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The blocking of scuppers on a ship is a nightmare. This ship has reduced that risk by fitting restrainer bars made by the crew. The device fits into the scupper hole and is ideal for use when the ship is in port (not suitable during bunkering operations). The Club recommends that these be coated in high-vis paint to reduce the risk of trip and falls. Click on the image to enlarge.
If you need to call our offices out of hours and at weekends, click After Office hours for a up to date list of the names of the Duty Executives and their mobile phone numbers.
This Ship Finder is updated on a daily basis. Members who need to advise the Club of updates to their recorded ships' details should advise their usual underwriting contact.


text: Freshman Justin Hardy averaged 25.5 points, 6.5 rebounds, and 2.5 assists per game as Washington University remained in a tie for first place in the UAA with a pair of road wins. He shot 69.0 percent from the field (20-for-29), including 9-of-12 from three-point range. Hardy totaled 25 points and five rebounds in an 87-85 win at Carnegie Mellon University on Friday and then finished with 26 points and a career-high eight boards in the Bears' 66-63 win at Case Western Reserve University. Leading by two with 22 seconds left, he stole a pass and went in for a layup to make it 65-61 and secure the victory.

subset: commoncrawl


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Grandwish Hip Hop Patch Designs Men Bomber Jacket
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Full Refund if you don't receive your order
Full or Partial Refund , if the item is not as described
Buy Grandwish Hip Hop Patch Designs Men Bomber Jacket Online In Pakistan
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Outerwear Type: Jackets
Gender: Men
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Model Number: PA573
Closure Type: Zipper
Collar: Stand
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Material: Polyester
Detachable Part: None
Brand Name: Grandwish
Type: Regular
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Returns Policy
You may return most new, unopened items within 7 days of delivery for a full refund. We'll also pay the return shipping costs if the return is a result of our error (you received an incorrect or defective item, etc.).
You should expect to receive your refund within four weeks of giving your package to the return shipper, however, in many cases you will receive a refund more quickly. This time period includes the transit time for us to receive your return from the shipper (5 to 10 business days), the time it takes us to process your return once we receive it (3 to 5 business days), and the time it takes your bank to process our refund request (5 to 10 business days).
If you need to return an item, simply login to your account, view the order using the 'Complete Orders' link under the My Account menu and click the Return Item(s) button. We'll notify you via e-mail of your refund once we've received and processed the returned item.
We can ship to virtually any address in the world. Note that there are restrictions on some products, and some products cannot be shipped to international destinations.
When you place an order, we will estimate shipping and delivery dates for you based on the availability of your items and the shipping options you choose. Depending on the shipping provider you choose, shipping date estimates may appear on the shipping quotes page.
Please also note that the shipping rates for many items we sell are weight-based. The weight of any such item can be found on its detail page. To reflect the policies of the shipping companies we use, all weights will be rounded up to the next full pound.


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The internal politics of both Scotland and Wales now resemble those of most Continental countries more than they resemble the English. The voters do not directly elect a government. They create circumstances in which the political parties negotiate to decide which of them will form the government.
05 May 2007
Widening the gap...
2 comments:
- Harald Korneliussen said...
Sounds good to me, if by government they mean the executive branch. There should be no more power in the executive branch than it needs to be to keep day-to-day affairs running.
I don't like the British/US idea that government works best when one party has absolute control. When the people is divided, it's a good thing that parties have to work together in the executive branch. What it usually means is that they have to compromise on their more controversial points, and we get a government that nobody likes (when did that ever happen anyway?) but most can at least stomach.
Did I mention that I don't like the Daily Telegraph, either? Well, Matt's pretty good. And the crossword, although the threshold is quite high for us non-native speakers!
- 07 May, 2007 07:16
- Ronnie Horesh said...
I take your point, but I think it's unhealthy for people not to know what policies they are voting for. The tendency then is to disengage from politics completely, to be cynical about all politics, and to resent every policy as being imposed from above. I'd like, of course, to see people voting for outcomes, along Swiss lines. I like the Telegraph for its website (all free). I'll take look at the crossword now.
- 08 May, 2007 17:19


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Kiyoko Lip Balm
Kiyoko Lip Balm is from a 100 % natural origin, made in a small factory in the netherlands specialized in natural cosmetics. The unique recipe was found after months of lab research and testing – not on animals of course.
• natural ingredients only, no parabens.
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• no color and a minimal taste and fragrance, just a hint of honey.
• a minimalistic and clean design and packaging.
• hand labeled with four different labels – it's all in the details.
About Kiyoko
Kiyoko is a lifestyle brand that represents quality and design.
Evelien and Merel started kiyoko in march 2014. Kiyoko stems from their ambition to chase dreams. In that spirit they both swapped their lives in Amsterdam for a long trip abroad. That meant taking risks (quitting jobs and giving up apartments), but both got to do what they really wanted – to experience the ultimate feeling of freedom and to prove that no goal is beyond reach.
This vision resulted in a business plan for Kiyoko: a product based on an entrepreneurial spirit and willingness to take risks. Travel remains a major theme in the development of the product and the brand. The details of the products are japanese for a reason: the founders draw their inspiration from japanese culture, and Tokyo is their next travel destination.
With their brand, Evelien & Merel hope to inspire others to take a little bit of risk as well and chase dreams as much as possible.


text:
I lost an old friend today
I lost an old friend today
I didn't know that he was ill.
I'm not sure what took him
He wasn't over the hill.
He was just found gone
Like some of us will be.
He lived alone and he lived free.
He didn't fit a mold
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Just him and his dogs
The old school way.
He loved to hunt
And he loved the woods.
He burned wood for heat
Off the grid, because he could.
Some thought that he struggled
He thought that of you.
He refused to conform to norms
He lived hard but never blue.
I saw him a few weeks ago
I knew he'd be the same.
Just living his one day at a time
No one else to blame.
I'll laugh when I think of him
The stories I could tell.
The falcon or the pet raccoon
The conservation officer from hell.
We'll miss you Russell Rice
I'll praise you for your will.
You never strayed from who you are
You passed when you had your fill.
I know we'll meet again some day
Kindred spirits that we are.
Don't forget to wear your orange
The CO won't be far.
In memory of my hunting buddy.
Share This Poem
This Poems Story
Lost a friend


text:
Catherine Whitfield did one of our short term 4 week courses and passed 1st time with a CLEAN sheet. Catherines instructor Steve said "Well done cath. You put in a months hard work and it paid off with a very easy pass. Have fun taking your little girl out now in the car" Best wishes Steve.
Catherine said: Steve assisted me with undertaking an intensive driving course over a four-week period and I found him to be a great teacher, patient and with a sense of humour. He had confidence in me even when I didn't hence the clean sheet pass! Thanks Steve 🙂


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Allan Carr, the flamboyant theatre and film producer who presented Broadway's La Cage aux Folles and the film "Grease," died June 29 of cancer, according to Reuters.
A Paramount Pictures spokeswoman told Reuters Mr. Carr died at his Los Angeles home at age 62.
Known for his extravagant lifestyle -- star-studded parties, wild clothes, full-length furs -- and his associations with mega celebrities such as Elton John, Mr. Carr was said to have discovered Marlo Thomas, Michelle Pfeiffer, Steve Guttenberg and Lisa Hartman.
He had health problems over the years, and in 1998 underwent a kidney transplant.
His 1978 film "Grease" -- which he co-wrote and co-produced -- became the highest grossing movie musical of all time, and he produced the sequel "Grease 2," starring Pfeiffer. In 1983, he produced the Jerry Herman Broadway musical version of the hit French play and film, La Cage aux Folles, which increased his fortune. The show won Best Musical, Best Book and Best Score Tony Awards in 1984. Despite his film producing muscle, a movie version of the Herman musical never materialized despite fanciful casting ideas. (At one point Frank Sinatra had been mentioned for the role of Georges.) However, 14 years after La Cage was in New York, an Americanized, non-musical film, "The Birdcage," based on the same source, was a Hollywood hit without Mr. Carr's involvement.
His love affair with show business began when he was growing up in Highland Park, IL., and his parents, Ann Niemetz and Albert Solomon, took him to see the national company of High Button Shoes in Chicago.
While still a student, he was a young investor in shows -- $750 in Ziegfeld Follies with Tallulah Bankhead, which he never saw because it closed on the road, and $1250 in The Happiest Millionaire, which was a hit.
He became an impresario in Chicago, at the Civic Center, presenting Bette Davis in The World of Carl Sandburg, Eva La Galliene in Tyrone Guthrie's staging of Mary Stuart, and Tennessee Williams' Garden District.
When he moved to the West Coast he produced Norman Krasna's Sunday in New York, starring a then-unknown USC actress, Marlo Thomas.
As a personal manager, he represented Thomas, Ann-Margret, Peter Sellers, Melina Mercouri, Marvin Hamlisch, Tijuana Brass, Dyan Cannon, Paul Anka, Petula Clark, Peggy Lee and Rosalind Russell, among many others.
-- By Kenneth Jones


