis C to support clinical and reimbursement decision-making. The objective of this study is to build a flexible model platform that can evaluate the cost-effectiveness of CHC drugs and drug regimens that will be brought forward to the Common Drug Review for evaluation in the next few years.
March, 2013 – September, 2013
Hong-Anh Tu, PhD
Wendong Chen, PhD
Jorden Feld, MD
Canadian Agency for Drugs and Technologies in Health (CADTH)
Cost-effectiveness of
Screening HEP C in Canada
Cost-effectiveness of Screening HEP C in Canada
Chronic hepatitis C (CHC) is often asymptomatic and most individuals are not aware that they have been infected, thus the disease is often discovered when symptoms of late stage liver disease become apparent. In Canada, it is estimated that roughly 250,000, or almost 0.8% of the population, is infected with hepatitis C virus (HCV). Around 75% of those infected become chronically infected with the virus. 10-20% of whom will silently progress to cirrhosis and thereby be at risk of dying prematurely of liver failure and/or liver cancer. Early recognition of CHC probably extends the lifespan of infected individuals. Universal screening or screening for CHC among some high risk groups seems a plausible strategy. However, the potential health effects, costs, and cost-effectiveness of implementing a universal or selective hepatitis C screening program are unknown. The objective of this study is to build a model that can project the health and economic effects of various screening strategies for CHC conducted in different populations in Canada.
July, 2013 – September, 2013
Public Health Agency of Canada (PHAC)
CIHR-ICRH Estimating ROI of
Circulatory Respiratory Health Research
CIHR-ICRH Estimating ROI of Circulatory Respiratory Health Research
As part of an international review, the Institute of Circulatory and Respiratory Health sought to determine the effects of research on the health of Canadians. Specifically, the Institute was interested in comparing the benefits obtained from funded cardiovascular-related research with the cost of that research in order to obtain an estimate of the return on investment.
The objective of this report was to estimate the return on public/charitable sector investment of cardiovascular-related research funded in Canada for the years 1975-2005. To do so, we performed a return on investment calculation closely based on the work of Buxton and colleagues, who estimated the return on investment of cardiovascular research in the UK. We also incorporated in our analysis an existing model, the Ontario IMPACT model, which characterizes changes in the burden of cardiovascular disease between 1995 and 2005 in Ontario, and determines the relative importance of specific risk factors and treatments. Wherever possible, we attempted to improve on the methods and approaches reported in previous analyses.
Our analysis involved several steps. First, we estimated the expenditures on cardiovascular research in Canada. Second, we estimated the health gains accrued in Canada between 1995 and 2005 from new cardiovascular treatments and procedures. This involved determining the number of unique users of these cardiovascular treatments and procedures, determining the quality adjusted life-years (QALYs) gained by each unique user identified above and the associated health care costs of these treatments, and determining the QALYs and associated health care costs from smoking cessation and potential smokers averted and monetizing the total number of QALYs. Third, we estimated the proportion of health gains attributable to cardiovascular research funded in Canada. Fourth, we estimated the time-lag between research expenditures realised and health gains obtained. Finally, we estimated the research and development spillovers from public sector investments. Once all the steps were performed, we were able to calculate the rate of return on investment and the internal rate of return.
Given our assumptions, we obtained an internal rate of return of 20.6% for research funded by the public/charitable sector. This means that every $1 invested in cardiovascular disease research in the public/charitable sector will yield a stream of benefits of roughly $0.21 to the economy per year, in perpetuity. If we consider a 12% hurdle rate as the minimum acceptable rate of return for a given investment, then our internal rate of return of 20.6% is very good. This suggests that Canadians obtain relatively high health gains for every dollar spent on cardiovascular disease research. When we added private cardiovascular disease-related research expenditures to the public/charitable ones and considered the impact of research spillovers, we obtained a combined social rate of return of 44% (12.9% + 31%).
Our analysis was based on previous work but also provided some improvements. In particular, our study improved methods for estimating the number of unique users in each patient group/intervention; considered differential treatment of health gains for individuals that quit smoking and for non- starters; estimated Canada's contribution to global medical research; modelled the time lag between incurred research expenditure and realised health gains as a distribution, among others.
This work involved many assumptions. Accordingly, there were some areas of uncertainty. For example, it was unclear what proportion of health gains can legitimately be assigned to research. We also did not evaluate risk factors other than smoking and thus, our calculated value for the internal rate of return was probably an underestimate.
Nonetheless, this research will guide the Canadian Institutes of Health Research in determining the value of its current research portfolio for cardiovascular disease research. In addition, it will provide valuable experience in conducting this type of work in Canada, which can potentially be used in other aspects of the portfolio of the Canadian Institutes of Health Research, or by other granting agencies. Finally, this may represent an opportunity to collaborate with other countries in establishing and refining methods to document the value of medical research.
PUMTT Study
FIELD EVALUATION
The purpose of this study is to evaluate the clinical and cost effectiveness of 'enhanced' multi-disciplinary wound care teams (EMDTs) vs. 'usual' care teams (UCTs) for the treatment of pressure ulcers in long term care (LTC) facilities.
The primary research question is:
Do EMDTs increase the rate of pressure ulcer healing, measured by wound surface area (cm2) over time (days), relative to Usual Care Teams (UCTs)?
Secondary research questions are:
Is the use of EMDTs to increase the rate of pressure ulcer healing cost-effective?
Are EMDTs more effective than UCTs in healing a greater proportion of pressure ulcers?
Are EMDTs more effective than UCTs in reducing the facility-acquired incidence rates of pressure ulcers?
Are EMDTs more effective than UCTs in reducing wound related pain and discomfort?
What are LTC facility staff perceptions and experiences associated with EMDTs for pressure ulcer management?
Facility Inclusion Criteria
The LTC facility:
must be located within the Toronto Central or Central LHIN geographic boundaries.
must have > 100 beds.
must be within 100 Km of the EMDT.
must be entering data into MDS.
must have a PU prevalence rate > the provincial average (5.5%) reported in the fourth quarter of 2009 MDS.
administrator must consent to participate.
This cluster, pragmatic randomised controlled trial is a mixed methods study employing quantitative and qualitative methodologies. The intervention will be delivered to 12 randomly selected facilities in the Greater Toronto Area according to a stepped wedge design consisting of three intervals: baseline (3-12 mos), Phase 1 (3 mos) and Phase 2 (2-11 mos). The study period is 17 months, with facilities randomly assigned to the start date of Phase 1. Usual care teams (UCTs) are the existing resident care personnel used in the LTC facilities to identify and treat PUs and other wounds. Enhanced multi-disciplinary teams (EMDTs) consist of an Advanced Practice Nurse (APN) who is regularly on-site who collaborates with the wound care team at St. Michael's Hospital. Phase 1 is a 12 week period where an Advanced Practice Nurse visits the LTC facility on a weekly basis and trains/mentors UCT staff as they assess and treat participating residents' PUs. The APN may consult other members of the EMDT via telemedicine, and/or certain residents may require transport to St. Michael's Hospital for on-site assessment and treatment. Phase 2 is of variable length and consists of primarily telemedicine contact between the UCT and EMDT via the APN (with facility and hospital visits as needed) in consultation with the specialty wound care team at St. Michael's Hospital.
