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Should General Practitioners Issue a Sick Certificate to Employees Who Consult for Low Back Pain in Primary Care?
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Purpose Back pain is a common problem and has significant societal impact. Sickness certification is commonly issued to patients consulting their general practitioner with low back pain. The aim of this study was to investigate the association of certification for low back pain with clinical outcomes and cost consequences. Methods A prospective cohort study using linked questionnaire and medical record data from 806 low back pain patients in 8 UK general practices: comparison of 116 (14.4 %) who received a sickness certificate versus 690 who did not receive certification. The primary clinical measure was the Roland and Morris Disability Questionnaire (RMDQ). Data on back pain consultation and work absenteeism were used to calculate healthcare and societal costs. Results Participants issued a sickness certificate had higher back-related disability at baseline consultation and 6-month follow-up [mean difference 3.1 (95 % CI 1.8, 4.4) on the RMDQ], indicating worse health status. After fully adjusting for baseline differences, most changes in clinical outcomes at 6 months were not significantly different between study groups. Productivity losses were significantly higher for the certification group, with most absence occurring after the expected end of certification; mean difference in costs due to absenteeism over 6 months was £1,956 (95 % CI £941, £3040). Conclusions There was no clear evidence of a difference in clinical outcomes between individuals issued a sickness certificate and those not issued a certification for their back pain. With little overall contrast in clinical outcomes, policy makers and care providers may wish to draw on the likely difference in societal costs alongside issues in ethical and moral care in their consideration of patient care for low back pain.
KeywordsBack pain General practice Certification Clinical effectiveness Cost effectiveness
Back pain is common in the workplace and the community at large, and its disabling characteristics render it a significant burden to society. In the United Kingdom (UK), the 1-month prevalence of low back pain in the adult general population (pain lasting >1 week) has been estimated to be 23 % [1]. One in seven consultations in primary care is for musculoskeletal pain, with back pain being the most common reason for consultation at an annual rate of 591 people per 10,000 registered persons [2].
It is well known that back pain has a major impact on productivity at work. In the UK, annual costs of back pain have been estimated as £1.6 billion for direct healthcare costs (including consultations with healthcare professionals, hospital outpatient visits and in-patient days) and £10.7 billion for indirect factors (including informal care and workplace productivity costs) [3]. In most countries a sickness certificate sanctions absence from work, although issuing requirements differ between countries. In the UK, a sickness certificate is required for periods of work absence in excess of 7 days [4].
Musculoskeletal disorders and mental disorders are the most frequent reasons for sickness certification [4, 5, 6, 7], and the most common causes of long-term work absence [8]. In the UK, approximately one-third of back pain general practice consulters are issued a sickness certificate [9]. Aside from workplace factors little is known about the comparative clinical features of patients who are issued a sickness certificate compared to those who are not: conceivably patients issued a certificate have greater physical impairment that interferes with their ability to perform usual work activities. Despite the high rates of sickness certification and possible rationale for alleviating work difficulties through sickness certification, recent research suggests that it may not be clinically effective [10], and several studies have shown that sickness absence and certification is associated with increased risk of long-term disability and subsequent award of a disability pension [11, 12, 13, 14, 15, 16]. There is little data contemporaneously comparing the clinical and cost outcomes of patients who receive a sickness certificate with those who do not.
In light of this evidence on high costs, particularly through workplace productivity loss, the UK government commissioned health and work as a key priority target for public policy, setting recommendation and guidelines for the provision of alternative/altered work duties for workers unable to perform their usual job activities [17, 18, 19]. Although plausible that this strategy will lead to reduced cost to society, there is no clear data or evidence to date to steer primary care policy makers and providers as to whether the strategy would be associated with improved clinical outcomes or reduced healthcare or societal costs.