text:
We have achieved outstanding experience with a solid understanding of the market and the marketing professionals working within them.
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This Item does not qualify for Free Shipping! More Info...
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text:
Lost in transition? Between paediatric and adult servicesBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7539.435 (Published 23 February 2006) Cite this as: BMJ 2006;332:435
- Janet E McDonagh, ARC senior lecturer in paediatric and adolescent rheumatology (firstname.lastname@example.com),
- Russell M Viner, consultant-honorary senior lecturer in adolescent medicine and endocrinology
- Institute of Child Health, University of Birmingham at Birmingham Children's Hospital, Birmingham B4 6NH
- University College Hospital and Great Ormond Street Hospital, London
P reventing adolescents becoming lost in the transfer between paediatric and adult health services is a major challenge for healthcare providers, paediatric and adult alike. Until recently British health services have largely ignored adolescents.1 But as increasing numbers of young people are surviving into adulthood with illnesses they developed in childhood, the need for transitional care appropriate to their age and development is becoming more obvious and acute.2 Adolescence is also a time when adult behaviours become established and therefore represents a window of opportunity to promote healthy behaviour and influence the public health burden of tomorrow's adults.1
Transitional care is a multidimensional, multidisciplinary process that addresses not only the medical needs of adolescents as they move from children's services to adult services but also their psychosocial, educational, and vocational needs. The need for such services has been shown by many surveys of young people with various chronic conditions and their care givers,3–6 and is supported by policy documents in the United Kingdom and United States.2–9 To date, however, there …
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text:
The Dumpling King fully endorses this article on Dumplings. We present you a history of Dumplings, and why Dumplings are truly a Global Comfort Food. Thanks to our guest author, Dale Phillips, we hope you'll enjoy this article as much as we did. Perhaps one day, McDonald's will add Dumplings to their menu. Oh gosh, we hope NOT! :) But, should they? Please post your comments below!Read More »
Tag Archives: China
China, Chopsticks & Some Table Manners (Plus A Quick Guide On What To Eat Healthily During Your Visit!)
When in China... Manners an etiquette reign supreme. Learn how to eat properly. And, as an added bonus, learn to eat right with some of these healthy choices!Read More »
Traditional Chinese Food is Best
Jews love Tradition. Jews love Chinese food. Traditional Chinese food? Now we are talking! This is what The Chinese Quest lives for. Let us take you along with us on this journey...Read More »
Ancient Chinese Jewish Community Celebrates Chanukah
A few dozen Chinese Jews in Kaifeng, China, gathered with an emissary of the Shavei Israel organization to celebrate the first night of Chanukah and light the traditional menorah candles.Read More »
"M" is for Mandarin #AtoZChallenge @AprilA2Z
Mandarin Cuisine is the cuisine of Beijing and is also knows as Beijing cuisine. As the Capital city its cuisine is influenced by people from all over ChinaRead More »
Don't Read This Article!
Don't read this article!!! Lest all those misconceptions that you had believed all your life about some Chinese foods were true, really aren't. Misconceptions About Chinese Food Misconception: Egg rolls are a Chinese food The Egg Roll that we eat in many parts of the western world isn't really all that much like the most similar Chinese food. The egg rolls ...Read More »
Celebrating Chanukah Atop The Great Wall of China
It was nine years ago that an historic Chanukah took place on the Great Wall of China, when Jews and Chinese came together to light the menorah! Read it!Read More »
Kosher Restaurants in China
It's hard to find Kosher food in China. Here's a comprehensive list of Kosher restaurants in China. Please feel free to add to our list!Read More »
New World Mall Food Court, Flushing, NY
The Mee's will definitely have to come back and conquer the New World Mall Food Court in Flushing. Down the escalator one enters a whole 'nother world!Read More »
Curious About Cumin
Cumin in Chinese Food It was just the other night when we dined at Red Tiger Dumpling House in Stony Brook that I first encountered the use of cumin in Chinese food. We asked the waiter about it, and it just made me more curious to learn more about this fascinating spice called cumin. It's not just used in Indian ...Read More »


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Many years ago when I was younger and fitter (best beloved) I did a fair bit of rock-climbing with ropes at a club in Birmingham that had lots of artificial cliffs and people who could dangle over the side of a sheer drop by one fingernail. After one session, I could hardly lift the tab on my Coke can or turn the key to start my car. But in the canteen, I came across a climbing magazine sporting the wonderful title 'The Importance of Being Crap' which extolled the virtues of Not Being Quite Good at Something. Because Being Crap gave you something to aim for, something to admire about people who Definitely Weren't Crap, and it kept you healthily humble.
'Florence Foster Jenkins' is the title of a wonderful new film about the celebrated eccentric (as in 'I am an individual, You are eccentric, She is Barking Mad') lady whose fortune enabled her to sponsor all sorts of musical events across New York City in the early 1940s.
As played by Meryl Streep, Florence absolutely loves music, constantly surrounding herself with musicians of rare talent and technique, but she has one tiny problem- she cannot sing. In fact, her singing voice is an instrument of such awfulness that it is surprising the Allies didn't employ her as a secret weapon. But that is only part of the story, because Florence's circle of friends have a real affection for her, protecting her from the words of harsh critics and politely applauding her latest efforts. Are they using her, exploiting her patronage? Possibly. But Florence's sheer delight for the music wafting through her head is quite beguiling. In a bizarre way, we admire her sheer dogged enthusiasm for the unknowingly awful.
A sad back-story emerges as the plot unfolds- of a disastrous first marriage, failing health- and the ridicule of audiences who treat her performances as a complete joke. Florence's decision to book Carnegie Hall to stage a concert for disabled war veterans appears to be heading straight towards disaster, but then...
You have to see it for yourself. There are some great set-pieces, especially Simon Helberg's turn as Cosme McMoon, Florence's pianist. But I wonder if the only people who will 'get this' film will be audiences over the age of 50, the ones beginning to notice that not everything we used to be able to do, is quite as easy as it used to be. How do you celebrate loss and transcend your limitations? By learning, painfully, slowly, to accept them. Florence and her friends show us the way of delightfully celebrating our imperfections together- and as her second husband says with feeling, 'Loyalty is all.'
Nobody's Perfect. So as they say in the film.... Let the Lady Sing!
Friday, 13 May 2016
Florence Foster Jenkins and the importance of being crap
Posted by Chris Hudson at 12:14
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Any requests of subjects for future posts in 2016? No idea too stupid for consideration. And yes, I know I am a bad writer, so don't bother saying that unless you can write something better. But maybe there's a topic buzzing around in your head that you'd like to see covered... because I've got a keyboard here, it's loaded with letters, and I ain't afraid to use it.
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Eggciting Easter Breaks in Limerick!
Available from 15th April to 28th April 2019
Offering unbeatable value and superb quality, the Limerick Strand has an array of irresistible Easter packages!
Whether it's a couple's breakaway you're looking for or a family escape this Easter; there's an impressive package on offer to suit you at the multi-award winning 4* Limerick Strand Hotel.
Gourmet Break for Two
Stay for two nights and enjoy a delicious gourmet break for two, including an Easter themed chocolate treat in your room on arrival, dinner on one evening with Award Winning dining in the Terrace Bar & Restaurant where renowned Executive Chef Tom Flavin, will delight you with some seasonal Easter inspired dishes including locally sourced spring lamb and decadent chocolate desserts. Relax and enjoy a complimentary post dinner "Eggciting" cocktail.
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Eggciting Easter Family Fun
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- Kiddies check-in with delicious Easter egg.
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- Kids will receive complimentary main course with each adult meal purchased during the duration of your stay.
- Under 12s stay for free.
- This year we are offering a two-night break including:
- The hotel also offers complimentary access to Energize Leisure Centre with 20m pool, kiddies pool, hydrotherapy pool, plunge pool, Swedish sauna, eucalyptus steam room and that all important FREE WIFI!
The Limerick Strand is the perfect base to explore the beautiful Shannon region whilst having the comfort of all the amenities a city can offer on the doorstep. Only 90 minutes from Dublin, 60 minutes from Galway and 70 minutes from Cork so no need to worry about the long car journey!


