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News World News
Scott Morrison insists Sydney fireworks will go ahead
But firefighting authorities have refused to rule out the chance of cancelling the display at the last minute.
Fireworks explode over the Sydney Opera House and Harbour Bridge on New Year's Eve 2017 (Rick Rycroft/AP)
By PA Reporter
Sydney's famous New Year's Eve fireworks will go ahead despite the country's wildfire crisis to show the world Australia's resilience, Prime Minister Scott Morrison has said.
https://www.independent.ie/world-news/scott-morrison-insists-sydney-fireworks-will-go-ahead-38819323.html
https://www.independent.ie/incoming/e7a2d/38819329.ece/AUTOCROP/h342/ipanews_07901fed-c524-4eee-9b93-75793cca0419_1
Firefighting authorities, however, have refused to rule out the chance of cancelling the display at the last minute.
Doubts have arisen in recent days over whether the world-famous fireworks should go ahead, due both to risks of sparking fires in dry harbour-side nature reserves, and to sensitivities over the plight of those affected by the fires.
The state of New South Wales (NSW), of which Sydney is the capital, has been the worst hit by wildfires that have left nine people dead nationwide and razed more than 1,000 homes in the past several weeks.
The fire danger in Sydney and northern New South Wales is currently at put at "very high".
"On New Year's Eve, the world looks at Sydney. Every single year," Mr Morrison told reporters. "And they look at our vibrancy, they look at our passion, they look at our success.
"And so, in the midst of the challenges that we have to face, subject to the safety considerations, I can think of no better time to express to the world just how optimistic and positive we are as a country."
Despite Mr Morrison's insistence, NSW Rural Fire Service Commissioner Shane Fitzsimmons has refused to rule out calling off the fireworks at the last minute.
"If I determine it to be too risky, that doesn't concern me," Mr Fitzsimmons told a press conference.
"The pyrotechnics organisations and local authorities are used to working with us around exemptions in the summer period, whether it is Christmas, New Year or some other event.
"They know the arrangements, the procedures, and we will work through to make sure that risk is appropriately addressed and, where necessary, we won't allow them to go ahead."
Mr Morrison also announced financial support for some volunteer firefighters in NSW.
Authorities meanwhile are braced for conditions to worsen in the next few days, with extremely high temperatures.
Sydney's western suburbs are set to hit 41C (105.8F) on Sunday, before temperatures rise still further later in the week.
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Kids & Kudos
Still going strong after more than 50 years, the Peoria Park District Youth Music Festival, one of the longest-running festivals in the area, is sure to deliver another great evening featuring talented local kids.
The first Youth Music Festival took place in 1947 as a showcase for the students who participated in the Park District's summer band and orchestra classes, said Park District Fine Arts Coordinator Linda Huff. "The music program is offered as an extension of District 150's school year music program so students can continue to pursue their music education in a recreational manner."
Over the years, Huff said the Youth Music Festival has expanded to include the show chorus, Great Expectations 2003. They've also added a fine arts exhibit featuring the work of students enrolled in the fine arts camp. The festival is conducted by Peoria Park District Band Director Peggy Bonner, along with Orchestra Director Rebecca Thompson, both of whom are District 150 music teachers.
Huff said the Youth Music Festival theme is different each year. "This year's theme is 'Join the Parade,' and will feature some great marches and patriotic music. Jazz, show tunes, pop, and classical music are also included in the program. Past program themes included 'America's Music—Jazz' and 'Summer Jam.'"
The music program behind the festival includes four levels of classes—beginner to advanced—offered by the Park District to band and orchestra students. "In addition, we have our Senior Summer Band, which is comprised of area high school students. Each level of band and orchestra performs several songs at the festival; the Jazz Band and Senior Summer Band are our featured performers," said Huff.
To prepare for the festival, students enrolled in music classes meet three days a week for an hour per day, she said. "Mondays, percussion and violins have their classes; Tuesdays, it's woodwinds and violas; and Wednesdays, brass and cellos meet. All band students meet on Thursdays and Fridays for beginner, intermediate, and advanced band rehearsals. The same schedule applies to the orchestra students."
Huff said students from ages seven to 18 may enroll in the programs—and those with no experience to students with more than three years' experience are welcome. "The Senior Summer Band is made up of area high school students who audition for Peggy Bonner. They perform throughout the summer at Brown Bag-It, West Peoria Fourth of July Parade, as guest performers with the Municipal Band, and at the Illinois State Fair. The Jazz Band is comprised of advanced students in the 'Jam Session' class. They also perform along with the Senior Summer Band. The advanced orchestra students attend the 'Studio Session' class and give performances with the other two bands."
The vocal portion of the Youth Music Festival, Great Expectations 2003, also has a busy schedule. "That chorus, which is directed by Kim Holdham and includes youth ages 12 to 18, rehearses several evenings per week and on Saturdays to learn choreography and their program of music, which includes pop, jazz, spiritual, and patriotic music. The chorus performs throughout the community from June through August and also performs at the Illinois State Fair," Huff said.
Keeping up skills and getting a head start on the next school year—not to mention the chance to take part in the Youth Music Festival—are common reasons students join the Park District's summer programs, but there are other benefits, as well. "Many experienced students use it as an opportunity to try playing a new or different instrument," she said. "We're able to offer very affordable instrument rental with our program and festival sponsor, Samuel Music."
Making music in a low-stress environment is also attractive to students. "We try to keep the students in educational classes in a relaxed atmosphere where they're encouraged to interact with both their teacher and the other band or orchestra members. We also provide them with opportunities to travel and perform together during the summer," Huff said.
The Youth Music Festival takes place at 6:30 p.m., July 25, at the Glen Oak Park Amphitheater. Admission is $3 for adults; students with ID are free.
For more information, call 688-3667, ext. 266. AA!

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Diabetes and other endocrinal, nutritional and metabolic conditions
Dapagliflozin in combination therapy for treating type 2 diabetes
Technology appraisal guidance [TA288] Published date: 26 June 2013 Last updated: 23 November 2016
3 The manufacturers' submission
6 Recommendations for further research
8 Sources of evidence considered by the Committee
Clinical effectiveness
Summary of Appraisal Committee's key conclusions
4.1 The Appraisal Committee reviewed the data available on the clinical and cost effectiveness of dapagliflozin, having considered evidence on the nature of dapagliflozin and the value placed on the benefits of dapagliflozin by people with the condition, those who represent them and clinical specialists. It also took into account the effective use of NHS resources.
4.2 The Committee discussed the clinical treatment pathway for type 2 diabetes. The Committee heard from the clinical specialists that treatment for type 2 diabetes is individualised for each patient (focusing on HbA1c reduction without weight gain or hypoglycaemia), resulting in some variation in clinical practice. However, although treatment is individualised, current UK practice broadly follows the NICE guideline on type 2 diabetes, which recommends a stepwise approach that includes using diet and exercise, various antidiabetic drugs and insulin. The Committee heard from the clinical specialists that each of the existing antidiabetic therapies had various advantages and disadvantages affecting their suitability for patients and that many patients do not achieve target HbA1c levels with existing therapies. The Committee heard from the clinical specialists that dapagliflozin may be more likely to be used as a triple therapy but could be used as a dual therapy if there was a perceived risk of hypoglycaemia. It was noted that its use may be limited by the restrictions in the marketing authorisation, which states that dapagliflozin is not recommended for use in people with moderate to severe renal impairment. The Committee understood that a new treatment providing an additional option would be valued by clinicians.
4.3 The Committee discussed the antidiabetic drugs that were used at each point in the treatment pathway for type 2 diabetes. The Committee heard from the clinical specialists that most people start treatment with metformin and that the use of a sulfonylurea as first-line therapy is diminishing because of the associated weight gain and the high incidence of hypoglycaemia compared with other oral therapies. The Committee heard from the clinical specialists that a sulfonylurea is often added to metformin as a dual therapy but if patients are unable to take a sulfonylurea because of concerns about weight gain or hypoglycaemia, then thiazolidinediones (pioglitazone), DPP‑4 inhibitors and GLP‑1 analogues may be used. The clinical specialists also commented that the same treatments could be used in triple therapy and as add-on to insulin therapy. The Committee heard from the clinical specialists that the use of DPP‑4 inhibitors was increasing and that the use of pioglitazone was decreasing because of concerns about safety. It was also aware that GLP‑1 analogues were used less frequently and usually later on in the treatment pathway because they are administered by subcutaneous injection and are more costly than other antidiabetic drugs. The Committee concluded that on the basis of the evidence from the clinical specialists, dapagliflozin was most likely to be used if a sulfonylurea was not appropriate, and the main comparator for dapagliflozin would be the DPP‑4 inhibitors.
