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Location address: France, Provence-Alpes-Côte d'Azur
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The Camargue (French pronunciation: [ka.maʁg]) (Occitan: Camarga in classical norm or Camargo in Mistralian norm) is the region located south of Arles, France, between the Mediterranean Sea and the two arms of the Rhône River delta. The eastern arm is called the Grand Rhône; the western one is the Petit Rhône.
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Bus Krasnik Kraśnik • Lublin Voivodeship » Blackpool
Coach and bus timetable from Krasnik to Blackpool
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If you're interested in more routes from Krasnik to United Kingdom, please visit Krasnik to United Kingdom tickets. You can also buy your return ticket at Blackpool to Krasnik or Blackpool to other cities in Poland.
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The date of our Open House is now May 6.
Career Training in Cabinetmaking
Our five-month program prepares both beginning and experienced woodworkers for careers or serious hobbies in the field of cabinetmaking.
Real World Projects, Real World Skills
By the time you're done, you'll be building cabinets of amazing quality with extraordinary efficiency, using standards set by the Architectural Woodwork Institute. View our project gallery to see what we mean. See what some of our graduates are up to now and check out previous class pictures and videos to get a feel for life in our shop.
Woodworking Workshops
Offered by our sister school, The Workbench. Nights & weekend workshops and summer intensives are available. We also offer Open Shop, where you can use our shop to build your project of choice!
Shop News
- The 2018 application form is now available. We're experiencing unprecedented interest for next January, so we suggest you don't delay applying if you're interested. Class size is limited and we only hold the program once per year.
- Join us on May 6, 2017 for our annual Open House.
- See Facebook for the latest happenings in the shop.
"Most tradespeople I know are not just welders, carpenters, or plumbers. Their talents always outreach the router table and torch…As much as they love what they do and take pride in their work, their trade gives them freedom. Their trade engenders creativity…The day you think you've seen it all is the day you're confronted with an inexplicable puzzle…And what do you do? You get creative. You become innovative. You fix it! You think outside the box and do whatever it takes to find a solution. Problem no more. That is fulfilling." Tradeslife.com


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Sasha summarises Professor James Coyne's recent no-holds-barred talk on the PACE trial and points you to the slides, video, audio and transcript.
Discuss the article on the Forums.
xmrv+ starting AV's tenofovir and raltegravir
Discussion in 'XMRV Testing, Treatment and Transmission' started by pinkytuscadaro, Jan 27, 2011.
Page 5 of 5
Page 5 of 5


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If you wanted to see a good high school football game last week, you had to go outside Denton's city limits. All three Denton ISD teams were off last Friday as they prepared for the start of district play.
That put the spotlight on the teams around the area. And they didn't waste their opportunities to shine.
Adam Boedeker and I take a look at some of the big games around the area in this Denton ISD-free edition of the Weekend Recap.
Lake Dallas 49, Dallas Kimball 34
AB: The Falcons continue to show they have one of the best offenses in the area, and despite giving up some points to a game Dallas Kimball team, it wasn't enough points to come close to outscoring Dagan Haehn, Courtenay Holder & Co. Holder had a career day with four rushing touchdowns on just 60 yards, and he also came through in a big way on defense with a 55-yard interception return for a score. With Grapevine's struggles and Birdville losing to Class 4A Abilene Wylie, it's looking more and more like the Falcons could be a favorite to win the District 6-5A title.
BB: Looking at the box score, a big reason why Lake Dallas was successful last Friday night was Haehn's ability to locate different receivers. No Lake Dallas receiver had more than five catches, and five different Falcons had a reception against Kimball. The array of passing options could be a huge factor in how well Lake Dallas does the rest of the season.
The Falcons overcame four turnovers against Kimball to pick up another nondistrict win that will certainly give Lake Dallas a little extra momentum heading into this Friday's District 6-5A opener against Grapevine. Like Adam, I think there's a good chance Lake Dallas can make a run the district title.
AB: This game had everything. Two teams ranked in the top 4 in the AP poll. The revenge factor with Graham looking to make up for an embarrassing state semifinal loss at the hands of the Eagles last season. A great small-town football environment. It literally had everything. Speaking of everything, Graham had everything it needed to beat Argyle, except for Nick Ralston. The Eagles running back had a historic night, rushing for 192 yards and four touchdown on 46 carries — yes, forty-six. Ralston admitted to being exhausted after the game, and Rodgers admitted to wanting to get him a breather, but Ralston wouldn't take it. The kid's a warrior, and he put his team on his back in a big game.
BB: Ralston's record-setting night was a big reason why the No. 2 Eagles knocked off a Graham team that was ranked fourth in last week's Associated Press Class 4A poll. Ralston's 192-yard, four-touchdown night played a big part in Argyle stretching its win streak to 20 games. Argyle's defense did a good job of coercing Graham into some costly errors. The Eagles (4-0) forced three turnovers in the win and held Graham quarterback Landry Turner to a 54.5 completion percentage. With a win against Paris this week, Argyle will have all the momentum it needs before it starts district play.
Sanger 26, Lone Grove (Okla.) 13
AB: Lone Grove proved to be a formidable foe for undefeated Sanger, which usually can't be said for Oklahoma teams outside of the likes of the big dogs like Norman, Tulsa Union and Jenks. Sanger has had its way with Plainview, Oklahoma, in the past, but Lone Grove presented a different challenge in the form of running back Jeremy Lewis. The Lone Grove back eclipsed 200 yards and scored twice, but that's all the Indians gave up. Tre'von Jackson rushed for a season-low 185 yards and scored three touchdowns. The Indians are still perfect and should start climbing into state poll consideration if they keep it up.
BB: Argyle isn't the only area Class 4A team undefeated this season. Sanger maintained its spotless record with a very good victory against a solid Lone Grove team. Lone Grove entered last Friday's game ranked No. 10 in the Associated Press Class 3A Oklahoma state poll. Lone Grove, which has an enrollment of about 420 kids, isn't much smaller than Sanger's UIL enrollment of 768. If Lone Grove was in Texas, it would be in Class 3A by about 24 kids.
But one of those kids is Lone Grove junior running back Jeremy Lewis (http://sports.yahoo.com/ncaa/football/recruiting/recruit-search-results?year=2016&sport_id=1&sport=football&keywords=Lone+Grove), who has a scholarship offer from Tulsa. Lewis carried the ball 36 times for 207 yards and a touchdown. Sanger senior running back Tre'von Jackson had 185 yards on 29 carries and had three touchdowns.
Somebody, anybody, please recruit Jackson.
AB: Dane White established his dominance early and often for the Bobcats on Friday, leading Krum to a 27-20 win over Paradise to even its record on the season. White had a big night on the ground with 217 yards on 34 carries and scored twice for the Bobcats, who will look to move above .500 with a win this week over Boyd.
BB: Krum will certainly take a 27-20 win over a Paradise team that almost had a shot at taking a late lead in the game. The Bobcats picked up a key interception late in the contest to seal their second victory of the season. Krum never trailed in the contest and has a good chance of putting together two straight wins when it faces Boyd this week on homecoming night.
AB: In an early-season big game between two undefeated teams, Pilot Point was the only one to stay that way on Friday night. And in many ways, Pilot Point coach Rob Best can thank his junior do-it-all threat DaCoven Bailey for that. Bailey racked up 314 total yards thanks to a 92-yard kickoff return score and approached 100 yards both on the ground and receiving.
BB: For the first time this season, Pilot Point found itself trailing on a Friday night. But the Bearcats used 17 straight points to erase a one-point deficit and pick up a 16-point win against Gunter. Bailey, who posted a dumbfounding stat line for yet another night, said this game was the Bearcats' toughest test this season. That will certainly bode well for coach Best and the Bearcats down the road.