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Indonesian Student Association in Maastricht is pleased to invite you to participate and join the fun with us on our prestigious 13th annual tournament "Maastricht Cup"! Our event will be held on:
Date: Sunday, May 14th 2017
Time: 08.00-19.00 CET
For recent updates please also check our fans page : https://www.facebook.com/maastrichtcup2017/
Click link below for download the registration form and tournament rules:
Ping pong (table tennis) Rules 2017
Disclaimer form must be signed by each participant. For badminton and table tennis rules must be signed by every team manager.
Signed forms and regulations can be scanned and emailed to email@example.com (no later than May 13, 2017) or printed and brought on the day of the tournament (May 14, 2017).
If there are other things to ask you can contact Anita (+31682722552) or email to email@example.com
We look forward to your participation.


text:
Available from Exclusive First Editions stockists from this week!
36712 - Plaxton SLF Dart - Norfolk Green
The popularity of Norfolk Green has created much respect for the fleet which was recently acquired by Stagecoach. Registered PX05 EMV, fleet number 34700 is working route 10 to Hunstanton prior to being painted in Stagecoach livery. RRP £34.50
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With the growing popularity of Continental touring holidays Tilling equipped their Panorama's to be suitable for this work. Registered PWC 345K, fleet number PL 9438 is operating a tour through Switzerland. RRP £34.50
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Project Management: How Long Will the Project Take?
This content was COPIED from BrainMass.com - View the original, and get the already-completed solution here!
You currently work for a retail store that carries basic household goods, some groceries and health and beauty products. The store is located in a small community (approximately 5,000 total residents) in which you live and is looking to expand its operations in some way. For this assignment, you are required to develop a major project proposal to be undertaken by your employer. You may decide to expand your product offerings or open an additional store in an adjacent community for example.
I need help with the following:
My goal definition.
My objective definition: how will I quantify the savings or benefits from completing the project. How much will it cost, hours material, methods, ect. How long will the project take?
Identifying the resources necessary to complete the project
The risk analysis.© BrainMass Inc. brainmass.com October 10, 2019, 5:01 am ad1c9bdddf
Solution Preview
Defining your goal.
In order to properly address this part of the assignment, you need to view the organization in the aggregate:
- Your organization has a loosely defined goal: expand operations. In other terms, the goal of the project is to increase revenue and increase profits. Your goal is defining how this can be accomplished by considering all the factors that can have an impact, thus, facilitating decision-making processes.
- Your task is to formulate a project that provides analysis of the current market demographics. Who is being targeted and why? The market only has about 5000 residents, so detail will be necessary in identifying what is defining the demographics and whether there are any gaps in the market that can be fulfilled. For example, out of the 5000 residents, there are 2000 car owners. Do these car owners have to drive out of town to purchase windshield fluid? If so, can your retail company supply the windshield fluid to them instead? How many of the residents have pets? Where do they purchase their pet food? Again, can you store supply it if you do not already? Your project goal is identifying all potential gaps in the market that can be filled by the retail store presenting them in a clear manner. Data can be gathered through various mediums, such as surveys, interviews, and questionnaires.
Quantifying the savings or benefits from completing the project.
This component involves ...
Solution Summary
The solution discusses how long will the project take.


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A trigger is a condition that evaluates to either true or false at runtime. It does this by comparing the value in a variable with the value that you specified when you defined the trigger.
When installing Divvit's script, there's two triggers that you have to use.
The first trigger is for the General Tracking Pixel. For this one, you can use the built in trigger called "All pages".
The second trigger you have to use, is for the Order Tracking Pixel.
This trigger is not built in, so you will have to it manually.
- Log on to your Google Tag Manager account and click on Triggers on the left side menu
- Click new, and name your trigger "Complete page trigger"
- Click on the icon in the middle and choose Page View as Trigger type.
- Now you have two checkboxes, one saying All Page Views and the other one Some Page Views, choose Some Page Views.
- By default, you will have Page Hostname, change that to Page URL, leave contains as it is
- In the blank field, you have to enter your complete page url, or a part of it, for example /purchase/complete, hit save in the top left corner!
Now we have set up a trigger, that you can use when implementing a script. The Complete page trigger will make sure the Order Tracking pixel only fires at the page where your customers end up after purchasing. Please note: /purchase/complete might be different from site to site. Please make a test purchase on your own site, and save the URL you end up at when it's done. Copy the part after your regular URL, so leave out https://www.yoursite.com/ and take everything after that. So for example: https://www.yoursite.com/purchase/complete becomes /purchase/complete, and enter that value in to Google Tag Manager.
One minute video:


text: Terry 5 Report post Posted January 20, 2006 I am now using the 459Mhz band for my R/C link. It works well but I am forced to use pre made UHF modules to make the receivers and these are very expensive. I have been looking at the vast amount of chips there are for making NBFM receivers but I can't find any application circuits for UHF. Have any of you amature radio guys know where I may find such a thing ? I am using my own PLL circuit for demodulating the 465khz but I am stuck for finding a crystal controlled front part to get this. Any ideas ? Terry Quote Share this post Link to post Share on other sites


text:
Some sort of threefold understanding would likely emphasize the significance of alternative energy resources in the future
The reasons behind the reason the mentality in regards towards the usage of alternative strength resources can change, within the next 50 percent century. Precisely how this transform (i. at the. the usage of substitute energy) will affect car technologies. Various kinds of alternative electricity resources that are offered, or perhaps currently under exploration, specifically used in automobiles
An alternative energy benefits for Future Car Release is the fact they can be renewable! We are going to never proceed short on products of electricity. As an illustration, solar power - sunlight will almost always be right now there! - the number of solar electricity intercepted through the Earth every single 60 second is greater than the vitality quantity that this entire human race uses throughout fossil fuels on a yearly basis.
The wind energy - wind will always exist instructions The power from the winds in which blow over the US every year produces greater than 16 tera- GJ of energy. Tidal energy - the phase of the moon will be below and so may its forces that cause tidal ocean. Hydroelectric strength - water power are invariably readily available unless there is an severe change in bad weather patterns or droughts. An additional is the fact renewable energy is environmentally friendly; hence indicate exude AS WELL AS, and that is indeed the most important provider for you to global temperature soars, in to the surroundings.
Bio-fuels usually are carbon neutral seeing that manufacturing all of them depletes about as much CO2 while expending them produces. Considering these kinds of renewable energy benefits, it really is apt regarding producing simple and easy inexpensive resources of one's. Non-renewable sources (for at the. r. carbon-based fuels) usually are restricted - their own supplies will at some point run out in the long run. Non-renewable assets like petroleum discharge CO2 in the surrounding ambiance. These are inadequate causes of fuel which are rapidly rarefying since the energy anxiety is bearing on us, consistently. So, we can easily firmly agree that the option resources would be the Future and will offer a greater Foreseeable future.
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If You Think You Understand Services, Then This Might Change Your Mind
Finding the Right Kitchen Remodeling Contractor
Finding a good kitchen remodeling contractor may feel daunting, but it doesn't have to be that way. If you know the steps are necessary, you will end up with your best option.
Seek referrals.
There is no doubt in the world that word-of-mouth is your best bet when it comes to finding a kitchen remodeling contractor. Your relatives, friends and neighbors could refer you to some of those they may have happily worked with. Most people will be glad to tell you their good experiences. As an option, you can read reviews featured on popular third-party consumer websites.
Check your prospect's credentials.
With a few prospects, you can start your preliminary research, which you can do through phone or by checking out the contractor's website. First and foremost, you'd like to know if they are licensed (state and local), and whether they belong to a professional association such as the National Association of Homebuilders (NAHB) or the National Association of the Remodeling Industry (NARI). While they don't guarantee a great job, they do increase the likelihood that you will be satisfied with the results. Do remember though that certifications can vary widely. Don't be shy asking what their certifications are and what it took to obtain them.
Talk to the candidates.
Trim down your list of prospects and book a meeting with all of them (separately, of course). How many contractors should you interview? Perhaps one but it won't hurt to stay open for three at most.
Too many quotes can make it confusing to decide. On the NARI's website, you will find a list of questions you should ask your potential contractor. Observe how they answer these questions, but take note that effective communication always works both ways. The most important thing at this point is finding someone who will listen to you rather than doing all the talking. This is a longstanding relationship, so it's important that you have a personal connection with your contractor. Trust is crucial.
Ask for references and check with them.
This part is more crucial than you might think. References give you a sneak peek into your future project through the experiences of those who have worked with the contractor before. If the contractor won't give you references, you already know what that means – they're hiding something.
Have a written contract.
After choosing a specific contractor, examine the contract. Is it presented professionally? Is it fair enough to you? The contract should include, among several other things, the bid price and payment schedule, a waiver of lien (so unpaid suppliers and subcontractors cannot put a lien on your property), an express limited warranty, and the job's start and end dates. If you have no background with kitchen remodeling contracts, find a friend or relative who can help you.
Where To Start with Services and More


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dustincolearmstrong needed a new logo and social media pack design and created a contest on 99designs.
A winner was selected from 166 designs submitted by 16 freelance designers.
Stay Off The Roof.com
We install Christmas & Holiday lights for our customers on homes, HOA's, malls, hotels you name it.
Holiday lighting & event installs, birthdays, weddings, retirement etc...
We want to target higher income home owners with expendable income & a want for a all inclusive service. We bring the lights, take them down, we store them, basically turnkey outdoor decoration!
We want a whimsical & memorable design. Something that looks like christmas, but we can repurpose for a year round logo by changing some of the features/colors of the look.


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At the LTER ASM
I spent several days this past week at the Long Term Ecological Research Network (LTER) All Scientists Meeting (ASM) in Estes Park, Colorado. The LTER is a network of 25 sites around the United States and further afield – I'm involved as the environmental history co-PI on the McMurdo Dry Valleys LTER. This was my third ASM meeting, and I'm starting to feel at home, despite being a historian rather than an ecologist. Along with Anita Guerinni from Oregon State University I helped to run a session on history and the LTER network. We're hoping to put together a workshop on this theme with the aim of producing an edited collection about history and the LTER network. If anyone is interested in this topic, please get in touch.