4.4 The Committee heard evidence from the patient experts that an advantage of dapagliflozin is that it will provide a further treatment option for people with type 2 diabetes who are reluctant to start treatment with insulin or wish to avoid insulin therapy because of fear of hypoglycaemia and its impact on their lifestyle (for example, the threat of losing their driving licence or their job). The Committee heard from the patient experts that the potential disadvantages of dapagliflozin include more frequent urinary tract and genital infections. However, the patient experts commented that the importance of these events would vary between individual patients and that, for some patients, the higher risk of urinary or genital infections could be balanced by the lower risk of hypoglycaemia. The Committee also heard from the patient experts that because dapagliflozin causes the excretion of glucose through the urine, this may cause anxiety for some patients who understand an absence of glucose in the urine to be a sign of good diabetes management and that this may lead to non-adherence to dapagliflozin therapy. However, the clinical specialists suggested that this was a risk that could be managed by providing appropriate information to people with diabetes.
4.5 The Committee considered the evidence on the clinical effectiveness of dapagliflozin compared with other antidiabetic therapies, noting that most of the data came from the network meta-analyses submitted by the manufacturers. The Committee noted that, although the WinBUGs programme code used to run the original network meta-analyses provided in the manufacturers' submission differed from the code recommended by the NICE DSU in their technical support document, the manufacturers had also provided revised network meta-analyses that were based on the recommended code. The Committee also noted that the results of the manufacturers' revised network meta-analyses were similar to those from the original analyses. The Committee concluded that the results of the manufacturers' revised network meta-analyses provided an appropriate basis for making decisions about the clinical effectiveness of dapagliflozin and other antidiabetic therapies.
4.6 The Committee discussed the outcomes collected in the clinical trials and network meta-analyses, noting that the primary outcomes were intermediate rather than clinical outcomes. The Committee noted that studies including the UKPDS had then been used to provide a link between these intermediate outcomes and long-term clinical outcomes including micro- and macrovascular complications. The Committee heard from the clinical specialists that there was some uncertainty about the impact of HbA1c reduction on longer-term macrovascular complications. The Committee also heard from the manufacturers that follow-up data were available for the clinical trials of dapagliflozin but that, because most of the trials of other antidiabetic drug therapies were of shorter duration, the clinical-effectiveness data used in the cost-effectiveness analysis had to be based on the short-term clinical trial data. The Committee concluded that, despite some uncertainty about the impact of HbA1c reduction on longer-term macrovascular complications, it was prepared to accept the link between the intermediate outcomes collected in the clinical trials and the longer-term clinical outcomes.
4.7 The Committee considered the clinical effectiveness of dapagliflozin in dual therapy for people whose type 2 diabetes is inadequately controlled by metformin alone. The Committee noted that the evidence came from 3 clinical trials and a network meta-analysis. The Committee also noted that only 1 of the clinical trials of dapagliflozin had an active comparator (sulfonylureas), and that the clinical trial results were based on a relatively small number of patients who were given dapagliflozin at its licensed dose. However, on the basis of these clinical trial results, the Committee considered dapagliflozin to have greater efficacy than sulfonylureas for the outcomes of weight loss and systolic blood pressure reduction and similar efficacy for HbA1c reduction. The Committee concluded that, on the basis of the results of the network meta-analyses (see sections 3.10 and 3.45), dapagliflozin in dual therapy as add-on to metformin appeared to provide similar glycaemic control to other antidiabetic drugs but may result in greater weight loss.
4.8 The Committee further considered the clinical effectiveness of dapagliflozin as dual therapy, noting that the manufacturers had not provided data on dapagliflozin as add-on therapy to a sulfonylurea, despite clinical trial data being available. The Committee accepted that most of the patients would start on metformin monotherapy, but noted the evidence provided by the clinical specialists that a proportion of patients who cannot tolerate metformin or for whom it is contraindicated would receive sulfonylurea monotherapy. It noted that the clinical effectiveness of dapagliflozin as an add-on to a sulfonylurea appeared to be consistent with its effectiveness when used as an add-on to metformin. The Committee concluded that, because the manufacturers had not provided clinical evidence on dapagliflozin as an add-on to a sulfonylurea, it could not make recommendations on this combination regimen.
4.9 The Committee considered the clinical effectiveness of dapagliflozin for people whose type 2 diabetes is inadequately controlled by insulin, noting that the evidence came from 2 clinical trials and a network meta-analysis. The Committee noted that both trials were placebo controlled and that 1 of these was of 12 weeks' duration only. Again, the Committee noted that the clinical trial results for dapagliflozin were based on a relatively small number of patients who were treated with dapagliflozin at its licensed dose. Further, the Committee noted that the network meta-analysis excluded trials of GLP‑1 analogues because they were not comparable to other trials included in the analysis and therefore consideration of the full range of possible comparators was restricted by the available evidence. The Committee concluded that, on the basis of the results of the network meta-analyses (see sections 3.12 and 3.45), dapagliflozin as add-on therapy to insulin appeared to have greater efficacy than DPP‑4 inhibitors for the outcome of weight loss and similar efficacy for HbA1c reduction.
4.10 The Committee considered the evidence on the clinical effectiveness of dapagliflozin in triple therapy. The Committee noted that dapagliflozin is currently being studied as a triple therapy add-on to 2 other oral agents and that, in the absence of any other currently available clinical-effectiveness data, the manufacturers provided a post-hoc analysis of pooled data from a subset of older patients with type 2 diabetes and cardiovascular disease recruited in 2 trials of dapagliflozin as an add-on to metformin and a sulfonylurea. The Committee also noted that no direct head-to-head studies comparing dapagliflozin with other antidiabetic drugs currently exist and that the clinical-effectiveness data used to indirectly compare dapagliflozin with other antidiabetic drugs were taken from a previously published systematic review that had not been updated since 2009. It was aware of the limitations of these analyses highlighted by the manufacturer and therefore concluded that significant caution should be taken when interpreting the results of these preliminary analyses on the clinical effectiveness of dapagliflozin in the triple therapy setting.
4.11 The Committee considered the adverse events associated with dapagliflozin. It noted that common adverse events included urinary tract and genital infections and that these events were more common in women than in men. However, the Committee heard from the manufacturers that the recurrence of these events in the clinical trials was low. It also heard from the manufacturers that, because of the mechanism of action of dapagliflozin, the clinical trials had actively looked for such infections and that only a small proportion of these infections needed treatment. The Committee also noted that the incidence of hypoglycaemia was low when dapagliflozin was added to metformin and that the currently available evidence suggested that dapagliflozin was not associated with increased risk of cardiovascular events. However, it was aware that regulatory agencies had identified some uncertainty about the risk of some cancers associated with dapagliflozin. The Committee heard from the patient experts that adverse events were a concern for patients with type 2 diabetes if they result in the need for additional drug therapies, especially for patients who are already receiving many drug therapies for their condition. However, it also recognised that a new drug therapy that was associated with a lower risk of hypoglycaemia than some other existing therapies would also be valued by patients for whom driving might be a significant factor in their lifestyle or livelihood. The Committee concluded that the adverse-events profile of dapagliflozin was different from those of other antidiabetic therapies and that it was important to examine these adverse events when considering the manufacturers' economic model.
4.12 The Committee considered the cost effectiveness of dapagliflozin as an add-on to metformin and insulin and as triple therapy in the manufacturers' submission, and the critique and exploratory analyses provided by the DSU and the ERG. The Committee noted that the manufacturers had provided a revised economic model in order to address concerns raised by the DSU about the original model and that the DSU considered that their concerns had been addressed. However, it also noted that the DSU and the ERG had identified a number of errors in the revised model which were subsequently addressed by the DSU in its exploratory analyses. The Committee concluded that the manufacturers' revised economic model with the subsequent amendments made by the DSU was acceptable for assessing the cost effectiveness of dapagliflozin in combination therapy for treating type 2 diabetes.