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"I went to the University of East Anglia in 1977 where I met Paul Whitehouse, Harry Enfield and Vic Reeves. At that time I was writing novels, but my main concern was pop music. I had a band for six years called, somewhat unimaginatively, The Higsons.
"I moved down to London in the mid-Eighties, and shared a flat with Harry who was launching his career as a stand-up at the time. Paul and I went on the Enterprise Allowance Scheme as comedy script writers, which took off when we did 'Loadsamoney'.
"After that, we did the Harry Enfield television programme for a couple of series and then Paul and I ended up doing The Fast Show, which we produced ourselves.
"I think it's good to do TV comedy late in life. Paul and I weren't coming in as 20- year-olds with no knowledge of the world. Everything I've done has basically been a series of lucky encounters because I've never had a proper career plan. I knew vaguely in the back of my mind that I would like to be a writer at some stage.
"I work very hard and when I'm writing I treat it as a job. I sit there every day and write, which is not difficult because I enjoy it so much. Paul and I work very well together - we both have the talent where the other doesn't.
"A good writing partnership is a rare thing. I attribute a lot of my success to being disciplined, focused, and of course working with Paul, who fortunately is much less anal than me!"
- More about:
- Harry Enfield
- Mark Williams
- Noel Clarke
- Stand-Up


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Mass Effect Update
We talk to BioWare about its newly announced next-generation sci-fi RPG that's coming to the Xbox 360.
We'll begin emailing you updates about %gameName%.
AMSTERDAM--Following BioWare's recent unveiling of Mass Effect at X05, we were left to ponder what the game was all about. The trailer shown was an effective tease for the galaxy-spanning adventure that featured quick cuts of bizarre aliens, massive creatures, and gun-toting humans set against a backdrop of alien worlds. We were able to meet with BioWare's joint-CEO Greg Zeschuk and project director Casey Hudson, who shed more light on the ambitious project from the veteran Canadian developer.
Mass Effect will be the first in a trilogy of games from BioWare that tells the story of humanity's journey to become a galactic power. The game is set in the 23rd century and picks up shortly after mankind, having begun extensive exploration of its solar system, makes a discovery that enables deeper penetration of the galactic interior than previously possible. The interstellar shortcut enables mankind to meet up with a collection of civilizations that make up a grand galactic community. Unfortunately, we're not quite ready to run with the big space dogs and are forced to work to be seen on equal footing with these galactic powers, which is where the initial part of the game finds you. However, a new conflict arises as man stretches his wings with his new neighbors: a definitive battle between organic life and artificial races. Our artificially created foes aren't too different from their organic counterparts, and the various artificial races have their own agendas for their fleshy cousins.
Unfortunately, said agendas aren't of the cozy "let's be friends" variety and are far more sinister in nature. Your role in all this is to play a human "specter," a member of a group of defenders of galactic peace. Your goal is to stop a rogue member of your group who controls armies that are advancing on defenseless worlds. Thankfully, you won't be doing this alone, as you're pretty high up in the ranks of your organization and merit command of a starship and a fighting force. The ambitious story marks a first for BioWare, which, after working on a series of Baldur's Gate games that ended up fitting as a trilogy, is now able to craft the rich tales you'll live over the course of Mass Effect's three entries. The homogenous approach lets the pack of veteran scribes at Bioware plot out some very special ways for ME's story to unfold.
The team responsible for crafting the ambitious game is no stranger to creating rich space epics. The group currently driving the Mass Affect project is almost entirely made up of the original Knights of the Old Republic team. Though there are more than a few similarities between elements in Mass Effect and the role-playing game set in the dawn of the Star Wars universe, Bioware is hardly recycling its work. Your actions will affect humanity on a galactic scale as you set out on your journey. This time out, besides the expected good and evil paths open to you, you'll find a third route that's far more self-serving and leans toward profiteering.
Now as good as Bioware's stories have been, they've always been given added depth, thanks to a rich visual presentation. BioWare's prowess at cinematic storytelling has been evolving at a steady clip, as evidenced by the leap between the original KOTOR and Jade Empire. Mass Effect represents an entirely new approach that the ambitious developer is touting as a unique way to tell a story. Above and beyond whatever new spin we'll see on in-game cinematics, Mass Effect will feature some truly unique content in its cinemas that's provided by two key components: your own choices and what the team is touting as digital actors. Your choices will influence how the game unfolds, just as they have in BioWare's previous games. However, this time you'll affect conversations and even character makeup, which is something new and intriguing. It sounds as though in many cases you'll have say in the way a character looks, which will, in turn, influence his or her behavior.
The digital actors in the game are equally provocative, as they seem to be a good deal more sophisticated than your average non-player character. From an appearance standpoint, the NPCs will look lifelike thanks to the incorporation of scans of real people and motion-captured animation. Full voice acting will also lend them an intriguing semblance of life that will come across during conversations, when combined with emotive animations. A new twist on the typical conversation tree will let you get a sense of the mood of the NPC you're interacting with, and it will offer him or her tips on how you're feeling as well. Bioware is hoping the end result of this will yield a more-dynamic, varied way of interacting with characters that will lend itself to real-time banter that changes dynamically.
As far as what you'll be doing in the game, your adventure will break down into basics, such as going out on specter missions or exploring the vast galaxy at your disposal. Specter missions will serve as the basic thrust of the adventure, but you'll have other options open to you. Besides the straightforward military missions you'll be sent out on, you'll also have the option to lead exhibitions to hostile worlds at the edge of space, which have never been explored. If you choose to visit these potentially barren worlds, you'll be surprised to find stuff through free-form exploration that's not found in the proper story arc. You'll get rewards you can bring in to the main game that will often come in handy as you progress through the adventure.
Speaking of the main game, you can expect to find a similar structure to KOTOR, in that you'll be alternating between set linear segments to move the story along and broader free-play-style segments, such as the free-form exploration. As far as combat goes, you'll find some KOTOR-style touches under the hood, but this time out, the Bioware gang is aiming to try something a little different. Combat will be in real time as you guide a trio of characters, including yourself, in to battle. Surprisingly, the combat will draw on squad-based shooter elements that will force you to think tactically in the heat of battle. Besides using weapons, the characters in your party will use a mix of biotics- artificial-intelligence-enhanced superhuman abilities and tech skills that can be as useful as a weapon. The different enhancements your party members will have will eventually force you to confront how you think about the definition of life during this conflict. It sounds as if some of the members of your team will be cybernetic to some degree, putting them a bit too close to the creatures you'll be pitted against.
As cool as all that sounds BioWare reps were quick to point out that three parts of ME's story will each feature a climax at some point. However, players should be prepared to take the game online, where they'll find downloadable content that will amount to stories designed to move the first game's themes of revenge over plot. Better still, if you're the type to invest hours perfecting your customizable character, know that your hard work will serve you well, as your character will travel with you over the course of the entire trilogy. And if Bioware pulls this off, it will be supercool.
As far as the visuals go, the imagery taken from in-game footage actually fits Bioware's somewhat odd description of the game by offering a "realistic" version of the future. The imagery we've seen looks futuristic, but not fantastically so. Granted, some of the aliens are a little "out there," but the humans look low-key, albeit well-armed. The game's art style features a very clean look that's nicely done. The alien vistas we got glimpses of are grand and cool-looking, but they aren't over-the-top or too busy, which is pretty much what the future looks like in most games.
All told, our sneak peek at Mass Effect left us wanting more. Sci-fi fans may be especially interested in the game because of the setting. Yes, yes, we know what you're thinking: 23rd century. Human in command of a starship zipping about space. All that begs the question of whether you'll have the opportunity to frolic with nubile green dancing girls or at least get to bump into James T. Kirk's Enterprise. Answer: No. However, we still expect big things from the game, thanks to BioWare's ambitious story and almost-episodic plans for downloadable content as the series unfolds.


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Product description for Camp ALP RACING from our collection of Outdoor Sports & Fashion:
The Alp Racing by CAMP is a new innovative, superlight and comfortable harness designed to take the competitive ski mountaineering world by storm.
The combination of lighter weight and greater comfort is accomplished using an innovative webbing with structural transparent longitudinal yarns that allow wider cross sections for greater comfort and support without increasing weight.
The Alp Racing by CAMP features a reinforced single tie-in point and a pre-threaded buckle on the waist.
The harness is available in 4 sizes:
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vBulletin enhancements
This project received 6 bids from talented freelancers with an average bid price of $29 USD / hour.Get free quotes for a project like this
Project Budget$25 - $50 USD / hour
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text: OfficeMax Althea Air Mesh Task Chair $59.99 $99.99 + Free Shipping See It! Flag this deal Edit deal What's the matter? Choose a reason Dead deal Duplicate Bad link Spam Inaccurate No value Alive again Comments (2) YesBoss May 22, 2014 $20 Price Dropped Since LAst Time. Reply Cancel ReturninVideoTps Sep 24, 2012 Hmm, really no a bad price for this chair. Looks like it would be fairly comfortable too Reply Cancel Load More Comments