Quantitative analyses will include data from: serial planimetry of wound digital photographs read by a blinded assessor (primary outcome), wound pain (VAS) and quality of life (EQ-5D), comprehensive case summary and referral tools and prospective resource utilization. Qualitative analyses will be carried out on a combination of testimony and field notes from: employee focus groups, individual interviews with facility leadership staff, ethnographic observations of team functioning and entries on an online forum.
Baseline data collection began in October 2010. Phase 2 for all LTC facilities will end in March, 2012.
A final report will be prepared for September 2012.
Funded by the Ministry of Health and Long Term Care, the Canadian Patient Safety Institute, and the Central Community Care Access Centre. The clinical trial registration page is here.
Anita Stern, RN, PhD
Murray Krahn, MD, MSc
Shabbir Alibhai, MD, MSc, FRCP(C)
Ross Baker,PhD
Connie Harris, RN, ET, IIWCC, MSc
Janice Hon, OT Reg (Ont), MCISt
Lianne Jeffs, RN, PhD
Matt Kowgier, MSc, PhD(c)
Les Levin, MB, MD, FRCP
Casey Li
Ann-Marie McLaren, DCh, BSc, MCISc
Linda Norton, OT Reg (Ont)
Mike Paulden, MSc, MA (Cantab.)
Ba' Pham, MSc, PhD(c)
Scott Reeves, PhD
Josie Santos, RN, MN
Laura Teague, RN, MScN, NP
George Tomlinson, PhD
Kevin Woo, RN, PhD
Gail Woodbury, PT, PhD
Merrick Zwarenstein, MBBCH, MSc, PhD
TURN Study
The purpose of this multi-site, randomized, controlled trial is to determine the most reasonably effective frequency of repositioning long term care (LTC) facility residents with mobility limitations who are at moderate and high risk for pressure ulcer development who are cared for on high density foam mattresses for the purpose of preventing pressure ulcers. In addition, the costs, the cost effectiveness, and the cost utility of various repositioning schedules for the prevention of pressure ulcers will be evaluated.
This study employs a 2 X 3 experimental design in which participants who are at two levels of risk for pressure ulcer development (moderate or high) are randomly assigned to one of 3 repositioning schedules (2, 3, or 4 hourly).
Age 65 years or older and legally able to grant consent, or have an available surrogate who may legally grant consent.
At risk for pressure ulcer development with Braden Scale Scores of 10 to 14, indicating moderate (13-14) or high (10-12) risk.
Scores of 1 to 3 on the mobility subscale of the Braden Scale indicating some mobility limitations.
Expected to have a length of stay of 3 weeks for study participation.
Sleeping on a high density foam mattress
Pressure ulcer(s) present on screening.
The resident cannot be turned on 3 anatomical surfaces (side, back, side) or has a contraindication to repositioning.
Participants will be studied prospectively for 3 weeks or until discharge from the LTC facility, whichever is earlier. Participants will wear an actigraph (a device that measures movement) during the second week of the intervention to determine if mobility is a covariate with repositioning frequency on pressure ulcer development, and to evaluate the integrity of the intervention. The primary outcome is the incidence and severity of pressure ulcers. Recruitment targets are 900 participants from the US, and 500 from Ontario.
THETA staff is collaborating with investigators from the University of Texas (Dr. Nancy Bergstrom-PI, Dr. Mary Pat Rapp-co-investigator) and the Institute for Clinical Outcomes Research [ISIS-ICOR] (Dr. Susan Horn-co-PI) on this study.
Please visit http://son.uth.tmc.edu/coa/turn_overview.htm for more information.
WIT Study
The purpose of this study is to evaluate the effectiveness and cost effectiveness of systematic referral to specialized multidisciplinary wound care teams (MDWCTs) in conjunction with comprehensive primary care delivery (Intervention group) vs. 'usual care' (Control group) for the treatment of community-based clients with chronic wounds in the Greater Toronto Area.
What is the clinical and cost-effectiveness of systematic referral to specialized MDWCTs in conjunction with comprehensive primary care delivery in contrast to 'standard care' for community-based patients with chronic wounds in the Greater Toronto Area?
Newly referred to Toronto Central Community Care Access Centre (CCAC) for wound management.
>18 years of age.
Client or Substitute Decision Maker (SDM) provides written informed consent.
Someone in the client's home (or SDM) must be able to speak English.
Surgical wounds.
Burns.
Malignant wounds.
Clients deemed palliative.
The study is a 2-arm pragmatic randomized controlled trial. Clients are referred to the study by case managers of Toronto Central CCAC. After informed consent, clients are randomized into Intervention or Control group. The Control group has 'usual care' as currently delivered to clients with chronic wounds in the community. Monthly digital wound photo is taken and monthly phone survey is conducted for 6 months (or until the wound heals, whichever comes first). For wounds that heal during that time, wound recurrence will be tracked for an additional 6 months. The Intervention group has, in addition, a specially trained wound care nurse to assess for systematic referral to multi-disciplinary wound care team at St. Michael's Hospital or Women's College Hospital.
The study started recruitment in May 2011. The target sample size was 450. Currently all data analyses are completed.
Dr. Murray Krahn gave the final presentation to the Ontario Health Technology Advisory Committee (OHTAC) on 24th May 2015. The preparation of the final manuscript iscomplete.
Abrahamyan L, Wong J, Pham B, Trubiani G, Carcone S, Mitsakakis N, Rosen L, Rac VE, Krahn M. Structure and characteristics of community-based multidisciplinary wound care teams in Ontario: An environmental scan. Wound Repair Regen. 2015 Jan-Feb;23(1):22-9.
Valeria E. Rac, MD, PhD, Director, Clinical Research (Faculty)
Josephine Wong, MD, MRCP(UK),
University Health Network
Toronto General Hospital
Eaton Building, 10th Floor, Room 248
200 Elizabeth Street, Toronto, ON M5G 2C4
Email: info@theta.utoronto.ca
Web: theta.utoronto.ca
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My last post on this site was before the season started, so I figure it's a good time for another one. Below are my picks for the 2019 playoffs. I am sticking with my preseason pick of the Tampa Bay Lightning!
My Shocking NHL Playoff Predictions!


Integrate their chest, middle voice, and head voice so they can maintain a beautiful, even tone throughout their range.
In addition, I help students develop proper posture and breathing to support their sound, release tension that can cramp their singing, hone their musical "ear". Students can sample different styles (pop, jazz, classic rock, or musical theater) or focus on a particular style of interest.
Joel sings and composes in the Bay Area. He's been playing guitar since the age of 7 and singing since the age of 3.