4.13 The Committee discussed the validation report provided by the manufacturers which compared the results from the revised model with the results that would have been obtained using the CORE diabetes model, which has been used in previous appraisals of treatments for type 2 diabetes (such as NICE's technology appraisal guidance on liraglutide and exenatide in combination with oral antidiabetic therapy). The Committee noted that the results generated from the CORE diabetes model were comparable to those obtained from the manufacturers' original and revised economic models for the dual therapy and insulin add-on therapy analyses. The Committee concluded that the results of the validation exercise with the CORE diabetes model provided reassurance about the integrity of the results obtained from the manufacturers' revised economic model.
4.14 The Committee discussed the cost-effectiveness analyses presented by the manufacturers, noting that these included a more restricted set of comparators than were specified in the scope. It was aware that GLP‑1 analogues had been included in the network meta-analysis for dual therapy but then subsequently excluded from the cost-effectiveness analysis. The Committee considered that it would have been more appropriate for all treatments in the network meta-analysis to have been included in the cost-effectiveness analysis. However, it noted the comments from the ERG and clinical specialists that GLP‑1 analogues were used in dual therapy on a restricted basis. On balance, the Committee concluded that the manufacturers had included an adequate range of comparators for the cost-effectiveness analysis of dapagliflozin in dual therapy as an add-on to metformin.
4.15 The Committee discussed the clinical-effectiveness data that were applied in the economic models. The Committee noted that the DSU had completed analyses of dual therapy add-on to metformin using different sources of clinical-effectiveness data. One analysis used the 24‑week network meta-analysis data for dapagliflozin, DPP‑4 inhibitors and thiazolidinediones and presented a separate comparison using head-to-head data from study 4 for dapagliflozin and sulfonylureas. The other analysis considered all treatments in a single analysis using the 52‑week network meta-analysis data. It heard from the manufacturers that, for the metformin add-on analyses, the trials of other antidiabetic therapies as add-on to metformin used a fixed dose but the trials of sulfonylureas did not have a stable dose over 24 weeks. Therefore, trials of sulfonylureas as an add-on to metformin were excluded from the 24‑week network meta-analysis. The Committee discussed which set of analyses was the most appropriate, noting that the estimates of efficacy differed between analyses. It considered that it was more appropriate to use a single source as was available in the 52‑week network meta-analysis, but was aware of the limited number of trials informing this analysis. The Committee noted that the 24‑week network meta-analysis only excluded sulfonylureas, and that the evidence from the clinical specialists suggested that dapagliflozin would be used where sulfonylureas were not appropriate. On this basis the 24‑week network meta-analysis data were appropriate. The Committee concluded that the results of the revised 24‑week network meta-analysis provided the most appropriate clinical-effectiveness data for the dual therapy analyses.
4.16 The Committee discussed the manufacturers' assumptions about the decision to switch or intensify treatment in the model, noting that this was based on baseline HbA1c levels taken from the clinical trials and network meta-analysis. The Committee noted that the HbA1c threshold levels for switching treatment in the original dual therapy and triple therapy analyses were above those recommended in NICE's guideline on type 2 diabetes and therefore may not reflect UK clinical practice. However, the Committee noted that the DSU's revised analyses applied an HbA1c threshold for switching treatment that is currently recommended in NICE's guideline on type 2 diabetes. The Committee heard from the DSU that the results from the revised model were sensitive to the timing of treatment switching in the model which was dependent on the relationship between HbA1c at the start of treatment, treatment-related changes in HbA1c levels and the HbA1c threshold levels for switching treatment. The Committee concluded that HbA1c threshold levels for switching treatment as recommended in NICE's guideline on type 2 diabetes were appropriate to use in the economic modelling and as a basis for decision-making.
4.17 The Committee discussed the manufacturers' approach to modelling changes in body weight. The Committee noted that in the revised model the effect of treatment on changes in weight was applied gradually over the course of the first year, and considered that this was more plausible than the original model in which the effect of treatment on changes in weight was applied immediately. The Committee noted that, for treatments associated with weight loss, the manufacturers made assumptions about how long weight loss was maintained in the model (weight plateau), and about how long it took for the weight to increase to its baseline level after the plateau (loss of effect). The Committee understood that the changes made by the DSU meant that for treatments associated with weight loss, the weight profiles of the treatment groups now converged over time, but that for treatments associated with weight gain, differences in weight were maintained over the model time horizon. The Committee acknowledged that unpublished data from the clinical study of dapagliflozin and sulfonylureas as add-on to metformin provided by the manufacturers showed that patients who remained on dapagliflozin treatment without switching to other treatments maintained their weight loss over 4 years. However, the Committee considered that uncertainty remained about the effects of stopping treatment with dapagliflozin and the impact on weight gain. Therefore, it concluded that the scenario analysis conducted by the DSU, which involved the convergence of differences in weight profiles between treatment groups at the time of switching to the last line of treatment, was more appropriate for decision-making.
4.18 The Committee considered the utility values applied in the model, noting that in all analyses the majority of the QALY gains associated with dapagliflozin arose from the direct impact of weight change on health-related quality of life rather than from a reduction of diabetic complications and other adverse events. The Committee noted that utility values associated with changes in BMI were taken from a study commissioned by the manufacturers and that the methods by which these values were obtained were not in line with the NICE reference case for measuring and valuing health effects. The Committee also noted that this study produced different utility values associated with a 1-unit increase or decrease in BMI and that these were larger than other utility values that were identified in the literature. The Committee acknowledged that the manufacturers presented scenario analyses using alternative utility values for weight change and that these resulted in higher ICERs for the metformin and insulin add-on analyses. The Committee also noted that the loss in utility associated with a 1-unit increase in BMI (−0.0472) was similar to the loss in utility associated with a myocardial infarction (−0.055), which may not be credible. The Committee concluded that the utility values associated with changes in weight may have been too large and that the values (±0.0061 per BMI unit decrease or increase) applied in the manufacturers' scenario analyses and DSU analyses were more reasonable.
4.19 The Committee considered the utility values associated with hypoglycaemic events. The Committee heard from the ERG that they considered that the loss in QALYs associated with hypoglycaemic events may have been too large. The Committee was also aware that the loss in utility associated with severe hypoglycaemic events (−0.047) was higher than that applied in the economic model of third-line therapy with insulins, thiazolidinediones or exenatide in NICE's guideline on type 2 diabetes (−0.010). However, the Committee noted that after the publication of this guideline, the Driving and Vehicle Licensing Agency issued new regulations for people who have experienced a severe hypoglycaemic event in the previous 12 months. Therefore, the Committee acknowledged that any loss in utility associated with severe hypoglycaemic events may be higher in people for whom driving might be a significant factor in their lifestyle or livelihood. The Committee noted that the DSU had completed analyses that included both the higher and lower estimates of loss of utility associated with hypoglycaemic events, and that these had made small differences to the estimates of the ICER. The Committee therefore concluded that the utility values associated with hypoglycaemic events were not a critical factor in the decision-making.
4.20 The Committee considered the utility values applied to urinary tract and genital infections in the model, noting that the loss in utility associated with these events was much smaller than the loss in utility associated with other adverse events. The Committee considered that it was likely that there would be a greater loss in utility associated with these events than had been proposed by the manufacturers. The Committee also noted that the study commissioned by the manufacturers to examine the impact of weight change on health-related quality of life had also estimated the impact of urinary tract and genital infections, although these data were not presented in the manufacturers' submission. The Committee noted that in scenario analyses the manufacturers had applied a range of estimates for the loss in utility associated with urinary tract and genital infections. It was also aware that the results of the revised analyses were not sensitive to changes in these utility values. The Committee concluded that, although the loss in utility associated with urinary tract and genital infections was likely to be greater than that proposed by the manufacturers, it was satisfied that this did not significantly impact on the relative cost effectiveness of dapagliflozin as dual therapy or add-on to insulin.
