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On this blog, I have repeatedly tried to explain why integrative (or integrated) medicine is such a deceptive nonsense; see for instance here, here and here. Today, I have reason to make another attempt: The International Congress on Integrative Medicine & Health.
In 2012, I published an analysis of the '3rd European Congress of Integrated Medicine' which had taken place in December 2010 in Berlin (in Europe they call it 'integrated' and in the US 'integrative' medicine). For this purpose, I simply read all the 222 abstracts and labelled them according to their contents. The results showed that the vast majority were on unproven alternative therapies and none on conventional treatments.
The abstracts from the International Congress on Integrative Medicine & Health (ICIMH, Green Valley Ranch Resort, Las Vegas, Nevada, USA, May 17–20, 2016) which were just published provide me with the opportunity to check whether this situation has changed. There were around 400 abstracts, and I did essentially the same type of analysis (attributing one subject area to each abstract). And what a tedious task this was! I spotted just two articles of interest, and will report about them shortly.
This time I also assessed whether the conclusions of each paper were positive (expressing something favourable about the subject at hand), negative (expressing something negative about the subject at hand) or neither of the two (surveys, for instance, rarely show positive or negative results).
Here are the results: mind-body therapies were the top subject with 49 papers, followed by acupuncture (44), herbal medicine (37), integrative medicine (36), chiropractic and other manual therapies (26), TCM (19), methodological issues (16), animal and other pre-clinical investigations (15) and Tai Chi (5). The rest of the abstracts were on a diverse array of other subjects. There was not a single paper on a conventional therapy and only 4 focussed on risk assessments.
The 36 articles on integrative medicine deserve perhaps a special mention. The majority of these papers were about using alternative therapies as an add-on to conventional care. They focussed on the alternative therapies used and usually concluded that this 'integration' was followed by good results. None of these papers discussed integrative medicine and its assumptions critically, and none of these investigations cast any doubt about the assumption that integrative medicine is a positive thing.
I should also mention that my attributions of the subject areas were not always straight forward. I allowed myself only one subject per paper, but there were, of course, many that could be categorised in more than one subject area ( for instance, a paper on an herbal medicine might be in that category, or in TCM or in pre-clinical). So I tried to attribute the subject that seemed to dominate the abstract in question.
My analysis according to the direction of the conclusions was equally revealing: I categorised 260 papers as positive, 5 as negative and 116 as neither of the two. That means for every negative result there were 52 positive ones. I find this most remarkable.
Essentially, my two analyses of conference abstracts published 6 years apart show the same phenomenon: on the 'scientific level', integrative medicine is not about the 'best of both worlds' (i. e. the best alternative medicine has to offer integrated with the best conventional medicine offers) – the slogan by which advocates of integrative medicine usually try to 'sell' their dubious approach to us. It is almost exclusively about alternative therapies which advocates of integrative medicine aim to smuggle into mainstream healthcare. Critical analysis seems to be unwelcome in this area, and – perhaps worse of all – in the last 6 years, there does not seem to have been any improvement.
And that's just on the 'scientific level', as I said. If you wonder what is happening on the 'practical level', you will find that, in the realm of integrative medicine, every quackery under the sun is being promoted at often exorbitant prices to the often gullible and always unsuspecting public. If you don't believe me, search for 'integrative medicine clinic' on the Internet; I promise, you will be surprised!
Personally, I am sometimes amused by the sheer idiocy of all this, but more often I am enraged and ask myself:
- Why are we allowing quackery to make such a spectacular come-back?
- Why is hardly anyone voicing strong objections?
- Is it not our ethical duty to do something about it and try to prevent the worse?
One argument I hear over and over again; it could be called 'the fallacy of the benign placebo' and goes like this:
- Alright, I accept that the evidence for xy isn't brilliant.
- I might even accept it is a pure placebo therapy.
- But that is not important.
- What counts is that it helps suffering patients.
- Who cares about the mechanism?
- As long as a therapy can be shown to be helpful, we should use it!
I am sure you agree, this fallacy is extremely common. What is more, it is damn difficult to argue against. Whatever I used to counter, people would look at me in disbelief thinking: those scientists really sit in their ivory towers and haven't got a clue about the real issues.
In my frustration of not getting through to many people, I have now thought of THE TELLING TALE OF THE PLACEBO BANKER.
Allow me to explain:
Imagine you are in real difficulties. You lost your job, your wife is ill, your children need feeding, the bills are stacking up – in a word, you need a loan to survive the next few months until things are sorted out.
Luckily, you know a very nice chap who is in charge of your local bank and who has a reputation of trying his utmost to help clients in need. So, you make an appointment and see him. He listens attentively and shows compassion for your situation. He gives you all the time to explain things in full detail and then re-assures you that there is hope: he will help you! At the end of the consultation you leave his office feeling well and optimistic. You even have in your hands a tidy amount of money that will get you through this bad patch. All is fine…because you have seen a real banker who knows his job in such situations consists mainly of two things:
- be kind, listen with empathy and give assurance that makes customers feel good,
- give the necessary credit.
- show compassion and empathy,
- prescribe an effective treatment.
Now, imagine you are in dire straights again. This time you go to a different banker, someone who has the reputation to be even kinder and more 'holistic'. The consultation proceeds much as the last one. The banker listens, offers help and shows compassion. If anything, this new chap is even better at this task. He is more understanding than the last one, he even explains why you got into difficulties, and he has a full hour just to talk with you. Consequently, you feel really good about the whole thing, and you are happy as he gives you an envelope full of money that will assist you solving your current problems. You go home and feel great…until, three days later, you need to pay your first bill, open the envelope and discover that it contains plenty of notes, but they are all Monopoly money. You discover that you have become the victim of THE PLACEBO BANKER.
The placebo banker is, of course, akin to the placebo therapist who can do little more than:
- show compassion and empathy,
- dish out placebos.
I know, the analogy is not perfect but is explains the fallacy a bit, I hope.
Good banking consists of courteous behaviour and adequate financial assistance.
Good medicine consists of compassion and effective treatments.
If one of the two essential elements is missing, neither the banking nor the medicine can be good or ethical.
You have to admit, quacks had a difficult time recently:
- homeopathy has been disclosed as humbug,
- chiropractic is not much better,
- 'acupuncture awareness week' left acupuncturists bruised…
Need I go on?
One has to pity these guys; their income is dwindling; they have no pensions, no unions to protect them etc., they know nothing other than quackery…what can they do? They are clearly fighting for survival.
I suggest we all focus, use our imagination and come up with come constructive ideas to help them.