My teaching philosophy is that every kid can sing. Kids don't need to be taught to love music, because each kid already has some song they love, which they'll blast full-volume in the car or the shower. Furthermore, kids learn naturally all the time. I see myself more as "guide on the side" than as sage on the stage.
Hi, I'm Joel Knopf. Writer, musician, life-long learner. Drop me a note at joelknopf [at] gmail.com!


Audio file is - "Understanding the urgent need for Divine Intervention defines you're searching for something MORE"
Prior to Pluto entering Capricorn in 2008, prior to Neptune entering Pisces in 2011 and prior to Uranus entering Aries in 2011 - I would have defined this page as "The Power of Your Prayers". However, all that has changed since Pluto entered Capricorn in 2008 - you no longer have the right to DEMAND from GOD anything - no longer is it your individuality - nor your "EGO" energy that can change anything in your life or in the world - and as you read this page - you'll comprehend WHY things have changed - and how "Divine Intervention" is actually happening at the moment and what "Divine Intervention" is really doing to everyone's lives.
"The power of Prayer" has been taken away from "humanity" - because people are asking selfishly for things they want - and not asking for anything good for the betterment of humanity - therefore "Divine Intervention" is now giving us everything we karmically deserve - and it is our duty to ACCEPT everything.
Out-of-time - we're all living on "borrowed time"
There's a fundamental spiritual law that as it is in the physical world - so it is a reflection of the spiritual world. All the governments and many huge corporations are living with massive "debts" - "they" are using borrowed money - that they can never repay - to live from. The only way these problems will be solved is when all go bankrupt - wipe their slate clean and start-over again.
Likewise "spiritually" - humanity has never been blessed with so much goodness - planet Earth is feeding and looking after 7 billion people - each and everyday - the words of "thanks" to mother Earth and to Divine GOD - for these daily miracles should be unbelievably loud - and yet many of us - sound grumpy, miserable and unappreciative. Yes - WE ARE IDIOTS. We are blind to see that we are being blessed - living on "borrowed" time - and living through miracles - each and every second of everyday.
"Technically" - NONE of us - should be alive - and yet we are - it's a miracle - and what's more of a miracle is that through the astrological energies of Pluto in Capricorn, Neptune in Pisces and Uranus in Aries we're having our lives "sorted out" - without even knowing it or truly appreciating it.
Since Pluto entered karmic Capricorn in 2008 - a definitive karmic destiny has been implemented in the World. It overrides everything else - overrides individual astrological charts and it ensures that we all do what we're destined to do. It is the fact of life - that DIVINE KARMIC DESTINY has taken-over our lives - to drive us, to motivate and to ensure that we all do what we're supposed to be doing.
The truth is we've messed up so much - we've made so many mistakes - we're screwed-up so much that each and everyone of us - is living on "borrowed time" - as we've all collectively failed to do what we're supposed to be doing with this wonderful gift of life - that "destiny" has taken-over control to ensure the "karmic job" gets done, is wholesomely completed and everyone will be doing what they're truly destined to be doing with the gift of life - enabling everyone to enter the karmic phase of World-Peace.
The first step in ensuring World-Peace is to ensure that each person and every individual is enlightened with wisdom and finds INNER peace - because when individuals have inner peace - that's when collectively the whole World will become peaceful. Hence "Divine Intervention" is being implemented right now - we are all individually and collectively living with "Divine Intervention" in our lives and even though we have the illusion of doing what we want to do - we're not really in "control".
Have you not YET noticed that NOTHING happens when you want it to happen? Especially if you're trying to do and trying to force something that you're not supposed to do - all it creates is stress, frustration and back-fires on you. Even if momentarily, there's success in doing what you want to do - within a short-time it collapses and fails - that's because Pluto in karmic Capricorn since 2008 - is ensuring you keep to the karmic script of your life.
Conversely, have you noticed that the best things that have happened in your life since 2008 - just suddenly unexpectedly and "magically" happen? Pluto in Capricorn defines that destiny pushes, drives and ensures these karmic destined events just happen - like magic. Inexplicable in their nature - unpredictable in their reality - and karmically perfect in making your life wholesome.
Pluto in Capricorn wants us to acknowledge our karmic ERRORS and MISTAKES - whilst Uranus in Aries wants each of us to begin a "fresh" new beginning - a time when we get-it-right without making all the past-life mistakes. Pluto-square-Uranus defines the need to stop looking back at the "past", stop holding onto the "past", heal and let go of the "past", adapt, change and "accept" life for whatever life is giving you. Most importantly - do what you instinctively and intuitively know you should be doing - instead of fooling yourself to do what you want to do.
The karmic wheel of life is going through full cycle and after the past 6000 years of humanity praying, asking, demanding, moaning and complaining to "GOD" - now this karmic phase - it's the DIVINE karmic time for ACCEPTANCE. The problem our generation has is a belief that if you annoy, complain, shout and scream enough - "someone" will listen to you - and answer your prayers to "shut" you up - but that's not so. This is the "karmic" time to "accept" whatever is given to us - and appreciate EVERYTHING we have with sincere gratitude - and continual non-stop thanks to GOD - for every moment of everyday of life - for we're all living on borrowed time.
Have you ever truly wondered why prayers aren't answered? Besides the obvious reason that people are asking for "stupid" things - which are in conflict with their true destiny - the real reason is because whilst the mouth is talking - there's NO interaction to any SPIRITUAL THOUGHT energies - and therefore the transcendence and connectivity to the spiritual realms is NOT happening.
Praying without thinking spiritually - is like typing on your computer - when the computer is switched off - so whatever you type on the keyboard - NOTHING happens. People who "pray" - even religious people who "pray" - nothing happens - because not only are they not thinking - but their emotional energies are NOT even connected - so it's no surprise - NOTHING happens - as NOTHING is transmitted into the ether - hence NOTHING is received back.
In this Karmic phase of Humanity - people who REFUSE to use their minds to think - have lives that are going-nowhere - now that DESTINY has determined that they need to begin to THINK - now things are beginning to happen - but not because you pray and ask - but because it is karmic blessing and gift for things to happen.
Prayer and Meditation has a purpose - but it should be asking for GUIDANCE - for whatever is bothering you. So if you're lonely and looking for relationships - ask for GUIDANCE to find your right destined relationships - don't ask GOD for a relationship with Brad Pitt or Courteney Cox - because they're not yours!
The main reason for "Prayer and Meditation" is actually MEDITATIVE TIME to AGREE with everything GOD is giving you - AGREE with everything that is happening in your life - AGREE with GOD that you don't have some things because you ACCEPT that you don't need them in your life - and AGREE that you ACCEPT everything that will happen in your life - ACCEPTANCE is your way of saying your AGREE with your DESTINY.
The ספר זרע קודש "Zera Kodesh" of Reb Naftoli Horowitz [1760-1827 - a famous spiritual Polish Rabbi of Ropshitz buried in Lancut] - explains that anyone who desires something materialistically that they don't have or/and are dissatisfied with whatever they do have - are not spiritually minded souls. And they need to change their attitude to "life".