Current recommendations about care of low back pain in primary care encourage patients to stay active (including work), and highlight the importance of self-management, whilst advocating the use of the Back Book for simple clinical guidelines [20, 21]. However, Bishop et al. [22] showed that current attitudes and behaviours of general practitioners and physiotherapists towards patients with low back pain are diverse, and that many practitioners wrongly held the belief that patients should avoid activities and work. Gerner and Alexanderson [23] reported that physicians were often faced with difficult and distressing decisions with regards to sickness certification, and that potential discordance in doctor–patient opinions was highly likely since sickness certification legislation is based on impaired work ability by assessment. In all, Soler and Okkes [24] asserted that sick certification was "an unwelcome administrative burden for the family doctor". It could be argued that this burden and contention in its use needs to be balanced against ethical considerations in relation to such issues as the need to: express empathy and provide compassionate care, reduce unnecessary pain and suffering, prevent an exacerbation of symptoms, or to avoid embarrassment and stigmatization at work.
This study aimed to; (1) compare clinical and demographic characteristics between patients issued a sickness certificate by their general practitioner (GP) for their low back pain and those who are not issued a certificate, (2) evaluate whether or not issuing sickness certificates is associated with clinical outcomes, and (3) estimate the cost consequences associated with sickness certification.
Materials and Methods
Study Population
This study is based on a longitudinal dataset describing the characteristics and clinical outcomes of patients from the Beliefs about Back Pain (BeBack) cohort [25]; a prospective observational cohort study that recruited consecutive back pain consulters receiving usual primary care, aged 18–60 years, from eight GP practices in North Staffordshire and Cheshire. The GP practices cover a heterogeneous socio-demographic population mix in terms of urban/rural profiles. The BeBack study used mixed-methods to investigate patients' illness perceptions and psychological obstacles to recovery in relation to back pain [25, 26], and investigate health care professionals' (general practitioners and physiotherapists) beliefs and attitudes about low back pain [27, 28].
Patient participants were identified if they consulted their GP for low back pain. Recruitment of participants was by weekly downloads of back pain diagnostic codes [29], from the computerised system of the eight general practices. Eligibility was based on primary care consultation for non-specific low back pain (i.e. excluding 'red-flags' indicative of possible serious spinal pathology e.g. cancer, ankylosing spondylitis, cauda equine syndrome, significant trauma) inclusive of acute, sub-acute and chronic pain. Downloaded lists were checked for suitability by the GPs concerned. In the UK, coding of morbidities by GPs follows the electronic Read code classification system; this system has been validated [30, 31, 32]. Broad morbidities, including back problems, are usually linked to several Read codes—to reflect different forms and symptoms of disease. The coding system is hierarchical to reflect the multi-layered pathway to diagnosis. Low back pain, particularly, has a diverse set of Read codes: The following Read codes were used to identify consultations logged for back pain: 16C2-16C9; 16CA; 16CZ; N140-1; N1402; N142; N142-1/3/4; N1420; N143; N143-1; N145; N145-1/2; S57z(0).
A study pack was sent from the patients' GP practice to each potential participant in the week following consultation. Non-responders were sent a reminder postcard after 2 weeks; if necessary, a further questionnaire was sent after 4 weeks. Patients were recruited between September 2004 and April 2006, with follow-up at 6 months. For those participants who completed the baseline questionnaire, reported being employed (for the employment status question in the questionnaire), and who gave consent to medical record review, the electronic records of their sickness certificates were downloaded to identify those with and without a sickness certificate. The date of questionnaire return was used as a reference and sickness certificates issued in the month prior to this date matched to individual patients. Since the baseline mailing process was initiated for each individual in the week following consultation with the GP and to allow for mailing response delay it was decided that we would adequately capture the associated GP-consultation and healthcare utilisation and sickness certification data relating to the back pain consultation if we targeted the medical record review as 31 days prior to baseline response. This method of data retrieval has been demonstrated to link 95 % of sickness certification records with self-reported absence for an episode of back pain [33]. Hence, the total time period of the study is 31 days prior to baseline response through to 6 months follow up (post baseline response) with healthcare utilisation being measured within this 7 months total time-frame.
Comparison Groups
- 1.
Sick certification (SC) group—Patients who did receive a sickness certificate during the 31 days prior to the completion of baseline survey.
- 2.
No sick certification (N-SC) group—Patients who did not receive a sickness certificate during 31 days prior to the completion of the baseline survey.