4.21 The Committee was aware that the ERG had proposed alternative estimates for some costs, including drug acquisition costs for pioglitazone and the costs associated with diabetic complications. The Committee noted that pioglitazone is now off-patent and that the latest acquisition costs are substantially lower than those presented in the manufacturers' submission. The Committee acknowledged that the manufacturers were unable to provide this estimate in their submission, but considered that the DSU estimate of an average annual cost of £69.09 was reasonable. The Committee also noted that the manufacturers' revised model did not correctly adjust the annual inpatient and non-inpatient costs (estimated as £483 in the UKPDS 65 study) for people who did not experience a macro- or microvascular diabetic complication. The Committee concluded that it was appropriate to consider the latest acquisition cost of pioglitazone and that the manufacturers' revised model should be amended to correctly account for the annual costs incurred by people who did not experience a macro- or microvascular diabetic complication.
4.22 The Committee considered the most plausible ICERs for dapagliflozin as dual therapy in combination with metformin. The Committee considered that, on the basis of clinical specialist opinion that suggested that the use of pioglitazone in UK clinical practice was decreasing, a thiazolidinedione was not a key comparator in the dual therapy setting. The Committee also noted the evidence from the clinical specialists supported by the manufacturers that, in clinical practice, dapagliflozin would predominantly be used in combination with metformin when a sulfonylurea is not appropriate. Therefore, the Committee also considered that sulfonylureas were not a relevant comparator in the dual therapy setting. The Committee considered the DSU deterministic analysis and scenario analyses, which included the convergence of differences in weight between treatment groups at the time of switching to the last line of treatment. It noted that these showed that DPP‑4 inhibitors were associated with higher costs and QALYs than dapagliflozin, but that these differences were small. It noted further that in the DSU probabilistic sensitivity analysis these differences were even smaller. The Committee noted that the differences in QALYs were largely explained by the changes in health-related quality of life (utility) associated with changes in weight (BMI). Overall, the Committee concluded that because of the small differences in costs and QALYs between dapagliflozin and DPP‑4 inhibitors, dapagliflozin in a dual therapy regimen in combination with metformin could be recommended as a treatment option for people with type 2 diabetes that is inadequately controlled with metformin alone if it is used in the same scenario as described for the use of DPP‑4 inhibitors in NICE's guideline on type 2 diabetes.
4.23 The Committee considered the most plausible ICERs for dapagliflozin as add-on to insulin. It noted that in all the analyses conducted by the DSU the estimate of the ICER for dapagliflozin compared with DPP‑4 inhibitors was below £20,000 per QALY gained. The Committee considered that, in comparison to DPP‑4 inhibitors, dapagliflozin had been shown to be a cost-effective use of NHS resources. The Committee recommended dapagliflozin as a treatment option for people with diabetes inadequately controlled by insulin with or without other oral antidiabetic drugs.
4.24 The Committee discussed the results of the manufacturers' revised base-case analyses for dapagliflozin as triple therapy add-on to metformin and a sulfonylurea. It noted that the sequence of treatments in the manufacturers' revised economic model had been amended so that the approach was consistent with the dual therapy and insulin add-on analyses, with patients in the model starting treatment with triple add-on therapy. The Committee noted that in both the manufacturers' original and revised triple therapy analyses, dapagliflozin dominated other comparator drug therapies, meaning that dapagliflozin was associated with lower costs and higher QALYs than the comparators. However, the Committee noted that the clinical-effectiveness data applied in the triple therapy model were based on an indirect comparison of pooled data of 2 trials of dapagliflozin and a separate systematic review of other antidiabetic drug therapies conducted in 2009. The Committee was also aware that dapagliflozin is currently being studied as a triple therapy add-on to 2 other oral agents. The Committee considered that the cost-effectiveness analyses should be considered as exploratory in nature. The Committee concluded that dapagliflozin as triple therapy in combination with metformin and a sulfonylurea should not be recommended for treating type 2 diabetes except as part of the ongoing clinical trials.
Appraisal title: Dapagliflozin in combination therapy for treating type 2 diabetes
Key conclusion
Dapagliflozin in a dual therapy regimen in combination with metformin is recommended as an option for treating type 2 diabetes, only if it is used as described for dipeptidyl peptidase-4 (DPP‑4) inhibitors in the NICE guideline on type 2 diabetes.
Dapagliflozin in combination with insulin with or without other antidiabetic drugs is recommended as an option for treating type 2 diabetes.
For dapagliflozin dual therapy regimens in combination with metformin, the Committee concluded that because of the small differences in costs and QALYs between dapagliflozin and DPP‑4 inhibitors, dapagliflozin in a dual therapy regimen in combination with metformin could be recommended.
For dapagliflozin as add-on to insulin all the analyses conducted by the DSU produced an estimate of the ICER for dapagliflozin compared with DPP‑4 inhibitors below £20,000 per QALY.
Dapagliflozin in a triple therapy regimen is currently being studied as an add-on to 2 other oral agents. The Committee considered that the cost-effectiveness analyses should be considered as exploratory in nature.
4.22, 4.23, 4.24
Current practice
Clinical need of patients, including the availability of alternative treatments
The Committee heard evidence from the patient experts that an advantage of dapagliflozin is that it will provide a further treatment option for people with type 2 diabetes who are reluctant to start treatment with insulin or wish to avoid insulin therapy because of fear of hypoglycaemia and its impact on their lifestyle (for example, the threat of losing their driving licence or their job).
Proposed benefits of the technology
How innovative is the technology in its potential to make a significant and substantial impact on health-related benefits?
The Committee recognised that a new drug therapy that was associated with a lower risk of hypoglycaemia than some other existing therapies would be valued by patients for whom driving might be a significant factor in their lifestyle or livelihood.
What is the position of the treatment in the pathway of care for the condition?
The Committee heard from the clinical specialists that dapagliflozin may be more likely to be used as a triple therapy but could be used as a dual therapy if there was a perceived risk of hypoglycaemia. The Committee concluded that on the basis of the evidence from the clinical specialists, dapagliflozin was most likely to be used if a sulfonylurea was not appropriate, and the main comparator for dapagliflozin would be the DPP‑4 inhibitors.
Common adverse events included urinary tract and genital infections and these events were more common in women than in men. However, the Committee heard from the manufacturers that the recurrence of these events in the clinical trials was low.
The Committee concluded that the adverse-events profile of dapagliflozin was different from those of other antidiabetic therapies and that these adverse events were important to examine when considering the manufacturers' economic model.
Evidence for clinical effectiveness
Availability, nature and quality of evidence
For dapagliflozin as an add-on to metformin, the evidence came from 3 clinical trials and a network meta-analysis. Only 1 of the clinical trials of dapagliflozin had an active comparator (sulfonylurea) and the clinical effectiveness of dapagliflozin compared with DPP‑4 inhibitors, thiazolidinediones and GLP‑1 analogues was based solely on network meta-analysis.
The manufacturers had not provided clinical-effectiveness data on dapagliflozin as add-on therapy to a sulfonylurea, despite clinical trial data being available. The Committee concluded that, because the manufacturers had not provided clinical evidence of dapagliflozin as add-on to a sulfonylurea, it could not make recommendations on this combination regimen.
For dapagliflozin as add-on therapy to insulin, the evidence came from 2 clinical trials and a network meta-analysis. Both trials were placebo controlled and 1 was of 12 weeks duration only. The trial results for dapagliflozin were based on a relatively small number of patients who were treated with dapagliflozin at its licensed dose. The network meta-analysis excluded trials of GLP‑1 analogues because they were not comparable to other trials included in the analysis and therefore consideration of the full range of possible comparators was restricted by the available evidence.
Dapagliflozin is currently being studied as a triple therapy add-on to 2 other oral agents and, in the absence of any other currently available clinical-effectiveness data, the manufacturers provided a post hoc analysis of pooled data from a subset of older patients with type 2 diabetes and cardiovascular disease recruited in 2 trials of dapagliflozin as an add-on to metformin and sulfonylurea. The Committee concluded that significant caution should be taken when interpreting the results of these preliminary analyses.
Relevance to general clinical practice in the NHS
The Committee discussed the outcomes collected in the clinical trials and network meta-analyses, noting that the primary outcomes were intermediate rather than clinical outcomes and that these were collected over a relatively short follow-up.