For it is impossible for a true spiritual soul to ever desire anything that they don't have - and if one doesn't have something it means that GOD has DIVINELY decreed that you do not need it. Believing in GOD - means and trusting that EVERYONE has everything one needs for the lessons one's soul needs to learn in earth-school - if you don't have something it means you DO NOT need it.
Searching for "spiritual" answers because you want a better life?
It's a "Neptune" illusion - but the only way that Divine GOD entices people to search for "spiritual" answers - is through the illusion of wanting a better life - more money - more prosperity - more "everything" - but that's a 100% "Neptune" illusion - even so it's a Divinely brilliant illusion - as it drives people to search for something they believe they're looking for.
It's like men and women - who are inexplicable made to fall in love with each other - to have a child - then inexplicably they realize they don't love each other anymore - the karmic illusion of "love" was in order to have the child - hence they were fooled into "love".
And in the biblical sense it's like the Garden of Eden - having a signpost saying - all who enter will become RICH - so everyone runs in - but in reality - the RICHNESS that is being offered is eternal wealth of wisdom and spirituality - which has nothing to do with "money" and worldly "riches in this physical world.
The illusion of "using" spirituality to attain a better life - captivates your mind - and then - once you've attained a healthy spiritual state of mind - you'll realize the truth that you were drawn-in in order to learn that wisdom of "spirituality" that you have been blessed with EVERYTHING YOU NEED. It's WITHIN you - and there's no need to LOOK for anything - because "it" is WITHIN YOU !
The true spirituality of life will make you aware that the miracle of life itself is WITHIN YOU. Suddenly, due to Neptune in Pisces - will ensure you stop looking for "external" lucky-charms - and wake-up to the truthful reality that the secret of life is WITHIN YOU.
No-one questions the most important "fact of life" - that babies are conceived and born - from an invisible power of creation within every adult - from nothing comes something amazing - that's the fact of life. Neptune in Pisces is teaching humanity that from WITHIN you - from absolutely NOTHING you can find EVERYTHING you're looking for. The secret of which will be to OPEN your mind to THINK.
As adults, we're convinced to think restrictively "WITHIN THE BOX" - but as many of you know - the greatness of creative imagination comes when you think expansively "OUTSIDE OF THE BOX". Logic might tell you that the "internet" is an impossible invention - but fact of life - the "internet" exists and works - it's brilliant - and the more websites you read and become inspired by the more you realize the karmic blessing of the internet. Have you ever tried to explain the "internet" to an old grandparent? Unfortunately many of them and their restricted confined and imprisoned minds cannot comprehend the "internet". It's too much for them to understand.
However, accepting and enlightened souls as YOU are - you can understand from examples of technology - that ANYTHING is POSSIBLE - that you can create SOMETHING from NOTHING - YES YOU - YOU CAN CREATE SOMETHING FROM NOTHING - through the power of your own THOUGHTS - through the intuitive power of your imagination - through your connection to an Eternal Spiritual power that is the power of the essence of LIFE itself - your SOUL that is DEEP WITHIN YOU.
Hence when I introduce the page as "Divine Intervention" you have now realized that the "Divine Intervention" is the "waking up" process to realize the truth that LIGHT, LOVE and WISDOM of the DIVINE is WITHIN YOU - all you need to do is LISTEN and ACCEPT.
When you think of the fact that a baby is conceived from nothing - except the positive energy from WITHIN you - then you can understand that you can CREATE and MANIFEST anything in your life - well "almost" anything. Neptune in Pisces is always associated with spiritual activity, the paranormal and most importantly associated with HEALING, karmic healing and spiritual wholesomeness.
Pisces has the power to envelope, protect and heal - for in the same way a FISH is immersed in WATER to keep it alive - Neptune in Pisces immerses people in the energy of their own spiritual aura - which brings HEALING from WITHIN. Neptune in Pisces will enable you to find the answers from WITHIN - in the same way - a baby is conceived from WITHIN - the life-energy you need - the healing you need - the positive energy you need - to make yourself wholesome is WITHIN YOU - and now is the time you'll FIND it.
Many people need to sit-in-the-sun to feel the healing of the Sun - Neptune in Pisces since April 2011 - has defined you will sense a strong healing energy transcending through the Neptune in Pisces - sense it - absorb it - and let yourself grow spiritually - as your inner soul feels it's connection to the Divine.
Going Up and Coming Down the "Ladder"
The visionary Rabbi Yehuda Ashlag a Polish-born kabbalist who lived 1886 - 1954 - believed and saw a vision of the future - he saw that "communism" in it's idealistic form - had a place in the world - and that was to show ALL HUMANS as equals - and ALL HUMANS when their EGO is eliminated are the same - and have the same ability to attain great spirituality.
He understood that the "communist" doctrine / belief - has a place in the world - in that EVERYONE IN THE WORLD - could and would become spiritually enlightened - everyone has the same potential when individuality and the selfish EGO is eliminated. He explained the סולם Sulam - the Spiritual Ladder - to be the method to acquiring spiritual knowledge - for EVERYONE - and not just the "few".
The סולם Sulam is the Spiritual Ladder - explains - that during a person's life - comes two phases - the 1st stage is when you TELL the world what you want - when you DEMAND from the world things you want - and when you believe that through asking, begging and pleading even through abusively shouting, screaming and demanding things to happen - you get what you want. You've been instinctively trained to know this - from the moment you instinctively cry as a baby - when you get attention from "others" - that's when you get what you want.
The 2nd stage of life is when you STOP asking for anything - when you mature to accept everything that happens in your life. Most people only achieve this stage with the maturity of mid-life - although I've seen many younger people with "old" souls inside them - have a refined dignity of "acceptance" in their aura much more that "selfish" older people who still demand things from life like screaming babies.
In this world - we all see people who DEMAND and ANNOY others - are the types that are never happy with whatever they get - sooner or later - their inherent impetulantly childish nature - continues to DEMAND and WANT MORE - it's a nonstop journey of being ungrateful. Whereas wise spiritually minded people - reache a specific point in life when we STOP asking for anything - instead we LISTEN and ACCEPT what "destiny" is telling us. That's the moment we live in harmony with "life".
These 2 stages are vitally necessary components of both your physical and spiritual life - each and every day - each and every phase of every day - and a fact that סולם the Sulam - the Spiritual Ladder - explains - that you can't ASK and RECEIVE at the same time. 1st stage is you need climb up the spiritual ladder - to ask and pray - and then you need to say NOTHING - and be in receptive acceptance mode to RECEIVE - and then the intuitive wisdom comes down to you into your thoughts.
"Method of Going-Up the Spiritual Ladder"
1. To begin the journey of "going-up" the spiritual ladder - you have to detach from earthly existence and earthly worries - and the best way is to SAY THANK YOU - THANK YOU - THANK YOU GOD - for everything you have in your life. This ensures that your aura is AT PEACE with your life at this very moment - for it is ONLY when you are AT PEACE - when you can meditate and pray properly.