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Electric Car Fleets: Coming Soon…?
Will we soon see fleets of electric cars on our roads? Electric cars seem to be everywhere at the moment; in the news, in the motoring forums and finally on our streets. With major car manufacturers, such as Ford, VW and Honda seemingly pinning their futures on electric cars, and with the UK predicted to have more electric car charging points by 2020 than petrol stations, the momentum behind electric cars does seem to be building. The latest sign of mass adoption came last month when Uber rolled out an electric taxi fleet in London. But will they make it into the famously conservative fleet sector?
Fleet Cars: Electric Cars Final Frontier?
There has been one sector of the motor market that has, as yet, remained largely unmoved by the draw of electric cars and that's the fleet market. Traditionally fleet managers and fleet drivers have been loath to entertain the notion of electric fleets on the grounds that electric cars didn't have the required range or speed and because their purchase costs were prohibitively high. But with electric car prices now comparable with standard fleet cars, battery life and vehicle ranges hugely increased and fleet tax levies largely bound up in emissions is the day of the electric fleet about to dawn?
What Are The Benefits?
Leaving aside the obvious environmental benefits of reducing emissions by up 40% compared to standard cars, the main benefits of an electric fleet are financial. In terms of fuel costs savings, the numbers are frankly staggering. According to a recent British Vehicle Rental and Leasing Association (BVRLA) report, electric cars cost between 2p and 4p a mile to charge (based on cars to doing journeys of around 100 miles per day). This compares to around 12p per mile for the equivalent diesel car – a saving that is surely music to a fleet manager's ears if not that of the finance director. The F.D. will also find the fact that there are enhanced capital allowances available for electric fleet vehicles hugely attractive. These means that companies can relieve the cost of an electric car or van against taxable profits in the year of acquisition.
Of course, electric cars do cost slightly more and that could sour of F.D.'s opinion of electric cars for the company's fleet. However, with grants of up to £5,000 off the price of an electric car, 20% off the cost of a van, and grants available for up to 75% of the cost of installing a charge point, their mood could quickly return to sunny…
While such savings may mean little to fleet car drivers, the prospect of not having to pay company car tax as electric vehicles are exempt from it, will. Mini-fleet owners, particularly those with vans, will also be cheered by electric vehicles exemption from van benefit charge, fuel benefit charge, fuel duty, vehicle excise duty and the congestion charge.
Fleet insurance costs are obviously a big concern for any fleet manager. At present, given the newness of the market and the level of uncertainty as to what could go wrong with electric cars, costs are slightly higher than for standard fleet insurance. That said as adoption grows and more insurance companies offer electric fleet insurance, so these costs will come down fast. The best thing to do if considering electric car insurance – be it for a fleet or personal use – is to talk to an insurance specialist such as Coversure Hull on 01482 434343.
Will Fleet Drivers Accept Electric Cars?
This remains an uncertain question for many fleet managers. Anecdotally fleet drivers seem to have the same questions as standard drivers when it comes to electric cars – range, cost, ease and availability of repair, speed and safety. Though given that 43% of fleet managers believe that their drivers would accept driver-less cars – the natural partner of electric cars – and given the personal savings outlined above, it would seem likely that from a driver's perspective electric fleets have little standing in their way.
Electric Car Fleets: Coming Soon? Oh Yes…
Given the cost benefits of electric fleets to companies large and small, the government grants, the environmental benefits, the improvements in technology and wider public acceptance of electric vehicles, it seems clear that electric fleets are on their way, and soon.
Like Some More Help?
Well we hope that's given you some food for thought. If you'd like to know more about saving money on your fleet costs, or would like some help getting the fleet insurance cover that's right for you, then please contact us. You can call us free on 0800 977 6037, email us by clicking here or get a no-obligation insurance quote here.
Coversure Hull is an independent fleet and business insurance specialist. From our base on the banks of The Humber, we offer comprehensive commercial vehicle cover, with particular focus on fleet and special types, alongside other essential business covers, namely commercial combined and liability.
Since opening in 2005, our combination of superb service and outstanding value for money business policies have established us as the insurer of choice for organisations both large and small.
Coversure Hull: We Mean Business
We have made it our business to protect your business. Whether you need fleet, landlord, liability or commercial combined insurance, we can offer you high quality cover from some of the UK's leading insurers, all at highly competitive premiums that's backed by our outstanding cover-to-claim service.
Contact Us Today
For a friendly independent service and great value cover, contact Coversure Hull today. You can call us on Hull (01482) 434343, for free on 0800 977 6037 or you can email us by clicking here.
We look forward to helping you with your requirements.
Andy Price
Managing Director
Join to The Fleet Management Group
In this group, you can know and share knowledge, experiences and meet people interested in Fleet Management over the world. Each week we publish posts, conferences, news, scientific papers, and technology related to Fleet Management.