Outcome Measures
The main clinical outcome measure was back-specific functional disability measured using the 24-item Roland and Morris Disability Questionnaire (RMDQ) [34], with a score ranging from 0 (no back pain-related disability) to 24 (highest back pain-related disability). A difference of 2.5 points on the RMDQ scale is considered a minimal clinically important difference [35]. Secondary self-report outcomes included measures of pain severity, quality of life and psychological consequences of pain: Chronic pain grade (CPG), including subscales measuring interference with normal functioning and work (using two 0–10 numerical rating scales) [36]; pain intensity ("today" and "over the past 2 weeks", using 0–10 point numerical rating scales); bothersomeness of pain in last 2 weeks (5-point ordinal scale) [29]; preference-based health-related quality of life (EQ-5D) [37]; anxiety and depression (Hospital Anxiety and Depression Scale, HADS) [38]; fear of movement (Tampa Scale of Kinesiophobia, TSK) [39]; catastrophising (subscale of the Coping Strategies Questionnaire, CSQ) [40], and pain self-efficacy (pain self-efficacy scale PSES) [41]. Higher scores on the numerical scales indicate worse symptoms/perceptions/interference, except for the pain self-efficacy scale and EQ-5D (where higher values denote better health status).
Statistical Analysis for Outcomes
Differences between groups at baseline were assessed using the independent samples t test (for numerical measures) and Chi squared test (for categorical measures) with statistical significance at the 5 % two-tailed level. Between-group mean differences in outcomes at follow-up were evaluated through linear regression. We performed a sequential adjustment on estimates of health outcomes to identify potential confounding with respect to: (1) baseline socio-demographic covariates only [age, gender, socio-economic class, GP Practice]; and (2) baseline socio-demographic and pain/disability covariates [socio-demographic plus RMDQ and pain-scales]; (3) baseline socio-demographic and pain/disability and psychosocial and general health covariates [socio-demographic and pain/disability covariates plus CPG; bothersomeness, EQ-5D; HADS-A; HADS-D; TSK; CSQ and PSES].
Resource Utilisation and Costs
Two cost perspectives were considered: (1) a health care perspective, which includes health care resource use in primary and secondary care, and (2) a broader perspective that incorporates costs associated with lost workplace productivity due to absenteeism.
Unit costs of resources based on 2005 UK prices
Cost (£)
Primary care/community care consultations
Curtis and Netten (S9.8b)
24 (10 min. consultation)
Curtis and Netten (S9.8b)
24 (10.8 min. consultation)
Curtis and Netten (S9.8b)
69 (inclusive of travel time)
Practice nurse
Curtis and Netten (S9.6)
Nurse practitioner
Curtis and Netten (S9.7)
Curtis and Netten (S8.1)
Health care social worker
Curtis and Netten (S10.2)
Secondary care referral costs
Orthopaedic surgeon—consult
Curtis and Netten (S14.5)
Orthopaedic surgeon—admission
NHS Exec. Code R02
Curtis and Netten (S14.4)
Hospital physiotherapist
Curtis and Netten (S12.1)
15a (per 20 min. session)
Curtis and Netten (S12.5)
Private referrals and to alternative care
Orthopaedic surgeon
As for NHS orthopaedic consultation
As for NHS physiotherapist
15a (per 20 min. session)
College of Chiropractors
Indirect costs
Based on average hourly wage within social economic class
ONS—Annual Survey of Hours and Earnings (ASHE)
Range 6.21–21.77
Data on indirect costs were ascertained by linking estimates of lost work time from information in the 6-month follow up self-report questionnaire and sick-certification medical record data with national salary estimates. Participant's current job titles were sought at baseline and these job descriptions were coded according to the Standard Occupational Classification (SOC: 2000) [42]: salary estimates were attached to each of these codes based on ONS national survey valuations [43]. At 6 months follow-up, productivity loss was established by enquiring about time off work (absenteeism) in the previous 6 months. Productivity cost was calculated as the product of the number of days off work and the average daily wage.