2. Then either write a list of all the questions you have - OR ask in prayer - everything you want to know - pray for Peace in the world - pray for everyone to accept everything that they have in their lives - pray that you too should be able to live in ACCEPTANCE.
"Living in acceptance" is not a contradiction to asking and wanting something. In fact it is in harmony - because when you understand true acceptance - you are agreeing and accepting your destiny - and you are also living in the search of answers to progress your life forward.
3. Never expect to get the answers immediately - in fact according to the Sulam - the Spiritual Ladders - any answers you intuitively get "immediately" are always WRONG. In the same way you see me "building" the website - first I have "headings" as questions I need answering and want to explain to you - and then I usually need to wait until the following day or even a few days - before I receive the intuition to know what to explain. So make a list of questions - put your thoughts out to the spiritual ether - then let go and wait.
The "sign" to know that your prayers are accepted is you suddenly STOP asking - you want NOTHING - and even the questions you have - you STOP asking for answers - and that's when you feel calm and peaceful WITHIN.
4. Then ..... in the silence - in the peace and quiet - either when you wake-up the following morning or a few days later - ideas and thoughts "come" into your mind - or real-life experiences present themselves as answers to your prayers.
But there is an IMPORTANT POINT and a twist in "spiritual pisces" and that's - you can never ASK for anything for yourself - as the spirituality of life is that Spiritual Pisces is always in service of others - and always wants to find answers to help others.
So if you've got relationship problems with someone - don't ask for yourself - ask what's going to happen to them instead - and then you'll see if you're involved or not - as you sense the answer of someone else's future. If you've got financial problems - then don't ask for yourself - ask for Divine help for your husband/wife/children / boyfriend/girlfriend - and then you'll see you will be included. If you're not health or well - then instead of asking for yourself to get better - ask and pray for all people to get well - and by default - you too will be included. If you're lonely and have no-one to love - then pray for other lonely people to find love.
When you pray for World peace, success and happiness for "others" - you will find that your aura becomes peaceful, successful and happy - as Spiritual Pisces sees you as a person to transcend down the spiritual energy of peace, love, success, happiness and compassion to the world - through your aura it exudes to the world - and therefore your aura becomes peaceful, loving and happy.
"How to Turn-on your own Spiritual Energy" - is a silly question - because the truth is you're always TURNED ON spiritually - wherever you are anytime of the day or night - the only problem is spiritual realms are trying to GIVE you wisdom and intuitive wisdom - meanwhile you're still telling the spiritual realms what you want. Now that you realize that spiritual traffic is ONE-WAY - you realize that you need to grow-up - stop being a "child" and become a wise adult.
When you realize this fact is when you learn the spiritual method of PRAYING for others - DOING NOTHING - and then ACCEPTING - is when you've transformed from being an annoying demanding impetulant "child" into becoming a spiritually mature adult who accepts and receives - and through you - the energy flows to give to others.
דרכי האמת לאור הגנוז The Book of Daniel explains that the karma of "the last generation" is to apologize on behalf of all of humanity that we've all collectively made mistakes and sinned. Book of Daniel Chapter 9 - explains the karmic need for "The Confession of Sins" - "We all make mistakes and we are all sinners". [Suggested Online reading of English Translation of Book of Daniel]. The Spiritual Prayer of Confession of Sins begins with Chapter 9, Verse 4 => Verse 19 - start the journey to Spiritual Enlightenment by a REAL CONFESSION and FEEL your aura changing.
In so doing - you're reconnecting your soul to the DIVINE source - whilst bypassing all the "garbage" created by prior past-generations and past-lives. "DIVINE INTERVENTION" is when all the "spiritual garbage" is removed from your aura, when you are cleansed - and able to sense and feel the power of the אור הגנוז "The Hidden Spiritual Light" all by YOURSELF and WITHIN YOURSELF.
is Finding the DIVINE LIGHT that's WITHIN YOU.
You might travel the world in search of answers - you might visit holy tombs and pray at ancient sites of spiritual importance - all of which CAN and DO change your aura. Because your physical aura is INFLUENCED by your PHYSICAL surroundings, the place you live and the energies of the city and country you live in - but the truth is the ANSWER is WITHIN YOU - it is the DIVINE LIGHT that's WITHIN YOU.
The moment you can sense and feel it "just a little bit" - is the start and beginning to a new way of thinking and a new life. As you will realize that your life has MEANING and has a DESTINED pathway - and ALL THE GARBAGE in your life - is NOT PART of that TRUE destiny.
The "garbage" of pain, anguish, frustration and "bad karma and bad luck" was and is only put in your aura in order to make you AWAKEN. Problem is many people tolerate a lot pain - more than they truly need to - UNTIL they realize it's an EMERGENCY. At that point the human mind is then capable of SEARCHING and FINDING all the answers it needs - especially in the age of the "internet" full of wisdom and inspirational ideas enabling you to find what you're looking for - at the TURNING POINT - you will have PEACE when you've found the right answer. That ANSWER is WITHIN YOU - it is finding the DIVINE LIGHT that's WITHIN YOU.
It's going to take a few days and then the next stage a few weeks - but once you SENSE the truthful reality of the DIVINE and that the DIVINE LIGHT is WITHIN YOU. You will realize the secret is to GLOW from WITHIN - and as you do - it will obliterate all darkness and all fears from your life.
The DIVINE LIGHT will obliterate all Darkness that's WITHIN YOU.
It's impossible to think of darkness in the daytime - as it has no power - likewise you won't be able to think "dark" in the "light".
Can Darkness survive in the Daytime ? Impossible !!!
When you have found the DIVINE light WITHIN you - then it's impossible for ANY darkness to survive in your aura.
I've studied a lot of astrological charts of many people and every time I see the ONLY reason for blockages and bad luck is that people have emotionally become DRAINED by being attached to a "darkness" that is NOT even there's to begin with. They have been emotionally influenced by OTHER PEOPLE and become DARK. Hence, when you have found the light and realize that all the darkness, fears and negativity in your aura is NOT YOURS - you can obliterate and eliminate it.
You don't need to argue nor fight with the "darkness" - because when you have found the DIVINE LIGHT WITHIN YOU - it will obliterate and make the "darkness" vanish. And if you still feel you need to argue with and get involved with "darkness" - that means you have NOT TRUTHFULLY FOUND THE DIVINE LIGHT.
Many people in the world - don't believe in Jesus Christ - and "they" influence others not to believe - that is a DARKNESS blocking out a LIGHT. These same people "influence" others to desire and want a materialistic life - that's darkness and will keep you in the dark too - if you continue to think like they do.