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An old, black-and-white photo depicts five dilapidated homes slowly crumbling away on an island in the middle of a vast, dismal ocean; the sea's endlessness and archaicness adds a sense of sentimentality to the picture. With such a glum album cover, it's a dazzling surprise once the effervescent, action-packed "New Tracy (I Will Learn To See)" - opening song on singer/songwriter Jon McKiel's self-titled EP - splashes in like a colossal wave against the dry, gravelly shore.
Compared to 2012's opiate, lo-fi Dot Dot Dot Dot EP, Jon McKiel is livelier and has cleaner production. McKiel's mix of vintage garage rock and poignant folk declares him a not-so-distant sonic relative of psych folkers Chad VanGaalen and Circulatory System.
VanGaalen and CS aren't the only artists in McKiel's sophisticated vernacular, though. "I Know, I Know" calls upon The Byrds' seminal acoustic pop rock and the exotic track "Twin Speaks" is painted with harmonies that are insanely similar to those of Fleet Foxes.
It's cheery most of the time, but the EP relaxes, especially with the somber waltz "Dying All The Time (Tropical Depression)." This is a reworking of Dot Dot Dot Dot's track of the same name, and it brings a dreary, yet serene essence to Jon McKiel.
I haven't listened to many extended plays this year, but the ones I have heard are truly stellar. Jon McKiel's latest work is undoubtedly one of my favorite 2014 EPs.
8.4 / 10
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Features January 2017 Issue
Is Heart Disease Keeping You Awake at Night? Learn to Reclaim Your Sleep
Your disease�or the medications you take for it�may affect your ability to sleep normally. But there are strategies that can help.
Physicians have known for years that obstructive sleep apnea, a condition that causes people to awaken countless times at night gasping for air, raises the risk of heart attack and sudden cardiac death. But the connection between sleep disorders and cardiovascular diseases runs much deeper. The most common sleep disorders—sleep apnea and insomnia—are associated with an array of adverse cardiovascular outcomes.
"It's very likely a bidirectional relationship: Sleep-disordered breathing can lead to cardiovascular disease. Once cardiovascular disease develops, it can be a perpetuating factor for sleep disorders," explains Reena Mehra, MD, Director of Sleep Disorders Research in the Sleep Center of Cleveland Clinic's Neurologic Institute.
Heart Failure and Poor Sleep
Up to 50 percent of heart failure patients develop sleep apnea, which fragments sleep and contributes to insomnia. Multiple arousals during the night cause fatigue and sleepiness during the day.
All reasons for this relationship are unknown. However, uncontrolled heart failure causes fluid accumulation in the body. Fluid in the neck further obstructs breathing, making sleep apnea worse. Constant interruption of breathing during the night lowers blood oxygen levels, raising the amount of carbon dioxide (CO2) in the blood. This worsens sleep quality.
"We also know that heart failure increases the fight-or-flight response, which could contribute to poor sleep," says Dr. Mehra.
Heart failure medications don't always help, either. Beta blockers, which are used to lower blood pressure and reduce the workload of the heart, generally make people feel fatigued. Conversely, they cause insomnia in some patients.
Diuretics interfere with sleep by causing patients to awaken several times a night to urinate.
Arrhythmias Tied to Sleep Disorders
The link between arrhythmias and sleep apnea may be more surprising. However, sleep apnea is known to trigger irregular heartbeats. "We are just starting to discover why, but it appears that there are a variety of reasons including alterations in the fight-or-flight response mechanisms, low oxygen levels, direct mechanical influences on the heart due to changes in pressure inside the chest and an increase in CO2 likely contribute to arrhythmia risk," Dr. Mehra explains. "It appears that if patients with atrial fibrillation are treated for sleep apnea before they undergo treatment for their arrhythmia, it reduces the likelihood the atrial fibrillation will recur."
Impact of Sleep on Risk Factors
Sleep apnea elevates blood pressure. It affects insulin production and glucose metabolism, raising the risk of type 2 diabetes. It also increases the desire to eat high-carbohydrate foods, which can lead to obesity.
Patients with sleep apnea tend to develop the dangerous type of atherosclerosis, in which soft plaques prone to rupture form in multiple vessels. This increases their risk of having a fatal or nonfatal heart attack by 30 percent over several years.
But you don't have to have a bona fide sleep disorder to develop cardiovascular disease or its risk factors. In September 2016, the American Heart Association/American Stroke Association released a statement explaining that consistently sleeping fewer than seven hours or more than nine hours creates a progressive risk of cardiovascular disease and mortality.
"There is a U-shaped distribution in the relation of sleep duration and several adverse health outcomes, with seven to nine hours representing the sweet spot," says Dr. Mehra. "We don't fully understand the reasons for this, but the findings are consistent in population-based studies."
Short sleepers may not be getting the full benefits that a proper sleep provides. They also tend to have higher levels of inflammatory markers in their blood. Increased inflammation is associated with heart attack and stroke. Stroke risk is also elevated by frequently interrupted sleep.
The negative impact of too much sleep is more of a mystery. "These people might not be getting good quality sleep," Dr. Mehra suggests.
Talking Sleep with Your Doctor
When your quality of life is adversely affected by problems sleeping at night, staying awake in the daytime or concentrating, or if you have become unusually irritable, tell your doctor.
"There's a high prevalence of sleep disorders in heart disease, so you should be aware of the signs. These need to be investigated," says Dr.�Mehra.
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Bryan Adams: "You can't be a true environmentalist if you eat animals!"
Canadian singer/songwriter Bryan Adams recently took to Facebook to post an image of him holding a copy of vegan cookbook Vegan Cuisine by Jean Christian Jury. In the post, the "Summer of '69" singer wrote:
"I stopped eating animals including fish when I was 28 and I've never looked back. (You can get all the protein you need from plants.) It's great to see the change that is happening as people embrace a more plant based diet, but we still have a long way to go."
The 58-year-old musician added:
"If you want to see your health improve and you care about the planet, go vegan 🌱🌏 PS: you can't be a true environmentalist if you eat animals!"
Last summer, Adams told Vegan Life Magazine that being vegan is "absolutely the best thing you could ever do for yourself," as it is a "great path."
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Picture the Christian ekklesias, or assemblies, in the first hundred or so years after the resurrection of Christ. They had in their hands the Old Testament canon which Jews and Christians alike hold to be divinely inspired Scripture, the latter understanding that these writings find their fulfilment in Jesus the Messiah. From the 40s AD onwards they had the writings of Paul successively circulating and probably by the end of the century gathered into a single volume and regarded as "Scripture" (2 Pet 3:16). From the 60s onward the gospels began to circulate, compiled from eyewitness sources such as collections of sayings of Jesus and "memoirs" of the apostles. By the end of the first century, there was an almost uniform acknowledgement of which writings were "Scripture," to be used in worship and for edification. These writings were characterised by an acknowledged apostolic connection or authority.
Later heresies in the church, such as that of Marcion (who wanted to shrink the canon) and Montanus (who wanted to add to it) forced the church to settle the matter of Scriptural authority by committing to a written list, or canon, of writings. These formed what we know as the New Testament. In contrast, apocryphal and pseudepigraphical works, particularly later Gnostic or proto-Gnostic works such as the "Gospel of Thomas" did not receive the same status. Nor did the much revered writings of the early church fathers such as Polycarp, who had been direct disciples of the apostles. The authority of the Word of God was paramount.
Nevertheless, the early church produced a significant volume of literature and began this process of writing even before the NT was itself complete. Most of these writings are no longer extant, some are known by quoted fragments or references in later literature and a small number have been preserved. What did they write about? The earliest Christian writers did not compile systematic doctrinal treatises, as far as we know. Instead, they wrote pastoral letters, handbooks for life and ministry, and apologetics to defend the Christian faith to the antagonistic world of their day. As various heresies, such as Docetism and Gnosticism crept into the church, Christians wrote polemical treatises against them. The fundamental doctrines of the very early church are seen within all these writings, informing their arguments and supporting their advice. Their writings are permeated with Scriptural citations and allusions and their references to the deity of Christ demonstrate this was simply accepted as fact.
As time went on, particularly when the burden of persecution was lifted, Christian thinkers gave more attention to addressing issues of doctrine in their own right. Appropriately, some of the earliest considerations involved the nature of the Godhead and the person of Jesus Christ. On the one hand, Christianity had its roots in Judaism and was decidedly monotheistic in contrast to the Graeco-Roman world and the eastern mystical religions. Nevertheless, the clear teaching of Scripture was that Jesus was divine as well as human, and needed to be included within the identity of "God" without sacrificing either monotheism or the distinctiveness of Father, Son and Spirit. As Stephen Holmes (Quest for the Trinity, 57–58) explains,
Certainly the technical terminology and conceptuality necessary to give a tight account of how it is possible to speak of one God existing in three hypostases is only developed in the fourth century, but we should see this not so much as the development of a new confession, as the discovery of the necessary theology to give firm intellectual grounding to an idea that is so deeply engraved in Christian devotion and confession as to be inescapable. The early Christians worshiped the Trinity from the first; the tale of the development of Trinitarian theology is an account of how they came to find a satisfying way of speaking of the One they worshiped."
So, as the church wrestled with how these truths should be understood, there was a development of doctrinal thought that nevertheless had its basis firmly rooted in Scripture. It was only much later that the papacy claimed the sole right to interpret and supersede Scripture as the ultimate authority. An understanding of God as one in essence/identity/ divinity but triune in expression/outworking/personhood can thus be traced from the earliest post-NT times through to today in mainstream Christianity. In contrast, doctrines such as the nature of salvation underwent enormous change during the medieval Roman Catholic period, to be reevaluated at the Reformation. Denominations or sects that have emerged since the post-Enlightenment period in the 1800s, such as the Christadelphians, typically reject these centuries of theological discussion and claim to return to the "original apostolic faith." Such self-styled "remnants/rediscoverers of original Christianity" espouse the view that "Christendom," by which they mean essentially all of the Christian church in its various forms over the centuries, rapidly departed from the truth of the New Testament into apostasy and have remained tainted with it ever since.
But was the development of doctrine a departure from Scripture, or a deeper engagement with it? Did the truth quickly become distorted and disappear with occasional, short-lived rediscoveries, or were certain truths understood fairly consistently through the ages? The answer seems to be, some of both, depending on which doctrines are considered. Very early on, the church was engaged in answering the question, "Who is God?" from which emerged the Trinitarian answer to what might seem a Scriptural paradox. This was closely followed by the fourth and fifth century Christological controversies which produced a greater understanding of the person of Christ. In contrast, Protestants as a group would agree that the medieval Roman Catholic Church departed significantly from Scriptural teaching in many areas (Mariolatry and sacramentalism, for instance) . In the Reformation period, with a fresh look at the Bible itself, major doctrinal positions were revised — actually rediscovered — to better align with Scripture, most notably those with respect to salvation, authority, the nature of the church and the sacraments. Interestingly, the essentials of the doctrine of the triune God and the divine and human natures of the Saviour were upheld, because they were shown to be scriptural rather than a product of the Roman apostasy.
Periodically, the church was convicted by the need to produce a statement of doctrinal interpretation that was regarded as normative. Such statements mark major landmarks in the history of Christian faith and were typically a response to controversy. For example, the early church fathers believed that Christ was divine, but was this divinity intrinsically his, as orthodoxy argued, or was it derived or bestowed on a mere superior creature, as Arius taught? The argument came to a head, and was resolved in favour of the Son being eternal with the Father and of the same essence, because this was seen as best according with the whole Scriptural testimony. The very fact that through the ages and even today, humans applied their intellects (and presuppositions) to God's word and arrived at different conclusions necessitated this process of deliberation and clarification. Questions arise which need to be answered, and interpretations are proposed which need to be debated in the light of Scripture. Inevitably, in order to avoid further confusion and express doctrine in context, statements of belief are required. Thus the trajectory of doctrinal development has been neither haphazard nor necessarily divergent. (This same process of wrestling with Scriptural teaching in order to achieve concordance concerning what the Bible means is also claimed by Christadelphians when they argue that their pioneers "discovered" the unifying truth of the doctrine of "God manifestation" and expressed it in the way they did.)
That is not to say that mistakes weren't made along the way, or that significant deviations from orthodoxy did not prevail from time to time. The teachings of Origen, for example, were very heavily influenced by Platonist philosophy and not entirely consistent with Trinitarian orthodoxy. Sometimes the Greek theologians seemed to head off down very complex, esoteric or even irrelevant lines of thought because that was the way they were intellectually wired. In contrast, the Latin theologians were more inclined to state things in clear-cut, "this is the way it is" concepts and accepted that if Scripture said it, don't try to over-think it. The Greeks were much more inclined to tease doctrines out to the nth degree, and wind up misunderstanding alternate positions. Also, the Greek and Latin theologians spoke different languages with different nuances and semantic ranges for translated words, which led to misunderstandings. The Greeks were typically more interested in the distinctiveness of Father, Son and Holy Spirit, whereas the Latins were more focused on the unity of the Godhead; yet both acknowledged a triune God. When their arguments are closely examined, apart from the extreme positions which were ultimately rejected by the various early Councils, they are seen to be the complementary sides of the same issue. God is not three in the same sense in which he is one, and from the perspective of an over-emphasis on either unity or distinctiveness, the other sense can appear dubious. Similarly, the Bible portrays Jesus as fully human, but also as divine. It is possible to overemphasise one of these natures to the underplaying of the other.
The major creeds of the early church, Apostolic, Nicene and Athanasian, and Chalcedonian definition, were written to summarise the conclusions which emerged from such periods of doctrinal controversy. They need to be understood in this context, as I have previously argued. None of these three state everything that was believed by orthodox Christians at the time, but they concentrate on the truth of Scripture as against the prevailing heresies of the day. The later Confessions of the denominations which emerged from the Reformation are more comprehensive. This is because many more doctrines had been thought about in detail in the interim and some represented a significant contrast to the teachings of the medieval Roman Catholic church. On the doctrines of Scripture, the Godhead, Jesus Christ, and salvation by grace alone, through faith alone they are in agreement. They disagree chiefly on things like the nature of the Lord's supper and baptism and the nature and government of the church, because those were the big controversies of that era. (The Christadelphian Statement of Faith and list of Doctrines to be Rejected is also a document of its time, addressing the issues which early Christadelphians believed are fundamental and in which they differ from the "churches.") Sometimes the creeds and confessions stated doctrines to be rejected, for example the anathematisation of Arianism in the addendum to the Nicene Creed. This can be open to misinterpretation if the nature of those controversial views is not understood. (The Christadelphian list of doctrines to be rejected has 35 elements because their doctrines are so distinct from those of mainstream Christians and other post-Enlightenment sects.)
In conclusion, doctrinal development throughout the history of the church is not to be dismissed as consistently divergent from Scripture, but as the natural expansion of thought in the context of the church's growth, encounters with alternative ideas and heresies and the ongoing desire to explore the richness of God's truth. Certainly there were divergences from truth heading into the dark ages, but the doctrine of the triune nature of God and the divinity of Christ can readily be shown to be among the earliest and most consistent beliefs. There is a clear continuity of thought from the apostolic period through the early church as it began to wrestle in a deeper sense with the questions evoked by a confession of Christ as Lord and God (John 20:28; Rom 10:9). To "search the scriptures" and appreciate their riches (Psa 119:97–105; Prov 25:2; Acts 17:11; 2 Tim 3:14–17) has always been the duty and delight of God's people.
Further reading:
Donald K. McKim, Theological Turning Points: Major issues in Christian Thought. (Louisville: Westminster John Knox Press, 1988). A very readable explanation of the development of major Christian doctrines and the controversies that marked turning points n Christian thought. The first two chapters, "Trinitarian Controversy: Who is God?" and "Christological Controversy: Who is Jesus Christ?" are particularly relevant to our current discussion.
Stephen R. Holmes, The Quest for the Trinity: The doctrine of God in Scripture, History and Modernity (Downers Grove: IVP, 2012) Holmes explores the whole 2000 year history of the doctrine of God and challenges some recent interpretations.
Gerald Bray, Creeds, Councils and Christ: Did the early Christians misrepresent Jesus? (UK: Mentor, 1997). Focuses on the first five centuries of development of the doctrine of the Trinity and person of Christ.