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Full name Michael Douglas Martell
Born September 28, 1966, Perth, Western Australia
Current age 50 years 215 days
Other Umpire
|ODI debut
|Kenya v Netherlands at Lincoln, Jan 23, 2014 scorecard
|Last ODI
|Australia v Pakistan at Sydney, Jan 22, 2017 scorecard
|ODI matches
|ODI statistics
|T20I debut
|Australia v South Africa at Melbourne, Nov 7, 2014 scorecard
|Last T20I
|Australia v Sri Lanka at Adelaide, Feb 22, 2017 scorecard
|T20I matches
|T20I statistics
How RCB can still qualify for the playoffs
Two wins, six losses and a washout. With only five more matches to go for them, Royal Challengers Bangalore can lose another match and still make it to playoffs
All-time IPL XI : The spinners
Pick your two spinners for our all-time IPL XI and help put together the team with our panel of experts
Mid-season review: Rising Pune, soaring Mumbai, sinking RCB
ESPNcricinfo's review of where the teams stand at the halfway stage of the IPL season, and what they must do moving forward to clinch a spot in the playoffs
Embarrassing hat-tricks and untouched bat bits
The best, the worst and everything in between from the past ten days of the IPL's tenth season
Wicket with a wide, and Afghanistan's Test player
Also, which player waited more than 100 Tests to get a century?
How RCB can still qualify for the playoffs (65)
Two wins, six losses and a washout. With only five more matches to go for them, Royal Challengers Bangalore can lose another match and still make it to playoffs
How to build the ideal T20 side (37)
To start with, stop thinking of players as batsmen, bowlers and allrounders; it's far more nuanced than that
'Whatever Bangladesh achieves in Champions Trophy will be big' (37)
Bangladesh coach Chandika Hathurusingha on preparations for England, and his team's recent success in Sri Lanka
'I want to see Afghanistan at No. 5 in the rankings' (35)
Atif Mashal, the chairman of the Afghanistan Cricket Board, talks about his plans for cricket in the country during his tenure
Williamson finds a place in T20 world (19)
Sunrisers Hyderabad batsman Kane Williamson struck a 26-ball fifty and outpaced his more illustrious T20 shoo-ins


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- Control Panels
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- Testing & Approvals
ACT Meters International Ltd
Address: The Old Smithy, Church Road, Rainford, Merseyside, WA11 8HD, United Kingdom
Telephone Number: +44 (0)1744 886660 Email Address: firstname.lastname@example.com
ACT Meters Ltd is a mail order supplier of specialist test equipment and alarm troubleshooting products. We have served the security industry since 1987. More recently, we have transformed into a Group, with separate companies ACT Meters (UK) Ltd and ACT Meters International Ltd being created to focus further on customer needs.
Our products are available either direct from ACT or through our worldwide network of distributors, who include the Farnell PLC Group and ADI Global.
We have built our success on listening to our customers' needs. We develop truly unique products - products that help an engineer complete their daily tasks simply and solve their problems quickly. Within the security industry we are a trusted name. Mainstream customers include ADT, Chubb and Romec.


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Giraffe print
Explore related topics
Giraffe print rug for jungle / safari / zoo / African animals themed nursery or toddler room
Giraffe Print. $15.00, via Etsy. @Briana O'Higgins Harrison
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Menagerie: Sharon Montrose's Evocative, Minimalist Portraits of Animals | Brain Pickings
Plush Animal Print Sherpa Throw - 50 x 60 (Giraffe) Northpoint,http://www.amazon.com/dp/B00AAZODEY/ref=cm_sw_r_pi_dp_k0TPrb712F1E4A83
animal prints :)
Why be like the rest of them when you could be a giraffe wearing a licorice allsort print? Sooo much better! Don't Be Like the Rest of Them Darling - Giraffe print by Kate Stieren
Giraffe Scentsy my favorite animal and my favorite Scentsy warmer :) if interested please let me know ill order you one :)
Chuck Taylor Giraffe Print Sequins Converse Low Tennis Shoes XTRA Laces NWOT WMS @Ana Horan
Image detail for -CONVERSE SEQUINS Giraffe Womens Designer Shoes Sneakers 7.5 EUR 38 ...


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Cross Posted at Legal Schnauzer
Republican felon Jack Abramoff has written a new book that appears to be long on titillation and short on details. "Casino Jack" seems to pull more punches than "Smokin' Joe" Frazier ever threw.
But while withholding more evidence than he provides, Abramoff confirms our worst fears: He helped soil our democracy in a way that almost certainly is unprecedented--and Alabama was one of his prime playgrounds.
How did he do it? Mainly by playing conservative Christians for fools.
The book is called "Capitol Punishment: The Hard Truth About Washington Corruption from America's Most Notorious Lobbyist." And after reading it, even the least rational Alabamians are likely to understand the following:
* Bob Riley rose to the governorship on a wave of GOP criminality;
* Don Siegelman, indeed, was targeted for a political prosecution--partly to assuage Abramoff's clients, the Mississippi Band of Choctaw Indians;
* Milton McGregor was targeted for a political prosecution in the ongoing Alabama bingo case--again to protect the Mississippi Choctaws.
The big loser in Abramoff's book, however, is the U.S. Department of Justice. We learn that the DOJ uncovered only a fraction of the criminal actions connected to Abramoff--or perhaps we should say the department acted on only a tiny portion of what it uncovered. In fact, the Abramoff "prosecution" now looks mostly like an exercise in political damage control--one that, so far, has helped protect Bob Riley and his henchmen in Alabama.
Most importantly, Abramoff indicates that the DOJ remains a dysfunctional mess under Barack Obama, with enough embedded Bushies and spineless Obamaphiles on the loose to pull off a charade like the Alabama bingo case.
In a sense, "Casino Jack" is at the heart of a story about simple mathematics. Mary Orndorff, of al.com, explains the numbers for us:
Jack Abramoff helped his Indian gaming clients in Mississippi protect $400 million in annual revenue by spending $20 million of their money to defeat gambling expansions in Alabama, the convicted former lobbyist wrote in his new book.
Abramoff spent 3 - years in jail after pleading guilty to corruption-related charges, including bilking the Mississippi Band of Choctaw Indians and others out of millions of dollars and bribing public officials in Washington, D.C.


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Ladies, are you looking for something to liven up your wardrobe but not go overboard? Are you tired of the man in your life not paying attention to your new shoes that you spent hours choosing?
If so, then visit etsy.com for your next pair. Here you can find sparkly and eye-catching designs that are too far over the edge of good-taste. I guarantee your husband or boyfriend will compliment you on your 1-UP designed shoes faster than you could imagine.
Read More