Costs were averaged across all individuals in the two groups and represent approximately half-year costs (not annualised costs). Differences in mean outcomes and mean costs were compared between the two study groups: the N-SC group being used as the reference group in the analyses. Cost data in health care research is, typically, positively skewed. Accordingly, bias-corrected and accelerated bootstrapping (BCa) was used to derive confidence intervals for cost estimates (1,000 replications) [44, 45].
Sensitivity Analysis
The main approach to calculating productivity costs was through the human capital approach (HCP) whereby costs were calculated over the full period of absenteeism. As a sensitivity analysis we also calculated productivity costs using the friction cost approach (FCA) with a valid friction period of 3 months [46].
Ethical Approval
Ethical approval for the BeBack study was granted by North Staffordshire LREC, reference number 04/16.
Baseline characteristics of the sickness certification (SC) and non-certification (N-SC) groups
SC group
n = 116
N-SC group
n = 690
Mean (SD)
42.1 (9.8)
43.4 (9.9)
52 (44.8 %)
384 (55.7 %)
64 (55.2 %)
306 (44.3 %)
Occupational class*
43 (37 %)
370 (54 %)
73 (63 %)
320 (46 %)
Roland and Morris Disability Questionnaire*
Mean (SD)
11.6 (5.8)
7.4 (5.4)
Usual pain—past 2 weeks*
Mean (SD)
5.4 (2.6)
4.1 (2.5)
Pain today*
Mean (SD)
4.7 (2.7)
3.5 (2.6)
Duration of pain
<1 month
39 (34.8 %)
292 (44.0 %)
1–3 months
34 (39.3 %)
203 (30.6 %)
4–6 months
14 (12.5 %)
56 (8.4 %)
7 months—3 years
11 (9.8 %)
58 (8.7 %)
>3 years
4 (3.6 %)
54 (8.1 %)
Chronic pain grade*
15 (12.9 %)
213 (31.3 %)
7 (6.0 %)
182 (26.7 %)
38 (32.8 %)
176 (25.8 %)
56 (48.3 %)
110 (16.2 %)
Not very much
37 (31.8 %)
364 (53.3 %)
Very much
79 (68.2 %)
318 (46.7 %)
Mean (SD)
0.55 (0.27)
0.69 (0.24)
Hospital Anxiety and Depression Score—anxiety*
Mean (SD)
8.6 (4.0)
7.7 (4.3)
Hospital Anxiety and Depression Score—depression*
Mean (SD)
7.6 (3.9)
5.7 (3.9)
Tampa Scale of Kinesiophobia*
Mean (SD)
41.5 (6.1)
38.9 (6.7)
Catastrophising Scale
Mean (SD)
11.0 (7.9)
8.7 (7.2)
Pain self-efficacy scale*
Mean (SD)
31.0 (13.4)
41.6 (12.8)
Satisfied with work*
Mean (SD)
31.0 (13.4)
41.6 (12.8)
Comparison of measures of health consequences between the sickness certification group (SC) and non-sickness certification group (N-SC) at 6-month follow up
SC group
n = 63
N-SC group
n = 404
Mean difference (95 % CI)
Roland and Morris Disability Questionnaire
7.3 (6.2)
4.2 (4.6)
3.1 (1.8, 4.4)***
2.9 (1.6, 4.2)***
0.9 (−0.3, 2.2)
0.5 (−0.8, 1.8)
Average pain—past 2 weeks
3.4 (2.6)
2.6 (2.4)
0.8 (0.2, 1.5)*
0.7 (0.1, 1.4)*
0.0 (−0.6, 0.7)
−0.3 (−1.0, 0.4)
Pain today
3.3 (2.6)
2.2 (2.5)
1.1 (0.4, 1.7)**
0.9 (0.2, 1.6)**
0.2 (−0.4, 0.9)
−0.1 (−0.8, 0.6)
Hospital Anxiety and Depression Score—anxiety
7.8 (4.4)
5.6 (4.1)
2.2 (1.0, 3.3)***
1.9 (0.8, 3.1)**
1.1 (−0.1, 2.2)
1.3 (0.2, 2.3)*
Hospital Anxiety and Depression Score—depression
6.3 (4.2)
3.8 (3.4)
2.5 (1.5, 3.5)***
2.3 (1.3, 3.3)***
1.4 (0.3, 2.4)**
0.9 (−0.1, 1.8)
Catastrophising Scale
9.0 (7.4)
7.0 (6.5)
2.0 (0.0, 4.1)*
1.3 (−0.8, 3.4)
−0.4 (−2.4, 1.7)
0.5 (−1.6, 2.5)
Tampa Scale of Kinesiophobia