Alright, I start: HOLISTIC DOPING
The fate of the poor (not in a monetary sense, of course) tennis star Sharapova gave me that brainwave.
Our elite athletes are in a pickle: they feel the need to enhance their performance but more and more ways of achieving this with cleverly administered drugs are becoming illegal. Their livelihood is at stake almost as much as that of our dear quacks.
What if the two groups jointed forces?
What if they decided to help solve each others' problems?
This could be a classical win/win situation!
I am sure homeopaths, chiropractors, acupuncturists etc. could design holistic program for improving athletic performance. It would be highly individualised and embrace body, mind, spirit, sole and anything else they can think of. It could include the newest concepts in quantum healing, energy field, qi, vital force, etc. The advantages are obvious, I think:
- none of these interventions will ever be found on a list of forbidden drugs,
- the program will work perfectly well because it will generate large placebo responses,
- performance will therefore increase (as always in alternative medicine, anecdotal 'evidence' will suffice) ,
- and so will the quacks' cash flow.
Is there a downside? Not really…oh, hold on…yes there is!
My idea is not that original; others have had it already. In fact, there are quite a few quacks offering alternatives to good old-fashioned doping.
MORE than £150,000 was spent by NHS Grampian on homeopathic treatments last year. Referrals to homeopathic practitioners cost £37,000 and referrals to the Glasgow Homoeopathic Hospital cost £7,315 in 2014-15. In view of the fact that highly diluted homeopathic remedies are pure placebos, any amount of tax payers' money spent on homeopathy is hard to justify. Yet an NHS Grampian spokeswoman defended its use of by the health board with the following words:
"We have a responsibility to consider all treatments available to NHS patients to ensure they offer safe, effective and person-centred care. We also have a responsibility to use NHS resources carefully and balance our priorities across the population as well as individuals. We also recognise that patient reported outcome and experience measures are valued even when objective evidence of effectiveness is limited. Homeopathy can be considered in this arena and we remain connected with the wider debate on its role within the NHS while regularly reviewing our local support for such services within NHS Grampian."
Mr Spence, a professional homeopath, was also invited to defend the expenditure on homeopathy: "When a friend started talking to me about homeopathy I thought he had lost his marbles. But it seemed homeopathy could fill a gap left by orthodox medicine. Homeopathy is about treating the whole person, not just the symptoms of disease, and it could save the NHS an absolute fortune. If someone is in a dangerous situation or they need surgery then they need to go to hospital. It's often those with chronic, long-term problems where conventional treatment has not worked that can be helped by homeopathy."
What do these arguments amount to, I ask myself.
The answer is NOTHING.
The key sentence in the spokeswomen's comment is : "patient reported outcome and experience measures are valued even when objective evidence of effectiveness is limited." This seems to admit that the evidence fails to support homeopathy. Therefore, so the argument, we have to abandon evidence and consider experience, opinion etc. This seemingly innocent little trick is nothing else than the introduction of double standards into health care decision making which could be used to justify the use of just about any bogus therapy in the NHS at the tax payers' expense. It is obvious that such a move would be a decisive step in the wrong direction and to the detriment of progress in health care.
The comments by the homeopath are perhaps even more pitiful. They replace arguments with fallacies and evidence with speculation or falsehoods.
There is, of course, a bright side to this:
One of the most common claims of alternative practitioners is that they take a holistic approach to health care. And it is this claim which attracts many consumers. It also makes conventional medicine look bad, reductionist and inhuman, as it implies that mainstream medicine is non-holistic.
The claim can be easily disclosed to be a straw man, because all good medicine was, is and always will be holistic. Moreover, the claim amounts to a falsehood, because much of alternative medicine is everything but holistic. I will try to explain what I mean using the recent example of acupuncture for neck pain, but I could have used almost any other alternative treatment and any other human complaint/condition/disease:
- chiropractic for back pain;
- homeopathy for asthma;
- energy healing for depression;
- aromatherapy for jet lag;
- etc. etc.
The recent trial found that adding acupuncture to usual care yields a slightly better outcome than usual care alone. This is hardly a big deal; adding a good cup of tea and a compassionate chat to usual care might have done a similar thing. Acupuncturists, however, will say that their holistic approach is successful.
How holistic is acupuncture?
A 'Western' acupuncturist would normally ask what is wrong with the patient; in the case of neck pain, he would probably ask several further questions about the history of the condition, when the pain occurs, what aggravates it etc. Then he might conduct a physical examination of his patient. Eventually, he would get out his needles and start the treatment.
A 'traditional' acupuncturist would ask similar questions, feel the pulse, look at the tongue and make a diagnosis in terms of yin and yang imbalance. Eventually, he too would get out his needles and start the treatment.
Is that holistic?
Certainly not! If we look at alternative practitioners in general, we cannot fail to notice that they tend to be the very opposite of holistic. They usually attribute a patients illness to one single cause such as yin/yang imbalance (acupuncture), subluxation (chiropractic), impediment of the life force (homeopathy), etc.
Holistic means that the patient is understood as a whole person. Our neck pain patient might have physical problems such as muscular tension; the acupuncturists might well have realised this and placed their needles accordingly. But neck pain, like most other symptoms, can have many other dimensions:
- there could be stress;
- there could be an ergonomically disadvantageous work place;
- there could be a history of injury;
- there could be a malformation of the spine;
- there could be a tumour;
- there could be an inflammation;
- there could be many other specific diseases;
- there could be relationship problems, et. etc.
Of course, the acupuncturists will claim that, during an acupuncture session, they will pick up on all of these. However, in my experience, this is little more than wishful thinking. And even if they did pick up other dimensions of the patient's complaint, what can they do about it? They can (and often do) give rather amateur advice. This may be meant most kindly but it is rarely optimal.
And what about conventional practitioners, aren't they even worse?
True, there often is far too much room for improvement. But at least the concept of multifactorial conditions and treatments is deeply ingrained in everyone who has been to medical school. We learn that symptoms/complaints/conditions/diseases are almost invariably multifactorial; they have many causes and contributing factors which can interact in complex ways. Therefore, responsible physicians always consider to treat patients in multifactorial ways; in the case of our neck pain patient:
- the stress might need a relaxation programme,
- the work place might need the input of an occupational therapist;
- in case of an old injury, a physio might be needed;
- specific conditions might need to be seen by a range of medical specialists;
- muscular tension could be reduced by a massage therapist;
- relationship problems might require the help of a psychologist; etc. etc.