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Comparison of patient experiences of the osteoarthritis consultation with GP attitudes and beliefs to OA: a narrative review
- Zoe Paskins1Email author,
- Tom Sanders1 and
- Andrew B Hassell2
© Paskins et al.; licensee BioMed Central Ltd. 2014
Received: 17 October 2013
Accepted: 7 March 2014
Published: 19 March 2014
Osteoarthritis (OA) is a common cause of disability and consultation with a GP. However, little is known about what currently happens when patients with OA consult their GP. This review aims to compare existing literature reporting patient experiences of consultations in which OA is discussed with GP attitudes and beliefs regarding OA, in order to identify any consultation events that may be targeted for intervention.
After a systematic literature search, a narrative review has been conducted of literature detailing patient experiences of consulting with OA in primary care and GP attitudes to, and beliefs about, OA. Emergent themes were identified from the extracted findings and GP and patient perspectives compared within each theme.
Twenty two relevant papers were identified. Four themes emerged: diagnosis; explanations; management of the condition; and the doctor-patient relationship. Delay in diagnosis is frequently reported as well as avoidance of the term osteoarthritis in favour of 'wear and tear'. Both patients and doctors report negative talk in the consultation, including that OA is to be expected, has an inevitable decline and there is little that can be done about it. Pain management appears to be a priority for patients, although a number of barriers to effective management have been identified. Communication within the doctor patient consultation also appears key, with patients reporting a lack of feeling their symptoms were legitimised.
The nature of negative talk and discussions around management within the consultation have emerged as areas for future research. The findings are limited by generic limitations of interview research; to further understanding of the OA consultation alternative methodology such as direct observation may be necessary.
KeywordsOsteoarthritis Primary health care General practitioners Communication
Osteoarthritis (OA) is the most common arthritis, a common cause of disability and frequent cause of consultation with a GP. OA is predominantly managed in primary care, and comprehensive guidance suggests that much can be done to alleviate symptoms from osteoarthritis; a combination of therapeutic options including pharmacological and non-pharmacological treatments are recommended [1–5].
However, evidence suggests that for many patients with OA, effective interventions appear not to have been adopted.
Firstly, various studies that have evaluated OA treatment according to guidance generally report low uptake of 'core', first line non-pharmacological measures, such as weight loss advice, provision of patient information and aerobic and strengthening exercise [6–9]. The reasons for this are not clear, although likely to be influenced by a number of variables including awareness of the guidance [10].
Secondly, patient reported measures suggest the condition may be inadequately treated. A large survey of patients commissioned by Arthritis Care in the UK reports that patients experience long delays before they are diagnosed and that they don't feel OA is a priority for the healthcare system [11]. More worryingly, the survey suggests nearly three quarters of people with OA are living with constant pain, with 40% of those surveyed reporting their treatment either 'not very' or 'not' effective.
One significant barrier to treatment in OA, is choosing not to seek healthcare. A recent review suggests a number of patients with painful OA chose not to visit their GP; reasons for this include believing that OA is a normal part of ageing or perceiving a negative response from the GP [12]. However, when patients do visit their GP, little is known about what actually happens in the consultation. Understanding more about the consultation may further explain the reasons for the apparent gap between the guidance, and the positive view conveyed by OA experts and the apparent 'real world' experience.
This review aims to illuminate this issue, by summarising and reviewing existing literature regarding patients' experiences of consultations regarding osteoarthritis in primary care, and comparing this with literature reporting GP attitudes and beliefs to OA. Understanding patient experience, while considering GPs views, may provide insight into aspects of the consultation that could be targeted for intervention with the aim of enhancing OA care, and this review is conducted in the context of a larger programme of work with that aim.
Search terms used to identify experience of GPs and patients consulting with OA
1 Setting: consultation in primary care
2 Population: patients with OA
3 Experience
Primary health care
Qualitative research
Family practice
Osteoarthritis, knee
General practice
Osteoarthritis, hip
Family physicians
General practitioners
The initial research question aimed to compare patient and doctor consultation experiences; however, the first literature search, performed as a scoping exercise, revealed that papers exploring GPs' perspectives addressed more abstract components of 'experience', and tended to report attitudes and beliefs, rather than 'experience' of consultations, per se. For this reason, attitudes and beliefs were added to the search string, and the research question changed accordingly. As in qualitative research generally, this review seeks to describe a range of phenomena, and with this in mind, inclusion criteria were deliberately non-restrictive. Papers were included if any of the empirical data in the results related to patient consultation experience, or GPs' attitudes and beliefs regarding OA. However, only the findings relating to consultation experience or GP attitudes and beliefs were extracted for inclusion in the review. Quantitative studies reporting GP consultation behaviours only were excluded, for example, medical record reviews, unless additional methodology elicited attitudes and beliefs e.g. free text responses on a survey or additional GP interviews.
Papers were included if they concerned patients with a diagnosis of OA or if the population studied were aged over 45 and had a clinical syndrome of chronic peripheral joint pain without a specific clinical diagnosis of OA. These were included with the assumption that the majority of those included were likely to represent people with OA; in primary care research a clinical rather than radiographic indicator or diagnosis may be more pragmatic, and there is high discordance in the use of the label osteoarthritis [14]. The only exclusion criteria were as follows: non-English language paper; consultation experiences not described (patients); attitudes or beliefs not described (GPs).
To appraise the evidence, no single tool was appropriate for the range of methodologies; however, qualitative research appraisal was informed by the CASP tool [15]. Key themes were extracted from the relevant findings of the included papers by the first author and a narrative review approach [13] applied to the results.
Results and discussion
Summary of papers identified exploring consultation experiences in OA
First author, year, country
Extracted findings relating to consultation experience and/or GPs attitudes and beliefs
Comments and limitations
Alami (2011),France [24]
81 patients, 11 GPs, 6 Rheum, 4 Orth, 4 Alt Med
To explore views on management and barriers to improvement
Patients report importance of doctor patient relationship and various barriers to treatment including side effects, fear of addiction, fear of masking pain, and a wish to focus on preventative options. GP's report range of attitudes including the belief that OA is not a disease. Some patients and GPs identified OA as an area of uncertainty for GPs.
Not always clear which results (health care practitioners) pertained to GPs. No findings in results to support author claims in abstract and conclusion that patients feel they are not taken seriously and that GPs act as 'technicians'; findings do not entirely match authors' conclusions.
Busby (1997), UK [18]
80 patients, 3 GPs, 1 Rheum
Interviews fieldwork
To understand perceptions and experiences of OA
Patients describe multiple attempts at seeking healthcare, explanations couched in terms of ageing meant OA was inevitable and that nothing could be done. GPs report lack of therapeutic options threatening doctor-patient relationship.
Results in book chapter. Authors' report findings from GPs don't constitute 'a systematic study'. 80 patients but only 7 cited in findings. No reported analysis methods.
Coar (2004), UK [23]
9 GPs, 3 Physio, 3 Rheum
To explore GP's beliefs and attitudes regarding OA
Diagnosis and use of 'wear and tear' emergent themes. Use of 'wear and tear' perceived as acceptable and useful given lack of alternative terms. Evidence of practitioners playing down severity.
MPhil thesis. Author (GP) reports on limitations and influence of interviewing their peers.
Davis (2004), USA [34]
57 Patients
Focus groups
To explore barriers to chronic pain management in arthritis
In the theme 'relationship with healthcare providers', patients describe unwelcome focus on prescriptions, and miscommunication in the consultation.
Small part of results relevant to this review; 'Relationship with healthcare providers' was one of nine emergent barriers to pain management
De Bock (1992), Netherlands [35]
14 GPs
Interviews [Medical record review]
To explore GP's 'policy' in managing OA
Marked variance in the perceived importance and management of OA. Authors conclude consensus needed
Small part of results relevant to this review; small focus on interview findings in results. Little information on analysis of qualitative data.
Gignac (2006), Canada [17]
53 patients
Focus groups
To compare health experiences of middle aged and older adults with OA
Patients reported being told OA was normal for age, going to get worse, and were encouraged to accept their symptoms. Conversely, patients felt they had more control over the trajectory of OA. Delays in diagnosis reported and insufficient communication around prescriptions
Study design included 'control' focus groups which did not appear to add to conclusions or findings.
Glauser (2011), USA [33]
152 GPs, 99 NP & PAs
[Vignettes] survey
To examine the knowledge, attitudes and beliefs and practice of GPs regarding management of OA
Most common educational need identified in free text part of survey was around treatment
Small part of results relevant to this review; methods state researchers elicited barriers to care and confidence in managing OA, but only vignette results and educational needs reported in results. As a result, results mainly address 'practice' aspect of study aim.
Grime (2010), UK [22]
27 patients
To explore perceptions of wellness in elderly people with OA
Reports both discordance and acceptance of 'wear and tear' used in diagnosis
Small part of results relevant to this review; most of the results relate to everyday activities and not consulting with a doctor.
Hill (2010), UK [29]
29 patients
Focus groups
To explore perceptions and experience of treatment and management of hand OA
Patients described dissatisfaction with amount of information, feeling that 'nothing can be done', and held perceptions that GPs lacked understanding of the impact of hand OA. Authors conclude some of the findings imply lack of knowledge of treatment options.
Sample included 14 patients from secondary care, and not always clear which setting consultation experiences related to.
Jinks (2007), UK [20]
22 patients
Survey interviews
To investigate population and individual needs assessment
Patients report being told their pain is 'wear and tear', related to age, to 'live with it' and that nothing can be done. Patients also held the view nothing could be done.
Small part of results relevant to this review; most of the results relate to living with knee pain. Patients were > 50 years and had self-reported knee pain, and may not all have had OA.
Kee (1998), USA [37]
20 patients
To gain an 'insider view' of living with OA
The theme 'staying in charge' describes patients' lack of adherence with GP recommended interventions, with examples of miscommunication.
Small part of results relevant to this review; most of the results relate to living with OA.
Kingsbury (2012), UK [31]
232 GPs
To identify GP reported management of OA
GPs described barriers to effective OA management including inability to manage pain adequately, time in the consultation and enabling patients to make lifestyle changes.
Small part of results relevant to this review; most of the findings relate to self-reported GP behaviours. Low response rate
Lambert (2000), USA [28]
12 patients, 14 Doctors (including GPs, rheum and others)
Focus groups
To understand views and experience of OA care and expressed needs
Patients value 'low-tech' treatments with doctors tending to value medicines and surgery. Doctors report OA as being related to ageing, which patients report as difficult to accept. Doctors reported lack of musculoskeletal training as an issue, and specific educational needs were identified.
Authors do not specify number of GPs, and sample includes other secondary care doctors; not clear which findings relate to GPs.
Mann (2011), UK [16]
16 patients, 2 GPs, 1 Rheum, 1 OT, 2 Physio, 4 NPs
Focus groups and interviews
To explore views on provision of care and possible improvements
Patients reported delays in diagnosis, a feeling that 'nothing was done', and difficulty knowing when to return to the doctor. Patients reported OA was not a priority and health professionals reported lack of time as an issue. A GP participant reported not perceiving a need for patient information, although the HP as a whole identified a need for more information
Only 2 GP participants.
McHugh (2007), UK [27]
21 Patients
Semi-structured interviews
To investigate the experiences of patients on the waiting list for joint replacement
Patients reported hiding their symptoms from their GP after previous negative experiences.
Small part of results relevant to this review; much of the results about living with OA and self-management etc.
Pitt (2008), Australia [36]
13 GPs
Focus groups semi-structured interviews
To explore enablers and barriers to referring patients with OA to self-management programmes
A range of referral patterns and attitudes to self-management in OA were uncovered. Barriers to referral included GPs holding the belief that OA was different to other chronic diseases and time in the consultation
Small part of results relevant to this review; attitudes to OA not primary objective of researchers, and so attitudes elicited were only those of relevance to self-management programme referral. Small sample.
Rosemann (2006), Germany [32]
20 patients 20 GPs, 20 NPs
To identify health care needs and obstacles for improvements
Patients reported pain and fear of disability as their most important concerns that were inadequately addressed in the consultation, with insufficient information about prognosis. Doctors reported resource issues as barrier to effective treatment, while patients reported communication deficits.
Issues of transferability due to healthcare funding in Germany which reportedly does not 'value' conservative treatments equally with non-conservative, and due to large number of non-surgical orthopaedic specialists working in primary care. More findings reported from GPs than patients.
Sanders (2002), UK [19]
27 patients
To examine the meanings of symptoms of OA
Delays in diagnosis reported. Older participants reported down-playing symptoms.
Small part of results relevant to this review; paper concerns general experience of living with OA.
Sanders (2004), UK [25]
27 patients
To explore barriers to joint replacement
Participants describe being told nothing can be done; often those who asked about surgery reported being told they were unsuitable for various reasons, including age, by their GP
Small part of results relevant to this review; data extracted from one of 3 themes relating to experiences of primary care.
Thomas (2013), UK [30]
11 patients
Semi structured interviews
To describe patient experience of seeing their GP with foot OA
Patients described being given little information, felt foot OA was low priority, and felt there was an 'unwelcome focus on drugs'.
Conference Proceeding, and therefore limited information on findings
Turner (2007), UK [26]
31 patients
To investigate beliefs about causes of OA
'Overwhelming majority' reported no negative psychological reaction to diagnosis. Some patients reported that GPs had reinforced the belief that OA would deteriorate over time.
Small part of results relevant to this review, around the theme of diagnosis.
Victor (2004), UK [21]
170 patients
Interviews [Patient diaries, Group sessions]
To explore patients' perspective on meaning and significance of OA
Participants reported a lack of information that had been given by GPs previously and uncertainty about the nature, self-management and outcomes of OA.
Small part of results relevant to this review; research conducted in the context of a randomised controlled trial therefore only data relating to participants' previous interaction with healthcare was extracted.
The evidence is grouped below under four themes derived from the included studies: diagnosis; explanations; management of the condition; and the doctor-patient relationship. Patient and doctor perspectives are discussed under each theme.
