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Radisson Blu Hotel, Durham
Radisson Blu Hotel, Durham
Radisson Blu Hotel, Durham
Radisson Blu Hotel, Durham
Radisson Blu Hotel, Durham
Radisson Blu Hotel, Durham
Current Weather
City hotel in Durham overlooks River WearFrankland Lane City of Durham DH1 5TA Durham United Kingdom+ 44 (191) 3727200 | Email Hotel
An attractive home base amidst the rugged countryside, the Radisson Blu Hotel, Durham is the perfect home base for exploring North East England. Guests can take in sweeping views of the River Wear, and the city centre location affords easy access to Durham Castle, a UNESCO World Heritage site. All 207 rooms and suites feature Free high-speed, wireless Internet. Located within the hotel, our own Filini Restaurant treats patrons to delectable Italian fare. We also boast a health club and spa on site, providing ample opportunity for rest and relaxation. For guests planning a meeting, banquet or other special event, we offer a total of 11 fully equipped meeting rooms to accommodate a variety of occasions.
- With ideal proximity to both the A1 (M) and Durham Mainline Railway Station, it's easy to navigate the area.
- This Durham city hotel comprises 207 rooms, including Business Class Rooms and Junior Suite options.
- Indulge in Italian specialities at Filini, or stop by The Bar for a cocktail.
- Guests can take advantage of complimentary access to PACE Health Club, where they can swim in the pool, unwind in the sauna or experience a spa treatment.
- Our 11 conference rooms span a total of 1,100 square metres accommodating a maximum capacity of 450 guests.
At a Glance
A Scenic Escape
This charming town boasts 18th-century architecture, the rolling Palace Green, ample shopping and bustling businesses.
Comfort and Convenience
From Free high-speed, wireless Internet access to modern décor, these rooms and suites provide guests with a restful stay.
Filini Restaurant
Dine on classic Italian fare, steak and seafood at this casual, on-site restaurant. In the morning, enjoy the Super Breakfast Buffet.
Relax with a Drink
Visit the Filini Bar for after dinner drinks or stop by The Bar for afternoon tea and a beer.
On-site Car Park
Leave your car with us in the secure, on-site car park while you explore the region or attend business meetings.
Spacious Event Facilities
The 11 meeting rooms available at the Radisson Blu Hotel offer a flexible space for special events, conferences, charity events, proms and more.
Memorable Weddings
Stunning views, elegant facilities and all-inclusive packages make the Radisson Blu Hotel an ideal location for weddings of all sizes.
PACE Health Club
The PACE Health Club provides guests with a pool, modern gym equipment and a refreshing sauna. For more pampering services, visit the Lime House Spa.
Take advantage of fitness #BluRoutes during your holiday.READ MORE
Explore the North East
Discover the breathtaking countryside of Durham.
Responsible Business
Taking responsibility for the environment and local community is an important part of the Rezidor Hotel Group.READ MORE
Meeting Planner
Plan events at the Radisson Blu Hotel, Durham.READ MORE
Green Tourism Business Scheme
The Radisson Blu Hotel, Durham is the proud recipient of the GTBS - Gold label.
Hotel Brochure
See everything we have to offer at the Radisson Blu Hotel, Durham.READ MORE
Gift Card
Treat someone to the perfect gift for those special occasions. The Radisson Blu Gift Card is easy to use and valid for 2 years.READ MORE
Enjoy more points, more partners and more places with Club Carlson – the global hotel rewards programme from the Carlson Rezidor Hotel Group.READ MORE


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Medical students' choices of specialty in The Gambia: the need for career counseling
1 Department of Obstetrics and Gynaecology, KorleBu University Teaching Hospital, Accra, Ghana
2 Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Department of Medicine, School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia
4 Department of Medicine, Royal Victoria Teaching Hospital, Banjul, The Gambia
BMC Medical Education 2012, 12:72 doi:10.1186/1472-6920-12-72Published: 8 August 2012
Understanding preferences for specialties by medical students and the factors driving choices assists policy makers in ensuring optimal spread of personnel across disciplines.
This cross-sectional survey using self-administered structured questionnaires was conducted on consenting students of the first medical school in The Gambia, established in 1999. Data collection was in June/July 2011. Questions were on sociodemographic characteristics of students, their parents, factors related to career preferences and opinions about counseling services. Data were analysed using JMP 8.0 software.
Respondents were 52.4% of 202 eligible students. Mean age was 24.1 ± 5.0 years. Females constituted 54.7%. Muslims were 72.7% while Gambians formed 77.0%. Commonest specialties chosen by females were Obstetrics/Gynaecology, Paediatrics and Surgery in that order, while males preferred Internal Medicine, Surgery and Obstetrics/Gynaecology. Commonest factors influencing choices by females were 'focus on urgent care' (65.5%) and 'intellectual content of specialty' (56.9%). For males, these were 'intellectual content of specialty' (60.4%) and 'focus on urgent care' / 'individual's competence' (50.0% each). More females (30.0%) than males (23.0%) had ever received career counseling, but all students desired it.
Significant gender differences exist in specialty choices and factors influencing these choices amongst these students. All want career counseling.

subset: commoncrawl


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Ben Crair
The Supreme Court Just Approved a Lethal Injection Drug that No One Understands
June 29, 2015
Lethal injection is often beyond the expertise of nearly everyone who participates in it.
Lethal Entanglements
May 19, 2015
Lethal injection was supposed to be a cleaner, more humane version of capital punishement. Instead, this happened.
The Exhibitionist
March 04, 2015
Daryl Richardson built a jungle in the heart of Dallas and filled it with exotic creatures. No one asked any questions—until he set his sights on the world's rarest sloth.
Exclusive Emails Show Ohio's Doubts About Lethal Injection
August 17, 2014
Five years before Arizona took two hours to execute an inmate, officials in Ohio worried the same drugs would cause prisoners to "gasp" and "hyperventilate"—and used them anyway.
2014 Is Already the Worst Year in the History of Lethal Injection
July 24, 2014
He gasped for air 660 times.
Photos from a Botched Lethal Injection
May 29, 2014
In 2006, mistakes in the Florida death chamber inflicted chemical burns on a prisoner and may have suffocated him to death.
Cruel But Not Unusual
April 30, 2014
Clayton Lockett's death revealed a problem with lethal injection more fundamental than the drugs.
Chipotle Is Ruining Lunchtime
April 03, 2014
Long lines and too many choices is a recipe for stress.
Can't Work, Must Chat
March 05, 2014
How Internet chat made everyone's jobs impossible.
Now You Can Spend $35.99 on 'Small Batch' Artisanal Toothpicks
January 29, 2014
How much would you spend on a toothpick soaked in scotch or rolled in sea salt?


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Tribal health care changes promised
Tribes run clinics with Indian Health Service funding, along with reimbursements from Medicaid, Medicare and insurers. Still, nearly all involved agree the health service is chronically underfunded and ill-equipped to deal with a population that suffers from much higher than normal incidences of diabetes, tuberculosis, alcoholism, infant mortality and suicide. "Less is spent on providing health care to American Indians per capita than any other sub-population," Pallone said. "In fact, we spend more to provide health care to federal inmates than we do for American Indians." Yvette Roubideaux, director of the Indian Health Service, said President Barack Obama had proposed the largest increase in funding in 20 years for the agency. Though more money won't solve all the problems, she said, it would help.