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Diagnostic Imaging of the Shoulder
Original Editor - Naomi O'Reilly
Top Contributors - Naomi O'Reilly, Wanda van Niekerk and Lucinda hampton
Crowell et al [1] suggest that the relationship between musculoskeletal imaging and physiotherapy practice can broadly be divided into three areas:
- imaging as an aid to clinical diagnosis;
- imaging as an aid to injury management rehabilitation and, finally,
- imaging as an aid to treatment accuracy, specifically ultrasound-guided injections.
Diagnostic Imaging can be a useful resource for shoulder conditions and where used appropriately can be an invaluable tool for physiotherapists. Imaging such as MRI, X-ray, CT Scans, and Bone Scans are prime examples of practical diagnostic imaging that facilitates accurate diagnosis, prognosis, intervention, and assessment of injuries and dysfunction that physiotherapists' address daily. Unnecessary imaging will not only potentially squander financial resources, increase the failure rate of conservative physiotherapy and and increase potential for premature surgery, so it is key to understand and recognise when imaging is appropriate.[2] Some researchers have suggested the increase in use of diagnostic imaging including x-ray, diagnostic ultrasound and magnetic resonance imaging (MRI) for shoulder pathology is possibly related to the challenges in classification of shoulder pain and low levels of practitioner confidence in making an accurate clinical diagnosis, specifically a pathoanatomic diagnosis. [3][4][5]
While there are a number of studies which indicate diagnostic imaging is underutilized such as x-rays identifying fractures or bone scans identifying osteoporosis[6], there are also many more studies which suggest over utilization of imaging, such as X-rays or MRI for acute and uncomplicated shoulder pain.[7] While a thorough history and physical examination are the most important instruments in evaluating shoulder pain, musculoskeletal imaging can be an important adjunct.[8]There may also be an expectation from patients in relation to the needs for imaging studies, many who often demand investigations believing it is necessary for adequate diagnosis and management of shoulder pathology, which can present a multitude of problems for the physiotherapist in managing these expectations and advising or educating patients around the diagnostic imaging and its role.[9] Conservative treatment can be impacted as a result of patient expectations following findings on diagnostic imaging e.g. perception that if a tear is there then physiotherapy has no role to play. Cuff and Littlewood [10] highlight a wide range of factors that influence patient beliefs about the cause of their shoulder pain, but suggest the information they receive from healthcare professionals has the strongest influence, hence, the language and terminology we use is key to achieving good clinical outcomes. Successful physiotherapy management of shoulder pain is often impacted by the patients expectations about how effective they believe physiotherapy to be and has been shown to be the strongest predictor of future surgical intervention in people with shoulder pain and associated rotator cuff tear. [10]
If the patient perceives their problem as one not amenable to physiotherapy following diagnostic imaging, for example an osteophyte (bone spur) impinging on their rotator cuff, the opportunity to achieve a satisfactory outcome might be compromised." [10]In the evaluation of shoulder pain, the role of diagnostic imaging is to guide clinical management, and can be useful in identifying when operative treatment may be required, and where required can be used further to plan the surgical approach whether it be open or arthroscopic. Currently magnetic resonance imaging (MRI) and ultrasound are the most commonly used cross-sectional imaging modalities in the diagnostic work-up of shoulder pain. [11] Where a thorough and detailed subjective and objective physical assessment has been completed, imaging in some cases may aid in confirming diagnosis, but diagnostic imaging findings can also lead to misdiagnosis if not reviewed in the overall context of the patients symptoms and physical exam findings. As such shoulder examination and development of adequate differential diagnosis is therefore key to establish if advanced imaging is required.
Direct access to physical therapy evaluation and intervention has the potential to reduce costs and improve outcomes in musculoskeletal medicine. The results of multiple studies show that direct access to physical therapy is associated with improved patient outcomes and decreased costs, with minimal risk of harm to the patient.[1][2][3][4][5][6] The diagnostic accuracy of a physical therapists clinical examination has been shown to be the equivalent of orthopedic surgeons and well above non-orthopedic providers when compared to an MRI diagnosis.[3] Direct-access to physical therapy is associated with decreased rates of diagnostic imaging. Additionally, numerous case reports describe the appropriate identification of patients whose pathology lies outside the scope of physical therapy by physical therapists operating in a direct-access setting..[1][6]
Traditionally it was assumed that the utilisation of advanced imaging modalities would provide additional benefits and increase diagnostic accuracy, however as highlighted by Jarvie et al [9] there are many studies which now refute this and suggest the use of additional advanced imaging has minimal impact on the care patients receive. [9] We will review the options and principles of shoulder investigations as they can play a role in the effective management in some shoulder conditions. There are many different types of imaging and each type is used for a specific purpose. For shoulder related problems the main forms of imaging include X-rays (Plain Radiography), Ultrasound, computed tomography (CT) and MRI Scans although direct access to these types of testing vary dramatically worldwide, and even within countries
Imaging Options
X-Ray (Pain Radiography)
Plain X-rays can be important in the diagnosis of some shoulder conditions, with a good overview provided by routine views which should include a true Antero-Posterior view in the scapular plane (Grashey View) with the arm in maximal internal-rotation, with the arm in External Rotation and Axillary View and Y View (less important). In the context of traumatic injuries or the unstable shoulder, x-rays allow the identification of any dislocations / subluxations and associated fractures, which are more frequent in older patients, such as: tuberosities, surgical or anatomical humeral neck and coracoid and patients should be referred for immediate x-ray if there is any suspicion of these injuries.[12]
The conditions that can be identified on Plain Films include;
- Calcific Teninopathy
- Glenohumeral Joint ARthritis
- Scelrosis of Anterior ad Lateral Acromion
- Sclerosis of the Greater Tuberosity
- Proximal Humeral Head Translation
- Fractures
Indications for X-ray
To detect or exclude pathology when diagnosis is obscure and thus contribute to decisions regarding further management. Consider an x-ray and discussion with the patients GP if the patient has; [13]
- Exquisite Pain - Exclude Acute Calcific Tendonitis;
- Subacromial Pain (ONLY if suspect a structural deformity or is unresponsive to treatment);
- History of Trauma - Exclude Fracture and / or Dislocation / Subluxation;
- Possibility of Metastases, particularly in patients with a previous history of Cancer (Breast or Lung)
- AC Joint Pain - Persistent pain with continued functional impairment;
- Older Person with a stiff, painful shoulder +/- crepitus.
"X-ray is currently considered an indicated imaging modality for diagnosing adhesive capsulitis and ruling out an intrinsic cause for motion loss (e.g., glenohumeral arthritis)." [9]
"X-ray studies are also considered indicated for suspected instability to identify concentric reduction and the absence of fracture or bone loss." [9]
UltrasoundMusculoskeletal ultrasound has evolved as a useful and powerful tool for both diagnosis and treatment of shoulder pain, as it provides both static and dynamic visualization of structures surrounding the shoulder including the lateral third of the acromion, the subacromial/subdeltoid bursa, supraspinatus tendon, and the head of the humerus.and their biomechanical relationships.[14] A sensitivity level of 79% and a specificity of 94% was found in a meta-analysis of five studies (311 Shoulders), which used ultrasound to diagnose Rotator Cuff related disorders, so can be considered a valuable investigation for rotator cuff related shoulder pain where indicated. [15] Similarily Henderson et al [16] show that shoulder ultrasound had high diagnostic value for subacromial bursitis, while Ottenheijm et al [17] report a sensitivity and specificity of 79-81 and 94-99%, respectively, when compared to arthroscopy or MRI when detecting bursitis, as do Le Corroller et al [18] who showed a sensitivity and specificity of 96% and 90%, respectively, when compared to MRA. [14]
"High resolution ultrasound, completed by an experienced operator, is a reliable, non-invasive technique for imaging the rotator cuff and adjacent muscles, the bursae, and the long head of biceps muscle." [19]
MRI allows for multiplaner, non-invasive examination of the shoulder. Currently there are many debates surrounding the use of MRI with many studies questioning the clinical relevance of the findings seen on MRI, which have been shown to not always correlate well with surgical findings. [20][21] These studies suggest that the findings on shoulder MRI may not always be clinically relevant. [22] Baudi et al [12] suggest that MRI is considered the gold standard for the evaluation of soft-tissue injuries in the unstable shoulder. MRI can also be used to evaluate bony injuries in detail, as yet it is still unclear whether MRI is more accurate at detecting shoulder related disorders compared with Ultrasound, specifically in relation to Rotator Cuff or Subacromial Related Shoulder Pain, but both have been shown to be equally effective in the detection of partial or full thickness rotator cuff tears [23]. Onward referral to a specialist rather than requesting a MRI may often be a much better management strategy due to the cost implications for shoulder MRI. [24] . Magnetic resonance arthrography (MRA) in particular has shown high sensitivity (86-91%) and high specificity (86- 98%) for the capsulo-ligamentous complex, labral and cartilaginous structures.[12]