The issues identified around diagnosis predominantly relate to delays in diagnosis and the diagnostic term or phrase used at the time of diagnosis. Patients describe long delays before being diagnosed in both UK and Canadian research [16–18] in addition to difficulty obtaining a diagnosis and 'relief' at symptoms being legitimised [19]. There is some evidence to suggest multiple visits prior to receiving a diagnosis may be a particular issue in younger patients [17].
'Wear and tear' has been reported by patients as conveying a range of negative meanings including 'it's your age' and 'nothing can be done for you' [20], or that the physician who used the term is 'giving up' [21]. Busby [18] argues that the connection with ageing results in the phrase conferring inevitability. However, the phrase is not exclusively associated with negative connotations. Grime et al. found participants used it as 'shorthand for normal bodily change' and adopt a 'use it or lose it' philosophy to exercise; Grime et al. report the latter finding is in contrast to other reported research suggesting patients may avoid activity due to connotations of wear and tear [22].
In one UK study of GPs' perceptions of OA, GPs reported withholding or 'playing down' the diagnosis, using 'wear and tear' in preference to osteoarthritis or degenerative arthritis, in order to either avoid upsetting the patient or prevent the adoption of a 'sick role' and increased disability [23]. 'Wear and tear' was reported by GP participants as a term that may facilitate acceptance on the part of the patient and that saves time; introducing the term osteoarthritis was felt to necessitate a more detailed explanation [23]. In one French study, GPs described their diagnostic priority as identifying inflammatory joint pain, with the precise nature of mechanical pain being considered unimportant and unrelated to treatment [24].
Explanations and patient information
There are a number of studies in which patients report that they have been told their joint pain/ arthritis is normal for their age [17, 18, 20, 24, 25], and is likely to deteriorate over time [17, 26]. Similarly, reports of being told 'nothing can be done' are common [17–20], and this has been described as a 'fatalist' viewpoint. Patients describe being encouraged to accept their symptoms and 'live with it' [20].
Some patient narratives do indicate a degree of acceptance of their symptoms and perseverance with daily activities. Beliefs about symptoms being 'normal for age' are moderated by shared experiences of friends and family, and the societal view of ageing [19, 26]. It is also worthy of note that patients holding beliefs that nothing could be done or that symptoms were 'just' age related have reported withholding symptoms from the GP [19, 27].
However, there is evidence of patients rejecting the notion that OA is age-related [28], particularly younger adults [17] who may search for alternative explanations [19].
In an interview study with 81 patients with knee OA, a general dissatisfaction with the 'vague' information about the condition is reported [24]. Dissatisfaction with the amount of explanation is also reported in other UK studies [29, 30], with a feeling that OA is low priority [30]. The lack of precision in explanations has been interpreted as both lack of interest and lack of knowledge on behalf of the doctor [24, 29]. Patients reported that more information regarding disease progression may facilitate self-management and coping [16].
Education regarding prognosis has been identified as a particular area of unmet need in patients with OA [21], underpinned by fear of lifelong pain, and of becoming disabled. Victor et al. [21] tested knowledge of 170 patients with OA and found that 51% agreed with the statement 'most people with osteoarthritis end up in a wheelchair'.
General Practitioners have reported giving patients advice on likely outcomes, but in the same study avoidance of the term 'osteoarthritis' for fear of upsetting patients, appeared to be associated with a perception by GPs that OA does in fact have a poor outcome [23].
Some General Practitioner interview findings do concur with the patients' reports regarding consultation experience, with some GPs holding the belief that OA is a normal part of ageing and inevitable [24]. GPs have also clearly expressed the view that OA is 'not a disease' [16, 24] and in some instances, that there was therefore not a need for patient education [16].
General Practitioners have reported reasons for not giving written information, including lack of availability of quality resources and limited time [31]. Time in the consultation has been reported as a barrier to information giving in other UK studies [16, 31], but did not appear to be an issue in a non-UK European study [32]. GPs have also reported their own knowledge needs as a barrier to information provision [24, 28, 33].
Management of condition
In considering management, a number of studies referred to priorities, barriers, and challenges in treating patients with OA.
For patients, pain management and fear of disability have been reported as consultation priorities [32]. Jinks et al. [20] reported that patients tended to make their own decisions about medications, implying that consultations did not seem to contain lengthy discussions about the pros and cons of medication. Gignac et al. [17] report patient concerns that medication masks rather than cures symptoms and dissatisfaction with the amount of explanation accompanying prescriptions. Fear of side effects is reported [24, 32] and the presence of co-morbidities has also been described as contributing to patient hesitancy to take medication, in addition, again to suboptimal communication around prescriptions [34]. Throughout these studies is a recurring belief among patients that they receive inadequate information and communication around prescriptions, and Alami et al. describe this as leading to suspicion of drugs [24]. Alami et al. also describe patient expectations, with those with more chronic symptoms seeking 'cure'. Patients describe physicians communicating treatment options as 'palliative', causing patients to question the efficacy of 'modern medicine' [24].
Two studies of patient experience suggest practitioner focus on pharmacological intervention is 'unwelcome', suggesting patients want more information about other approaches [30, 34].
Patients in focus groups discussed the inconsistency in advice regarding referral for joint replacement [16]. Patients also expressed having inadequate knowledge to make choices about surgery and anxiety about feeling the decision was theirs [16]. Patients have reported care for OA to be reactive, and not proactive with some expressing difficulty in knowing when to return to the doctor for follow-up [16].
GPs feel that patient led follow up is appropriate [23], particularly if they also hold the view that OA is 'not a disease' [35]. Interestingly, this belief seemed to underpin a reluctance to refer to self-management programmes, with GPs not identifying OA a chronic disease with the same standing as diabetes, but as a condition with little or no opportunity for modification of outcomes [36].
General Practitioners also report pain control as the biggest challenge in a survey of OA management in the UK [31]. GPs in this study identified practice and logistical barriers to managing pain such as lack of specialist teams and time in the consultation, in addition to lack of training. In a German study, GPs talked about specific patient barriers to managing pain; for example, they reported patients either did not accept paracetamol as a treatment due to its common use or had already tried it [32]. Rosemann et al. [32] also described a reluctance among GPs to prescribe opiates for OA, considering that patients would automatically reject these 'heavy' drugs, in addition to GPs perceiving opiates were 'over-treatment' for OA.
With regard to lifestyle change such as promotion of exercise and weight loss, GPs have described getting patients to change their lifestyle as challenging [31] and described patients as generally unwilling to change, having 'learned to live' with their symptoms [32]. GPs have also expressed uncertainty regarding exercise prescriptions [28]. Lambert et al. [28] highlights the different perspectives of patients and physicians; in their study doctors were reported as valuing surgical options and medication in OA treatment, with the implication non-pharmacological, non-surgical treatments were less valued by physicians, than patients.
OA and the doctor-patient relationship
The need for doctors to value or legitimise symptoms emerges strongly from published studies [19, 22], with patients in one study describing that they have not been taken seriously [24]. Patients report feeling OA is not a priority [30].
Patients described the importance of the doctor-patient relationship in the study by Alami et al. [24] and the need for doctors to be patient centred. Kee [37] describes participants with OA 'stay[ing] in charge' by not taking medications recommended by GPs, or not seeing doctors again who had recommended joint replacement, when this was not favoured by the patient. However, this also represents a breakdown in communication and shared decision-making. As previously mentioned, Davis et al. [34] found that patients reported communication and unmet expectations as barriers to effective pain management, in addition to personal barriers such as comorbidities and emotional distress.
General Practitioners have reported feeling that the lack of therapeutic options or cure in OA threatens the doctor-patient relationship [18, 23]. Further evidence of this comes from GP reports of either requesting X-Rays or referring patients to secondary care, when they don't believe it clinically indicated, in order to preserve the relationship [23, 32]. GPs may have resultant feelings of frustration [23] and feel that patients have 'unrealistic expectations' [28]. An alternative viewpoint is provided by Gignac et al. who suggest doctor and patient have different orientations; doctors may approach OA from a perspective of acceptance whereas patients may believe they have more power to exert control and influence over their symptoms [17]. Busby et al. [18] describe the GP as translator of knowledge, and suggest how tensions in the doctor-patient relationship may exist between biological and sociological knowledge; if a doctor has uncertainty about biological explanations he or she may favour sociological descriptors e.g. wear and tear.
GPs' prioritisation of OA is described by Coar, with GPs reporting it as less important than other 'life-threatening' conditions such as ischaemic heart disease [23]. Coar [23] also discusses the notion that a common condition may be considered less important by GPs: 'familiarity breeds contempt'.
A broad range of literature has been reviewed in order to understand what happens when patients consult with osteoarthritis. A strength of this review is the breadth of included literature, including a MPhil thesis, which has been particularly useful in illuminating the GP perspective.
From the literature reviewed, a number of issues have emerged. Firstly, patient studies indicate a range of patient-perceived negative talk that may occur in the consultation. This includes the phrase 'wear and tear' which may have negative connotations, reporting OA is something to be lived with and nothing can be done. The negative perception of 'wear and tear' is likely an unintended outcome of a term that GPs may choose with the best of intentions, to avoid causing alarm. However, patient preferences for diagnostic labelling are not clear. This review also highlights that negative comments about OA may relate to the GP's underlying beliefs that OA is 'not a disease' and that it is likely to deteriorate. Importantly, negative talk may not always originate from the GP with evidence that patients may hold similar views. A need for primary care to endorse a more positive view of OA has previously been identified [38] and this review serves as a useful reminder for clinical practice of the impact of negative talk in the consultation.
Secondly, this review highlights marked divergence over management, between patient and doctor. Patients may have complex expectations and fears regarding treatment that are inadequately explored in the consultation. While patients seem keen to explore non-pharmacological options, GPs report frustration and lack of knowledge around issues to do with lifestyle change. When asked about challenges to management, GPs tend to report resource issues or time in the consultation, or patient factors, whereas patients report lack of communication. Both GPs and patients have identified knowledge deficit, and it is possible that enhanced management of OA requires an approach that addresses knowledge, communication and shared decision making, which in turn may promote greater self-management [39].
Finally, this review highlights the importance to patients of feeling that their joint pain is being taken seriously and validated. GPs that hold the belief that OA is a normal change may not adequately legitimise their patients' symptoms and engage with management approaches. The failure to adequately validate a patient's symptoms may lead to a downward spiral of discordance within the consultation, and this finding has resonance with work with patients' with medically unexplained symptoms [40].
In considering the limitations of this review, it is worthy of note that the majority of cited studies concentrate on deficits in quality of care, and this may reflect publication bias to some extent. Some of the studies described are over 10 years old and may not accurately reflect the issues relevant at the current time, especially in light of new insights with regard disease pathophysiology, treatment and outcomes. Furthermore, the attitudes and beliefs of patients and doctors who agree to take time to participate in research about OA may not be representative of the population as a whole. Some of the qualitative research included had only brief mentions of a consultation with a GP, and it is possible that some of the views elicited were not entirely based on consultation experiences.
Patient preferences around the labelling of the condition, the nature of doctor explanations of osteoarthritis and discussion around management options (including the degree of shared decision making) have emerged as areas for further research. Given the limitations of the studies reviewed, observational research would be well placed to explore these issues further. Observing the consultation, and matching patient and doctor behaviours and reactions will go much further in unlocking the important 'chain of events', and the origin of any negative talk. In the meantime, practicing GPs may wish to reflect on the influence of negative statements on patient outcome, and whether training needs exist around the management of patients with osteoarthritis. Communication within the consultation is clearly linked to patient satisfaction, but whether interventions to enhance the doctor patient interaction influence other health outcomes remains to be seen [41].
Author information
ZP is a Clinical Lecturer and Honorary Consultant Rheumatologist and conducted this review as part of a PhD using mixed methods to explore the osteoarthritis consultation in primary care. This is part of a larger programme of work aiming to enhance the care of osteoarthritis in primary care. TS is a Senior Research fellow with an interest in consultation research, and supervisor to ZP. ABH is a Professor of Medical Education and Consultant Rheumatologist and PhD supervisor to ZP.
General Practitioner
National Health Service (United Kingdom)
This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0407-10386). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
The authors wish to acknowledge and thank Professor Peter Croft for helpful comments on the manuscript.
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- Turner A, Barlow J, Buszewicz M, Atkinson A, Rait G: Beliefs about the causes of osteoarthritis among primary care patients. Arthritis Care Res. 2007, 57 (2): 267-271. 10.1002/art.22537.View ArticleGoogle Scholar
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- Lambert BL, Butin DN, Moran D, Zhao SZ, Carr BC, Chen C, Kizis FJ: Arthritis Care: Comparison of Physicians' and Patient's Views. Semin Arthritis Rheum. 2000, 30 (2): 100-110. 10.1053/sarh.2000.9203.View ArticlePubMedGoogle Scholar
- Hill S, Dziedzic KS, Nio B: Patients' perceptions of the treatment and management of hand osteoarthritis: a focus group enquiry. Disabil Rehabil. 2011, 33 (19–20): 1866-1872.View ArticlePubMedGoogle Scholar
- Thomas MJ, Moore A, Roddy E, Peat G: 'somebody to say ''come on, we can sort this''': A qualitative study of health-seeking in older adults with symptomatic foot osteoarthritis. Rheumatology (United Kingdom). 2013, 52: 124-Google Scholar
- Kingsbury SR, Conaghan PG: Current osteoarthritis treatment, prescribing influences and barriers to implementation in primary care. Prim Health Care Res Dev. 2012, 1 (1): 1-9.Google Scholar
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- Glauser TA, Salinas GD, Roepke NL, Chad J, Reese A, Gutierrez G, Abdolrasulnia M: Management of mild-to-moderate osteoarthritis: A study of the primary care perspective. Postgrad Med. 2011, 123 (1): 126-134. 10.3810/pgm.2011.01.2254.View ArticlePubMedGoogle Scholar
- Davis GC, Hiemenz ML, White TL: Barriers to managing chronic pain of older adults with arthritis. J Nurs Scholarsh. 2004, 34 (2): 121-126.View ArticleGoogle Scholar
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/15/46/prepub
Pre-publication history
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.