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Grace Brethren Church
5675 Basore Rd
Dayton, OH 45415
Tom Shroyer
[email protected]
Note: Any overlapping times indicate multiple, simultaneous sessions
|Sun, Apr 07
|9:30 a.m. -10:30 a.m.
|Bob Gillespie
|The 7 C's of History (All Ages)
|10:30 a.m. -11:30 a.m.
|Bob Gillespie
|The Key to Reclaiming the Culture (All Ages)
|6 p.m. -7 p.m.
|Bob Gillespie
|Building a Biblical Worldview (Adults)
|7 p.m. -8 p.m.
|Bob Gillespie
|Why Won't They Listen? (All Ages)
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- Filed Under
Purdue will fill the opening for a 12th game on its football schedule next season by hosting Division I-AA Indiana State.
The Boilermakers and Sycamores will play Sept. 2, 2006 at Ross-Ade Stadium, Indiana State sports information director Jason Yaman said. It will be the season opener for both teams.
Purdue coach Joe Tiller said last month when the NCAA passed legislation permitting a 12th game for Division I schools that he hoped the Boilermakers would be able to play at home against a lower-level Division I team or nearby Division I-AA ...


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Famous trainer offers tips
If you don't recognize Tony Little's name, you probably know his face. Little, a fitness trainer and infomercial pitchman, is famous for his enthusiasm, expertise, bright smile and long blond ponytail.
He offers these tips...
Read the rest of the story on Oklahoman.com
Read the rest of the story on Oklahoman.com
Continue reading this story on the...


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Smartest guy in the world talks about school tests
Panic attack over the Atlantic Air Canada passenger flips on route to London - Dec 6, 2007
Disappearing car door Pimp up your mundane motor with these futuristic doors
the world fastest bike today. in once eye blinking.... New 2007 Yamaha R1 Superbike. When Yamaha first introduced its radical R1 in the late 1990s, it was described as a 'no compromises', high-performance
the funny guy on top of mountain So the bright regions could be plateaus or mountains with hydrocarbon ice on top. In order to get hydrocarbon ice, you have to have a mountain
Try Bollywood
Just Fun


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It seems funny to me that in a state that abortions are legal and public money can be used to perform them that we would even be having a debate on a Death with Dignity bill. If women can make a choice on the life of a fetus than I should be able to decide my own fate if faced with a terminal illness. Could an opponent of this bill please explain the difference between the two to me?
Im pretty sure there isnt one other than they like sticking their nose in somebodys elses business, which, by the way, they know nothing about.If you are opposed to the bill and it hopefully passes you are allowed to make your own decision on ending your life or not so do the people who choose to end there live without undo suffering and butt out.
Richard Smith
NorthfieldMORE IN Letters
Recent testimony to Congress by economics professor Laurence Kotlikoff indicated America is... Full Story
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I am writing to call attention to a couple of groups of awesome professionals in our community. Full Story
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Atlus unboxes Etrian Odyssey III on camera.
Views: 4,689 | Posted: 09/30/2010
The universally feared creatures of Etrian Odyssey spells certain doom should you cross them.
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Explore the greater areas and quests of The Drowned City in this featurette from Atlus!
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Assign a subclass to your party's characters and use them smartly to make your team more resilient!
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Build your very own world in The Drowned City on Nintendo DS!
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Learn the ropes of The Drowned City's combat system on the Nintendo DS!
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Explore the uncharted high seas and discover long lost civilizations.
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Learn to develop your own team from the class selection of The Drowned City and this video tutorial!
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A stormy adventure begins on the high seas this September in Etrian Odyssey 3: The Drowned City.
Views: 6,770 | Posted: 07/12/2010
There are as many stories as there are players in Etrian Odyssey III: The Drowned City.
Views: 8,106 | Posted: 06/23/2010


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How the heck did he end up owning a home....and with a pool ???
He recieved a sizable cash dispensation from the city of LA.
From the money he got from the lawsuit.
I was more surprised that he STILL owned a house.
A fool and his money you know.
Gee, with Rodney gone, who are the cops going to beat up on next?
Keep the fire inside the fireplace.
AOP Forum Rules:
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I would wager that he had a heart attack in the pool due cocaine abuse...payed for by who else but the tax payers.
Millions of individuals making their own decisions in the marketplace will always allocate resources better than any centralized government planning process. -- Ronald Reagan
I like what I heard today on "Core Values" regarding the topic
Controls Forum Rules Site Rules Tridium
Ironically, he just did an interview a couple months ago saying how much he loved the water. And something about how most black people can't swim, but he loved swimming......go figure.
Tough times don't last...Tough people do.
Midnight Sun Astrophotography
Anybody ever see him on Celebrity Rehab?
We're awl pawthetic and kweepy and can't get giwrls. That's why we fight wobots.
Reginald Denny was the real victim!
Forum Rules


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Quote Of The Day
We never repent of having eaten too little.
Drug Boosts Rats' Memory
Based on research done with rats, a cancer drug shows promise in helping dementia and Alzheimer's patients regain the ability to make new memories.
The drug is used in cancer therapy to prevent the activation of genes that turn normal cells into cancerous ones. Its effects on the brain, according to a study published in the Journal of Neuroscience, suggest that it helps make neurons better able to make connections and enhances memory.
Researchers found that when they gave the drug to rats, it made their hearing better, they were better able to retain and remember more information and develop connections that allowed memories to be transmitted between brain cells.
They discovered this by teaching rats to associate a certain sound with a reward. They found the rats given the drugs responded more frequently and correctly than those that were not given the drug. The drugs were able to give the rats an enhanced ability to reorganize and create new pathways so more information could become long-term memory.
This new research suggests that the drug could help "rewire" the brain in dementia and Alzheimer's patients.
This Week's Slice of History: 1st U.S. Insane Asylum: Oct. 12, 1773


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Celiac disease is known as genetic autoimmune disease that results in damage to the small intestine villi, and interferes with nutrient absorption. Approximately 1 in 133 Americans have the disease, ..
There are many reasons why people adopt a vegetarian lifestyle: some for ecology, economy or religion, and others for ethics, ..
In many parts of the world, cold and flu season is upon us. One of the best ways to avoid getting the Common Cold is to boost ..
Organic food sales have grown by 20 percent annually! Experts are predicting that the this trend will continue to grow. ..
Approximately three-fourths of teens and adults in the United States are deficient in vitamin D. These deficiencies are being ..
Some call them Chickpeas, and they are otherwise known as Garbanzo Beans. Whatever you call these power-house beans, know ..
The Mediterranean diet is based upon the traditional foods consumed by those in Italy and Greece in the 1960s. Research ..
Bipolar disorder is a serious mental health diagnosis that affects nearly 5.7 million American adults.(1) This disorder ..
Check out this raw vegan pine nut Parmesan recipe – it's super easy and only has 4 ingredients! I was surprised ..
Turns out, grandma's cure for constipation may be loaded with nutrition and health benefits! Prunes have long been ..
With so many forms of communication, many people are gravitating away from face to face conversation. Even talking on the phone ..