Arthrography is when the joint is injected with a dye and is generally combined with CT or MR to provide detailed anatomical information of the Shoulder Joint including strong detail of the Capsular Attachments, Labrum and can very clearly highlight small avulsion fractures of the Glenoid Rim (Bankart Lesions) and Humeral Head (Hills-Each Lesion).[19] Magnetic resonance arthrography (MRA) has shown high sensitivity (86-91%) and high specificity (86- 98%) for capsulo-ligamentous complex, labral and cartilaginous structures.[12]
The high prevalence of asymptomatic pathology on imaging complicates the interpretation of imaging with respect to symptoms even when radiological imaging investigations are available. Imaging findings such as tendon tears and bursal thickening, often diagnosed as bursitis, are as common in individuals with no shoulder pain, as they are in those with shoulder pain. One study suggest as much as 96% of individuals without any shoulder pain or loss of function were found to have imaging changes, such as tears, and bursal thickening.[10] This suggests that what can be seen in imaging is not always the cause of the problem, and in many cases imaging findings do not tell you what structure is specifically causing the pain. Cadogan et al [15] suggest that problems associated with the pathoanatomic approach to the clinical diagnosis of shoulder pain often utilised in primary care can lead the practitioner to inaccurate diagnosis, often resulting in inappropriate treatment interventions that may adversely affect patient outcome and result in inappropriate use of healthcare resources, and higher incidences of failed conservative treatment.[15]
Currently in many cases MRI often represents a more universally accepted imaging modality, which may be due to ease of use with the ability for imaging to be evaluated by more than one radiologist. Ultrasound on the other hand, can be slightly more challenging to perform and is operator dependent, requiring a skilled individual.[25]
It is important to consider that diagnostic imaging findings in the acute setting in many cases will not actually change the management of the injury, so knowing and recognising when diagnostic imaging is required is key.[8][22][23] Keeping that in mind, current research suggests that Ultrasound is a valuable for rotator cuff related and subacromial related shoulder pain, in particular complete or incomplete ruptures of the Rotator Cuff, and is more cost effective than use of MRI.[25] MRI on the other hand is indicated when there is question of an abnormality related to the labrum, articular cartilage, bone marrow, or deep soft tissues and is much more accurate when evaluating for Hill-Sachs Lesions or bony Bankart Lesions, while MR Arthrography is far superior when looking for labral capsular ligamentous complex lesions.[25] Ultrasound has some advantages over MRI in particular when imaging around hardware, for detecting foreign bodies, or when there is need to perform a dynamic maneuver to elicit pathology, or for guiding procedures such as injection. Ultrasound is indicated also if the patient has a pacemaker, has a non-MRI-compatible metal implant, or is claustrophobic.[11] When clinical examination findings suggest the need for diagnostic imaging relation to the rotator cuff Levine et al suggests the choice between MRI and ultrasound is influenced by access to imaging, radiologist experience, referring physician preference, MRI contraindications, and patient choice.[11]
Physical therapists operating as musculoskeletal primary care providers in a direct-access sports physical therapy clinic appropriately ordered advanced diagnostic imaging in over 80% of cases. They ordered MRI/MRA in only 8% of all new evaluations, suggesting judicious use of advanced imaging.The following pathway provides guidance on the imaging of adult patients with new onset traumatic and non-traumatic shoulder pain or instability.
If you are interested in learning more about diagnostic imaging take a look at these resources for the shoulder
Diagnostic Imaging Pathways - Shoulder (Pain or Instability)The Diagnostic Imaging Pathways website is an evidence-based and consensus-based education and decision support tool for clinicians. It guides the choice of the most appropriate diagnostic examinations in the correct sequence in a wide range of clinical scenarios. Guidance is summarised in flow charts (diagnostic algorithms) and these are supported by appropriate documentation and links to other sources of information and evidence where possible. Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
Norwich Image Interpretation Course: Shoulder
The Norwich Image Interpretation Course is aimed primarily at radiographers who provide a preliminary clinical evaluation service to A&E, however it will also benefit those keen to review image interpretation skills. It is anticipated that by reading through each module and referring to the associated images provided, the user will become more accurate in their interpretation skills. You also have an option at the end of each module there is an online self-test which is designed to assess the concepts taught.
They also have a pathology image gallery which can aid with reviewing image interpretation skills when viewing pathologies. These pathologies may arise incidentally when looking at trauma radiographs, or may be encountered when reviewing images from GP or Rheumatology referrers.
- ↑ 1.0 1.1 1.2 Crowell MS, Dedekam EA, Johnson MR, Dembowski SC, Westrick RB, Goss DL. DIAGNOSTIC IMAGING IN A DIRECT-ACCESS SPORTS PHYSICAL THERAPY CLINIC: A 2-YEAR RETROSPECTIVE PRACTICE ANALYSIS. International journal of sports physical therapy. 2016 Oct;11(5):708.
- ↑ 2.0 2.1 Van Tulder MW, Tuut M, Pennick V, Bombardier C, Assendelft WJJ. Quality of primary care guidelines for acute low back pain. Spine. 2004;29(17):E357-62. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15534397.
- ↑ 3.0 3.1 3.2 Cadogan A, McNair PJ, Laslett M, Hing WA. Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain. PloS one. 2016 Dec 9;11(12):e0167738.
- ↑ 4.0 4.1 Awerbuch MS. The clinical utility of ultrasonography for rotator cuff disease, shoulder impingement syndrome and subacromial bursitis. Med J Aust. 2008;188(1):50–3. pmid:18205566
- ↑ 5.0 5.1 Johal P, Martin D, Broadhurst N, Johal P, Martin D, Broadhurst N. Managing shoulder pain in general practice—assessment, imaging and referral. Aust Fam Physician. 2008;37(4):263–5. pmid:18398526
- ↑ 6.0 6.1 6.2 Freeborn DK, Shye D, Muttooty JP, Eraker S, Romeo J. Primary Care Physicians ' Use of Lumbar Spine. Journal of General Internal Medicine.3-9.
- ↑ Carey TS, Garrett J, Back C, Project P. Patterns of Ordering Diagnostic Tests for Patients with Acute Low Back Pain. Medicine. 1996.
- ↑ 8.0 8.1 McMahon KL, Cowin G, Galloway G. Magnetic resonance imaging: the underlying principles. The Journal of orthopaedic and sports physical therapy. 2011;41(11):806-19. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21654095. Accessed March 16, 2012.
- ↑ 9.0 9.1 9.2 9.3 9.4 Jarvie GC, Pike JM, Goel DP. Diagnoses and imaging utilization for common shoulder disorders by referring physicians in British Columbia. How would you like to die?. 2017 May:222.
- ↑ 10.0 10.1 10.2 10.3 Cuff A, Littlewood C. Subacromial Impingement Syndrome - What does this mean to and for the Patient? A Qualitative Study. Musculoskeletal Science and Practice. Elsevier Ltd; 2017 Oct 17;:1–14.
- ↑ 11.0 11.1 11.2 Levine BD, Motamedi K, Seeger LL. Imaging of the shoulder: a comparison of MRI and ultrasound. Current sports medicine reports. 2012 Sep 1;11(5):239-43.
- ↑ 12.0 12.1 12.2 12.3 Baudi P, Rebuzzi M, Matino G, Catani F. Imaging of the Unstable Shoulder. Open Orthopaedics J. 2017 Aug 31;11(Suppl-6, M7):882–96.
- ↑ Bussières AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints in adults—an evidence-based approach—part 2: upper extremity disorders. Journal of manipulative and physiological therapeutics. 2008 Jan 31;31(1):2-32.
- ↑ 14.0 14.1 Saulle M, Gellhorn AC. Approach to the diagnosis of shoulder pain using physical exam and ultrasound: an evidence-based approach. Current Physical Medicine and Rehabilitation Reports; 2017 Mar 30;:1–11.
- ↑ 15.0 15.1 15.2 Roy, J. S., Brae ̈n, C., Leblond, J., Desmeules, F., Dionne, C. E., MacDermid, J. C., ... Fre ́mont, P. (2015). Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(20), 1316–1328. doi: 10.1136/bjsports-2014- 094148
- ↑ Henderson RE, Walker BF, Young KJ. The accuracy of diagnostic ultrasound imaging for musculoskeletal soft tissue pathology of the extremities: a comprehensive review of the literature. Chiropr Man Therap. 2015;23:31.
- ↑ Ottenheijm RP, Jansen M, Staal JB, van den Bruel A, Weijers RE, de Bie RA, et al. Accuracy of diagnostic ultrasound in patients with suspected subacromial disorders: a systematic review and meta- analysis. Arch Phys Med Rehabil. 2010;91(10):1616–25
- ↑ Le Corroller T, Cohen M, Aswad R, Pauly V, Champsaur P. Sonography of the painful shoulder: role of the operator's experi- ence. Skelet Radiol. 2008;37(11):979–86.
- ↑ 19.0 19.1 Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.
- ↑ Wnorowski DC, Levinsohn EM, Chamberlain BC, McAndrew DL. Magnetic resonance imaging assessment of the rotator cuff. Is it really accurate? Arthroscopy 1997;13:710-9.
- ↑ Tortensen ET, Hollinshead RM. Comparison of magnetic reso- nance imaging and arthroscopy in the evaluation of shoulder pathology. J Shoulder Elbow Surg 1999;8:42-5.
- ↑ 22.0 22.1 Bradley MP, Tung G, Green A. Overutilization of shoulder magnetic resonance imaging as a diagnostic screening tool in patients with chronic shoulder pain. Journal of shoulder and elbow surgery. 2005 Jun 30;14(3):233-7.
- ↑ 23.0 23.1 Gazzola, S., & Bleakney, R. R. (2011). Current imaging of the rotator cuff. Sports Medicine and Arthroscopy Review, 19(3), 300–309. doi: 10.1097/JSA.0b013e3182189468
- ↑ Leung R. Common Sports-related Shoulder Injuries. InnovAiT. 2017 Jan;10(1):30-8.
- ↑ 25.0 25.1 25.2 Pavic R, Margetic P, Bensic M, Brnadic RL. Diagnostic Value of US, MR and MR Arthrography in Shoulder Instability. Injury. 2013 Sep 30;44:S26-32.


