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Commercial-All Types
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Great deal! 40 gated storage units on 4 acres. This is the perfect place for your new business. Property sits just off Hwy. 86 in Shell Knob near Table Rock Lake. Purchase is subject to lot split. Property currently a part of 11 acres with residence. Home on property with 7 additional acres is also for sale, see MLS 60138069. Properties may be purchased as a package for $279,800. See MLS 60137859 for details.**Information contained in this listing has been obtained through third party sources deemed reliable. Listing Broker assumes no responsibility for its accuracy and Buyer shall independently confirm any information set forth above.
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Totally updated, totally furnished and ready for you to start enjoying. Located right by the entrance into Viola Public Access Area/Kings River Marina, with boat launch and boat slips for rent just a couple minutes away. This is not a condo; the land goes with the unit. Community Pool. Lower...
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The data relating to real estate for sale on this web page comes in part from the Internet Data Exchange (IDX) of the Southern Missouri Regional MLS, LLC, Inc. Real estate listings held by Brokerage firms other than [Displaying Broker's Name] are marked with the IDX logo and detailed information about them includes the name of the listing Brokers. The information being provided is for consumers' personal, noncommercial use and may not be used for any purpose other than to identify prospective properties consumers may be interested in purchasing. The information being provided is not guaranteed, and all information should be verified by the consumer. Any representation that a web site contains all listings shall only mean that the website contains all listing available to the public through the IDX data feed. There may be other properties offered through a REALTOR® that have not been displayed on this site. © 2019 Southern Missouri Regional MLS, LLC. All rights reserved. Additional disclosure at https://www.somomls.com/
Updated: 25th January, 2020 11:56 PM.
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School for Tibetan Language and Translation Ka-ter Project
Do you wish to study Tibetan (colloquial, classical or calligraphy) and Drajyor? These are our offers, at Merigar, in Florence, London, Venice and online!
Do you wish to study Tibetan (colloquial, classical or calligraphy) and Drajyor? These are our offers, at Merigar, in Florence, London, Venice and online!
In January a Stress Management in Tibetan Medicine seminar with Dr. Phuntsog Wangmo was held at the Medical University of Moscow in collaboration with SSI
The School for Tibetan Language & Translation offers a new online initiative to deepen knowledge of the Tibetan language to better understand the Teachings
We are planning a 2-hour online meeting every two/three weeks in which we will focus on parts of Chögyal Namkhai Norbu's Tibetan text "The Precious Vase"
The Shang Shung Institute Austria is strongly connected to the third major milestone of human mankind: writing.
On December 4-7, 2017 in Moscow, an international forum on traditional medical systems of the world took place.
Webinar on medical anthropology "Benefits of breathing practices in Yantra Yoga, Tibetan yoga of movement" conducted by Oleg Tanakov, Yantra Yoga instructor
An announcement made by Chögyal Namkhai Norbu by webcast at Dzamling Gar, Tenerife, December 1, 2017, with Marco Baseggio and Giovanni Boni
The activities of Shang Shung Foundation at Dzamling Gar for the year of 2017/2018 began this September. The idea is that each season is dedicated to one of the five pillars of Tibetan culture. During…
Organized for the first time by the Shang Shung Foundation School for Tibetan Language & Translation and held in the Merigar West library reading room


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With over 30 years experience, Lou Rera is an expert in the creative arts.
Lou's career spans over three decades working with video and film, graphics and animation, original music, original short stories, multimedia and web based projects. Lou Rera has an extensive background as a producer, director, graphic designer, musician—writing original scores and fiction.
His experiences have taken him to studios in Los Angels and New York City. Lou has worked for clients that range from corporations to the U.S. Government agencies.
Lou Rera is currently examining social media in education. He is exploring new ways to work in the classroom through the integration of social media tools.
His novel first novel SIGN, was published by Netherworld Books in the U.K. and worldwide in 2014. Lou is writng his next novel, The Tin Mask, a tale of love, tragedy and murder.
Winter 2019
HWA New York
With a move to the New York City area, Lou will participate with members of the Horror Writers Association New York Chapter in events and other related activities.
SIGN: Audio Book Available
The Audible.com version of Lou's first novel SIGN, a supernatural thrilller of deception and murder read by actress, Emily Yancey is now available for free. Click here


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Why is feature scaling important? — Without feature scaling, it can take gradient descent much longer to find the local minimum. The function may oscillate in small movements for much longer.