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All very speculative. Poor moving film formats will be trimmed, others will stay. Manufacturers are catering for a shrinking, not growing market. That's the reality. No amount of sweet talking will convince me we're on a boom home run. We are the ones who said Fuji would continue to provide the films we enjoyed in the formats we used. Then came the announcement last year and the discontinuation of the formats, and surprise, surprise, we were shocked. Why? We cannot deny the undeniable. The news did not surprise pro-level dealers or labs dealing with Fuji films with so little film being sold (at least by them; very different story for online e-sellers). There was a rumour that Fuji would pull two more films "next year" (2013) but nothing has been heard of said of that. The Dealer Bulletin which I read (both at Michaels and PRISM) made it clear that demand for film was continuing to fall and that would steer the decisions made by Fuji's parent (Japan) company re manufacturing.
I am puzzled by the China situation. We saw more digital cameras on our family trip to China than film,and that was 2009. I don't know where the observation is coming from that film is booming in China; they population seems hooked on the latest and greatest of digital; indeed, China is where a large number of digital cameras are assembled, making them cheap for the masses and thus more appealing. Perhaps RattyMouse, being a resident there, can enlighten us on the present situation in China v.i.z. film vs digital.


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Post: Phil Lesh Central Park May 31 - One Ticket
~ Got back to me immediately, set up the trade, and we met up within walking distance of the venue well before show time. And the show was great. Couldn't have asked for a better trade.8/12/14
Post: Phil Lesh Central Park May 31
~ Nice quick and reliable. Super easy and everything was as promised!5/24/14
Post: I Have A Couple Of Extra Fro Trey In NYC.
~ Met in NYC a week or so before the show; smooth transaction. Great show. Thanks!3/01/11
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I bet she was all for this kind of thing when her precious Bushy Boy was the boss.Read more »
SEOUL—Shoppers at the new International Finance Center Mall in Seoul can find their way around the four-story complex by approaching one of 26 information kiosks. When they do, they also are being watched.Read more »
After getting the ACS in the mail, this guy calls the Dept. of Commerce to tell him he won't fill it out. They threaten him with a $5000 fine. Instead, he puts the entire 28 page document online. If you were ever curious what's in this thing, here you go.Read more »
At the heart of Apple's security architecture is the Advanced Encryption Standard algorithm (AES), a data-scrambling system published in 1998 and adopted as a U.S. government standard in 2001. The algorithm is so strong that no computer imaginable for the foreseeable future—even a quantum computer—would be able to crack a truly random 256-bit AES key. The National Security Agency has approved AES-256 for storing top-secret data. Now if they would provide a way to turn off the tracking function....Read more »
Appeals court rules law enforcement agencies don't need a warrant to "ping" and track prepaid cellphone locations.
He is the creator of Cryptocat, a project "to combine my love of cryptography and cats," he explained to an overflowing audience of hackers at the HOPE conference on Saturday, July 14.Read more »
Jonah Falcon was stopped and frisked by the TSA at the San Francisco International Airport on July 9 because of a bulging package hidden in his pants. But the 41-year-old New Yorker wasn't packing a dirty bomb, drugs or a Costco-sized tube of toothpaste. The New Yorker has the world's largest recorded penis. In an exclusive interview with The Huffington Post, Falcon described his hard times with security guards after his extra carry-on became suspect. "I had my 'stuff' strapped to the left. I wasn't erect at the time," said Falcon, whose penis is 9 inches flaccid, 13.5 inches erect.Read more »
Governmental Secrecy: Shield for Tyranny, Incompetence, and Corruption
An essential pillar of democracy is openness. There is no way that people can meaningfully participate in government, even if only by voting for representatives, if they do not have access to accurate information related to government operations. This was well understood by the founders of the US and embedded in the Bill of Rights. Conversely, a salient characteristic of undemocratic systems of all types, such as Czarist Russia, the Soviet Union, and Nazi Germany is a high degree of governmental secrecy.Read more »
Washington, D.C. - Electronic Frontier Foundation (EFF) Staff Attorney Jennifer Lynch will testify this week at a Senate hearing on facial recognition technology and the privacy and civil liberties risks associated with rapidly growing biometric databases. The hearing is set for Wednesday, July 18, at 2:30 p.m. Facial recognition technology is becoming increasingly sensitive and sophisticated, creating new ways for government and private entities to identify and track people throughout the United States.Read more »
A drop in file-sharing following a court ordered block of the Pirate Bay was short-lived, data seen by the BBC suggests. A major UK internet service provider (ISP) said peer-to-peer (P2P) activity on its network returned to just below normal only a week after the measures were enforced earlier this year. Critics had warned the ban would prove ineffective. But the BPI, the music industry trade body, has defended the action. Its chief executive Geoff Taylor told the BBC the group would continue to pursue similar action in future.Read more »
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Which sex is the worst about washing up? Why is it so important? We've got the dirty truth on how and when to wash your hands.
Stem Cell Research and Studies Directory
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In a paper in the journal Current Biology, Dr Brendan Godley and an international team describe how they used satellite tracking systems to follow the journeys of ten turtles from Cape Verde, West Africa, which is one of the world's largest nesting sites for loggerheads and a hotspot for industrial fishing. What they found could turn current conservation strategies upside down, as the team discovered the turtles adopted two distinct approaches to finding food, linked to their size.
Previously it was thought that hatchlings left the coastal region to forage far out at sea before returning, later in life, to find food closer to shore. However the new findings show that the oceanic habitats contained far larger animals than was previously thought. The team tracked the turtles as they left nesting sites, following them for up to two years over ranges that covered more than half a million square kilometres.
Dr Brendan Godley, of the University of Exeter, said: "We were surprised to find such large turtles looking for food out in the open ocean, as it was previously thought that animals of this size would have moved back to forage in coastal zones. This means there are much greater numbers of the breeding population out at sea and far more that are vulnerable to the intensive longline fishing effort that occurs in that region."
Dr Michael Coyne, of Duke University, added:"From the information collected, we have been able to determine how much time these animals are spending within the sovereign boundaries of each country in the region. This research highlights how complicated the migration of marine vertebr
Source:University of Exeter


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General Info
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Articles from Britannica encyclopedias for elementary and high school students.
- Emily Hobhouse - Children's Encyclopedia (Ages 8-11)
Emily Hobhouse was a British social worker known for helping women and children in South Africa. During the Boer War (1899-1902) British soldiers took many Boer women and children from their homes and placed them in concentration camps. Hobhouse worked to improve conditions for those women and children.