I am NOT saying that all of this is necessary in each and every case. But I am saying that, in conventional medicine, both the awareness and the possibility for a professional multidisciplinary approach is well established. You don't believe me? Ask a physiotherapist or an occupational therapist who refers more patients to them, an acupuncturist or a GP!
Alternative practitioners claim to be holistic and some might even be aware of the complexity of their patients' symptoms. But, at best, they have an amateur approach to this complexity by dabbling themselves in issuing more or less suited advice. They are not adequately trained to do this job, and they refer very rarely.
My conclusion: professional multidiscipinarity is an approach deeply engrained in conventional medicine (we don't often call it holism, perhaps because many doctors associate this term with charlatans), and it beats the mostly amateurish pseudo-holism of alternative practitioners any time.
We could have expected it, couldn't we? With so much homeopathy in the press lately, Dr Dixon (we have seen him on this blog before, for instance here, here and here) had to comment. His article in yesterday's NURSING IN PRACTICE is far too perfect to abbreviate it; I just have to cite it in full (only the reference numbers are mine and refer to my comments below).
Should homeopathy be blacklisted in general practice?
I have not prescribed them myself but I know of many GPs and patients who find homeopathic preparations helpful, especially in clinical areas where there is no satisfactory conventional treatment [1]. They are cheap and entirely safe [2], which cannot always be said of conventional treatment [3]. Is the concern about cost? That is implausible as GP prescriptions cost a mere £100,000 per annum, approximately £10 per UK General Practice but effectively less as some patients will be paying for them and they may reduce other prescriptions or medical costs [4]. Is it about evidence? [5] Possibly, and that is because the necessary pragmatic trials on comparative cost effectiveness have never been done [6]. Homeopathy thus joins the frequently quoted 25% of general practice activity that has an insufficient evidence base… So, why not do the research rather than single out homeopathy for blacklisting [7]? Apparently, because it irritates a powerful fraternity of "scientists" [8] with a narrow biomedical perspective on health and healing, who feel the need to impose their atheism [9] on others. They seem opposed to "patient-centred medicine" which factors in the mindset, culture, history, wishes and hopes of each patient, and a wider concept of science that might take account of them [10]. Led by the World Health Organization, many countries are examining the appropriate role of complementary and traditional medicine (CAM). Indian Prime Minister Modi has created the first minister for medicine in this area (called AYUSH with the "H" standing for homeopathy). Australia, whose government and medical deans (unlike the UK ) are not intimidated by this breed of scientific fundamentalism, has invested money in research, regulated its herbal [11] practitioners and created important trade links with China in this area [12]. Meanwhile the UK invests 0% of its research budget on CAM and appears to have a closed mind [13]. General practice is at its best a subtle and complex blend of science and art combined in a heady mixture, which recognises personal belief and perspective and respects differences [14]. Blacklisting homeopathy would be the thin edge of the wedge. It would be a mean-minded act of outside interference by many who do not treat patients themselves, denying patient choice and signifying a new age of intolerance and interference [15]. It is a threat to the autonomy of general practice that should concern every GP and patient whatever their views on homeopathy [16].
About the Author
Chairman of the NHS Alliance and a GP
Mike Dixon, chairman of the NHS Alliance and a GP at College Surgery in Cullompton, Devon and a Royal College of General Practitioners presidential candidate.
- Whenever this argument comes up, people fail to cite an example. Are they afraid that we would point out what can be done for such a patient other than prescribing placebos?
- Actually, they are extremely expensive considering that they are just lactose or water. And the claim that homeopathy is safe merely displays an embarrassing lack of knowledge; see the many posts on this blog that deal with this issue.
- Classical 'tu quoque' fallacy; display of the ignorance of the risk/benefit concept for judging the value of medical interventions.
- Display of ignorance regarding the actual evidence, see here, for instance.
- Yes, it's the evidence but also it's the biological implausibility and the fact that disregarding it undermines rationality in general.
- Pure ignorance again, see my point 4.
- Are ~ 300 clinical trials and about 100 systematic reviews not enough? How much more money needs to be wasted?
- It seems that Dixon has a problem with science and those who pursue it to improve future health care for the benefit of patients.
- Does Dixon admit that homeopathy is a religion?
- Patient-centred medicine which factors in the mindset, culture, history, wishes and hopes of each patient, and a wider concept of science that might take account of them – does Dixon not know that all good medicine fits this description, but homeopathy certainly does not?
- Every one with an IQ above 50 knows by now that herbal is not homeopathic; is Dixon the exception?
- What about the Australian report which concluded that "Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments."
- This is simply not true, and Dixon should know it.
- No reason to include disproven nonsense like homeopathy.
- Intolerance is on Dixon's side, I think. Improving health care by abandoning disproven therapies in favour of evidence-based treatments is no interference, it's progress.
- This can only be true, if we misunderstand autonomy as arbitrariness without rules, checks, ethics and controls. Good general practice has, like all medicine, be in the best interest of patients. An obsolete, expensive, unsafe, ineffective and implausible treatment is clearly not.
I am probably more used to nonsensical statements by promoters of alternative medicine than the average person. But the 'ALTERNATIVE MEDICINE ZONE' just broke my BS-meter. Here are a few samples from their most remarkable website, all relating to homeopathy:
There has always been a debate whether allopathic treatment methods of the modern age are more beneficial or are the natural homeopathic treatment ways more reliable. The goal of healing the sick is the same in both these groups of treatment, but there is a strong contrast in the methods use, the ideology behind the treatment and the detailed theories. The following is a detailed comparison between homeopathy and Allopathy for those who wish to pick between the two:
Allopathic practitioners aim to target that part of the body that has been affected by a problem or disease and they do so by identifying the causing agent. On the other hand, in Homeopathy, doctors believe that emotional stress or psychological reasons make the body more susceptible to diseases and use more of a holistic approach of treatment.
Allopathic doctors make use of those medications which are produced by pharma companies or are man-made. On the other hand, Homeopathy uses natural supplements and cures such as herbs, dietary changes and other such ways to cure a disease. Allopathic doctors use an aggressive approach whereas homeopathic doctors consider one dose enough to treat a disease.
While on one hand, allopathic doctors consider surgeries to be very important for removal of tumors etc. or correcting problems inside the body, Homeopathic doctors almost never use surgery as a treatment method. Only when certain tissue in the body has become seriously damaged they practice this technique.
Allopathic surgeons heavily rely on surgical procedures in case of serious diseases which cannot be cured by medicines or any other approach. Homeopathic doctors try to treat each and every condition with a natural method or by recommending strong dietary changes.