Google Interview
This flashcard deck made by jwasham contains knowledge about google interview. For more details, please follow https://github.com/jwasham/google-interview-university


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Oil – the black gold of the planet, but all is not gold that burns. Precious hydrocarbons can be useful to mankind, and to bring harm to the environment. Oil clogs the ecosystem due to the human factor and as a result of natural emissions. To make amends with nature trying scientists of the research Institute of St. Petersburg. As microbiologists improve appetite neftegastruba bacteria, learned Natalia Dmitrieva.
"Here in the tube, no oxygen, and is an integral part of the oil, if you look, you'll see bubbles of gas formed is methane. With the help of microorganisms. Chemically, nothing happens."
This scientific experiment clearly shows that the micro-organisms have a good appetite. If quite simply, they eat oil. And they are so delicious that if the gas is not time to release the vial will explode from the metabolic products of the bacteria. Scientists use culinary preferences of microorganisms for the environmental good of the planet.
Alexander Galushko, head of the sector of environmental Microbiology "Agrophysical scientific research Institute", "To clean contaminated sites, it is necessary to use not one kind, but several, we combine and send it back to the same environment from which we took it".
Of particular interest to the present kobilarov Northern regions of the country, including Yamal, global warming, or rather the plummeting temperatures negatively affect the digestion and microorganisms, and they freeze until better times. The objective of the research laboratory to teach bacteria – to enjoy life in extreme conditions.
At low temperatures, it metaboliziruet slowly and can live for years, but when high it's different, some microorganisms die, even if they have power, and adapted microorganisms function".
Anna Zhuravleva PhD student "Agrophysical scientific research Institute": "Backlash look beautiful, it is allocated from the Baku soil."
Scientists hope, to the South, the microbe will appeal not only to them but to their Northern brethren. Perhaps this combination will lead to greater activity, and consequently to the improvement neftegastechnika qualities. The researchers also kept control over the toxic effects of microorganisms. For kobilarov it is important to learn to control the bacteria, so they do not have to control us.


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HILLSBOROUGH (WWSB) - One man tried to avoid Florida deputies by jumping into Hillsborough river, but wasn't successful.
On Tuesday, July 23, troopers say 43-year-old Jack Knapper rear ended a Hillsborough County Sheriff's Office detective in an unmarked vehicle while the detective was stopped at a red light on Bruce B Downs Boulevard, just south of Commerce Palms Boulevard.
Troopers say they tried to pull Knapper over for a traffic investigation, but he did not stop. A short time later, troopers were called when a tipster spotted Knapper on I-75, just north of the Fletcher Avenue exit.
Florida Highway Patrol says as troopers neared, Knapper got out of his car and ran into a heavily wooded area before jumping into the Hillsborough River. FHP says a trooper and a deputy jumped into the river to get the suspect as the sheriff's office helicopter hovered overhead.
Knapper was taken into custody and charged with Leaving the Scene of a Crash, Fleeing to Elude, Driving without a Valid License and Resisting Arrest without Violence. Deputies say he could also possibly face DUI charges.
"We couldn't have asked for a better outcome in this case. Our HCSO deputies and FHP troopers worked together seamlessly to take a dangerous driver off of the road and take him into custody without anyone getting hurt," said Sheriff Chad Chronister. "Criminals don't care about county lines or whose jurisdiction they are in, so it's up to us as law enforcement officers to work as a team to keep our communities safe. I'm proud to say we did just that."
Due to the Knapper jumping into the river, he was taken to Tampa General Hospital to get checked for exhaustion.
Copyright 2019 WWSB. All rights reserved.


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Operational guidelines for gendarmes for the prevention and the fight against racist, anti-Semitic, xenophobic, discriminatory acts and hate related crime
The prevention of racist, anti-Semitic, xenophobic and discriminatory acts, and of hate-related crime.
- France
- Other violence
- Initiatives
- Training
Promotion of social-emotional competences and violence prevention.
- Germany
- Other violence
- Initiatives
- Youth
- Training
The response to tackling domestic violence is included in the Governments Call to End Violence Against Women and Girls.
Published on 25 November 2010, the strategic narrative sets out the...