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Caring for the caregivers: How to use alternatives to ease the way through stress
If your duties as a patient advocate have you stressed, know that some facilities care about your and other caregivers' well-being just as much as they care for your patient. More hospitals are offering services such as focused breathing, mindfulness exercises, massage therapy and various forms of yoga to help ease nurse and physician fatigue. StudiesRead More
Congress Overwhelmingly Approves Bill Bolstering Medicare Patients' Hospital Rights
The U.S. Senate unanimously approved legislation Monday night requiring hospitals across the nation to tell Medicare patients when they receive observation care but have not been admitted to the hospital. It's a distinction that's easy to miss until patients are hit with big medical bills after a short stay. The vote follows overwhelming approval inRead More
Prevention Task Force Recommends Depression Screenings For Pregnant Women, New Moms
One in seven women experience depression during pregnancy or the first year after giving birth, yet many may not realize it or report their concerns to clinicians. A new proposal by the U.S. Preventive Services Task Force could help change that. It recommends that all women who are pregnant or within a year of givingRead More
Keep the restraints to a minimum to keep your patient safe
Though restraint and seclusion may be required from a safety perspective, many in the health care industry believe the practice to be harmful to a patient's well-being. Hospitals should instead focus on managing patients in such a way that restraints and seclusion rarely — if ever — need to be used, remarks Kevin Huckshorn, Ph.D,Read More
AARP report calls for more national support of family caregivers
Family caregivers for adults in 2013 provided an estimated 37 billion hours of care, worth about $470 billion, but of course that was largely unpaid, according to a new report, "Valuing the Invaluable: 2015 Update," published recently by the AARP Public Policy Institute. Without such family-provided care, the economic cost to the U.S. health careRead More
How Much Does It Cost To Have A Baby? Hospital Study Finds Huge Price Range
By Michelle Andrews | Kaiser Health News Which hospital parents pick to deliver their baby can have serious cost consequences, according to a new study. Hospital costs for women who had no maternal or obstetric risk factors to complicate childbirth ranged from less than $2,000 to nearly $12,000, the analysis of discharge data found. TheRead More
Home Visits By Nurses For First-Time Mothers Help Reduce Government Costs
Symphonie Dawson was 23 and studying to be a paralegal while working part-time for a temporary staffing agency when she learned that the reason she kept feeling sick was because she was pregnant. Living with her mom and two siblings near Dallas, Dawson worried about what to expect during pregnancy and what giving birth wouldRead More
Ensure qualified medical interpreters are available to help LEP patients
The Joint Commission (TJC) is trying to raise awareness among hospitals and other accredited health care professionals about the need to ensure that patients with limited English proficiency (LEP) are provided the proper information about their health care in a manner they can understand. In an issue paper published online in TJC's "Quick Safety" issueRead More
Decoding Your Diagnosis: Psychiatrists Unveil Plain-English Guide For Patients
As mental health professionals, policy makers and advocates focus on taking steps to mend the fragmented mental health care system, the role of patients and their friends and families is sometimes overlooked. That's why the American Psychiatric Association is releasing a first-of-its-kind book to decode in plain English the Diagnostic and Statistical Manual of Mental Disorders – a guide forRead More
Care for the Caregiver: Strengthening Mindfulness to Improve Patient Care
More and more hospitals are reaching out to offer services to their patients' caregivers in an effort to help them help those patients. For instance, the Children's National Health System is offering a variety of services — some new, some longstanding, some free, others charged to private payers — as part of its efforts toRead More


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Great Location & Value Pricing...The "New" Milford Estates Has It All...Minutes From the GW Bridge, Leave Your Commute Behind...Distinctively Different...Dramatically Designed...
We are centrally located only minutes from Rte. 4 and 15 minutes from New York City via the GW Bridge. You can walk to shopping, mass transportation and recreation. With fully renovated apartments, you'll want to visit Milford Estates today and call us home tomorrow.
Visit our website at: http://www.affiliatedmgmt.com !
Lease Terms: 12 months. Security Deposit: 1.5 month's rent.
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Serving Size:2
Prep Time:25 mins
Your Rating:Login to rate this recipe.
Print Recipe
Ingredients150 gram dried noodles, your choice
2-3 cm fresh ginger chopped
150 gram dried mushroom, soak in hot water
1 small carrot, julienne cut
1 handful green beans, sliced thinly on diagonal
8-10 shallots peeled, or 3-4 green onion sliced on diagonal
4 cloves garlic, minced
1 cup shredded white cabbage
3 tablespoon peanut oil
In a separate bowl:
3-4 tablespoon light soy sauce
3 tablespoons oyster sauce
1 lemon, juice of
pinch of sugar
drizzle of sesame oil
Coriander sauce:
1 bunch coriander finely chopped
1 inch ginger finely chopped or grated
1 tablespoon chili paste
1 tablespoon low sodium soy sauce
sesame oil to taste
1 teaspoon sugar
optional fresh chilli sauce
InstructionsCook the noodles in boiling water. For best results, undercook so they can finish cooking in the sauce later. Drain and set aside.
Prepare all the ingredients for stir fry.
In a small bowl, stir together ingredients for sauce.
Heat oil in wok or other suitable pan. Add rest of ingredients in the following order, with a 30 second interval between each addition:
dried mushroom
green beans
cabbage and carrot
Season with more pepper if you'd like.
Add the noodles, pour in the sauce.
Option to serve with coriander sauce on the side. To make the coriander sauce, stir all the ingredients together.
Have a better photo? Please send it to us: contact123 (at) happycow.net


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Hair Stick with Feathers, Mylar Strips and Silver-Plated Brass Charms
-- Designer --
Rose, Jewelry Production Specialist, Marketing Content Development Group, Exclusively for Fire Mountain Gems and Beads®To learn more about Rose Wingenbach, read her jewelry artist success story here
: : : Materials : : :
- Bead, Czech fire-polished glass, iris green, 3mm round
- Charm, silver-plated brass, 17x11mm angel
- Bell cap, nickel-finished brass, 10mm 7 prong, fits 10-13mm bead
- Strip, Mylar, black holographic, 14x1/32 inch
- Feather, chicken, brown, 3-1/2 to 7-1/2 inch saddle hackle
- Hair stick, wood, dark brown, 6 inches long
- Crimp bead, sterling silver, 2x2mm cut tube, 1.1mm inside diameter
- Crimp, sterling silver, 3x1mm tube with loop
- Jumpring, silver-plated brass, 3mm round, 20 gauge
- Jumpring, silver-plated brass, 4mm round, 20 gauge
- Component, Oh! Ring, rubber, red-orange, 3mm round with 2mm hole
- Chain, silver-finished brass, 3x2.5mm cable
- Adhesive, Loctite 409 Gel
- Pliers, flush-cutter
- Pliers, crimping
- Pliers, bent-nose
- Pliers, chain-nose
- Scissors
The pieces featured in the Gallery of Designs are copyrighted designs and are provided for inspiration only. We encourage you to substitute different colors, products and techniques to make the design your own.
Have a question regarding this design idea? Email Customer Service.
Customer Photographs
Fire Mountain Gems and Beads is proud to feature your artwork, and we invite you to submit images of your favorite projects to the Customer photographs section. Here's how you can be included:
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If you have any questions or concerns regarding the artistic credit of the artwork displayed here, please contact us at firstname.lastname@example.com.


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Kidney Disorders
The kidneys are two small fist-sized organs located behind the abdomen on each side of the spine. By producing urine, kidneys remove toxic by-products and excess fluids from the body to help maintain a critical balance of salt, potassium and acid.
Diseases of the kidney are found more often in racial and ethnic minority populations in the United States than in the Caucasian population. African Americans, Asian Americans, Hispanics/Latinos, and Pacific Islander Americans are three times more likely to suffer from kidney failure than Americans of European descent.
Urinary Obstruction
One of the most common conditions affecting the kidneys is urinary obstruction. Obstruction can occur anywhere in the urinary tract and when it occurs, medical attention is required. A urinary obstruction can create serious side effects like infections and kidney stones. If left untreated, blockages can cause chronic pain and may damage the kidney over time.
Blockage of the Ureter
The condition known as blockage of the ureter (tubes that transport urine from the kidneys to the bladder) is found in adults, but more commonly in children. Normally, a single ureter drains a single kidney but sometimes there may be two ureters draining one kidney. One ureter drains the upper part of the kidney and the second ureter drains the lower part. As long as they both enter the bladder normally, this "duplicated collecting system" is not a problem.
In rare cases, a child may be born with an ectopic (abnormally positioned) ureter. This is a ureter that fails to connect properly to the bladder and instead drains somewhere outside the bladder. In girls, the ectopic ureter usually drains into the urethra or even the vagina. In boys, it usually drains into the urethra near the prostate or into the genital duct system. The urethra is a canal that carries the urine from the bladder and in males also serves as a passageway for semen.
UPJ Obstruction
The most common cause of obstruction in the urinary tract in children is a congenital obstruction. This occurs at the point where the ureter joins the renal pelvis (called the ureteropelvic junction or UPJ). This is the area at the center of the kidney where urine collects and is funneled into the ureter. This type of obstruction occurs in roughly one in 1,500 children.1 These obstructions develop prenatally as the kidney is forming. Today, most cases are diagnosed on prenatal ultrasound screening.
In UPJ obstruction, the kidney produces urine at a rate that exceeds the amount of urine able to drain out of the renal pelvis into the ureter. This causes an accumulation of urine in the kidney. The accumulation, also called hydronephrosis is visible on ultrasound and often allows the doctor to predict the presence of UPJ obstruction before the baby is born.
Although less common in adults, UPJ obstruction can occur as a result of kidney stones, previous surgery or disorders that cause inflammation of the upper urinary tract.
Learn about: Treatment Options for Kidney Disorders
- "Ectopic Ureter", American Urological Association Foundation, www.urologyhealth.org , URL: http://www.urologyhealth.org/pediatric/index.cfm?cat=01&topic=71
Important Safety Information
Serious complications may occur in any surgery, including da Vinci® Surgery, up to and including death. Individual surgical results may vary. Patients should talk to their doctor to decide if da Vinci Surgery is right for them. Patients and doctors should review all available information on non-surgical and surgical options in order to make an informed decision. Please also refer to http://www.daVinciSurgery.com/Safety for Important Safety Information.
© 2015 Intuitive Surgical, Inc. All rights reserved. Product names are trademarks or registered trademarks of their respective holders. The information on this website is intended for a United States audience only.