Even the most difficult of negative spiritual garbage such as Earthbound spiritual souls can be eliminated by the LIGHT too. For they failed their life's purpose both in this life and past lives too - they remain attached to this physical world - because that's all they believe in. They never wanted to believe in the LIGHT and discarded all thoughts of the infinite DIVINE creator of the Universe - and now they are dead - they attach themselves to anyone they can find and create BAD LUCK - for they interfere with other people's energies by their darkness that they are - wanting others to become materialistically earthbound dark souls too.
So when you realize this and now that you've become ENLIGHTENED with a DIVINE LIGHT within you - even they will VANISH from your aura. As explained on "Rescue work" for earthbound spirit souls - the DIVINE LIGHT and infinite energy of LOVE eliminates Earthbound souls - as if they never existed - so even if you've got inexplicable fears and negativity - that seems impossible to BREAK - Think of the LIGHT eliminating DARKNESS - and you'll see how easy it is to BREAK - the darkness simply vanishes.
When you Meditate on understanding the mystery of GOD - all your need to do is THINK OF the DIVINE LIGHT and all the darkness, all your fears, all your anger, all your greedy thoughts and all your hatred will vanish - to be replaced by constant thoughts of LOVE, COMPASSION and KINDNESS.
For when you have found the DIVINE LIGHT that is WITHIN YOU - you will realize that this is the same DIVINE LIGHT that fills the whole world and is WITHIN everyone and everything - everywhere - for GOD is everything and everything is GOD.
Greedy, selfish and arrogant "individuals" - think of themselves as being DETACHED from everyone else - and indeed "they" are DETACHED from the DIVINE GOD too - but loving, kind and compassionate souls always think of themselves as NOTHING - and always see themselves as being ATTACHED to everyone else. When you realize this - you too - will have crossed over from being an individual being influences by "darkness" to becoming an enlightened LIGHT soul.
The Spiritual Secret of 40 days of "DIVINE LIGHT"
The spiritual secret of change in this physical world - means transcendence of time from spiritual energies to physical reality takes TIME. I should add there are many things that happen immediately - but for the explanations here - the element of TIME is important.
From the 1st day when you begin to Meditate and from the 1st day you have truthfully found the DIVINE LIGHT - it then take 40 days for things to materialize in REAL life.
During this 40 day period - you might waiver in your belief - you will have STRONGER moments of connection to the DIVINE than others and you will even find yourself sometimes FORGETTING you have found the DIVINE. But as the "40 days" completes - you will find yourself WHOLESOME in your DIVINE LIGHT - and even though darkness will attempt to come into your life - it will be obliterated on the 40th day - when NO darkness can come in anymore and NO darkness will even attempt to come near you anymore - as it senses it will be obliterated by your INTENSE LIGHT.


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In the adoption phase and beginning from the QNG malls in Indonesia, QNG also shall open applications to vendors for gateway integrations of qnode coin in Indonesia, Nigeria, Switzerland and other countries of patronage. We hope to target over 150 Malls in every country. QNC adoption policy shall include online and offline malls/stores, where qnc will serve as a payment method.
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AppleTV+ Sets Premiere Date for Limited Series 'The Last Thing He Told Me' Starring Jennifer Garner and Angourie Rice
During the streamer's presentation at the Television Critics Association's winter press tour today, AppleTV+ announced the premiere date for its upcoming original limited series The Last Thing He Told Me starring Jennifer Garner and Angourie Rice.
The 7-episode limited series will premiere on Friday, April 14 with its first two episodes. New episodes will then be released weekly every Friday until the season finale on May 19.
Based on the novel by Laura Dave, the series follows Hannah (Garner), a woman who must forge a relationship with her 16-year-old stepdaughter Bailey (Rice) in order to find the truth about why her husband has mysteriously disappeared.
In addition to Garner and Rice, the cast includes Nikolaj Coster-Waldau, Aisha Tyler, Augusto Aguilera, Geoff Stults and John Harlan Kim.
Dave co-created the series with her husband, Josh Singer. They executive produce with Garner, Reese Witherspoon, Lauren Neustadter and director Olivia Newman. 20th Television and Hello Sunshine produce.
Labels: Apple , Premiere Dates , The Last Thing He Told Me


This week I'm talking the A-word. Autism. Autism is a lifelong developmental condition that affects social interaction, communication skills and how you perceive the world. It is a condition that is widely misunderstood and its spectrum can include people with learning disabilities, asperger syndrome as well as 'high functioning' individuals. Autism affects 1 in 100 people in the UK yet there are many misconceptions about the condition which can lead to many people and their families feeling isolated and unsupported.
A feeling that Daisy Chain's founder, Lesley Hanson, recognised after her own son Jacob was diagnosed with autism. Lesley (quite literally) dreamt of a place where autistic children and their families could go to have fun in a supportive and non-judgemental environment. Determined to build such a place, Lesley and her husband set about rallying friends and family to make their dream a reality. Despite the doubters they were able, with the support of the local community in Tees Valley, to raise enough funds and remarkably open the farm within just a year of the initial idea. Sadly not long after Daisy Chain opened its doors, Lesley died during a routine operation. Staff wondered whether or not to carry on but families were continuing to arrive at the farm needing support and it was obvious what needed to be done. Some 14 years on since opening its doors Daisy Chain now supports around 1,841 families affected by autism in the Tees Valley area.
Much to my delight I spent my first afternoon at Daisy Chain up on the farm with barn manager Michelle, carer April and 13 year old Samir. Samir was diagnosed with autism as a toddler and visits Daisy Chain farm every week. I spent the afternoon as Samir's assistant, mucking out the shetland ponies. Once on the topic of horses you were unable to stop this initially hesitant chatterbox from talking! I enquired about the snakes in the reptile house, at which Samir's face lit up and together we bounded over to visit the more exotic animals at the farm. Samir took great delight in trying (and succeeding) to make me jump whilst stroking one of the lizards (not cool dude!) and he reminded me a great deal of my own brothers. After speaking to carer April I was interested to learn how he had arrived as quite a shy boy 8 years ago and that through Daisy Chain his confidence and interaction has grown and grown. Not only did Samir teach me a lot about reptiles but he is living proof that, contrary to misconception, children with autism often have a brilliant sense of humour.
Studies have shown time and time again that with animals in their lives, children's assertiveness is greater and social skills improve. You only need to spend an afternoon with Daisy Chain to learn that children with autism are highly individual and some will respond better to certain animals than others. Daisy Chain recognise that each of their children is unique and as such their farm has an enormous menagerie of animals that it many ways it would be more accurate to call it a zoo! From pigs to alpacas, skunks, reptiles, ponies, guinea pigs, skinny pigs, goats and chickens, Daisy Chain Farm has it all.
One of the things Daisy Chain does is to support parents as well as children living with autism through their parent support groups. I attended the Links group on Thursday morning and spoke to a number of parents who opened my eyes to matters like the (often) protracted process of getting a diagnosis in the first place; the hurt of watching their child be ostracised by their neurotypical peers; the assumption their child is just naughty because they do not 'look disabled' and the tutting, isolation and disapproval that often follows. It is when you hear stories like theirs that you realise just how important and vital a place like Daisy Chain is to parents in providing a place to relax, share stories, strategies and their highs and lows.