- British Policy on Domestic Violence233.23 KB
- United Kingdom
- Domestic violence
- National policy
- 2014
The UK government is committed to tackling sexual offences. The principle focus is on the rights and welfare of the victim, and ensuring that every victim of sexual crime has access to...
- British Policy on Sexual crime171.89 KB
- United Kingdom
- Sexual violence
- National policy
- 2014
One of the most important tasks of the police consists in preventing violence and to ensure that individuals can lead a life without being afraid of assaults. Established in 1997, the Anti...
- Austria
- Domestic violence
- National policy
- 2014


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Pros & Cons of Vengeance
Five jobs. Five chances for redemption.
There's nothing like being blackmailed by a dead man to really bring a group of cons together. And what a group we are: a hacker, a thief, a con artist, a thug, and a Federal agent with an ax to grind.
The deal is simple: We do the jobs, and Charlie's lawyer wipes the slate clean for each of us, one at a time. Since job number one calls for some muscle, it looks like I'm up first. I'm Steele Alvarez, ex-Special Forces close protection specialist (aka, a bodyguard for some not-so-nice guys).
After learning what the job is - taking down a seemingly untouchable senator with a penchant for beating up young male prostitutes - I'm in. No questions. A bullet ought to do the trick. Then I met Senator Harlan's latest victim: Breck Pfeiffer, the gorgeous hooker with a heart of gold and the soul of a fighter. One look at him, and I'm gone. That kid laid me out harder than any punch ever did.
I'll do anything to protect Breck, even kill for him. But Breck doesn't want the senator dead, he wants vengeance. If we're going to find a way bring down the slimebag and get the blackest mark on my record erased, I'm going to need all the help I can get.


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I'm one of the gourmets of a sex doll and a naughty sexual meeting. My favorite is a hole in fame. It makes me happy and challenges me to accept my neck as much as possible. To enjoy and not to know who is on the other side, to guess the cock is a very incredible experience. I like the position of the dog so that I can play it violently and play with my cat.
I am very happy to lose myself in sex and to let myself go. I like that when a person knows how to control and is a bit aggressive, like choking and beating.The production of lifelike sex dolls increasingly shows that modern science and technology play a crucial role in connecting sexual energy with health and well-being. Plus, it's the perfect time to inspire your passion for sex with the most realistic sex tools for adults that inspire a true partner. With a realistic silicone doll, you can train your sexual skills and improve your sexual skills.
The silicone sex doll is like a real woman: she has all the parts of a woman, including realistic and intimate parts, a fleshy breast and big buttocks. The holes that can be used include the mouth, vagina, and anus, which can satisfy the intercourse of all men. In addition, it can satisfy your life as your friend accompanies, attracts, and belongs to your family.
Realistic top-quality silicone cheap sex dolls offer all the benefits of women and offer the same sexual experience as real women to the owner who bought them. Therefore, silicone dolls have become the market leader in adult products and are very popular in all countries of the world.
Sex dolls have certainly come a long way over the years. Not so long ago, men and women had to settle for barely functional, stuffed dolls and inflatable items. Now things have changed completely. Dolls can now be positioned anywhere. You can sit on chairs, get up, bend over or whatever you want. If a person can move that way, so will their mechanical sex dolls. All of this is due to science. Let's take a closer look at how advances in science and technology give you a better sex doll experience.
We even think they work even better. You know that you really have a really nast
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Save your lifelike sex dolls sex as intended. If your doll is not used, store it carefully. It should not stay in a bent position between uses. This can lead to distortions. If you switch between applications for a long time, you should adjust the position of your dolls from time to time. This prevents wear on its structure.
Our dolls are really modern wonders. Engineers and artists both work very hard to create puppets that are both beautiful and functional. With a little care, the mechanics of your sex doll can work perfectly for years. The skeleton of your doll is literally the frame. It gives your doll structure. Without them dolls would be pretty tired. The skeleton also makes your doll mobile. That's because it's full of moving, bendable parts that work almost as well as the human body.
Developed the "female love doll sex doll robot" can be simple and exchange of people and feelings of people and robots produce some simple expressions, memory is permanent, you can also upgrade the most pleasant surprise is that sex robot is coming soon a dozen different types of robots to choose from, there are shy, there is shy, has a brave, angry girlfriend, otaku "polygamy" dream come true.