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R's 2 Upholstery
R's 2 Upholstery
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Upholstery Preparation
R's 2 Upholstery
Custom Rod Interiors and Much Much More !!
Look 2 Us for all of your Upholstery needs !!
Complete Interiors from Factory Restoration to Full Custom.
We are now booked for the winter of 2015-16 and summer of 16 for complete interior builds.
We are now scheduling build dates for fall and winter of 2016-17
Please contact us for scheduling information.
We are still able to schedule in smaller task jobs depending on the job .
Thank you for your interest in our business
Because we're interested in yours !!
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Seymour, Iowa 52590
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EcoAlert: Space Satellites Confirm Dramatic Loss of Artic Sea Ice
The September 2012 record low in Arctic sea-ice extent was big news, but a missing piece of the puzzle was lurking below the ocean's surface. What volume of ice floats on Arctic waters? And how does that compare to previous summers? These are difficult but important questions, because how much ice actually remains suggests how vulnerable the ice pack will be to more warming.
Combining the UW model and the new satellite observations suggests the summer minimum in Arctic sea ice is one-fifth of what it was in 1980, when the model begins: "Other people had argued that 75 to 80 percent ice volume loss was too aggressive," said co-author Axel Schweiger, a polar scientist in the UW Applied Physics Laboratory. "What this new paper shows is that our ice loss estimates may have been too conservative, and that the recent decline is possibly more rapid."
The system developed at the UW provides a 34-year monthly picture of what's happening to the total volume of Arctic sea ice. The Pan-Arctic Ice Ocean Modeling and Assimilation System, or PIOMAS, combines weather records, sea-surface temperature and satellite pictures of ice coverage to compute ice volume. It then verifies the results with actual thickness measurements from individual moorings or submarines that cruise below the ice.
"Because the ice is so variable, you don't get a full picture of it from any of those observations," Schweiger said. "So this model is the only way to reconstruct a time series that spans multiple decades."
The UW system also checks its results against five years of precise ice thickness measurements collected by a specialized satellite launched by NASA in 2003. The Ice, Cloud, and Land Elevation Satellite, or ICESat, measured ice thickness across the Arctic to within 37 centimeters (15 inches) until spring of 2008. The U.K.'s CryoSat-2 satellite resumed complete ice thickness measurements in 2010; this is the first scientific paper to share its findings about the recent years of record-low sea ice.
Between 2008 and now, the widely cited UW figures have generated some controversy because of the substantial ice loss they showed: "The reanalysis relies on a model, so some people have, justifiably, questioned it," Schweiger said. "These data essentially confirm that in the last few years, for which we haven't really had data, the observations are very close to what we see in the model. So that increases our confidence for the overall time series from 1979 to the present."
Arctic sea ice is shrinking and thinning at the same time, Schweiger explained, so it's normal for the summer ice volume to drop faster than the area covered, which today is about half of what it was in 1980.
Schweiger cautioned that past trends may not necessarily continue at the same rate, and predicting when the Arctic might be largely ice-free in summer is a different question. But creating a reliable record of the past helps to understand changes in the Arctic and ultimately helps to better predict the future.
"One question we now need to ask, and can ask, is what are the processes that are driving these changes in the ice? To what degree is it ocean processes, to what degree is this in the atmosphere?" Schweiger said. "I don't think we have a good handle on that yet."
The Daily Galaxy via UW Applied Physics LaboratoryImage credit: With thanks to earthtimes.org
It then verifies the results with actual thickness measurements from individual moorings or submarines that cruise below the ice.
Your chart and data does not seem to agree with that of the Naval Ice Office. See their chart at: http://www.natice.noaa.gov/ims/images/ims_data.jpg According to the Naval Ice Office, ice levels seem to be pretty much static.
Hey Jer,
I think the fundamental difference in the discrepancies might be explained by the difference between the volume of ice and the surface area of ice. This article highlighted the loss of volume, while the Naval Ice Office highlighted surface area.
Also, look at the time period of the two graphs. The Naval graph is the last 6 years, while the article looks at trends over 30 years. If you broke the graph in this article down from 2006-2012, the change in volume will look less significant than compared to the 30 year average.
Hope this helps.
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Aaron's 499
David Reutimann, driver of the Burger King/Dr. Pepper Toyota, and... News PhotoAaron's 499,Burger King,Control,David Reutimann,Driver,Escape,Greg Biffle,Gulf Coast States,Horizontal,Motorsport,Sport,Sprint Cup Series,Stock Car Racing,Talladega,Talladega Superspeedway,Toyota,USAPhotographer Patrick SmithCollection: Getty Images Sport 2013 Getty ImagesTALLADEGA, AL - MAY 05: David Reutimann, driver of the #83 Burger King/Dr. Pepper Toyota, and Greg Biffle, driver of the #16 3M Safety Ford, slide out of control as other drivers avoid them in turn one during the NASCAR Sprint Cup Series Aaron's 499 at Talladega Superspeedway on May 5, 2013 in Talladega, Alabama. (Photo by Patrick Smith/Getty Images)


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Ranomafana, Madagascar
Photos from RanomafanaPictures of Ranomafana (521)
Hotel Deals in Ranomafana
Videos from RanomafanaRanomafana Videos (3)
Hotels in RanomafanaRanomafana Accommodations (3)
Domaine Nature Ranomafana
, Ranomafana, Madagascar
Setam Lodge Ranomafana
56, Avenue du 26 Juin, Ranomafana, Madagascar
Manja Hotel Ranomafana
, Ranomafana, Madagascar
Travel Blogs from RanomafanaRanomafana Travel Blogs (35)
... . It was a great a great way to spend a birthday. We arrived home pleasantly knackered. One meal and a couple of Three Horses Beer, Madagascar's' own special brew, later we then went off to bed, very happy. The next morning we went for a 3 hour trek and ...
Ranomafana National Park
... ! the biggest problem being that the tourists are mainly French. Infact, the French presence was the only complaint I have about Madagascar!! (sorry for any French people reading this but u have to admit you're not the most friendly of travellers!!) We ...
Forest Walk
Had an early breakfast and left at 7:00AM for the Ranomafana National Park in hopes to see birds and lemurs. Louise decided to sleep in to get rid of a nasty cold and so the three of us left with the guide and driver. We started the hike with our guide ...
Narrow Shave with the Wood Chipper
... mental shield. On Saturday, just as I was considering sticking my head in the nearest wood chipper, I made it to Ranomafana, population 1500. Just what I needed. Ranomafana is a beautiful little village surrounded by rainforest, just a few miles from ...