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Taking over the world by doing nothing, brought to you live from the Command Bunker at the Lightning Man World Propaganda Network....Of all the blogs you've ever read, this one is the most recent.
Sunday, July 15, 2007
I want my eMpTyVee
I'm beating a dead horse here, I'm sure, but what happened to "Music Television"? Part of me wonders why artists even bother to make videos for their singles anymore( unless it's to sell on DVD compilations) when the chances of the clip seeing serious airplay rotation are about the same as seeing Rosie O'Donnell in a thong doing a believable love scene with George Clooney.
As a teenager, I thought that music videos were a brilliant concept. In early 1984, in my freshman year, there were after-school video shows, and on the USA Network there were shows like Friday Night Videos and the Saturday night Nightflight all-video show. These were in addition to the fledgling MTV, which was barely 3 years old at the time and still played vids all day & night. For a not-quite-15 year old music fanatic like me, this was simply the coolest shit, indeed.
There was even an MTV for "old" people over 30 starting in 1985 called VH-1, also playing videos 24/7.
Life was good. Then something went HORRIBLY wrong.
Sometime in 1987 or so, MTV's focus shifted, and Music Television started to become Miscellaneous Television by abandoning the all-video format and doing "shows". Granted, not all of it was bad. Liquid Television gave exposure to avant-garde animators like Peter Chung, and for better or worse the American public was gifted with Beavis & Butthead and Ren & Stimpy. Then the 90's saw the MTV Unplugged phenomenon, which was pretty cool for awhile. But for every novel concept there was a plethora of complete and utter GOBSHITE. Such drivel and dreck as Remote Control, The Grind, Made, Jackass, Road Rules, Next, Date My Mom, My Super Sweet Sixteen, and the worst offender of all, The Real World, which spawned the genre of reality TV. Bastards...
Even once-clever ideas like Cribs or Pimp My Ride have become trite, jaded mockeries of their original selves. Cribs was a chance to look inside the homes of celebrities and see how they lived. Now they struggle to find people to showcase, so now you get to see the third-string quarterback for the Houston Texans show off the obligatory fridge full of Cristal champagne and stating that the bedroom is "where awl da' magic happens" before showing off a bloated garage full of SUV's and sports cars and a giant-screen TV home theater.
Pimp My Ride has gone from a really novel customization of broken-down cars for needy young adults to seeing just how much ridiculous and goofy-assed shit you can bolt onto a 400 dollar hooptie just for the sake of doing it.
VH-1 is no better. They play more videos than MTV by far, but after the obligatory 3-4 ours of music in the early morning, their litany of lame-assed shows starts up. Only they have fewer to choose from and thus repeat them ad nauseum, flogging the entire stable of dead horses in marathons of Celebrity Fat Camp, Surreal Life, the train wreckages of the Flavor of Love shows, Hoboken's Next Top Model, and the I Love the 70/80/90's shows. The "I Love…" shows are cute nostalgia the first time; after 25 viewings, not so much.
In 1996 MTV tried to get back to its music roots by launching M2 (later called MTV2), intended to show videos again, with a more eclectic and alternative mix, and now it's all rap and rap-related shows when not playing repeats of other MTV shows. VH-1 finally launched VH-1 Classic to pander to old farts who remember videos, playing clips from the 70's and 80's, new clips from older artists, and occasionally dusting off the old alternative vids left in the vault from MTV's "120 Minutes", circa 1987.
There's other choices out there if you dig around a bit. Fuse TV is a pseudo-music channel catering to the 17-year old text-messaging Emo crowd, but they're a pale shadow of what they could be. I don't get Much Music on my provider, so I miss out on Canada's answer to MTV. Instead, I now watch a lot of IMF, the International Music Feed, which plays vids and interviews 24/7 from all over the world and from a lot of different genres. In the space of a typical hour you can see bands from Ireland, Italy, Ukraine, Finland, England, Germany, Japan, and Brazil, all singing in their native languages. I've been exposed to some cool stuff that I'd never see elsewhere, even if I don't always understand the lyrics. But, good music and good songs are good no matter what the language.
So, if you're like me and you miss the good old days of real videos and not some rehashed gobbledygook bullshit, take heart. It's still out there but you gotta dig deeper to find the nuggets of gold. Or, do what the real die-hards do: search out stuff on You Tube. Crap quality streaming of an old Smiths video beats watching Hulk Hogan raise his kids any day.
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