The advent of sex robot for the solution less male than female phenomenon is very helpful, and the price is very cheap sex robot, yet the most expensive of a $ 100,000, with the development of sex robot, since you can customize your own sex Robots, according to their own requirements, can order the size of body parts, appearance according to our own look is customized just like a goddess, not marry her true goddess, a sex robot exactly silicone dolls buys the same is possible, like, sex The robot is very good!
Along with the evolution of today's society, the word "technology" has become the leading industry in various countries. Artificial intelligence, discount sex dolls AI robots and professionals have also said that in the future, real human sex dolls will be created, all replaced by intelligent robotic sex dolls.
Otaku can buy more sex robot again, to true polygamy, can daytime sex doll robot clean up, do housework, and you can sleep with the same girl and has a gentle, very realistic look of the mountain at night! Friend, goodbye! The robot friend comes, the temperature is very realistic! It can be seen from the point that the present society is being slowly replaced by "technology".
Are you thinking about getting yourself a sex doll? If so, you could be wondering just what is a TPE sex doll ? Or maybe, how do sex dolls work? Can you see people having sex with sex dolls? What about how they're made? Does it make a difference? Or maybe you're just wondering who invented sex dolls, whatever the case, this post is for you.
There are many reasons for purchasing a sex doll, but for most there is just one reason. People buy cheap sex dolls because they want a realistic sexual experience that mimics or is even better than sex with a real woman. Now that you know what a sex doll is, the next question you might have is how sex dolls are made.
With this goal in mind, life like sex dolls are designed to provide this experience out-of-the-box. They are soft and lifelike to the touch, and their internal textures are made to feel just like a real woman should. Some sex doll owners even report more intense sexual pleasure for their sex dolls over an actual partner.
An important distinction is that sex dolls are not sex robots. Sex robots have animatronic features and are equipped with more technology. In terms of who invented sex dolls, their history dates back to the 1700s when sailors would use cloth sewn fabric for sex during long voyages.


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We have new product coming in weekly. We love to share with you our excitement over these new products. We love to support our local community by linking arms with our neighbors, as well as finding...
Eat Better, Feel Better: Tips for Reducing Sugar
It's not just the obvious treats that pack a punch of the sweet stuff. Added sugars are found in foods most people wouldn't think of.
PTSD: 5 Ways to Release Trauma That Haunts You
For most of us, trauma fades over time into an unpleasant memory. For others, there will be triggers that bring those memories back to life.
Natural Interventions for Anxiety
We all struggle with stress and anxiety. However, some people have too much of it, every day.
Strategies to Help Quit Smoking
Try these natural alternatives to the patch.
Combat Holiday Weight Gain
The holidays should be a time of good feelings. Keep yourself feeling good by keeping yourself fit.
Full-Spectrum Hemp Oil
Cannabis sativa languished for decades, neglected by researchers and practitioners alike.
Five Keys to Manage Stress and Anxiety
Stress also makes it hard to focus and can affect our moods and our relationships, but there are many ways to keep it at bay.
Gluten-Free Baking Tips
The standard rules don't apply to gluten-free baking. But with a little know-how, you can make treats to be proud of.
A Thanksgiving Ritual
In our family, Thanksgiving is about much more than just food! Oh yes, every year I make homemade cranberry sauce, a huge rice-stuffing filled turkey roasted with onions, mushrooms and carrots till...
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Adelle Laudan lives in Southern Ontario, Canada. She is a mother of 4, a Gramma of one & keeper of a little dog Chachi who always manages to make her laugh.
Some pretty major back surgery, quite a few years ago made it impossible for her to work outside the home. After one too many days watching the walls close in on her, she picked up a pen and paper and revisited her childhood love of writing. With several books published and several more in the works, Adelle invites you to travel the many twists and turns her stories will take you. Be sure to fasten your seatbelt, it will be a ride you won't soon forget.
Ride On or Go Insane!
Adelle 'Legs' Laudan
aka Elle Laudan - Adult Fiction
aka Lora Richards - Middle Grade Mystery
The paper mill where Dani has worked for the past twelve years is closing. A single mother of a sixteen-year old, she quickly learns her tattoos aren't helping her land a decent job. Should she stand up for her choice to have full sleeve tattoos, and settle for a job at Teasers, the local stripper bar? Maybe she should hide her beautiful artwork and try for a steady job in one of the design houses in the city?