Uncertainties generated by the evidence
The Committee concluded that, despite some uncertainty about the impact of HbA1c reduction on longer-term macrovascular complications, it was prepared to accept the link between intermediate outcomes collected in the clinical trials and longer-term clinical outcomes.
Are there any clinically relevant subgroups for which there is evidence of differential effectiveness?
Estimate of the size of the clinical effectiveness including strength of supporting evidence
The Committee concluded that, on the basis of the results of the network meta-analyses, dapagliflozin in dual therapy as add-on to metformin appeared to provide similar glycaemic control to other antidiabetic drugs but may result in greater weight loss.
The Committee concluded that, on the basis of the results of the network meta-analyses, dapagliflozin as add-on therapy to insulin appeared to have greater efficacy than DPP‑4 inhibitors for the outcome of weight loss and similar efficacy for HbA1c reduction.
Evidence for cost effectiveness
Availability and nature of evidence
The manufacturers had provided a revised economic model in order to address concerns raised by the DSU about the original model and the DSU considered that their concerns had been addressed. However, the DSU and the ERG had identified a number of errors in the revised model which were subsequently addressed by the DSU in its exploratory analyses. The Committee concluded that the manufacturers' revised economic model with the subsequent amendments made by the DSU was acceptable for assessing the cost effectiveness of dapagliflozin in combination therapy for treating type 2 diabetes.
The Committee concluded that the results of the validation exercise with the CORE diabetes model provided reassurance about the integrity of the results obtained from the manufacturers' revised economic model.
Uncertainties around and plausibility of assumptions and inputs in the economic model
In terms of the clinical-effectiveness data that were applied in the economic models, the Committee considered that it was more appropriate to use a single source as was available in the 52‑week network meta-analysis, but was aware of the limited number of trials informing this analysis. It also noted that the 24‑week network meta-analysis only excluded sulfonylureas, and that the evidence from the clinical specialists suggested that dapagliflozin would be used where a sulfonylurea was not appropriate. On this basis the 24‑week network meta-analysis data were appropriate.
The Committee heard from the DSU that the results from the revised model were sensitive to the timing of treatment switching in the model which was dependent on the relationship between HbA1c at the start of treatment, treatment-related changes in HbA1c levels and the HbA1c threshold levels for switching treatment.
The Committee considered that uncertainty remained about the effects of stopping treatment with dapagliflozin and the impact on weight gain. Therefore, it concluded that the scenario analysis conducted by the DSU, which involved the convergence of differences in weight profiles between treatment groups at the time of switching to the last line of treatment, was more appropriate for decision-making.
Incorporation of health-related quality-of-life benefits and utility values
Have any potential significant and substantial health-related benefits been identified that were not included in the economic model, and how have they been considered?
The Committee considered the utility values applied in the model, noting that the majority of the QALY gains associated with dapagliflozin arose from the direct impact of weight change on health-related quality of life rather than a reduction of diabetic complications and other adverse events. The Committee concluded that the utility values associated with changes in weight may have been too large and that the values applied in the manufacturers' scenario analyses and DSU analyses were more reasonable.
The Committee noted that the DSU had completed analyses that included both the higher and lower estimates of loss of utility associated with hypoglycaemic events, and that these had made small differences to the estimates of the ICER.
The Committee concluded that, although the loss in utility associated with urinary tract and genital infections was likely to be greater than that proposed by the manufacturers, it was satisfied that this did not significantly impact on the relative cost effectiveness of dapagliflozin as dual therapy or add-on to insulin.
Are there specific groups of people for whom the technology is particularly cost effective?
What are the key drivers of cost effectiveness?
The Committee noted that in all settings the majority of the QALY gains associated with dapagliflozin arose from the direct impact of weight change on health-related quality of life rather than from a reduction of diabetic complications and other adverse events.
Most likely cost-effectiveness estimate (given as an ICER)
For dapagliflozin as dual therapy in combination with metformin, the Committee considered the DSU deterministic analysis and scenario analyses, which included the convergence of differences in weight between treatment groups at the time of switching to the last line of treatment. It noted that these showed that DPP‑4 inhibitors were associated with higher costs and QALYs than dapagliflozin, but that these differences were small. It noted further that in the DSU probabilistic sensitivity analysis these differences were even smaller.
For dapagliflozin as add-on to insulin, the Committee noted that in all the analyses conducted by the DSU the estimate of the ICER for dapagliflozin compared with DPP‑4 inhibitors was below £20,000 per QALY.
Additional factors taken into account
Patient access schemes (PPRS)
End-of-life considerations
Equalities considerations and social value judgements
The Committee concluded that its recommendations would not have a particular impact on any of the groups whose interests are protected by the equalities legislation and that there was no need to alter or add to its recommendations.


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Posted on November 22, 2016 by Simon Phipps Tagged LinuxMicrosoftSoftware PatentsThe Linux Foundation	Comments20 Comments on Microsoft & Linux & Patents & Tweets
Microsoft & Linux & Patents & Tweets
Fact-checking some tweets about Linux Foundation's newest member and their harvesting of other members' money.
Microsoft recently joined the Linux Foundation while still asserting its patents against the rest of the membership. As I found that odd, I tweeted some casually-calculated statistics about Microsoft's patent revenues that seemed to me to simply be the aggregation of common knowledge. But maybe people have forgotten the details; at least two respondents asked me to substantiate the figures. Having struck a nerve, this post is by way of explanation.
Microsoft has joined the Linux Foundation as a Platinum member. According to Schedule A of its bylaws, the payment needed to gain this membership level is $500,000. In return, as well as joining an elite club of super-rich corporations (for example, Red Hat can't afford this level and is a Silver member), Microsoft also gets a seat on the Board of Directors, which was recently flushed of the last two member-elected directors (Linux Foundation appointed two very capable women to the large Board instead).
Microsoft's representative employee is Azure architect John Gossman. The appointment of an employee from Microsoft's Azure (cloud) business unit reflects the driving force behind this and all other open source moves by the company. There is little indication that the rest of the company shares the Azure product group's commitment to open source, especially not the patent licensing group.
Revenue From Patents
Microsoft's revenue for 2016 was $85bn using conservative accounting rules. Microsoft does not break out patent income in their 10-K, so it can only be estimated (and doing so involves a decoder ring according to Ed Bott who suggests about $8bn of Microsoft's revenue comes from IP licensing). As a report in CRN explains,
Microsoft is believed to make between $5 and $15 in royalties on each Android device sold. In 2013, Wall Street analyst Rick Sherlund estimated this was generating a $2 billion annual revenue stream, while other estimates have ranged as high as $6 billion.
That $2bn figure comes from a Nomura research note according to Business Insider. As the lowest frequently-cited figure, I prefer to cite this than any other estimated number but it is clearly a matter of preference rather than objective fact which number is used.
Nature Of Patents
The revenue Microsoft gains comes a range of targets than can be colloquially called "Linux" with varying qualification. That includes embedded Linux and things that use it such as Android and shared SMB filesystems as well as Linux as a server and things that use it. Again, identifying the ratio of income per usage is impossible for anyone outside Microsoft (and probably for most people inside).
Certainly the range of patents Microsoft is known to be attempting to monetise includes a broad range of functions. The best list I have found appears to have been inadvertently published by the Chinese Ministry of Commerce in 2014. But licensing activity is certainly not limited to Android; Microsoft also targets ChromeOS, Linux servers, Linux in consumer devices (each of those is a sample; there are plenty of other press releases) and much of the Android licensing actually appears to related to xFAT filesystem interoperability as in the Tom Tom case.
Although those figures refer to "licensing", take care not to assume that relates to intentional licensing of innovative technology sourced from a inventors or researchers. The 95% margin on the revenue suggests that the patents Microsoft is monetising here do not relate to technologies where their mark has sought assistance or advice. Rather, each company is likely to have been proactively approached by Microsoft and invited to take a license based on a somewhat vague assertion that they are infringing a basket of rights.
The "sales process" is lawyer-led and well-understood. The target "customer" is likely to be asked to sign an NDA at the beginning of the process, and the price is likely to be set to be a little less expensive than contesting a patent lawsuit. This approach, introduced by IP Hall Of Fame inductee Marshall Phelps (who invented it first for IBM), is similar to the approach used by patent trolls. Almost everyone settles rather than fighting — everyone remembers Tom Tom — and the NDA means there's little public information to study.