Homeopathy is basically based on beliefs of German Physician Samuel Hahnemann whereas Allopathic system of treatment or cure of diseases is based on the principles of the ancient Greeks, for example Hippocrates. Allopathic is considered to be regular medicine in many countries such as US but Homeopathy is argued to be a natural and holistic way of cure.
Both these schools of medicine consider the other to be non-beneficial. Homeopathy thinks that allopathic medicines tend to make people even sicker in the long run whereas Allopathy doctors believe that Homeopathy only uses Placebo as its mechanism to cure people. Supporters of both schools are often seen defending their preferred method of treatment.
The 'ALTERNATIVE MEDICINE ZONE' also does not shy away from giving concrete medical advice on their website. Two examples will have to suffice:
Compare to anti-viral medicines, homeopathy has proved more effective for shingles and chicken pox. It offers rapid and successful approach in treating this infection. People with weak immune system are more prone to get shingles. Homeopathy medicines influence the immune system efficiently from within and improve body's healing capacity. The homeopathy medicines are also capable of defusing pain, discomfort in body due to shingle. It also refrain shingles from spreading.
The homeopathic treatment is considered much better than surgery because it corrects the problem from the root which is not the case in surgery. Homeopathy is considered very useful in the early cases of piles and can help in complete healing. However as the problem becomes complex, it can only help in the healing of the symptoms.
Both articles finish by giving a list of homeopathic remedies that are recommended for the two conditions.
So there we have it!
My BS-meter has just broken.
Who can I sue?
We used to call it 'alternative medicine' (on this blog, I still do so, because I believe it is a term as good or bad as any other and it is the one that is easily recognised); later some opted for 'complementary medicine'; since about 15 years a new term is en vogue: INTEGRATED MEDICINE (IM).
Supporters of IM are adamant that IM is not synonymous with the other terms. But how is IM actually defined?
One of IM's most prominent defenders is, of course Prince Charles. In his 2006 address to the WHO, he explained: "We need to harness the best of modern science and technology, but not at the expense of losing the best of what complementary approaches have to offer. That is integrated health – it really is that simple."
Perhaps a bit too simple?
There are several more academic definitions, and it seems that, over the years, IM-fans have been busy moving the goal post quite a bit. The original principle of 'THE BEST OF BOTH WORLDS' has been modified considerably.
- IM is a "comprehensive, primary care system that emphasizes wellness and healing of the whole person…" [Arch Intern Med. 2002;162:133-140]
- IM "views patients as whole people with minds and spirits as well as bodies and includes these dimensions into diagnosis and treatment." [BMJ. 2001; 322:119-120]
During my preparations for my lecture at the 16th European Sceptics Congress in London last week (which was on the subject of IM), I came across a brand-new (September 2015) definition. It can be found on the website of the COLLEGE OF MEDICINE This Michael Dixon-led organisation can be seen as the successor of Charles' ill-fated FOUNDATION FOR INTEGRATED HEALTH; it was originally to be called COLLEGE FOR INTEGRATED MEDICINE. We can therefore assume that they know best what IM truly is or aspires to be. The definition goes as follows:
IM is a holistic, evidence-based approach which makes intelligent use of all available therapeutic choices to achieve optimal health and resilience for our patients.
This may sound good to many who are not bothered or unable to think critically. It oozes political correctness and might therefore even impress some politicians. But, on closer scrutiny, it turns out to be little more than offensive nonsense. I feel compelled to publish a short analysis of it. I will do this by highlighting and criticising the important implications of this definition one by one.
1) IM is holistic
Holism has always been at the core of any type of good health care. To state that IM is holistic misleads people into believing that conventional medicine is not holistic. It also pretends that medicine might become more holistic through the addition of some alternative modalities. Yet I cannot imagine anything less holistic than diagnosing patients by merely looking at their iris (iridology) or assuming all disease stems from subluxations of the spine (chiropractic), for example. This argument is a straw-man, if there ever was one.
2) IM is evidence-based
This assumption is simply not true. If we look what is being used under the banner of IM, we find no end of treatments that are not supported by good evidence, as well as several for which the evidence is squarely negative.
3) IM is intelligent
If it were not such a serious matter, one could laugh out loud about this claim. Is the implication here that conventional medicine is not intelligent?
4) IM uses all available therapeutic choices
This is the crucial element of this definition which allows IM-proponents to employ anything they like. Do they seriously believe that patients should have ALL AVAILABLE treatments? I had thought that responsible health care is about applying the most effective therapies for the condition at hand.
5) IM aims at achieving optimal health
Another straw-man; it implies that conventional health care professionals do not want to restore their patients to optimal health.
In my lecture, which was not about this definition but about IM in general, I drew the following six conclusions:
- Proponents of IM mislead us with their very own, nonsensical terminology and definitions.
- They promote two main principles: use of quackery + holism.
- Holism is at the heart of all good medicine; IM is at best an unnecessary distraction.
- Using holism to promote quackery is dishonest and counter-productive.
- The integration of quackery will render healthcare not better but worse.
- IM flies in the face of common sense and medical ethics; it is a disservice to patients.
The Americans call it 'INTEGRATIVE MEDICINE'; in the UK, we speak of 'INTEGRATED MEDICINE' – and we speak about it a lot: these terms are, since several years, the new buzz-words in the alternative medicine scene. They sound so convincing, authoritative and politically correct that I am not surprised their use spread like wild-fire.
But what is INTEGRATED MEDICINE?
Let's find out.
If the BRITISH SOCIETY OF INTEGRATED MEDICINE (BSIM) cannot answer this question, who can? So let's have a look and find out (all the passages in bold are direct quotes from the BSIM):
Integrated Medicine is an approach to health and healing that provides patients with individually tailored health and wellbeing programmes which are designed to address the barriers to healing and provide the patient with the knowledge, skills and support to take better care of their physical, emotional, psychological and spiritual health. Rather than limiting treatments to a specific specialty, integrated medicine uses the safest and most effective combination of approaches and treatments from the world of conventional and complementary/alternative medicine. These are selected according to, but not limited to, evidence-based practice, and the expertise, experience and insight of the individuals and team members caring for the patient.
That's odd! If the selected treatments are not limited to evidence, expertise, experience or insight, what ARE they based on?
Fascinated I read on and discover that there are 'beliefs'. To be precise, a total of 7 beliefs that healthcare
- Is individualised to the person – in that it takes into account their needs, insights, beliefs, past experiences, preferences, and life circumstances
- Empowers the individual to take an active role in their own healing by providing them with the knowledge and skills to meet their physical and emotional needs and actively manage their own health.