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< Full site
Yucca man accused of killing mother
Roger Drake
Welfare check started probe that ended at shallow grave
A Yucca man with a history of mental problems is in custody after a woman's body was discovered Friday in a shallow grave in the yard of a home the suspect shared with his mother.
Investigators with the
Mohave County Sheriff's Office
believe that Carol Drake, 66, the mother of the suspect, was the person found in the grave. Roger Drake, 46, has been booked in the Mohave County Jail on charges of first-degree murder and abandonment/concealment of a dead body, which is a class 5 felony.
The investigation began Tuesday when deputies with the MCSO conducted a welfare check on Carol Drake at the home in the 16000 block of Lynn Avenue in Yucca. Family members had been trying unsuccessfully to speak with her by phone for three weeks, and they told authorities it was uncharacteristic of her to not be in contact with them.
In addition, family members reported they had received numerous phone calls from Carol Drake's neighbors who said they had not had contact with her for three weeks.
Neighbors, aware that Roger Drake had been diagnosed with paranoid schizophrenia, checked with him and learned he was out of medication and low on food. When deputies contacted him Tuesday, he told them his mother was in California with family.
Deputies contacted other family members and learned that wasn't true.
That led to the issuance of a search warrant for the Drake residence on Friday and the discovery of a shallow grave that contained the human remains. As of Saturday morning, the body had not been positively identified.
Roger Drake was not present while the warrant was executed, having self-admitted to Mohave Mental Health in Kingman. Detectives transported him from there to the Sheriff's Office, where he confessed during an interview to the homicide of his mother.
According to the MCSO, Roger Drake told detectives he first punched his mother and then stabbed her numerous times with a kitchen knife. He said the "dream police" told him to kill Carol Drake.
Latest News
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Indictments: Tuesday, Oct. 6, 2015
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Mantaray Grey metallic fleece parka coat
Item No.0540101216
Item No.0540101216
70% Off - Save a total of £62.30
From Mantaray, this grey parka coat has a metallic finish with an inner fleece lining and faux fur hood trim. It has a zip and popper fastened front with two outer pockets and a drawstring waist.
UK Home Delivery Free (UK orders over £30) or £3.49
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Subject to exceptions, Debenhams is happy to exchange or refund your purchase within 28 days of delivery. Please check here for more details on our returns policy and exceptions.


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Hotels, Restaurants and Leisure
Company Overview of National Archives Foundation
Executive Profile
A'Lelia Bundles
Chair and President, National Archives Foundation
|Total Calculated Compensation
|This person is connected to 2 Board Members in 2 different organizations across 1 different industries.
See Board Relationships
Ms. A'Lelia Bundles serves as the Chair and President at National Archives Foundation. ms. Bundles serves as the director of talent development for ABC News in Washington, D.C. and New York. She has enjoyed an award-winning broadcast journalism career with both ABC and NBC News and is the author of the critically-acclaimed, best-selling biography, ON HER OWN GROUND: The Life and Times of Madam C. J. Walker. She serves as a Member of Board of Trustees of Columbia University. ...
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Learn more about SEBMF's journey and our focus on delivering patient-centered care.Read More about SEBMF Celebrates 10 Years of Family Centered Care
Clare Rudolph, M.D., has a unique and enduring connection to her current medical partners Risa Kagan, M.D. and Marilyn Honegger, M.D.Read More about Generations Connect 3 OB/GYNs
The test of a good idea is how long it lasts. It has been 10 years since a small group of East Bay health care pioneers created a network that allows physicians to focus on building strong relationships with their patients.
Sutter East Bay Medical Foundation (SEBMF) and East Bay Physicians Medical Group (EBPMG) are celebrating the anniversary of a 10-year partnership. On Oct. 1, 2005, with approximately 100 employees, 49 physicians and four allied health professionals on board, SEBMF started providing hospitalist services for Alta Bates Summit Medical Center and opened its doors at three care centers in Berkeley. Read More about SEBMF Celebrates 10 Years of Family Centered Care
Strong partnerships and working relationships among physicians are a vital part of great health care, but Clare Rudolph, M.D., has unique and enduring connections to her current medical partners Risa Kagan, M.D. and Marilyn Honegger, M.D.
The effects of breast cancer treatment can linger for months or years. It's common to wonder how your body should feel during this time and to worry about signs that cancer is coming back.
"It's not so much 'getting back to normal' as it is finding out what's normal for you now," says Risa Kagan, M.D., FACOG; Sutter Health gynecologist. "Your new normal may include making changes in the way you eat, the things you do and your sources of support."
These tips from the National Cancer Institute can help with the most common challenges for breast cancer survivors: Read More about Help in Managing Lingering Effects of Breast Cancer Treatment
By Chris Graham
Eden Medical Center
Fall-related injuries are a serious health threat to older adults, who are five times more likely to be hospitalized after a fall than for any other accident.
At least 20 to 30 percent of falls in older adults lead to serious injuries, such as hip fractures and head injuries.
What can you do to prevent a fall? Safeguard your independence by reducing your risks at home and in your daily activities. Read More about Take Action to Prevent Fall-Related Injuries
As he talks about his current situation, Ed Stump quickly mentions he is thankful for the blessings he's received. While he was recuperating from a heart attack at Alta Bates Summit Medical Center, social workers discovered that Stump, 57, didn't have a safe place to go when he was discharged.
"I was new to the area and I didn't have a place to live," he recalls. "I was dealing with a number of health problems and I was afraid of being on the street."
In the past, when a person in Ed's situation was released from a hospital stay they would recuperate on the streets, out in the elements. Their health would have improved more quickly if they had rested in a bed in a safe place. Often their conditions worsened and they were soon re-admitted into the hospital. Read More about Caring for Our Community: Safe Housing for Homeless Hospital Patients
To get the school year off to a safe and healthy start, Lisa A. Hills, M.D., Sutter East Bay Medical Foundation pediatrician, recommends:
Read More about Your Child's Back-to-School Health and Safety Checklist
Q: I've heard urinary tract infections (UTIs) are getting harder to treat. Why is this and who's at risk of developing one?
Jonathan Lynne, M.D., MPH, answered:
UTIs are one of the most common infections doctors treat: More than half of women living in the United States will get a UTI. Urinary tract infections are caused by microorganisms—usually bacteria—that enter the urethra and bladder, causing inflammation and infection. UTIs are more common in women because women have a shorter urethra than men do. That means bacteria travel a shorter distance to a woman's bladder. Read More about Ask the Expert: Are You at Risk for a Urinary Tract Infection?