After taking the brave decision to locate in a retail park as opposed to a high street, Daisy Chain have launched a retail outlet comprising a cafe, furniture, clothing and household goods shop all under one roof. After opening two years ago they have since moved units and are now three times their original size due to the amount of footfall the shop gets. Donations quite literally spill out in the back and people wait outside in the morning for doors to open, it is certainly a model that other charities would do well to take note of. The superstore serves a number of purposes, firstly as a valuable source of unrestricted funding, secondly as a way of raising awareness in the local community and thirdly, and possibly most importantly, as a centre for training and employability programmes for adults with autism.
On employability, I was shocked to learn that just 32% of autistic adults are in some kind of paid work compared to 47% of disabled people. This demonstrates that there is a significant gap for autistic people in government employment programs and I was therefore intrigued to be spending much of my week with Donna, Hannah, Mary in the charity's employability program. I met Malcolm one of the students working in the cafe. With hands scrubbed and apron tied, Malcolm showed me the catering ropes and I learnt that he graduated from university with a degree in mathematics. Malcolm and the other students are very much front of house at the superstore and are encouraged to take on people facing tasks to the extent they feel comfortable. Rightly so because he is highly articulate and very perceptive although, like many people with autism, at times he gets a little overwhelmed and suffers with anxiety. Daisy Chain provides an environment where people like Malcolm can learn valuable skills and step outside of their comfort zone in a supported environment. As such Malcolm can take himself off in those frenetic moments and either have some time alone or chat to Hannah or Donna in order to give himself the head space he needs.
There is a preconception that autistic people are all suited to maths and IT because of the recall and attention to detail that is stereotypically associated with the condition (fuelled in part by Hollywood's 'Rain Man'). Whilst it may be true that in Malcolm's case he is naturally adept at arithmetic, such preconceptions are dangerous as they ignore the wide variety of skills and interests of people with autism. Daisy Chain's talent show Autisms Got Talent held last year, in which children and young adults wowed audiences with signing, dancing, magic and comedy, really demonstrates the breadth of talent within this social group.
You may be thinking that talent shows are one thing but paid employment is quite another and we have seen already statistically how difficult this can be for autistic people to obtain. Well during my time with Donna this week, we received some very exciting news in that vein. Chloe*, an employability student with a love of children has taken on the charity's first placement in a children's nursery. Chloe has been so successful in the role that staff there have put her forward for an apprenticeship to become a nursery assistant. It is early days in her journey but an exciting step forward and the charity are rightly very proud.
I met a number of other students at the superstore who were less vocal than Malcolm and Ashley I was able to see first hand just how broad a spectrum autism is. However each student can contribute something different and valuable and it is Donna and Hannah''s lovely job to get to know each person and unlock what that is. As it was put to me rather poignantly this week, sometimes people don't speak or appear to do very much but that doesn't mean they don't have things they want to say or do.
On my final day I spent time back at the farm with Lucy, a young girl of 12 diagnosed with both downs syndrome and autism. Lucy receives a bespoke education programme at Daisy Chain, teaching her a mixture of skills like ironing, shopping, cooking and of course soft play. When Lucy first attended Daisy Chain she was very shy but wandering around the building with her she greets staff confidently by name and is certainly a popular lady with everyone around the farm! Lucy has got a fantastic memory for names and was boldly effecting introductions to everyone that happened to wander passed us by exclaiming "hello, this is Alice!". I could do with Lucy on the road as a companion! You should not let her initial shyness fool you because Lucy is very very cheeky, she loves spiders and we had a lot of giggles pretending to throw them at each other as she guided me by hand around the soft play area. The play area was somewhere Lucy was initially reluctant to go, being a bit too hectic and noisy for her, now she leaps about quite happily and loves an audience for her super speedy skills on the slide.
Lucy is very considerate, warning me gently to be careful with the pans as I removed them from the hob. Lucy has a natural curiosity about the world which is very endearing and the depth of her questions are developing, at times leaving Donna and I quite stumped and having to google answers to things like what centipedes and worms eat! Lucy began our afternoon by exclaiming "no hug for Alice" but by the end of the session I was delighted to receive three, helped in part by my 'green cat furry' cardigan! Daisy Chain provide unconditional, non-judgemental care and support to children and you can see that in the right environment barriers dissolve, friendships develop and interactions can happen in the most gentle and genuinely beautiful ways.
This charity does so much to provide hope and happiness to families affected by autism and my thanks in particular to the lovely Katy Carmen for organising such a stupendous week for me and for everyone at Daisy Chain for making me feel so welcome.
It is the biggest misconception of all that autistic people can't form meaningful relationships, in fact in many ways I have seen this week that an autistic person will make the best friend you could ever have. I have been privileged to witness children at play and students on placement encouraging and supporting one another with no ulterior motives, limited sense of oneupmanship and no white lies but with a refreshing and unabashed honesty. In life we celebrate openness and honesty as virtues and merits but in practice absolute honesty can lead us to becoming exposed and disliked, perhaps as a society we need to recognise autism not as a condition but merely as a different way of being that we could all learn a little from.
P.S. Are you in the Tees Valley area? This charity needs kind people like you to volunteer. If you are interested in finding out more please take a look here.


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Treat your appetite at the Restaurant called 'Jungal Me Mangal '. The Restaurant is designed in such a way that you are actually sitting in jungle surrounded by animals. 24 hrs. Room Service If you are tired and do not want to go to the Restaurant, you can order your food in your room through the Room Service.
"Tarika - e - Jharokha" A fine dining restaurant offers a unique luncheon and dining experience for visitors alike. The best of traditionalindian dining is complimented with our new Indian - Asian fusion dishes to add a real international flavor and innovation for those who love fine dining. Our spacious dining room overlooks a specticular view of the lush green hills and majestic view of Solan and Shimla.
"Aroma" A 24 hrs coffee shop with the choicest of food and beverages. the surroundings of the coffee shop gives you a picturesque view of the mountains.
One would like to get in the spirit of things and have fun when one is on holiday. Good food and beverage is an excellent vehicle in the sense that every time one gets a ride, one is transported to a pleasure zone which is oh-so beautiful and complete. Our Cocktails and Mocktails do bring people together.


Join Dr. Colleen Yarger, Curatorial Assistant for the Virginia Museum of Fine Arts European and Mellon Collections, for a look inside the private world of Napoleon Bonaparte and the propaganda machine that modernized and legitimized his reign as self-titled Emperor of France. A man of continual reinvention, Napoleon used exquisite works of art to craft his image and document his political agenda. More than 200 objects—many of which have never before been exhibited in the United States—reveal the intricacies of the Emperor's daily life and the range of commissions by and for him. This exhibition of international loans includes major masterpieces of painting, an array of sumptuous decorative arts, sculptures, engravings, and more—brought together from the Château de Fontainebleau, the Louvre, and the Musée de l'Armée in Paris.