- Attempts to identify and address the main barriers or blockages to a person experiencing their health and life goals. This includes physical, emotional, psychological, environmental, social and spiritual factors.
- Uses the safest, most effective and least invasive procedures wherever possible.
- Harnesses the power of compassion, respect and the therapeutic relationship
- Focuses predominantly on health promotion, disease prevention and patient empowerment
- Encourages healthcare practitioners to become the model of healthy living that they teach to others.
I cannot say that, after reading this, I am less confused. Here is why:
- All good medicine has always been 'individualised to the person', etc.
- Patient empowerment is a key to conventional medicine.
- Holism is at the heart of any good health care.
- I do not know a form of medicine that focusses on unsafe, ineffective, unnecessarily invasive procedures.
- Neither am I aware of one that deliberately neglects compassion or disrespects the therapeutic relationship.
- I was under the impression that disease prevention is a thing conventional medicine takes very seriously.
- Teaching by example is something that we all know is important (but some of us find it harder than others; see below).
Could it be that these 'beliefs' have been 'borrowed' from the mainstream? Surely not! That would mean that 'integrated medicine' is not only not very original but possibly even bogus. I need to find out more!
One of the first things I discover is that the 'Founder President' of the BSIM is doctor Julian Kenyon. Now, that name rings a bell – wasn't he mentioned in a previous post not so long ago? Yes, he was!
Here is the post in question; Kenyon was said to have misdiagnosed/mistreated a patient, exposed on TV, and eventually he ended up in front of the General Medical Council's conduct tribunal. The panel heard that, after a 20-minute consultation, which cost £300, Dr Kenyon told one terminally-ill cancer patient: "I am not claiming we can cure you, but there is a strong possibility that we would be able to increase your median survival time with the relatively low-risk approaches described here." He also made bold statements about the treatment's supposed benefits to an undercover reporter who posed as the husband of a woman with breast cancer. After considering the full details of the case, Ben Fitzgerald, for the General Medical Council, called for Dr Kenyon to be suspended, but the panel's chairman argued that Dr Kenyon's misconduct was not serious enough for this. The panel eventually imposed restrictions on Kenyon's licence lasting for 12 months.
Teaching by example, hey???
This finally makes things a bit clearer for me. There is only one question left to my mind: DOES BSIM PERHAPS STAND FOR 'BULL SHIT IN MEDICINE'?
In a recent Editorial, I wrote: "Complementary and alternative medicine (CAM) is popular, and many nurses seem to be embracing it in the hope of helping their patients…But despite its popularity, CAM has remained a highly controversial area: the evidence-base is often unconvincing or non-existent. For most forms of CAM, we thus know too little to claim with confidence that they generate more good than harm. In the interest of our patients, it might, therefore, be wise to exercise caution and be aware of some of the fallacies which can easily mislead us."
Yet, my calls for caution seem to fall on nurses' deaf ears. This is at least what a new article on this subject implies.
This paper investigated how frequently nurses include CAM in their clinical practice. In so doing, its authors investigated nurses' knowledge of and attitudes towards CAM as well as their ability to communicate the risks and benefits of these therapies with patients. For this purpose, a review was conducted in five stages: (1) identification of research question(s), (2) locate studies, (3) selection of studies, (4) charting of data, and (5) collating, summarising, and reporting of results.
Fifteen papers met the inclusion criteria for the review, among which 53·7% referenced how frequently nurses include CAM in their practice. The researchers found that 66·4% of nurses had positive attitudes towards CAM; however, 77·4% did not possess a comprehensive understanding of the associated risks and benefits. In addition, nearly half of the respondents (47·3-67·7%) reported feeling uncomfortable discussing CAM therapies with their patients.
The authors concluded that the lack of knowledge about complementary and alternative medicine among nurses is a cause for concern, particularly in light of its widespread application. Findings from this study suggest that health care professionals need to promote evidence informed decision-making in complementary and alternative medicine practice and be knowledgeable enough to discuss complementary and alternative medicine therapies. Without involvement of complementary and alternative medicine communication on the part of our profession, we may put our patients at risk of uninformed and without medical guidance.
I think I understand why many nurses feel attracted by CAM; if nothing else, it offers the opportunity to exercise compassion and empathy in patient care – and these are qualities that are often badly needed in routine practice. But it would be important (not just for nurses but for all health care professionals) to realise that compassion is best when it is paired with evidence-based care and effective treatments rather than with quackery and unproven therapies.


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This began life originally as a 1939 Buck Rogers serial starring Buster Crabbe. It was edited into a 69 minute feature-length film in 1953 which the version I'm reviewing. Apparently there is also a 90 minute version released in 1977 to cash in on Star Wars-mania.
Buck Rogers, and sidekick Buddy, crash their dirigible(!) in the arctic and are left in suspended animation for 500 years. Revived by Dr. Huer, they discover that Earth is in the villainous grip of the outlaw Killer Kane. With the help of the lovely Lt. Deering, Buck is able to defeat Kane and the world is safe again! Until next Saturday afternoon anyway.
You can't help but love these old serials. They're action-packed with thrilling derring-do, and are now charmingly anachronistic, as when Buck marvels that his spaceship must be travelling a thousand miles per hour (gasp)! Yes, they are hopelessly old-fashioned and primitive, but they are also wonderfully fun with their art deco buildings and cities.
And it is Buster Crabbe's sincere charm that carries the film. He anchors it with an honest presence that most actors today must wish they had.
This was how the future should have been.

subset: commoncrawl


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All the News They Won't Print
Before you read further, go use the restroom, make yourself a snack, grab your favorite sipping beverage, and make yourself comfortable. Ready? Okay, now you are ready to proceed.
Chrenkoff has an amazingly long account of good news from Iraq. Go ahead. Read it. Fox will repeat their coverage of the Sheehan saga every 15 minutes so you won't miss a thing.


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1st) Would Shelley H that bought my kits in Rhode Island please get ahold of me. Email me here:
Thank You!!
Good morning all my cheerful beady readers!!! I had to be concerned when I awoke this morning and saw very thick fog!! We watched Stephen King's new flick last night 'The Mist', so ironically I had to look around before I walked out the door LOL If you like Stephen King, it naturally has to go on the 'watch' list!!!!! The ending will leave you speechless!!!