Will she listen to Ryan and accept his help, knowing he wants to take their special friendship to another level. Is she willing to take the risk of losing him and cross that proverbial line?
Kat is the envy of everyone. She owns RazzamaJazz, a successful dinner club, an incredible lakefront property and she is beautiful. The statuesque blonde with ice-blue eyes commands attention wherever she goes. She has it all....or does she? Kat has been harboring a deep, dark secret for quite some time. Little by litter her ruse is unraveling. If she doesn't face her demon soon, she stands to lose everything, including her life.
Jack & Jenna from the Christmas short story Snow Angel
Continue their journey together in Dear Angel
Jack and Jenna's happily-ever-after is interrupted by the death of her father. She must leave the man she loves to return to the estate where she learns she's a wealthy woman.
Will the allure of high society coupled with the discovery of her deceased mother's well-kept secret keep her in a world where wealth and status can, and does, buy anything? Or does she learn the one thing she wants most money can't buy?
A tragic fire has put a major damper on Grace Payne's holiday spirit. She'd just as well skip Christmas all together. A series of circumstances brought self-imposed bachelor, Justin Carron to care for his sixteen year old niece, Mykaela, whom he'd never laid eyes on.
A winter storm, and an unexpected turn of the wheel, on their way home from the airport, changes all three of their lives forever. Each one is faced with their own mortality, the prospect of becoming a family, and the kindness of strangers.
Mr. C. is a kind old man, who lives alone, and tends to a stable of deer.
There is something different about the jolly old man with a white beard and suspenders. After several unexplained incidents, he shows Grace that all things are possible, if she'd just let go of the past, and believe in the magic of Christmas.
Rosa is deaf. She was adopted by loving parents after her mother died in childbirth. Rosa teaches deaf children music. At her 21st birthday party she crosses paths with the manager of the band, Devon Barnes. The first encounter is not, pleasant when Devon mistakes her deafness for being rude. Is Devon simply another man who sees her being deaf as also being mentally challenged? Why is she attracted to such a man?
Juliana spent the entire duration of her marriage a prisoner in her home. Subject to unspeakable abuse, her escape came in the form of her husbands' sudden death. She must now step into a world she had almost forgotten existed...
Join Juliana on her healing journey where she learns Love IS Good.
Shani is a woman of color, adopted by loving parents. After her mothers' untimely death, she learns of a deep, dark secret that makes her question everything about her life and those who loved her.
How often do we search for answers and find they are not necessarily what we want to hear? Is time a great healer, or are some things unforgivable?
Becca and Randy are Harley riding detectives who join forces to find the ruthless killer the press have dubbed The Florist. What does the flower he places in his victim's hands have to do with the sick, twisted way he ends their lives? Will they track him down before he strikes again, or will a turn of events find one of them at the mercy of a demented killer?
Special Edition of Iron Horse Rider Trilogy - Books 1 2 3 in one book!
After losing his wife in a terrible motorcycle accident Shane flees from everything and everyone that reminds him of Kelly. He discovers solace in a summer Micmac camp, and with the aid of Chief Gray Owl and the beautiful Tia, Shane's heart begins to heal.
On his journey he is introduced to a world of fire breathers, belly dancers, and crystal balls. Just when he thinks he's found a new place to call home, a powerful evil presence descends upon the unsuspecting Micmac camp.Shane joins forces with the Spirit World to confront this threat and defend all he has come to know and love.
Is Shane strong enough to face such a merciless entity, or is he destined to a life alone, riding in the wind?
Taylor rides into the small oceanfront town of Johnstown with hopes of starting fresh. He takes over the local auto body shop and puts the open sign in the window. Unfortunately the previous owner left the townsfolk with a bad taste in their mouths in regards to Bikers. When a photo of the pastor's daughter bound and gagged, is found on the post office bulletin board, all fingers point to him.
Will the sexy Agent, Dianne Parker, be able to prove his innocence, while trying to ignore their growing attraction? Will they find young Casey in time?
Lizzy would give it all back just to hear her mother's voice one more time... the house, the furniture...even the money. Regardless, her heartless stepfather is determined to take what he feels is rightfully his. Handyman, Adam Woodward rides into Lizzy's life and vows to keep her safe, but is it enough to stop the cold, callous determination of Ben Stokes?