This tour is open to all current members of the Trust but is restricted to 25 participants. As per our membership policy, members at the Benefactor-level and above may register a non-member as a guest.


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Do Best Friends Make Good Baes?
By Parthshri Arora May. 29, 2017
Is dating your bestie a bad idea? Who will you bitch about your broken heart with if your best friend is gone?
In the year 1989, India embarked on a spiritual journey. Mohnish Bhel of sanskaari brother fame, proclaimed in Maine Pyaar Kiya, "Ek ladka aur ladki kabhi dost nahi hote". He was roundly panned for it in the film – but the panning was more because he followed it up with some really bad alliterative dialogue involving "kapkapati raatein" and "bhadakti aag." However, that same year, when Billy Crystal told his bestie Meg Ryan in Harry Met Sally, "What I'm saying is that men and women can't be friends because the sex part always gets in the way," we applauded him.
After these two cultural milestones, movie after movie, book after book, song after song, fucked up the concept of a platonic friendship (special shout out to Dawson's Creek). Popular culture began incepting the idea of sexual-tension-with-opposite-sex in the deep recesses of our innocent minds for the proverbial low-hanging narrative fruit. All because we didn't call bullshit on Billy Crystal, movie studios and TV programming heads got more stoked about the idea of these "sexually charged friendships" that would later yield Kuch Kuch Hota Hai. That movie turned every mohalla ke perfectly platonic Rahul and Anjali into raging lovers overnight. Then came How I Met Your Mother in which Ted Mosby basically tells his kids over eight seasons that he never wanted to meet their mother because all his life he only wanted to bone his best friend.
A study in the US charted the rise of the best friend – romantic relationships where 80 per cent of the respondents admitted to their partners being their best friends, up from 44 per cent in 1993. Small wonder it found its way to our screens.
The hypothesis that men and women can't be friends is the most eloquent piece of dangerous nonsense ever put forth, as those with an education and frequent interactions with the opposite sex already know. But those on Spankbang searching for Mia Khalifa and Johnny Big Wood are still hung up on the "best friend will have sex" story. The idea is so deep-rooted in millennials that due to comfort and proximity and all the confusion over grappling with concepts like "friends with benefits" many of us fuck up a perfectly good thing and end up dating our friends. Or worse. Best friends.
In hindsight, when we decided to "go out", it was as if we checked the emotional weather, saw the forecast for incessant rain, and chose to wear cream pants and a white linen shirt anyway.
In school, I was only concerned with two things: Playing football with everyone and having sex with everyone. There might have been honourable exceptions but that's just how most teenage boys are wired. Then I met this girl and she was goofy and smart and artistic. We became friends through a common friend, and by the time summer vacay rolled in, we had been, for about a year, speaking for hours every night, mostly about nothing, sometimes about everything. One fine day we both figured this must mean something more, and a David Archuleta song later, we were dating.
And that's when we fucked it up. When love and sex went out of the window (as it often does) friendship followed.
In hindsight, when we decided to "go out", it was as if we checked the emotional weather, saw the forecast for incessant rain, and chose to wear cream pants and a white linen shirt anyway. The muck was as inevitable as the end of every teenage romance. We should've remained friends. We were great at being friends.
Writing about the blurry distinction between friendship and romance, American psychologist Rick Zubin stripped the idea down to its emotional core: Liking and loving. The two emotions, he argued, tend to have the same characteristics, differentiated only by intensity. Loving, he argued, is more passionate liking, a bridge 182 people who took his survey later demonstrated.
Popular culture, bereft of nuance and useful insight, thought it would be cool then, to portray the mistake of one confused writer as a rite of passage written in the stars, defacing the institutions of friendship AND romance in its wake.
So, fuck Monish Behl. Fuck Billy Crystal and fuck Rahul and Anjali. The arc does not need to be friend to best friend to lovers to strangers because no matter what you do, there will always be two casualties: your heart and your best friend. Who will you bitch about your broken heart with if your best friend is gone?
Love and Sex We Met, We Marched, We Kissed: Love in the Age of Protests
We have a glut of dating apps, but no idea about the political leanings of a person we'll be hooking up with. A march like the anti-CAA protest can take care of several filters.
Love and Sex The Toughest Part of Breaking Up is Learning to Live with Yourself, Just for Yourself
For five years I was suffocated in a relationship of co-dependence. We were always together. But I was never present. It took me a while, but this year, I realised that I cared about my erstwhile partner a lot, but when I was with him, I had forgotten how to love myself.
When Millennials Grew Up Goodbye 2010s: How Dating Apps Changed the Way We Love in the Last Decade
It was love at first sight with Tinder in 2012. Now, as we near the end of the decade, we millennials know no other way to love. "No labels" is the default setting. Ghosting is pretty much par for the course. Collectively we're all playing the largest ever game of "Who cares the least?"
Love and Sex What Makes Relationships Work? My Husband and I Try to Find Answers in Noah Baumbach's Marriage Story
In Marriage Story, Nicole and Charlie spend two hours discovering that abandoning your individuality doesn't make the heart grow fonder. It just leaves you more confused. My husband agreed. This was the ultimate takeaway from the film – I felt we'd struck gold with our experiment.
Love and Sex The Space Between Us: Finding the Beauty & the Balance in a Long-Distance Marriage
As my husband and I sleep in separate beds, miles apart, thrust into our own individual struggles, loneliness overpowers us. Phone calls and Skype can only achieve so much. We've been wrung out of patience, yes, but this has been our most courageous effort as a couple.


So, you have done online dating correctly and you successfully courted your partner for three years already. Now what? When the courting is done, there is a definite need to keep control of the various steps that are involved to have initiated you to make this bid decision in your life.
Now, it makes perfect sense that you use online features to make personalization to the big day (probably!) Of your life. Since you met your partner through online dating, is not it just pure logic that the both of you should negotiate and arrange the relevant social events.
An example will be the selection of a wedding reception venue. There's no need for the hassle of driving all around town to look for one. Instead of wasting time, there is the option of searching for online directories to compare the various costs and quality without even leaving your house.
Snuggling together at home becomes so tempting as the internet is always handy for selecting gifts for the big day. Furthermore, there is the online facility that allows you to post photos online (about the wedding venue) that let the invited guests know what they should expect.
Since ancient times, the whole idea about marriage is to legalize and formalize the whole relationship. If you are intending to get married on some special events, like above the cruise ship, it is better for you to make extra check on the pre-requisites to make it sure that you are not violating any laws.
The power of the internet has crossed certain boundaries. Since, it is a grand affair, there should be a video about it and this video should have images that the both of you would want to remember. Such examples of items will include personalized wedding cake figures, your partner's favorite exotic flowers and the correct clothes for the entire wedding party. eBay just makes purchasing so convenient!