While I was watching the movie I was also finishing up another class 'prototype'. I had made one before, but it has sold, so I think I will have to make many more of these! This appeals to the 'crow' in all you women, and yes, some men LOL This is the class, but I am also going to make this into a bangle, available for sale and in kits, in different colors, of course. It is laden heavily with Swarovski Crystals!! 55 alone in my size. I hope you like it!


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One of the campaigns I was working on through EcoCascadia.org over the past year was the "One Less Plastic Bag" at MEC campaign.
At the MEC Annual General Meeting a resolution was passed, that will take some steps to reduce the use of plastic bags at MEC. I think they could have gone further but this is a move in the right direction.
Friday, June 03, 2005
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In Focus posts the Winners of the 2014 National Geographic Photo Contest. "National Geographic Magazine just announce the winners of this year's photo contest. The Grand Prize Winner, Brian Yen, will receive $10,000 and a trip to National Geographic headquarters to participate in its annual photography seminar. Gathered below are the winning images from the People, Nature, and Places categories, as well as honorable mentions, with captions written by the individual photographers. Be sure to see earlier selections of the entries, Part I, and Part II, earlier on In Focus. [19 photos]"
I find most of them interesting, but not exactly beautiful.


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Dates: 08/02/2018
Start Time: 19:00
Location: Cardiff
Venue: Motorpoint Arena
Competition: PDC Darts
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- Angelina Harmon
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2 CYCLING IN THE NETHERLANDS 16 mln people own 16 mln bicycles ride 16 mln bicycle trips/day
3 CYCLING IN THE NETHERLANDS 27% of trips are by bicycle, 19% by walking, and increasing Car driver Bike Car pass. Walk Train Other Modal split in the Netherlands, period Bus/tram metro Motorcycle/ scooter Source: Mobility Survey Netherlands 3
4 SUCCESS FACTORS OF DUTCH BICYCLE POLICY 1. Cultural and political 2. Geography and spatial development 3. A high level of bicycle infrastructure, also parking 4. Good integration with public transport 5. A strong and innovative industry 6. Effective traffic safety policies and legislation 7. High level of knowledge and experience in spatial and transport planning and the ability to apply this in practice 4
5 CYCLING: THE SUSTAINABLE TRANSPORT MODE Cycling is part of the transport system in high motorized countries Cycling contributes to livelihood, to urban quality and the economic vitality of cities: Active and healthy Efficient, particularly at the short to medium distances Door-to-door (home school, work home) Relatively cheap Cycling is an important feeder (access and egress) for public transport Zero-emission The social, economic and environmental benefits of cycling are therefore high
6 CYCLING IN AN AFRICAN CITY CONTEXT This also applies to cycling in the context of African cities: Cycling provides better access to urban services and facilities that society considers vital for survival Cycling can assist to overcome transport financing constraints (it is expensive to be poor!) Cycling creates job opportunities and access to job opportunities (for the most vulnerable urban population) Cycling can enhance the maintenance of social networks (very important in African societies) Etc. But despite all these benefits.
7 CYCLING IN AN AFRICAN CITY CONTEXT Cycling has remained an unrecognised and inferior mode in most African cities due to the association of cycling with poverty and rurality due to lacking or no facilities to cycling safe and comfortably etc. (JICA, 2008; Olvera et al., 2008; Nkurunziza et al., 2010) Which is resulting in very low modal shares in many large African cities: e.g. Dar-es-Salaam ~5%, Nairobi <2%
8 DAR-ES-SALAAM, TANZANIA Largest commercial city Population: 4 million in 2010 Population: growth rate per year > 4% 70% informal settlements Modal share (JICA, 2008): PMV: 10% Public Transport: 60% Cycling: 5% Walking: 25%
9 RAPID URBANIZATION DAR ES SALAAM 1945 ~65,000 inh ~400,000 inh ~2,300,000 inh Source: Dr. S. Amer, University of Twente - ITC
10 URBAN TRANSPORT CHALLENGES OF DAR-ES-SALAAM Urban sprawl and informal development Increased automobile/motor bike ownership and use Heavy traffic congestion High levels of air pollution Traffic unsafety Lack of quality road infrastructure Lack of, or poor, infrastructure for walking and cycling (NMT) Transport-related social exclusion, particularly for the urban poor population
11 BRT AS AN OPPORTUNITY TO PROMOTE CYCLING The introduction of the BRT system (DART) and other transport projects in Dar es Salaam have created a favourable environment to relook at the potential of cycling Integrated with high quality cycling facilities along the corridors and beyond (Nkurunziza et al., 2012a;2012b)
12 RESEARCH NEED There is a need to examine how people can be influenced to change their travel behaviour towards bicycle use Analysis of attitudes and perceptions of daily commuters towards bicycle use may provide useful information for designing targeted travel behaviour change strategies Keeping in mind that people behave differently as: They are driven by different travel needs They are motivated by different factors Experience different impediments to change Are affected in different ways by transport and urban policy (Anable,2005; Shiftan,Y. et al, 2008)
13 WHAT INFLUENCES TRAVEL CHOICES? Often interventions geared towards changing travel behaviour do not target people in their different stages of change of cycling behaviour someone who cycles is in another stage of cycling behaviour than someone who ever cycled, but does not cycle anymore, or someone who never cycled! Travel choices are influenced by: Personal/individual factors such as social economic factors (income, age, gender etc.) as well as psychological factors (attitudes, norms, beliefs etc.) Social environmental factors (e.g. culture, social norms etc.) Physical environmental factors (e.g. topography, infrastructure, climate, land use characteristics etc.) and differ between people in different stages of change of cycling
14 MAIN RESEARCH QUESTIONS How to identify and characterize potential cycling market segments to target cycling policy and promotion in Dar-es-Salaam? What are the factors that can potentially influence bicycle commuting in Dar-es-Salaam?
15 IDENTIFYING AND CHARACTERIZING CYCLING MARKET SEGMENTS Segmentation done using the stages of change model of Prochaska and Di Clemente (1984; and further), also called the transactional model of behaviour change The model deals with intentional changes in behaviour In an attempt to change behaviour, an individual typically moves through different stages of change (Prochaska and Diclemente, 1984)
16 TARGETED CAMPAIGNING, EXAMPLE: SMOKING (Prochaska and Velicer, 1997)
17 TARGETED CAMPAIGNING, EXAMPLE: PHYSICAL EXERCISE Denmark campaign You won t believe it you re safer on the bicycle than on the sofa! Lack of daily exercise is harmful to your health, while physical activity keeps your body healthy. Cycling extends your life daily exercise for a minimum of 30 minutes extends your lifespan by up to five years.