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Episode 155-Mara Senn on FCPA Investigations and the Decision to Self-Disclose
The NLRB's Decision In Browning-Ferris Industries Of California (2015) One Month Later: Is The Sky Falling For Employers? -
The short answer to the question is, "Not yet." Browning-Ferris Industries of California, Inc....more
Earlier this month, the Illinois Appellate Court (First District) issued an opinion addressing a number of important student discipline and executive employment issues. Because the Appellate Court agreed with the trial court...more
Over the past several years, EmployNews has reported on dozens of National Labor Relations Board cases expanding the concept of employee rights in even non-unionized workplaces. Earlier this month, the NLRB added to this list...more
We have frequently commented on the National Labor Relations Board's (NLRB) expansion and creation of sweeping protections to employees engaging in union organizing and other activities protected under the National Labor...more
Since we last discussed "Deflategate," New England Patriots Quarterback Tom Brady appealed his four-game suspension resulting from the NFL's finding that he had committed "conduct detrimental to the league," based on 1) his...more
The Ninth Circuit released a precedent-setting Americans with Disabilities Act ("ADA") decision yesterday, and it's a big win for employers. The Court held that an employee who makes "serious and credible threats of violence...more
In a refreshing decision for employers, the D.C. Circuit Court of Appeals earlier this month tossed an eyebrow-raising NLRB decision which permitted AT&T customer-facing and publicly visible technicians to wear faux prison...more
Welcome to Reed Smith's Monthly Global Employment Law blog post. This month's post covers the legality of employee strikes in five key jurisdictions: France, Germany, Hong Kong, the UK and the United States.
Whenever an employer is considering disciplining an employee for misconduct, three names from 1967, 1975 and 1985 continue to be associated with employer investigations and interrogations, in much the same way that Mr....more
Most school administrators would be shocked to learn that the National Labor Relations Board (NLRB) could, in some circumstances, find that their school engaged in an unfair labor practice for disciplining or terminating an...more
Over the past few years, many employers have found out—the hard way—that the National Labor Relations Board is serious in policing employee handbooks for provisions that the Board believes are "overly broad" under Section 7...more
Hi there,
As a parent and grandparent I have long felt it was a necessary right of parents to swat their kids on the behind occasionally. Swift justice often makes the most impact....more
Under the National Labor Relations Act, certain union activities are considered "protected." That is, employees engaging in union activity, or union representatives carrying out their duties in the context of grievance...more
To begin with, full disclosure: I am a lifelong New England Patriots fan (and season ticket holder). However, as an attorney I am trained to be objective. The aftermath of the "Deflategate" investigation should be of...more
On June 15, 2015, the Colorado Supreme Court held in a unanimous decision that employers are still free to prohibit employee marijuana use in their workforces, and can still discipline and terminate employees who test...more
WTF already?! As in, "where's the fairness?" Time for an acronym update from our favorite government acronym, the NLRB. You will certainly remember that we have recommended asking yourself three questions before determining...more
The "Legal Question of the Week" is a regular feature of the CAS Weekly NewsBlast. Readers are invited to submit short, law-related questions of practical concern to school administrators. Each week, CAS will select a...more
In this episode I visit with Mara Senn, a partner at Arnold & Porter on how to think through a FCPA investigation and she provides a decision making calculus on how to make a decision...more
A 6'2', 300-lb employee's hostile, intimidating comment to a smaller co-worker in the company washroom was just cause for a three-day suspension, an arbitrator has decided. The evidence was that the suspended employee said,...more
If you like getting lost on roads with your head spinning on which way to go, this is your post. (Everyone else, well, try to keep up.) I recap a case for companies with unions to pay attention to....more
I recently overheard a plaintiff's employment lawyer quip that the best form of job security for an employee is to file a retaliation claim. While there may be some plausibility to that, it is certainly not a truism. There...more
As discussed previously (see Best Practices in Social Media for Employers Part 2), adopting a National Labor Relations Act (NLRA)-compliant social media policy is the first step in ensuring that the policy can be enforced. ...more
In a slip opinion released on Monday, March 9, 2015, styled Perez v. Mortgage Bankers Ass'n, No. 13-1041, slip op. (U.S. Mar. 9, 2015), the United States Supreme Court effectively gave federal agencies carte blanche to...more
Employers walk a fine line when it comes to employee discipline: they must enforce their rules while also protecting employee rights. Target seems to have missed the mark recently—a lawsuit alleges an employee committed...more
The recent decision in Ha v. Northwestern University, reiterates the leeway educational institutions have under Title IX when crafting a response to claims of sexual harassment. The plaintiff in Ha alleged that in February...more
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Studio DC: Almost Live is a special for the Disney Channel. The special is a half-hour variety show that features both The Muppets and Disney Channel stars performing comedy sketches and musical numbers together. The style is similar to that of The Muppet Show in that it features mayhem occurring on the Disney Channel Studio sets in place of the Muppet Theater. A second special aired October 5, 2008 with Selena Gomez, Demi Lovato, Jake T. Austin, Jason Earles, Jason Dolley, Moises Arias, David Henrie and The Cheetah Girls guest starring. At the D23 Expo, it was announced that both specials will be released on DVD sometime in 2010. Its only DVD releases so far have been in the UK, in Germany and in Argentina.
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Osteoarthritis (OA), the most common type of arthritis in the world, is associated with suffering due to pain, productivity loss, decreased mobility and quality of life. Systemic therapies available for OA are mostly symptom modifying and have potential gastrointestinal, renal, hepatic, and cardiac side effects. BMC Musculoskeletal Disorders recently published a study showing evidence of reparative effects demonstrated by homing of intra-articularly injected autologous bone marrow stem cells in damaged cartilage in an animal model of OA, along with clinical and radiographic benefit. This finding adds to the growing literature showing the potential benefit of intra-articular (IA) bone marrow stem cells. Other emerging potential IA therapies include IL-1 receptor antagonists, conditioned autologous serum, botulinum toxin, and bone morphogenetic protein-7. For each of these therapies, trial data in humans have been published, but more studies are needed to establish that they are safe and effective. Several additional promising new OA treatments are on the horizon, but challenges remain to finding safe and effective local and systemic therapies for OA.
Please see related article: http://www.biomedcentral.com/1471-2474/12/259 webcite
Keywords:osteoarthritis; intra-articular; novel; treatment; gene therapy; stem cell
Osteoarthritis (OA) is the most common type of arthritis and the leading cause of disability in the United States [1]. OA alone is responsible for $3.4 to $13.2 billion in job-related costs every year in the US. [2,3] and is associated with significant healthcare utilization, deficits in quality of life, and productivity loss [4-7]. Several systemic treatments, mostly symptom-modifying rather than disease-modifying agents, are available for OA [8]. Recently published OA treatment guidelines highlight the strength of evidence for various therapies [9-12]. However, there is a real need for effective, safe, disease-modifying OA therapies that can not only effectively treat those with established OA, but also possibly delay or prevent progression in those with early OA [13]. None of the potential therapies discussed in this editorial have been approved by regulatory agencies such as the US Food and Drug Administration (FDA), and therefore these therapies are experimental.
Stem cells for OA: a potential new treatment on the horizon?