After losing his wife in a terrible motorcycle accident, Shane flees from everything and everyone that reminds him of Kelly. He discovers solace in a summer Micmac camp, and with the aid of Chief Gray Owl and the beautiful Tia, Shane's heart begins to heal.
However, even paradise can turn chaotic. To save Tia from a man she fears, Shane is sent on a quest. Throughout his journey, he learns that sometimes friendship comes from the most unusual circumstances, that love never dies, and anything's possible when you're riding in the wind.
Bikers, gypsies, and natives... three very different cultures are brought together when Tia and Shane join a caravan of travelling Romani on their way back to the mountains. They are introduced to a world of fire breathers, belly dancers, and crystal balls. Not all of Tia's Micmac family are happy about it, which puts her in grave danger. Will Shane come to the lovely Tia's rescue? Can the ghosts of his past finally rest in peace so he can love again, or is he destined to a life alone riding in the wind?
News of Tia's pregnancy gives Shane reason to celebrate. Unfortunately, not everyone is as happy about this turn of events. When a powerful evil presence descends upon the unsuspecting Micmac camp, Shane joins forces with the spirit world to confront this threat and defend all he has come to know and love.
Is Shane strong enough to face such a merciless entity, or will he lose his life protecting the people he loves, including that of Tia and his unborn child?
Whatever happened to good, old-fashioned romance? Remember reading about a man's clothed physique, or how a fellow admired a woman in a pretty red dress? How about stories where couples fall in love with just one glance or that first gentle touch? Then open this anthology and enjoy 18 beautiful stories of love lost, love found, intrigue, heartache healed, the miracles of life, passionate admissions, and tearjerkers that make one sigh with longing. From best friends who find romance to time travel to a bit of Christmas magic, step into the realm of hearts on fire and love everlasting.
Authors: Gwen Hayes, M.E. Ellis, Maryann Miller, Adelle Laudan, K. Starling, Trinity Blacio, Debbie Gould, Ava James, Faith Bicknell-Brown, Savannah Chase, Lisa Alexander Griffin, Kensana Darnell, Nicolette Zamora, Kathleen MacIver, Missy Lyons, and Jambrea Jo Jones
Lizzy would give it all back just to hear her mother's voice one more time... the house, the furniture...even the money. Regardless, her heartless stepfather is determined to take what he feels is rightfully his. Handyman, Adam Woodward rides into Lizzy's life and vows to keep her safe, but is it enough to stop the cold, callous determination of Ben Stokes?
Biker Fiction/Contemporary - Winner of Freya's Bower's Anniversary Submissions Call


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She grew up in the White House and in front of America.
And on Saturday Chelsea Clinton was once again in the public eye, as she married long-term boyfriend Marc Mezvinsky.
On a 50-acre estate in Rhinebeck, New York, the only child of the former U.S. president and the current U.S. secretary of state, said "I do" in front of over 400 guests.
Those guests included several dignitaries and celebrities, including former secretary of state Madeline Albright and actor Ted Danson.
Media estimates put the cost of the ceremony at between $3 million and $5 million dollars.
Since Bill Clinton left the White House in 2001, Chelsea has kept a low profile.
But during her mother's failed run for the 2008 Democratic presidential nomination, Chelsea re-emerged to hit the campaign trail.
The bride has most recently studied health policy at Columbia University, while the groom works at a hedge fund.
The couple have known each other since they were teenagers.


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Hsc 525 Week 2
University of Phoenix
HCS 545 Health Care Law and Ethics
Louise Underhahl
July 23, 2012
Ethical Health Care Issues: Organ Transplant Allocation One of the areas that is currently affecting the United States is the ethical issue of organ transplant allocation. Since the first single lung transplant in 1983 and then the first double lung transplant in 1986 there have been thousands of people who have lived because of the surgery. One must examine, evaluate, and apply the four ethical principles to Organ transplant allocation to look at the ethical issues involved. Once must look at the fact that not every patient who would benefit from a transplant will receive one in time …show more content…


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Investigators reported a 1.23-fold increase in the likelihood of surgery for nonspecific low back pain if patients lived in areas with the greatest concentrations of MRI scanners, compared to places with the fewest units.