The Tweets
Putting all these points together:
The $500k Microsoft paid to join Linux Foundation is about ¼% of their revenue from patent threats against Linux, as far as I can tell.
— Simon Phipps (@webmink) November 17, 2016
This year Red Hat reported $2bn in revenue. Adding that to the mix:
Linux Foundation member Microsoft's income from patent threats against Linux is about the same as Red Hat's entire turnover.
I thus believe all those statements are correct, but I would welcome better sources for any of the points made and will correct anything that's clearly wrong.
What could Microsoft and the Linux Foundation do?
The Linux Foundation should include in its membership agreement a good-faith commitment not to initiate any patent litigation relating to the Linux platform against anyone and exclude those who break it. A trade association should not permit its members to fight among themselves.
Microsoft should declare that no part of the company will in future initiate software patent claims against the Linux platform and as a sign of its good faith join the Open Invention Network. That's not of itself magical — Oracle and Google are both OIN members and still litigating Android patents — but the combination of gestures could make a tremendous difference to community trust.
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20 thoughts on "Microsoft & Linux & Patents & Tweets"
Jason Kemp (@dialogCRM) says:
That all looks like useful research but yet there are no conclusions or recommendations. I'm guessing this is because of legal reasons. Surely a member organisation that wants to stay a member shouldn't be coercing other companies to cough up.
At the very least this is a PR problem. It doesn't seem to be in the spirit of open source to be taking with one hand and making a token donation (platinum membership) with the other.
It seems to me that it is inconsistent to benefit from patent revenues and questionable legal tactics (salesmanship – really?) and be a member of Linux. Of course the foundation would probably have to refund the membership fee.
This kind of news is what makes me very cynical about current business practices at both Linux Foundation and MS. In my opinion Linux Foundation should not have accepted the membership at this time but we know that nothing will happen and people will just argue that ambiguities are a fact of life. And that is just bizarre and wrong – in my personal view.
Simon Phipps says:
Thanks for your comments. The post was more to support the tweets than to reach a recommendation, but the second sentence – that it's odd Microsoft should be admitted to Linux's trade association while still attacking its other members – conveys the gist of the recommendation! However, I have now added a call to action.
mtelesha says:
There is little indication that the rest of the company shares the Azure product group's commitment to open source, especially not the patent licensing group.
Microsoft is a subject that creates alot of different emotions in the Linux world, but their official Open Source commitment is far more then Azure.
Inclusion of Ubuntu bash in Windows 10
That THIS exist at all: https://github.com/Microsoft
I think the above quote is being short on Microsoft's indications towards Open Source support from the company.
The issue is that Software Patents exist and that we haven't gotten past FAT32 file system as a default. Why haven't we moved to a open and free file format?
I'm not sure that shows anything other than the influence of the Azure product group on the company. Each of those things you mention is needed to support or drive developer adoption of Azure.
Simon you are 100% correct in that the money is found in the cloud and you must be Open Sourced for that cloud to really work/scale. My spin is Open Source has won on the cloud and it is now taking over other areas. Hope this "Open by Default" spreads. http://www.forbes.com/sites/adrianbridgwater/2016/11/08/microsoft-is-now-open-by-default-says-xamarin-founder-miguel-de-icaza/#6b1c1b8820e7
VS Code doesn't have anything to do with Azure.
I do find that Microsoft official statements and actions are a difference for the company for 10-15 years ago. Personally I have always seen Apple as Open Source's number one enemy with their business policies. Right now Apple is showing in Mobile Closed Source wins and until that is broken we won't see a Open Source victory. Apple lost the market share (12%) but they have 92% of the profits. http://www.wsj.com/articles/apples-share-of-smartphone-industrys-profits-soars-to-92-1436727458
The patents for file systems and its effect on hardware like TomTom and Android phones will expire and we can move on to better battle lines.
James Price says:
It's funny how the younger group in IT have forgotten MS's history with Linux. Whenever MS's bad rep is brought up, they point to MS's 'Open Source' contributions. Could this be another step in their white-washing of the past?
Is it also possible that their joining of the Linux Foundation they are just scoping out their next group of victims?
No, I don't think that's likely to be the case. Far more likely that this is simply business units who prioritise easy revenue over community reputation.
We've not forgotten, as such. But we do recognise that the Microsoft of 2016 is a very different beast from the Microsoft of 2006 or 1996… they've seen huge changes both at the management level and in their market position.
And that's not saying that they've suddenly become nice, that they're now our best friend. But remember, there's no such thing as a "Microsoft" which makes decisions – only the group of people currently running it. And I think it's foolish to make assumptions about what the current management will do, based on what we think previous management would have done – why should we expect Nadella to act exactly the same as Ballmer or Gates?
bojanmarkovic says:
While the point of your post is sound, I can't see how the previous situation of Microsoft only taking, without giving back, was in any way better for the Open Source community. Furthermore, while most of us in wider OS camp are against software patents it still isn't a basic issue. Open Source is a pragmatic business idea and the way Microsoft is behaving is increasingly aligned to that. Being opposed to IP abuse is a Free Software thing and I don't see Microsoft, Apple, Oracle, SAP, some CID that reads Gartner reports or any other old school IT business type subscribe honestly to that point of view. We should take what we can and be thankful that all the disruption happening in the technology world is making all of them less and less relevant and slowly more aligned to our values if they wish to survive.
abatishchev says:
Your bragging around Azure org as a main and only influencer of open source inside Microsoft indicates the lack of knowledge of internal Microsoft kitchen. It's understandable but then you make incorrect assumptions.
You're right, I don't work there. So what's the truth (with citations, please?)
It's funny how the younger group in IT have forgotten IBM's history with Jews and PCs. Whenever IBM's bad rep is brought up, they point to IBM's 'Open Source' contributions. Could this be another step in their white-washing of the past?
The point being, corporations and society change.
I don't think that's an appropriate comment, since Microsoft is still actively pursuing patent monetisation against open source deployers.
Note that Oracle indeed used to be part of OIN, but dropped out when it started to sue Google. See the very end of http://www.openinventionnetwork.com/community-of-licensees/
(Oracle exercised a Limitation Election under section 2.2 of the License Agreement on March 29, 2012.)
I think this actually happened when OpenJDK was added to the Linux System Definition.
It was a month after IcedTea and OpenJDK were added to OIN:
https://gnu.wildebeest.org/blog/mjw/2012/03/06/icedtea-and-openjdk-now-part-of-oin/
The lawsuite was already going since 2010. In May 2012 the jury found that Google did not infringe on Oracle's patents.
In August 2012 Android and specifically Dalvik were also added to the system definition:
https://lwn.net/Articles/514154/
Yes, that's it. Oracle left because OIN was giving communities defences against them, not because of the Android lawsuit.
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Padres Reportedly Not "Committed" To Adding Starter
July 14, 2019 by MLB Trade Rumors Leave a Comment
Running contrary to recent reports linking the Padres to starters Matt Boyd and Noah Syndergaard , MLB.com's A.J. Cassavell today indicated that the team "seems unlikely" to "push" for either pitcher. While Padres general manager A.J. Preller is willing to add a controllable starter, he's not "committed" to doing so, Cassavell writes.
It was just this week that we heard San Diego was "evaluating" Detroit's Boyd, and they were similarly said to have "checked in" on the availability of the Mets' long-maned Syndergaard. Their courtship of such controllable, proven starting options dates back to at least last year's trade deadline. However, as Cassavell points out, the team is internally striking a posture of confidence in regard to their stable of in-house starters.
"It's the most upside, from a talent perspective, that we've had in the rotation," manager Andy Green told Cassavell in reference to the Padres current big league staff. Though San Diego's rotations have hardly been the envy of baseball during Green's four-year stint at the helm, he may not be entirely off-base in evaluating its current staff as a promising group.