18 STUDY AREA AND DATA COLLECTION Data were collected from individual commuters who travel to their daily activities on a regular basis along the proposed BRT corridors Also locations with lots of cyclists Around 600 data samples (long personal questionnaires) were collected and analyzed: 1. Socio-economic/demographic information 2. Travel behavioural information 3. Attitudes and perceptions towards bicycle use with help of DCC, Uwaba, ward leaders, DART Agency, UDSM, Ardhi.
19 ATTITUDINAL-VARIABLE STATEMENTS Statement shown to respondents I never really think about and not even consider cycling to my daily activity I never used a bicycle but sometimes think about cycling to my daily activity I rarely or sometimes cycle and seriously consider riding to my daily activity I have fairly often cycled to my daily activity I cycle regularly to my daily activity I no longer cycle to my daily activities Corresponding stage of behaviour change Pre-Contemplation (PC) Contemplation (C) Prepared for Action (PA) Action (A) Maintenance (M) Relapse (R)
20 IDENTIFIED STAGES OF CHANGE SEGMENTS OF CYCLING BEHAVIOUR IN DAR-ES-SALAAM Classification of the data sample by stages of change 13% 47% 18% 7% 6% 9% Pre-contemplation Contemplation Preparedness to Action Action Maintainance Relapse (Nkurunziza et al., 2012c)
22 CHARACTERISTICS OF MARKET SEGMENTS Pre-contemplators (negative to cycling): middle/high income male working predominantly in government and private offices, and uses private car and public transport (-) distance, status of cycling, safety opportunity: infra, cycling training and enforcement, but less likely to work Contemplators (positive attitude to cycling): low income, secondary school students and women (-) fitness to cycling, cultural barriers, access to bicycle opportunity: personal guidance in cycle route testing if infrastructure is there Prepared to cycle (very positive attitude to cycling): both male/female, no vehicle ownership, low/medium income, aware of benefits of cycling and cost saving (-) access to bicycles, infrastructure, safety opportunity: develop specific action plans to remove critical constraints
23 CHARACTERISTICS OF MARKET SEGMENTS Action (actually cycling, but irregularly) male dominated, low education, bicycle ownership, bicycle is an alternative (-) infrastructure, enforcement and safety opportunity: combating feelings of loss, re-iterate long term benefits Maintenance (actually cycling) regular bicycle commuters, male, income generating cycling, bicycle means more accessibility (-) other traffic opportunity: positive feedback, social support and reminders of good behaviour Relapse (stopped cycling) medium/high education, both male/female, vehicle owners (-) no dedicated infrastructure, lack of enforcement Opportunity: re-assess motivation and barriers to cycling, stronger coping strategies
24 INFLUENCES ON STAGES OF CYCLING BEHAVIOUR Social-ecological frame work (Sallis and owen, 2002) to reveal keymotivational factors for the segments that show behavioural change intention and manifestation
25 SUMMARIZING KEY MOTIVATORS - I Policy-related factors: Low bicycle price (access to bicycles) Quality of bicycle Cycling training Exemption of import tax on bicycles are the major potential influencing (key motivators) of bicycle commuting
26 SUMMARIZING KEY MOTIVATORS - II Individual (personal) factors: Social (in) security Social status Not being comfortable on a bicycle Safety on the road have the most negative impact on bicycle commuting
27 SUMMARIZING KEY MOTIVATORS - III Physical factors: Weather (tree shade) Lack of cycling infrastructure & facilities (safe parking, showers etc) have a negative impact on bicycle commuting All three sets of key motivators seem equally important Interestingly enough most key motivators resemble the key success factors of Dutch cycling-inclusive urban policies
28 CONCLUSION AND FURTHER RESEARCH Individual commuter perceptions and attitudes can help in understanding bicycle commuting behaviour Addressing physical barriers alone is likely to have little impact on bicycle commuting promotion The stage of change model can indicate the target market and the potential for modal change Determining key motivational factors specific to users groups can guide cycling promotional strategies Further develop segment based policy recommendations and promotional strategies now the climate for talking about cycling in Dares-Salaam is good. Need to investigate life changing/social events to better understand the large group of relapse users
29 THANK YOU! More information Alphonse Nkurunziza Mark Zuidgeest Acknowledgements DCC, DART Agency, Uwaba, University of Dar-es-Salaam, Ardhi University, University of Cape Town, volunteers 29
30 FURTHER READING NKURUNZIZA, A., ZUIDGEEST, M., BRUSSEL, M. & MAARSEVEEN, M. in press. Examining the potential for modal change: Motivators and barriers for bicycle commuting in Dar-es- Salaam. Transport Policy. [in press] NKURUNZIZA, A., ZUIDGEEST, M., BRUSSEL, M. & VAN DEN BOSCH, F. 2012a. Spatial variation of transit service quality preferences in Dar-es-Salaam. Journal of Transport Geography, 24, NKURUNZIZA, A., ZUIDGEEST, M., BRUSSEL, M. & VAN MAARSEVEEN, M. 2012b. Modeling Commuter Preferences for the Proposed Bus Rapid Transit in Dar-es-Salaam. Journal of public transportation, 15, NKURUNZIZA, A., ZUIDGEEST, M. & VAN MAARSEVEEN, M. 2012c. Identifying potential cycling market segments in Dar-es-Salaam, Tanzania. Habitat International, 36,
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Woocommerce UPS
Bajet ₱1200-10000 PHP
I need to customize the WooCommerce UPS plugin to calculate only by weight and shipping zone - to EXCLUDE the Dimensions requirement.
5 pekerja bebas membida secara purata ₱5200 untuk pekerjaan ini
I run European website design firm with years of design experience personally developing over 300+ websites. I can also provide a list of references from past customers if you'd like. I'm not the cheapest you'll find, Lagi
Sir, As one of the php web developer would like to fix the UPS plugin. I am looking forward to hear from you. Thanking you [login to view URL]
Hi, I'm expert in Wordpress, experienced in PHP/MySQL. Worked with Woocommerce, so I'm sure I can setup and configure UPS plugin pretty good and in short terms. If you're interested - please feel free to cont Lagi


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Because she's having a baby ... again. :)
Yeah, that's what I do. Weight loss can come later!
Due May 21st.
Where's Charlie Been?
6 years ago
I don't feel like a fat girl. Now my mission is not to look like one either!