Patients with nonspecific low back pain have significantly greater odds of having an MRI and undergoing subsequent surgery within the first year if they live in an area with an abundance of MRIs, according to a new study.
Despite questions about the efficacy of imaging or surgery for low back pain within the first year, and a number of professional clinical guidelines advising against either, researchers at Stanford University reported a 1.23-fold increase in the likelihood of surgery for nonspecific low back pain if patients lived in areas with the greatest concentrations of MRI scanners, compared to places with the fewest units.
About two-thirds of the scans occurred within the first month of pain onset, despite clinical guidelines that recommend waiting at least four weeks to see if patients recover on their own, as many do.
In 2004 alone, there would have been 5.4 percent fewer low-back MRIs and 9 percent fewer surgerical procedures if all patients had lived in areas with the fewest MRIs.
The findings were reported online Oct. 14 ahead of the print edition of the journal Health Affairs, a public policy research publication.
Senior author Lawrence Baker, PhD, professor of health research and policy, and Jacqueline Baras, a Stanford medical student with a master's degree in health services research, assessed the number of scans and surgical claims in a 20 percent sample of Medicare patients living in 318 metropolitan areas. They then compared the data with the number of MRI units in each area.
The final sample included claims for 666,455 episodes of low back pain, of which 15.6 percent resulted in an MRI and 2.7 percent resulted in surgery within one year.
Extrapolated to the entire Medicare population in 2004, 456,250 patients in the highest MRI-availability areas had a 17.2 percent chance of receiving an MRI within one year. If all patients lived in the lowest availability areas there would have been 6,388 fewer scans, according to the study.
"Not only are patients in high-availability areas getting more MRIs, but they are getting them earlier," the authors noted.
Practice guidelines issued in 2007 by the American College of Physicians and the American Pain Society "strongly" advise against imaging in patients with nonspecific low back pain within the first six weeks unless severe or progressive neurologic deficits are present, or serious underlying conditions are suspected.
The Agency for Healthcare Policy and Research recommends waiting at least three months before referring patients for surgery, while a European working group has advised waiting two years. According to a literature review published in the February 2009 issue of the Journal of the Academy of Orthopedic Surgeons, 90 percent of low back pain symptoms resolve within three months.
Nonetheless, the number of MRI units in the United States more than tripled between 2000 and 2005, from 7.6 to 26.6 per million individuals, according to the Organization for Economic Cooperation and Development. MRI was among the fastest-growing service paid for under the Medicare Part B physician fee schedule during the same period.
High-end scanners can cost upward of $2 million per unit, but many of them are far less expensive, older, and their usefulness is questionable, said Gary M. Franklin, MD, research professor of environmental and occupational health sciences (neurology) at the University of Washington in Seattle.
Dr. Franklin studies the impact managed care delivery systems have on cost and outcome in neurological injuries.
"A lot of the increase in MRI availability has not been in high quality scanners but in lower quality equipment, but they charge the same amount for their services," he said. "What is clear from this paper is that there are too many MRIs being done too early in low back pain patients, and I know many of these are being done on lower-quality CT equipment."
Addressing excessive imaging and surgeries for low back pain should be considered an important part of health care reform, he noted.
"The paper is very well done, and confirms what a number of other researchers have reported. It is pretty clever that they matched Medicare data with other sources of MRI availability data. What they found is not especially surprising, but it is important," he said. "I think whoever buys a unit feels they have to use it."
He noted that Washington State recently passed the nation's first law mandating prospective review of MRI requests for Medicaid patients, using evidence-based standards.
"When it comes to Medicaid claims that need to be reviewed, MRIs for low back pain are at the top of the list. Within six months, Washingon's Medicaid and worker's compensation agencies will require prospective review of all imaging claims," he said.
Richard Deyo, MD, the Kaiser Permanente Professor of Evidence-Based Family Medicine at Oregon Health and Science University in Portland, noted that the bulk of evidence has shown MRIs and surgery to be unnecessary for such patients early on.
"Unfortunately, this study confirms what others have found — the more hardware there is out there, the more MRIs, and more surgeries," he told Neurology Today in a telephone interview.
"Excessive imaging is driving up the surgery rate for these patients — the more scans you do, the more surgeries — but it remains unclear whether any of it improves outcomes. There is a lot of evidence that it does not."