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Re: 1991 NDS Values for Lumber[Subject Prev][Subject Next][Thread Prev][Thread Next]
- To: seaint(--nospam--at)seaint.org
- Subject: Re: 1991 NDS Values for Lumber
- From: Seaintonln(--nospam--at)aol.com
- Date: Mon, 13 Sep 1999 18:52:02 EDT
In a message dated 9/10/99 3:25:07 PM Pacific Daylight Time, jmo_engineering(--nospam--at)email.msn.com writes: << Some jurisdictions require the use of the 1991 NDS design values on everything. Others say that if it was built before 1986 you can use the "old" values. I think it would be helpful if there was a mandate made by those knowledgeable in the subject which indicated when the 1991 NDS values are required to be used in all jurisdictions. Any thoughts on this subject would be appreciated. Joseph M. Otto, P.E. Ireland Engineering Fremont, CA >> Joseph, The problem is that the 91 standards is based upon the results of a twenty year study on the quality of wood. Although the quality of the wood may be the same after the '91 NDS was published as it was in 1980, the old stress values were allowed by code prior to adoption of the '91 NDS. In my opinion, there is sufficient room in the factor of safety (as well as the fact that this is a statistical average for wood) to accept the prior code stress when recalculating the member for revised loading or remodeling occuring after the adoption of the '91 NDS. I have faced this problem often when calculating the capacity of a roof member for new roofing. Often the members won't calculate due to the reduction in stress. However, I tend to inspect the wood and if there appears to be no noticible effect of the existing loads I accept the capacities allowed at the time the member was installed in the capacity for new roofing. Remember that a visually or mechanically graded member may change if the rafter or joist is cut to fit the field conditions. The grading is based upon the shipping condition of the wood which considers the location and spacing of imperfections over the length of the member shipped. However, if you were to cut off both ends of the piece, you may be altering the ratio of imperfections to good wood and inadvertently changing the ratings. You need to inspect and use your professional judgment when qualifying a piece of wood for allowable stresses. I think that consideration to the existing loads applied for the length of time it has been in service is a strong consideration for how the new applied load will affect the member. Dennis S. Wish PE
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+ Locations, Office Hours & Directions
Dr. Celso Acevedo is a cardiac electrophysiologist in Ocala who specializes in treating rhythm disorders of the heart, such as heart murmurs and palpitations.
We invite you to write a review about your experience with Dr. Acevedo.
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1500 Sw 1st Avenue, Ocala, FL 34471-6504
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|Cardiac Electrophysiologist
NOTE: Please contact the doctor's office to confirm your coverage before making an appointment.
Dr. Celso Acevedo graduated from University of Puerto Rico School of Medicine in 1996.
Dr. Acevedo has two offices in Florida where he specializes in Cardiac Electrophysiology and Internal Medicine.
Dr. Acevedo works with five doctors including Dr. Richard Han and Dr. Edward Santoian.
As a cardiac electrophysiologist in Ocala, Dr. Acevedo specializes in the electrical processes of the heart. He may perform both invasive & non-invasive procedures to help record the electrical activity within the heart. Dr. Acevedo may also implant defibrillators and pacemakers or evaluate the results of abnormal electrocardiograms.
As an internist in Ocala, FL, Dr. Celso Acevedo serves as a primary care provider for adults. He diagnoses and treats a wide range of conditions, including cross-system illnesses that may affect multiple organic systems. Dr. Acevedo may also refer patients to a specialist when required. For example, patients with diabetic complications may be referred to an endocrinologist for further treatment.
Please Note: The information displayed below is sourced from the 2014 Medicare Physician and Other Supplier National Provider Identifier (NPI) Aggregate Report. It's important to remember that the statistics below are not inclusive of all patients treated by Dr. Acevedo, but only those who participate in Medicare.
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Make Your Own Natural Acne Treatment Products
Stop using harsh and expensive acne treatment products. Make your own with these easy, and all-natural recipes instead
Acne products cannot only be harsh to your sensitive skin, causing side effects, they can also get expensive. If you're tired of paying for acne treatments that cause dry, itchy, and peeling skin, try making these all-natural cleansers you can use at home. They only take a minute to prepare, are inexpensive, and work naturally to clear your acne.
Honey-Apple Facial Mask
Finely grate one medium-sized apple. Add 5 tablespoons of honey and mix well. Smooth the mixture over your skin and let sit for 10 minutes.
Carrots make a great acne treatment for oily skin and clearing up acne. You can make a raw or cooked carrot facial mask by following the following recipes.
Raw Carrot Facial Mask
Finely grate two raw carrots. Add two teaspoons of fresh lemon juice. Apply the mask to your face for 10 minutes and rinse with clear, warm water.
Cooked Carrot Facial Mask
Boil three large carrots. Mash and add five tablespoons of honey or yogurt. Let the mixture cool until slightly warm. Smooth the mixture over your face and leave for 15-20 minutes. Rinse with warm water.
Oatmeal Scrub
This scrub is very good at exfoliating, clearing away dead skin and unclogging pores. Use it every three days and don't scrub too hard.
1/2 cup of oatmeal
1/8 cup of salt
1/8 cup of farina (Cream of Wheat cereal)
Mix the oatmeal and salt together and store in a sealed container.
When you want to use the rub, combine one teaspoon of the scrub with 1/8 cup of plain yogurt. Wet your face and gently rub the mixture on your face using circular motions. Rub for about one minute and rinse with warm water.
Vinegar Rinse
After using one of the natural acne recipes above to clear your acne, you can either rinse with clear, warm water or try this vinegar rinse. The vinegar restores the natural ph balance of your skin and works as a toner.
1/4 cup apple cider vinegar
1 quart warm water
Add the vinegar to the water and use as a rinse for your skin after any acne treatment.
Natural cleansers have been around since the beginning of time. They're effective in clearing the skin, reducing the oiliness of skin, and clearing acne. The next time you have an acne breakout, try one of these natural cleansers in place of harsh acne treatment products.