Sophomores Eric Lauer and Joey Lucchesi –though perhaps not perfect exemplars of "hot talent lava" –have continued to pitch effectively in their second full campaigns (3.82 and 3.75 FIPs, respectively); rookie Chris Paddack has, for his part, produced some enviable underlying stats in his first 15 career starts (9.51 K/9 and 1.97 BB/9 in 82.1 innings). Meanwhile, the whiff-inducing Dinelson Lamet was recently welcomed back to the rotation after a 2018 Tommy John procedure, and there is optimism that fellow TJ survivor Garrett Richards could bolster the rotation come September . Generally respected young arms like Cal Quantrill and Logan Allen remain on hand to provide innings, and top prospect MacKenzie Gore was recently moved up to Double-A Amarillo –though the implication of a possible late-season promotion for Gore is purely my addition.
As Cassavell notes, Padres starters have amassed a collective 4.41 ERA on the season, which ranks 14th among big league teams. At 45-46, San Diego sits just two games back in the NL Wild Card standings, so it will be interesting to follow whether the Padres are indeed content with this current group, or if they make yet another win-now gesture in pursuit of their first postseason appearance since 2006.
The Grind Line: Predicting Yzerman's First Red Wings Trade


Between February and May 2018, SPRING conducted a landscaping study to explore the lives of adolescent girls in Myanmar. Employing a range of qualitative and participatory approaches, the research endeavoured to complement insights from earlier literature reviews. The resulting report represents this effort to understand girls' lives in context – through their eyes and their aspirations. While rich in detail and grounded in locally led research, as with any research it cannot definitively capture and represent all the experiences of the numerous and diverse girls living in Myanmar. Nonetheless, we hope that by listening to girls and their parents, this report can provide a window into girls' lives and be a catalyst for future work to understand girls, meet their needs and support their aspirations.


text:
Workplace Articles & More
What Are You Grateful For?
Some of today's leading artists share their gratitude lists. What's on yours?
By Jill Suttie | November 22, 2010
In his recent book, On Gratitude, journalist Todd Aaron Jensen reveals what some of today's leading actors, musicians, authors, and other artists are most thankful for. Here we present excerpts from their gratitude lists; we hope they inspire you to draft your own, just in time for Thanksgiving. You can share your list through our Community Gratitude Journal or through Todd's website, www.thegratitudelist.org, where you can also learn more about his book.
More on Gratitude
Gratitude expert Robert Emmons explains "Why Gratitude is Good."
Watch videos of Robert Emmons discussing the power of gratitude.
Check out Emmons' list of "10 Ways to Become More Grateful"--and print it for your refrigerator!
Forest Whitaker is a highly acclaimed actor, who won an Academy Award for his performance in The Last King of Scotland:
My work has allowed me to be and see places where the polarity and duality of things are everywhere evident—the jungles of the world, where people are living, literally, in the mud to the palaces of kings, and all of the emotion and ideas and ideologies between them. These are all gifts—any chance you have to see the world through someone else's eyes is always a gift. It allows you to live your own life more clearly.
Adam McKay is the writer, producer, and director of such comedy films as Talladega Nights and Stepbrothers:
I am grateful for all of the people in the past thousands of years who died, were beaten, or were arrested for our rights and freedoms—the union people in the early twentieth century who decided they wanted a weekend or a forty-hour work week or didn't want nine-year-olds to work full-time jobs and get abused. We so take that for granted now, because we forget how much they sacrificed for the lives we live today.
Dolly Parton has recorded such hit songs as "Here You Come Again" and "I Will Always Love You," and has starred in the movies Steel Magnolias and Nine to Five:
I was born with a happy heart. I wake up every day expecting things to be right, and if they're not I get to making them right….Sometimes people like to wallow in their sorrows and their sad tales, but I really believe that's detrimental to the lives we should be living. It's natural to have hurts and disappointments, but you have to deal with it—pray out of it, dream out of it, and get to living.
Kurt Vonnegut is a one of the great American writers, best known for books like Slaughterhouse Five and Cat's Cradle. He passed away in 2007:
I tell everybody to practice some art, no matter how badly or how well. It doesn't matter. It's the experience of becoming—of creating—that truly matters. It is as important as sex or food. It's a tragedy to me that our schools have cut art out of the curriculum, because (they say) it's not a way to make a living. Well, it's not a way to make a living; it's a way to become, to find out what you are, what you can do, what's inside of you.
Danielle Steel is one of the best-selling fiction authors in the world, and has written such popular books as No Greater Love to Sisters and Going Home to Passion's Promise.:
Parenting is the most important job of my life—my greatest accomplishment and my greatest joy. I totally forgot they'd grow up and be gone, I was so busy shuttling between the soccer matches and the orthodontist and snuggling with them…Of course there are always challenges. I lost my son (Nicholas Traina) in 1997, and he was—and still is—an enormous blessing. Since his death, I've established two foundations in his name and we've been able to help thousands of people suffering with mental illness. That help has made a difference in the world. … That's one of the ways children—even in the heartbreak—can be a real blessing.
John Krasinski is an actor best known for his role as amiable, puckish Jim Halpert in the American version of the TV show The Office:
I can't describe how important my friends are to me, not only because I rely on them for inspiration and strength in good times and bad, but I would never be who I am without them. Each one of my friends has been so instrumental in opening up my mind to movies, books, plays, new experiences…My friends have helped me become who I always wanted to be.
Jeff Bridges has starred in the movies The Big Lebowski and The Last Picture Show, among many others. He won an Academy Award earlier this year for his role in Crazy Heart:
My wife is the big blessing in my life. We've been married more than 30 years. Marriage is a funny judo-deal—the so-called obstacles and pitfalls, the tough stuff, those are the real blessings. … You have to appreciate the obstacles as opportunities to open up more that you thought you could, connect more deeply than you thought you could. Nothing is too big for you when you're really with your partner.
Alicia Keys is a singer-songwriter, who was a piano prodigy at the age of 7 and a songwriter at the age of 13. She also does humanitarian work in Africa:
Giving is the greatest way to touch a life—to know that you really can affect the world around you. It's so empowering. You help a cause and then you learn the names and then you see the faces and then you feel their spirits and you're making a meaningful change in this lifetime, and it's extremely grounding and beautiful.
Good food is an amazing blessing. Whenever you can sit down to a table and eat food that is extremely delicious, and you are surrounded by people you love, and you enjoy every flavor and every bite, it's "wow, life is good." You can't truly grow until you can fully appreciate a good meal.
Get the science of a meaningful workplace delivered to your inbox.
Jill Suttie
Jill Suttie, Psy.D., is Greater Good's former book review editor and now serves as a staff writer and contributing editor for the magazine. She received her doctorate of psychology from the University of San Francisco in 1998 and was a psychologist in private practice before coming to Greater Good.
Alicia Keys is such a great role model. I totally agree
with her about eating and enjoying great food with
those you love
Elle | 12:54 am, November 29, 2010 | Link
Are Facial Expressions the Same Around the World?
We express at least 16 emotions in similar ways across cultures, a new study finds.
Take the Grateful Organizations Quiz
Does your organization elicit gratitude--or make people feel taken for granted?


text:
No State budget yet!
Sen. Rob Kane
As Governor M. Jodi Rell continues to run state government by executive order, it might help to keep things in perspective by remembering that this is not the first time in recent history that Connecticut has been without a budget.
Undoubtedly, many people remember the summer of 1991 -- the year of the income tax -- when Connecticut went without a state budget for more than fifty days as the General Assembly tried to pass a tax and spend plan that then Governor Lowell Weicker would sign into law.
Then, as now, the Democrats controlled the majority in both the House of Representatives and the Senate.
That year, the General Assembly passed several temporary appropriations measures to pay the bills for the first weeks of the new fiscal year.
Also, Governor Weicker issued several executive orders to, first, allow state government to keep running while minimizing discretionary spending and, secondly, to authorize funding in cases where there was a gap between the expiration of one continuing spending resolution and the beginning of the next.
Connecticut was again without a state budget in 2003.
That year, then Governor John Rowland vetoed the General Assembly's continuing spending resolution and issued his own series of executive orders.
At the time, Governor Rowland claimed that the General Assembly did not have the authority to pass its two-week resolution, which it did on June 30th, the day before the start of the new fiscal year.
The Attorney General disagreed -- but, while the Legislature had the authority to pass continuing resolutions, the Governor also had the authority to veto them and to issue his own executive orders.
Again, the Democrats controlled the majority in both the House of Representatives and the Senate.