He noted that study conducted by James N. Weinstein, MD, at Dartmouth Medical School, compared one-year outcomes in 400 low back pain patients following either an X-ray or MRI. " Although twice as many MRI patients had surgery, there was little difference in outcomes," Dr. Deyo said.
Professional guidelines, he added, offer little help. The American College of Radiology, the North American Spine Society, the American Pain Society, and the American College of Physicians have all weighed in with recommendations against surgery for most patients, but the criteria for selection "is ambiguous," he said. "There are too many conflicts and too much uncertainty. Patients and physicians need to understand that there are many people with abnormalities on their MRI that have never had any back pain or sciatica."
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Best Low-carb snack
After I turned 30, I feel it is getting easier to lose short-term memory, and gain weight. What was lucky to me was, at the time low carb diet started to be popular in Japan. You can find low carb snacks/foods at any supermarket and low carb menu at any restaurants. I am not on… Continue Reading Best Low-carb snack


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Seriously, life is stressful at the moment with load shedding, power outages and bad traffic jams, so we really need a lighter side to life- and I'm suggesting you head off to the theatre next month to enjoy Les Ballets Eloelle (say that out loud for your first laugh). Hot from new York, these boys are led by founder, Artistic Director and lead dancer Victor Trevino, and make up one of the few a…
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In the market for an iPhone? Here's a breakdown of all the currently shipping iPhones from Apple.
Apple Shares New Ads Highlighting iPhone X Features Like Animoji Karaoke
Apple's 38-second "Animoji Yourself" spot shows off "Animoji Karaoke," a phenomenon that kicked off shortly after the iPhone X launched. With Animoji Karaoke, the idea is to use Animoji to lip sync to popular songs, making it look like the Animoji are doing the singing.
The Apple Animoji ad features several Animoji characters singing the song "All Night" by Big Boi. Animoji Karaoke videos have been widely shared on Twitter, reddit, and other social networks, though interest in the feature has died down somewhat a few weeks following the iPhone X's launch.
Along with the Animoji ad, there are three new videos focusing on Face ID. The first view is an overview of the Face ID feature, explaining that it unlocks the iPhone X with a look.
The other two ads, which are 15 seconds in length, focus on specific Face ID features, including its ability to work in the dark and adapt to facial feature changes like makeup and glasses.
On its Canadian YouTube channel, Apple has also shared a video that explains how Face ID adapts to changes and works with facial hair growth. It's similar to the "Knows When You Change" video on the company's US YouTube site.
Apple shared several videos of the iPhone X when it was first introduced in September, but these are the first iPhone X specific videos that have been released since then, aside from a tutorial video walking users through the various iPhone X features and how to use them.
Apple will use these ads to show off iPhone X features on television, on the web, and on social networks like Instagram.
Top Rated Comments(View all)
Who still thinks that demand is high?
Who still thinks trolls predicting Apple doom aren't dreadfully wrong?
Amusing ourselves to death.
Who still thinks that demand is high?
What does demand have to do with anything? It's not just about the Animoji's, it's about the technology behind the Animoji and utilizing the new camera capabilities. Apple is using the Animoji's to demonstrate this.
I find it horribly embarrassing.Did you find this horribly embarrassing too?
Who still thinks that demand is high?So even THIS brings out the demand doubters? What exactly makes you doubt it? Marketing?
I know it's high.
Apple retail sold out daily with new stock each morning.
AT&T sold out
You expect Apple not to market their product? See you in January.
[ Read All Comments ]


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President of Swiss Confederation starts visit to Poland
President of the Swiss Confederation Ueli Maurer started a visit to Poland on Tuesday.
Following an official welcome ceremony Polish President Andrzej Duda and President Ueli Maurer were scheduled to hold a face-to-face conversation to be followed by plenary talks of both countries' delegations, co-chaired by both presidents.
Following the talks, Duda and Maurer are to hold a joint press conference.
The Warsaw talks are to focus on bilateral cooperation in the field of modern technologies, relations between Switzerland and the European Union, as well as historical issues.
The two presidents will also take part in a special ceremony marking the 100th anniversary of the establishment of Polish-Swiss diplomatic ties.
Later in the day, President Ueli Maurer will meet with Sejm Speaker Marek Kuchciński.


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Let us introduce ourselves, we are the Nation Broadcasting Group and we recruit extraordinary people.
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