The Fast Break Stage is a springboard that gives more power to the other three SparkDiet Stages. Just a little prep and practice give you a head start without the need for manic, life-altering changes. This Stage has three main purposes:


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If you can't find what you are looking for, you can use our search bar at the top, right-hand corner of this site. If you aren't able to find what you are looking for, send us a note and we'll respond as soon as we are able! - XOXO
Stoneham Studio
5 Central Street
Stoneham MA, 02180
The Dow Block Building, 4th Floor
Phone: (781) 435-0441
Medford Studio
269 Middlesex Avenue
Medford, MA 02155
Inside Serenity in the City Spa
Phone: (339) 221-0421
Beverly Studio
181 Elliott Street
The Cummings Center
100 Building, Suite B520-D
Phone: (978) 993-7107
North Reading Studio - EBIC Studio
197 Main Street
North Reading MA, 01864
Second Floor
Phone: (978)-880-8383


text: Manny Pacquiao Current Sports | July 7, 2017 By Current Sports • Jul 7, 2017 DeLeon Promotions Miles Bridges; Moneyball Summer League Pro Am; Bryn Forbes; NBA Summer League; Tori Jankoska; Ron Deleon; James Moore; The S.W.A.P. Meet Listen Listening... / 58:00 Current Sports #545 | September 10, 2015 By Current Sports • Sep 10, 2015 Michigan State Student Section, Oregon Preview, Floyd Mayweather, Matt Argillander, Throwback Thursday, and Fantasy Football. Listen Listening... / 58:31 Current Sports #462 | April 29, 2015 By Current Sports • Apr 29, 2015 Happy 'Hump Day,' Current Sports fans! On this show, Al brings you all of the latest news regarding the Red Wings, and how they will perform with Kronwall's absence, after his Game 6 hit was deemed worthy of suspension by the NHL. The NBA playoffs are also progressing interestingly, with the Clippers-Spurs series taking a turn in the Spurs favor, as they went up 3-2 Tuesday night as Game 6 awaiting the teams in San Antonio. Finally, enjoy a preview Al's special segment for this week's Current Sports TV and prepare yourself for a noteworthy story about Manny Pacquiao. Listen Listening... / 58:32


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National Fashion Retailer | Assistant Manager | 30hrs PW
Category: Retail - Store Management
Location: ACT
Work Type: Permanent / Full Time
- Exceptional career progression opportunities
- attractive base salary + super
- Supportive and fun company culture
About the Company
This is an opportunity to join one of Australia's most progressive and fast expanding retailers. This retailer is committed to excellence and their people. A brand with a fashion forward focus, this brand should be your go to destination for key seasonal trends.
About the Role
An opportunity has presented itself for a sales focused manager to lead a team of staff to achieving their targets, whilst providing quality service to your customers.
Skills & Experience
To be successful in the role you should have;
- Sales driven and excellent selling skills
- Experience managing a high performing team
- Experienced at training and coaching staff on selling and customer service
- A positive can-do attitude
- An understanding of KPIs
- Attractive base salary + incredible bonuses
- Career progression opportunities
- Staff discounts and incentives
- Ongoing training and development
- Build a rewarding and satisfying career


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Seeing August's Eclipse
August 9, 2017
For some time now my wife and I have planned to see the solar eclipse on Aug. 21, in Wyoming where the sun will be covered in its totality. My reasoning was that this was an awesome chance for our children to experience something entirely unique and pretty rare. Secretly, though, I was overly excited to experience the natural phenomenon first hand, which I have wanted to see after experiencing a partial solar eclipse at the age of five as a child.
I thought it was a no brainer that everyone would want to see such a thing in its entirety and especially since it is so close to home (some people take cruise ships or fly all over the world to see the same thing), but that was not the case. One individual I talked to asked, "Why would you want to? I mean what is there to see?" My response?
The total solar eclipse is really rare. The last one in North America was 38 years ago; the next one will be in 2024 but will occur mostly in Mexico and Texas. The next one after that will be in 2045. The point is you really won't get another shot to see one so closely. You will see many partial eclipses between those times, but those are not the same thing. Why?
The greatest allure to a total solar eclipse is that the event is not just an object moving in front of the sun. There is an added element to the event. It is is called the corona, or crown, of the sun. When the moon sits precisely in front of the sun, and all of the direct rays and radiation are blocked, a person can look directly at the eclipse with the naked eye, and be able to observe the sun's glowing atmosphere haloing the moon. The rays emanating off the sun resemble the spikes of an old middle ages crown giving the phenomenon its name, and drawing astronomers, hobbyists and the curious alike. Astronomers agree that this is one of the most dramatic celestial events visible with the naked eye. I mean, seriously, you get to see the atmosphere and rays of the sun without going blind. How cool is that?
I am certain not everyone gets as excited as I do about these things, but I am certain that travelling to see the eclipse will not be something we regret any time soon. Then again, we will be in a single car with five kids, so who knows?


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Mission accomplished for Italy's Olympic National team. The decisive game with Cameroon ended in a draw and the young Azzurri won Group D. The match against the African side finished 0-0, but there was no shortage of thrills, especially due to the Uruguayan referee's decisions. Vasquez first awarded a controversial penalty against Italy (Viviano saved), then he ignored a clear one on Giovinco and finally sent off a Cameroon player for a foul on Nocerino.
Thus Giovinco continues his tournament (he was replaced near the end with Cameroon) alongside De Ceglie (who played 90 minutes today after sitting out the South Korea game), but unfortunately it's all over for Claudio Marchisio. The injury to his right calf means he'll have to return to Italy together with the other injured player Tommaso Rocchi. The midfielder will be back in Turin already on Thursday, to begin therapies with Juventus' medical staff.
Sauce: Juventus.com


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April 6, 2014: Macro of Ranunculus at Carlsbad Flower Fields. Acres and acres of flowers blowing in the wind.
From Photo A Day 2014
Log In:
Thanks Nelli! It was a tricky shot. The wind was really blowing and I was stradled over a ditch filled with water :-)
excellent wow
Thanks for your encouraging comments. You motivate me!
Love this! Isn't it interesting what you see when you look so very close!


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I found a great fabric by Alexander Henry in my stash (Larkspur Bright, from Fabric Depot) and it called to me to make something. I had only 1/2 a yard so not much to work with, but this pattern for a tote from Unfortunately Oh! was perfect. She calls it the bubbles Bag, and now so do I. A great tutorial, easy to sew and I love it.
I made the straps a little longer … from 22″ to 32″ as I like to carry a bag over the shoulder, at least on my good one. I added fusible fleece to the canvas outer fabric an inside pocket and a heavy weight cotton lining. I love it!
What do you think?