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11 Marvelous Melissa McCarthy Hairstyles
Melissa McCarthy is an actress that first got the attention of the world on the hit TV show, Gilmore Girls. Since that time, Melissa McCarthy has really made headlines with her comedic style, and is now starring in a lot of hit movies that really showcase her comedic talent. McCarthy is married to Ben Falcone, and the couple has two adorable little girls. Don't believe us about how funny Melissa McCarthy is? Keep reading!
For different roles she has played, Melissa McCarthy has had to change her look, and she has played many that required different styles and colors of her hair. We have gathered up 11 Marvelous Melissa McCarthy Hairstyles to show you what we are talking about. Once you get done looking at this list, you'll have a new appreciation for this incredible talented woman and her many different looks! Okay, we have said enough about Melissa McCarthy because its time to see on your own! Are you ready to check out the list of Melissa McCarthy hairstyles? If so, you can go ahead and scroll down now.
Vintage Melissa McCarthy Curly Hairstyle
Wow Melissa McCarthy looks great rocking this older vintage style with the red lips and curly hair!
Vintage Melissa McCarthy Curly Hairstyle
Melissa McCarthy Pompadour
My goodness someone has mighty tall hair! Check our Melissa McCarthy wearing a tall pompadour with her hair straight!
Melissa McCarthy Curly Bun
Melissa McCarthy looked stunning at the Oscars with her hair put back in a bun with lots of curls!
Melissa McCarthy Shoulder Length Straight Hair with Side Swept Bangs
Such a simple style, yet Melissa McCarthy really looks great with her hair straight and side swept bangs!
Melissa McCarthy Shoulder Length Straight Hair with Side Swept Bangs
Melissa McCarthy Shoulder Length Curly Hair
Aww isn't this such a cute style for Melissa McCarthy?
Melissa McCarthy Shoulder Length Curly Hair
Melissa McCarthy Light Brown Short Wavy Hair
This hair color and style look great on Melissa McCarthy!
Melissa McCarthy Light Brown Short Wavy Hair
Melissa McCarthy Straight Hair with Bangs
Some hairstyles make women look younger, and with this straight style and bangs, Melissa McCarthy looks like a teenage girl!
Melissa McCarthy Straight Hair with Bangs
Melissa McCarthy Light Brown Curly Hair
Wow what a crazy curly style, but Melissa McCarthy looks so adorable in it!
Melissa McCarthy Light Brown Curly Hair
Melissa McCarthy Auburn Long Curly Hair
Auburn hair is a combination of red and brown hair, and here with her curls, Melissa McCarthy looks so beautiful!
Melissa McCarthy Auburn Long Curly Hair
Melissa McCarthy Blond Straight Hair
With her comedy talent, Melissa McCarthy proves that blonds really do have more fun!
Melissa McCarthy Blond Straight Hair
Melissa McCarthy Wild Crimped Style Shoulder Length Hair
Straight out of the 1980s, Melissa McCarthy is totally rocking this cool crimped styled hair!
Melissa McCarthy Wild Crimped Style Shoulder Length Hair
So, were we right about Melissa McCarthy? Did these hairstyles surprise or impress you? If you want to talk about this list, be sure to leave us a comment below. However, if you didn't like this list, we have links to even more lists below. All you have to do is click one and you'll be on a new page in no time. Now, what are you waiting for? Let's get started!
If you liked this list of 11 Melissa McCarthy Hairstyles, then check out 25 Fantastic Simple Heart Tattoos, 25 Adorable Matching Tattoos For Lovers, and 25 Elegant Kate Middleton Haircut.