Stem cells can differentiate into different cell lineages due to their self-renewing and clonogenic capabilities [14]. Embryonic stem cells have the capability to differentiate into any terminally differentiated cell in the body [15]. Adult stem cells were originally believed to only differentiate into tissue-specific cells. However adult stem cells may be programmed under specific signals to differentiate into other organ-specific cells with a phenotype distinct from that of the precursor. Certain barriers that exist to achieving this effectively in vivo must be overcome, namely, easy accessibility to sufficient concentration of stem cells at the site of tissue repair and generation of appropriate signals from the tissue repair site directing the cells to the site [15]. Stem cells can be administered via systemic intravascular route or a direct local implantation, such as that done to repair infracted myocardium [16,17] and in spinal cord injuries [18]. In a recent study by Mokbel et al. in BMC Musculoskeletal Disorders, labeled autologous adult stem cells suspended in hyaluronic acid were injected intra-articularly into carpal joints in an experimental arthritis induced by intra-articular (IA) Amphotericin-B in donkeys [19]. Significant improvement was noted in clinical and radiographic OA and significantly lesser histopathological changes of OA were seen in carpal joints that received IA autologous mesenchymal stem cells compared to control contralateral joints that received IA hyaluronic acid [19]. Importantly, injected stem cells were incorporated into the articular cartilage of the injected joint, as evident by their integration in the surface of the cartilage and also the interior of the cartilage. Interestingly, while some of these cells showed a chondrocyte-like phenotype indicating their differentiation, other injected cells retained spindle-like structure, characteristic of the mesenchymal origin. Previous studies have suggested that bone marrow and synovial mesenchymal stem cells have more chondrogenic potential compared to adipose or muscle mesenchymal stem cells [20]. While other studies have provided evidence that stem cells may offer potential therapeutic benefit in OA [21,22], challenges remain in the translation of this knowledge into available therapies for patients with OA. The challenges include homing of adequate number of cells in the tissues undergoing repair, long-term safety of such approaches especially those using viral vectors, the durability of the benefit, and feasibility of providing these treatments in busy practitioners' offices. Despite the challenges in bringing this potential therapy to clinic, stem cell therapy offers a revolutionary approach to the treatment of OA.
New pharmacotherapies for intra-articular use in osteoarthritis
While stem cell therapy may constitute a potential therapy for OA patients in the future, there is need for additional new effective and safe treatment options. Currently available systemic treatments for OA symptoms are commonly associated with gastrointestinal, hepatic, renal, and/or cardiac adverse events, especially in the elderly [8]. This makes IA and local therapies attractive options, especially for patients with limited OA in the knee or hip joints. The counter-argument is that OA is a systemic disease in many patients with involvement of several joints, and therefore there is also a great need for new systemic therapies. Additionally, IA administration may provide a higher concentration of the medication in the joint macro and micro environment, including the cartilage and synovium, and avoid several systemic adverse events [23]. The disadvantage of rare infection following IA injection (0.002%) [24] is far outweighed by its advantages. We discuss a few interesting potential new IA therapies with evidence of early efficacy in human OA. A more complete list is provided in Table 1.
Table 1. Emerging intra-articular therapies for osteoarthritis
Interluekin-1 beta (IL-1β), thought to play an important role in OA pathology, was targeted with IL-1 receptor antagonist administered IA (at 2 doses, 50 mg and 150 mg) as a single injection in 170 patients [25] and an antibody against IL-1 administered subcutaneously every 4 weeks for three months in 149 patients [26] in one placebo-controlled randomized controlled trial (RCT) each. There were no significant differences in the primary outcome, the Western Ontario McMaster Arthritis Index (WOMAC) scores, at 4-6 weeks follow-up between treatment and placebo groups, in either study. Biochemical and histopathogical changes, including decrease in synovial inflammation and hypertrophy, reduction in highly sensitive C-reactive protein and increase in proteoglycan content, were noted in the patients who received the active treatment. A high placebo response and short half-life of the molecule in the joint may be partially responsible for lack of an effect. It remains to be seen whether modifying the available preparations of IL-1β and/or targeting other cytokine targets in addition to IL-1β, can provide an effective treatment option.
There has been significant recent interest in the use of autologous conditioned serum, which is derived by incubating patient's serum with glass beads to induce the release of several anti-inflammatory cytokines such as IL-1 receptor antagonist, IL-4, IL-10, and IL-13, centrifuged and injected intra-articularly into the joints. However, the early results from two RCTs in humans are contradictory. One RCT of six IA injections showed no significant difference in WOMAC scores (primary outcome) compared to IA saline [27], while the other RCT reported significantly better outcome in IA autologous conditioned serum group, compared to IA hyaluronic acid or IA saline [28].
Another interesting approach is the use of IA botulinum toxin, which is hypothesized to have antinociceptive and possibly anti-inflammatory action. In three RCTs of a single IA injection of botulinum toxin in to 43-60 painful joints each (with painful OA or painful arthroplasty with OA as the underlying condition), clinically and statistically significant improvements in primary outcome of pain as well as extremity function (on WOMAC and shoulder indices) were noted in IA botulinum toxin group (with or without lidocaine) compared to control treatment (saline or saline plus lidocaine) [29-31]. In another RCT, IA botulinum toxin had efficacy similar to IA corticosteroid [32]. Botulinum toxin is known to inhibit substance P and calcitonin-gene related protein [33-36], the main mediators of neurogenic inflammation, a phenomenon of vasodilatation, protein extravasation, and stimulation of inflammatory cells induced by antidromic stimulation of primary afferent fiber [37].
Another therapy on the horizon targets bone morphogenetic protein-7 (BMP-7). In a phase I tolerability and safety study, IA recombinant human BMP-7 showed a higher response rate in treatment compared to the placebo group [38]. Other innovative therapies including human platelet-rich plasma [39,40], fibroblast growth factor-18 (FGF-18) [41,42], platelet-derived growth factor (PDGF) [43], and insulin-like growth factor (IGF) [43] are being tested in early (animal and early human) studies for their potential to repair cartilage (Table 1).
Conclusions: we are not there yet, but we are on our way
The interesting study by Mokbel et al. [18] provides additional evidence from animal models for the potential of autologous mesenchymal bone marrow stem cells as a potential future treatment for OA. Early evidence from human RCTs is also available for additional IA therapies such as IL-1β antagonists, autologous conditioned serum and botulinum toxin. Whether these approaches will translate into effective and safe therapies for humans remains to be seen. This next step will need more convincing evidence of therapeutic efficacy and safety in humans in large RCTs and correlation with improvements in disease pathophysiology, with the use of serum and joint biomarkers and/or imaging biomarkers (radiographs, magnetic resonance imaging, and so on). The future of OA therapeutics seems bright, with a lot of potential therapies targeting different mechanisms of action, different pathways and different approaches for this disabling disease.
Competing interests
There are no financial conflicts related to this work. JAS has received investigator-initiated research and travel grants from Takeda, Allergan and Savient; consultant fees from Takeda, Ardea, Savient, Allergan, Novartis, and URL pharmaceuticals; and is a member of the executive of OMERACT, an organization that develops outcome measures in rheumatology and receives arms-length funding from 36 companies.
Authors' contributions
JAS: Concept of the editorial, literature review, preparation of editorial, and revision of the manuscript.
Author information
JAS is a rheumatologist-epidemiologist, an Associate Professor of Medicine and Epidemiology at the University of Alabama at Birmingham and staff physician at the Birmingham Veterans Affairs Medical Center. JAS is a member of the American College of Rheumatology and serves as a committee member on the Guidelines subcommittee of the American College of Rheumatology's Quality of Care committee, Veterans Affairs Rheumatology Field Advisory Committee, and the executive committee of the Outcome Measures in Rheumatology Trials (OMERACT).
I thank Dr David Hunter for helpful suggestions related to this manuscript. No specific grant was obtained to support this work. This material is the result of work supported by the resources and the use of facilities at the Birmingham VA Medical Center, Alabama, USA. JAS is also supported by research grants from the National Institute of Aging, National Cancer Institute, and Agency for Health Quality and Research Center for Education and Research on Therapeutics (CERTs).
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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