According to an interesting report recently issued by the General Assembly's nonpartisan Office of Legislative Research, there is nothing in either state law or the state constitution spelling out what to do to pay the bills and keep government running in the absence of a budget.
When we found ourselves in this situation back in 1991, the state Attorney General based his opinion on how to proceed, in part, on an 1892 Connecticut Supreme Court decision. Not surprisingly, the bottom line is that the state has an obligation to pay necessary expenses -- with or without a state budget.
Based on the opinion issued by the state Attorney General in 1991, the two legal ways to run government in the absence of a state budget is to for the legislature to pass continuing spending resolutions and, or, for the Governor to issue executive orders.
As recent history has taught us, the Governor has the authority to veto a continuing resolution passed by the General Assembly.
As with all gubernatorial vetoes, it would take a two-thirds vote of the General Assembly to reinstate a continuing spending resolution struck down by the Governor.
This year, Governor Rell has issued two executive orders to keep the state running while she and legislative leaders continue to meet behind closed doors to negotiate a budget agreement.
It is my hope that such an agreement is reached soon, and that I have the opportunity to join my colleagues in the General Assembly in voting for a responsible state budget that Connecticut can afford.
I can be reached at my legislative office in Hartford at 1-800-842-1421 or via e-mail to Rob.Kane@cga.ct.gov.
Senator Rob Kane represents the 32nd Senatorial District, which includes the communities of Bethlehem, Bridgewater, Middlebury, Oxford, Seymour, Southbury, Thomaston, Roxbury, Watertown, Woodbury.


Even if Batiflore is not the only business occupied with ladders, it's among the best ones. A company involved in ladders, like this one, is not extraordinary to be positioned in France. That's not all there is; Batiflore deals with bending. Steels and metals may additionally be acquired from Batiflore. Arbent, France is where you can discover Batiflore. The list of outputs carries on with buildings, construction and frameworks.


It's a rainy day and I am waiting to go for a run, so let's do Volume 3 of the Insects of Japan by Yujin. I was originally thinking of putting all four series into one thread but it would have been a lot of images/species in just one thread, so I will break them up as they were released. There was a publicity photo for a potential fifth set, but to my knowledge it never materialized (it may have been sidetracked during the Yujin-Takara transition). As the name suggests, all species are Japanese/Asian.
All of the figures in each series appear to be molded after actual specimens. As such, all figures are 1:1 in size (also explains the exquisite detail in each of these, including the incredibly accurate wing venation on the odonates!!!). All figures require some degree of assembly, and given they are molded after actual specimens, it means legs and antennae can be very thin and delicate. Care must be taken with assembly; it also helps to secure some with glue. Several figures also come on habitat-style bases, which if you follow my posts, know I am a high fan of.
On to the figures, in order of the entire series.
This species is not made as commonly as D. hopei, but I still have seven figures, representing three different subspecies.
26. Japanese giant water bug, Lethocerus deyrollei.
This is a familiar species by Japanese manufacturers. It has been made five other times (including three times by Kaiyodo!). But, this is the biggest and baddest of them all .
27. Chinese peacock, Papilio bianor.
In toy/figure form this is technically a unique species, however I do have a magnet figurine by Doug Walpus Art Studio. Like some of the large dragonflies, this figure is elevated on a clear rod as if to appear in flight.
28. SECRET, golden-ringed dragonfly, Anotogaster sieboldii, nymph.
I already showed the adult of this species in Volume 1. You can refer to that review for a more information on this species. I did want to point out here, that the only other nymph of this species I am aware of is by Furuta (Insect Science).
This is the second darner in the entire series, and a unique species.
This is a unique species, unlike the related D. plexippus (monarch) which is ubiquitous in toy/figure form.
31. Common jay, Graphium doson.
While this is a unique species, the genus is well-represented. I have nine figures representing five species (you'll see another one in Volume 4...).
The quality and realism of these models are amazing! Many non-trained eyes would take it for the real insects!
Yes, they really are stunning.


Robert is reported to have been born at Catwick, the East Riding, Yorkshire, England, documentation needed.
"Our church history began around 1903, when Rev. R. Eltherington began a series of evangelistic meetings in Stouffville. It was decided to erect a new building and a lot was purchased for this purpose. The men performed most of the labour themselves, chopping down the timber that was needed and bricks came in by train. Dedication took place in November 1903 packed with people who arrived on horse and buggy"
[S2207] Cemetery - ON, York, Markham - Dickson Hill Cemetery.
[S713] Vit - ON - Death Registration, death certificate 37061 (1933), Robert Eltherington..
[S721] Vit - ON - Marriage Registration, marriage certificate 8641 (1873), Elthington-Dalson..
[S655] Vit - ON - Birth Registration, 36461 (1889), Violetta Eltherington..
[S655] Vit - ON - Birth Registration, 39313 (1891), Ethel Eltherington..
[S655] Vit - ON - Birth Registration, 34009 (1894), Alberta Eltherington..
[S655] Vit - ON - Birth Registration, 39150 (1896), Morley Eltherington..
[S293] Census - ON, York, Toronto - 1901, District 117, B. 29.
[S2210] GAMEO - Global Anabaptist Mennonite Encyclopedia Online.
[S721] Vit - ON - Marriage Registration, marriage certificate 19955 (1923), Eltherington-Haulman..


Well, what a bloody ripper! Thanks a million to the Coonawarra and surrounding Limestone Coast region for an incredible first for Grapes of Mirth in the district. We were all blown away by the reception we received. A full house, perfect weather, brilliant comedians and lots of wine…lots of wine!!! People from the Limestone Coast certainly know how to have a good time.
Every time we do Grapes of Mirth it is special but from a comedy perspective, this event was a standout. Every single comedian hit every single joke with the force of a freight train and as a result, the crowd was left with sides well and truly split. I kicked off the afternoon by explaining the concept of "Fire" to the crowd of country folk (I reckon they had a handle on it!).
Cal Wilson then jumped on stage and proceeded to actually create it using just her comedy stylings. Utterly dominating the crowd for her set. This was Cal's first GoM and we'd love to see her again because she's as funny as she is lovely.
Lehmo kicked off the second bracket and was in killer form. He was a late addition to the lineup, generously filling in for Dave Thornton who was waylaid in Bass Strait…don't ask. Lehmo had the crowd eating from his hand and his form was surgical in precision.
Nath Valvo returned to Grapes of Mirth and SA and within seconds had the crowd frothing! Super relatable material with an amazing delivery. Nath is a gun stand up and he brought his "A" Game.
Fiona O'Loughlin was the first act of the 3rd bracket and was electric. Fiona has such a beautiful delivery that makes it effortless to enjoy her jokes. Another amazing performance.
Dilruk Jayasinha closed the day and did so in unbelievable form. Lucky punters may have just enjoyed a sneak preview of Dil's next festival show because he delivered some new material that truly created a "wow" moment. Dil is going from strength to strength in everything he does and yet still maintains the greatest of charm and humility. A great mate, a great bloke, a stellar performer.
A huge thank you to everyone who came out to support us at the Penola Racing Club and a massive thank you to the Coonawarra Vignerons who's assistance made it possible for a community to share in the uniqueness of Grapes of Mirth. Also, we wish to thank Brand South Australia who's help in the early stages of planning was vital to producing this event. A few more to thank; the producers that came along and poured their wines on the day (Balnaves of Coonawarra, Penley Estate, Hollick Estates, The Blok Coonawarra, Patrick of Coonawarra, DiGiorgio Family Wines, Rymill Coonawarra, Brand's Laira Coonawarra, Whistle Post Wine, Majella Wines - Wattle Range Council - Grand Events Hire & Styling - Veolia - Aqua Essence Already looking forward to next years Coona' but for now we're gearing up for Coriole Vineyards in McLaren Vale 3rd March.
Till next time Bad Seeds!


Very pretty and very dangerous. NOT for internal use. Price is for one bean. Can be grown into a plant, or strung on a necklace if you drill holes. Traditionally used for a shaman necklace. If planting, typical Southwest desert conditions; scarify seeds and soak overnight to start. Various sizes. Limited Quantity.
Very poisonous seeds; Do not ingest or allow such. If ingested, induce vomiting. Keep away from small children who may swallow them. Be responsible with these seeds.