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Bradley Wiggins' hopes of a Tour podium went up in smoke yesterday in a pile-up around 40 kilometres from the finish line that saw the Sky leader suffer a broken collarbone.
Sixth overall, Wiggins' exit leaves Sky facing near-catastrophe after their goal of a strong overall finish for the Briton following his disappointing 24th place last year collapsed well before the Tour has even reached the mountains.
After days of rainfall and twisting roads turned this Tour into one of the most crash-ridden of recent years, Wiggins' untimely departure came – ironically enough – on a straight, tree-lined avenue in dry weather.
The peloton was riding fast, but not flat out in the final hour of yesterday's stage, when the final third of the bunch suddenly crumpled into a mass of bicycles and bodies. Wiggins was not initially shown on TV images, but the way Sky riders were clustering around at the side of the road in twos and threes – waiting for their British leader to remount and hopefully for them to guide him back to the finish – was the most ominous of signs.
Then suddenly Wiggins was in range of the cameras, his British national champion jersey ripped, clutching his left shoulder and arm in the classic symptoms of a rider with a suspected broken collarbone – one of the most frequent injuries for bike riders – hobbling across the road, and grimacing with pain. The race doctor and Sky's medic were by Wiggins almost immediately, easing the dazed British contender to the side of the road, where he sank down on the verge, suddenly unable to stand.
Most of the other riders affected in the one big crash of the day were able to remount and get on with racing, but not Wiggins: after a few moments' hesitation, the Briton abandoned the race in an ambulance, his next stop Châteauroux hospital for a check-up on his injuries.
"Everyone was jostling for the front," Wiggins said of the crash. "We were constantly told on the radio that we've got to stay in the front. There was a risk it could split at any minute. Everyone was being told that.
"When you have got 200 riders trying to stay at the front on small roads like that it's always going to happen. It's just one of those things."
He added: "I couldn't get up off the floor for love nor money, and once I did make it to the side of the road I kept saying I wanted to get back on the bike, but there comes a point where you just can't do it."
For Sky the loss of their overall contender is arguably the biggest setback any Tour team with aims of finishing high in the overall classifications can face in the race, and comes at a point when team morale could not have been higher, given that on Thursday they had had their best day ever in the Tour so far. Edvald Boasson Hagen had blasted to victory in Lisieux, claiming the team's first ever stage win in the Tour, and confirming that after 2010's difficult Tour, Sky finally seemed to be getting the measure of the race.
On top of that, there was Wiggins himself. A superb build-up, with victory in the Critérium du Dauphiné, the most important warm-up race for the Tour, coupled with a lone win in the British national road race, had radically raised the hopes of UK cycling fans that the Londoner could be on for some major success.
Even more encouragingly, there was Wiggins' performance in the race itself. Sky claimed a strong third place in the team time trial, and Wiggins maintained his chances when he stayed with the other top favourites on the difficult hilltop finish on the Mûr de Bretagne on Tuesday's stage four. Lying sixth overall, he was one of the best placed contenders.
"It's tremendously disappointing, he's built up the whole year for this and suddenly it all comes to an end," said Sean Yates, Sky's sports director and a former Tour de France leader. Sky's Team Principal, Dave Brailsford, added: "He was in great shape and it's a real shame we'll never see him going in the mountains. He was in the form of his life."
If Wiggins abandonment means the roof has fallen in for Sky, on the same day the walls all but came down as well, as almost all his team-mates waited for him, losing over three minutes.
Gone, too, was Geraint Thomas's white jersey of Best Young Rider as well as Boasson Hagen's remote options on the overall. Sky's luck has turned so fast it will have left the team stunned, given Wiggins is one of just two favourites – the other, Slovenian outsider Janez Brajkovic – to go home this year so far injured.
However, it is true that crashes have been particularly widespread this year, with top riders like Belgian Tom Boonen quitting the race yesterday after his injuries even before Wiggins left. Then Frenchman Remi Pauriol also abandoned in the same crash as the Briton, also with a broken collarbone.
"It has been specially nervous this year, but I think it is mostly because of the [difficult] weather conditions," commented the race leader, Thor Hushovd. "Everybody's been riding on the front, there's not room for everybody, they get stressed out and then crashes happen."
"Everybody's been fighting and there've been a lot of small roads. But it's not normal like this year when I'm fighting with Frank Schleck [overall contender] at four kilometres to go," said Britain's Mark Cavendish, the winner yesterday.
"It's quite distressing," Cavendish added. "Bradley was in great form – and I'm really, really gutted for him."
Race Details
Stage 7 (Le Mans - Chateauroux, 215km):
1 M Cavendish (GB) HTC-Highroad 5hrs 38mins 53secs
2 A Petacchi (It) Lampre - ISD
3 A Greipel (Ger) Omega Pharma-Lotto
4 R Feillu (Fr) Vacansoleil-DCM Pro Cycling Team
5 W Bonnet (Fr) FDJ
6 D Galimzyanov (Rus) Katusha Team
7 T Hushovd (Nor) Team Garmin-Cervelo
8 S Turgot (Fr) Team Europcar
9 J J R Gil (Sp) Movistar Team
10 S Hinault (Fr) AG2R La Mondiale all at same time
Selected Others:
15 N Roche (Rep Ire) AG2R La Mondiale,
18 D Millar (GB) Team Garmin-Cervelo,
19 J Van Den Broeck (Bel) Omega Pharma-Lotto all at same time
128 G Thomas (GB) Sky Procycling at 3mins 6secs
145 B Swift (GB) Sky Procycling both at same time
DNF: B Wiggins (GB) Sky Procycling
General classification: 1 T Hushovd (Nor) Team Garmin-Cervelo 28hrs 29mins 27secs; 2 Evans (Aus) BMC Racing Team at 1sec, 3 F Schleck (Lux) Leopard Trek at 4secs; 4 D Millar (GB) Team Garmin-Cervelo at 8secs; 5 A Kloden (Ger) Team RadioShack at 10secs; 6 J Fuglsang (Den) Leopard Trek at 12secs; 7 A Schleck (Lux) Leopard Trek at same time; 8 T Martin (Ger) HTC-Highroad at 13secs; 9 P Velits (Slovak) HTC-Highroad at same time; 10 R Gesink (Neth) Rabobank Cycling Team at 20secs. Selected: 18 N Roche (Rep Ire) AG2R La Mondiale at 1.12; 38 G Thomas (GB) Sky Procycling at 3mins 18secs; 59 M Cavendish (GB) HTC-Highroad at 6mins 6secs; 70 B Swift (GB) Sky Procycling at 6.mins 56secs.
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Shop Personalized StationeryCarlson Craft Wedding Invitations Customize any Address Stamp to match your style!
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Calculation of the entropy
This book is based on a course that I have been teaching for the past several years to first year graduate students in the biological sciences at Duke University. These stu- dents have not studied physical chemistry as undergraduates and typically have not had more than a year of calculus. Many faculty believe that an understanding of the principles of physical chemistry is important for all students in the biological sciences, and this course ...
180p banhkem0908 24-11-2012 30 5 Download
Lecture Thermodynamics: An engineering approach (8/e): Chapter 7 (Part 1) - Yunus A. Çengel, Michael A. Boles
Chapter 7 (part 1) - Entropy: A measure of disorder. The objectives of Chapter 7 are to: Apply the second law of thermodynamics to processes; define a new property called entropy to quantify the second-law effects; establish the increase of entropy principle; Calculate the entropy changes that take place during processes for pure substances, incompressible substances, and ideal gases.
52p whocarea 05-09-2016 3 1 Download
In this chapter, the analytical embedded atom method and calculating Gibbs free energy method are introduced briefly. Combining these methods with molecular dynamic and Monte Carlo techniques, thermodynamics of nano-silver and alloy particles have been studied systematically.
0p 123859674 02-07-2012 52 13 Download


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Les Peupliers also known as Maison Guiette, is a house in Antwerp, Belgium, designed by Le Corbusier in 1926 and built in 1927. It was the studio and living quarters of René Guiette, a painter and art critic. One of the Franco-Swiss architect's lesser-known works, it is an early example of the International Style.
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