40.8 (5.1)
37.1 (6.2)
3.8 (1.9, 5.6)***
3.4 (1.5, 5.3)***
1.9 (0.0, 3.8)*
1.4 (−0.3, 3.0)
Pain self-efficacy scale
36.4 (13.3)
45.8 (11.1)
−9.4 (−12.9, −5.8)***
−9.1 (−12.8, −5.4)***
−5.4 (−8.9, −1.9)**
−3.0 (−6.4, 0.5)
0.69 (0.22)
0.81 (0.19)
−0.12 (−0.18, −0.07)***
−0.11 (−0.16, −0.05)***
−0.06 (−0.11, −0.00)*
−0.04 (−0.10, 0.02)
Interference with daily activities
4.5 (2.8)
3.0 (2.6)
1.5 (0.8, 2.2)***
1.5 (0.8, 2.2)***
0.6 (−0.1, 1.2)
0.1 (−0.6, 0.8)
Altered ability to work
4.6 (3.3)
2.4 (2.8)
2.1 (1.4, 2.9)***
2.1 (1.3, 2.9)***
1.2 (0.4, 1.9)**
0.5 (−0.3, 1.3)
Resource Use and Cost Estimates
Comparison of healthcare resource use (and associated costs) and productivity losses (and associated costs) between the SC and N-SC groups
Mean no. of consultations (mean cost, £)
Mean difference in cost, £ (95 % CI)*
SC group
N-SC group
Primary healthcare
3.23 (80.93)
1.91 (49.33)
31.60 (19.92, 49.08)
13.98 (−1.46, 22.74)
Secondary care referrals
1.00 (50.22)
0.88 (25.18)
25.04 (−7.96, 86.34)
15.64 (−37.62, 112.01)
Referrals to private practitioners/alternative healthcare providers
0.043 (1.45)
0.058 (1.91)
−0.46 (−2.46, 2.22)
0.85 (−1.03, 2.95)
Mean no. of working days
Mean difference in cost, £ (95 % CI)*
Lost (mean cost, £)
Time off work (absenteeism)
36.67 (3,185.39)
7.78 (598.14)
2,587.25 (1,743.69, 3,629.74)
1,956.06 (941.55, 3,039.99)
Aggregated (total) mean cost (£)
Mean difference in cost, £ (95 % CI)*
Health care perspective (primary healthcare and referrals)
56.20 (20.40, 172.53)
30.46 (−12.46, 148.28)
Societal perspective (health care perspective + time off work)
2,643.44 (1,688.97, 4,255.29)
1,986.53 (928.55, 3,377.04)
A summary of the societal costs for the two groups is also shown in Table 4. Overall, mean societal cost was greater in the SC group compared to the N-SC group, with a mean difference of £987 (95 % CI 929, 3,377). This difference was mainly due to greater work absence in the SC group (36.7 vs. 7.8 days in the N-SC group) resulting in significantly larger productivity losses.
Sensitivity Analysis
There were 22 individuals who reported time off work in excess of 3 months in our dataset. For the FCA analysis, these individuals had their recorded number of days off work values truncated to 60 days. Productivity and overall societal costs for this sensitivity analysis were still significantly higher: mean differences were £1485.09 and £1547.90, respectively.
Summary of Findings
The findings from this study suggest that there is little difference in outcomes of pain, function and general well-being for low back pain patients who are issued a sickness certificate compared to those not issued a sickness certificate—when adjusted for imbalances in baseline characteristics. Furthermore, any difference in healthcare costs through issuing certificates is also likely to be small. Hence, from a healthcare perspective there is little to choose between issuing or not issuing sickness certificates. These data suggest that 'sick notes are not necessarily bad for you' and offer a reasonable support strategy for some patients. However, not unexpectedly, patients issued a sickness certificate are significantly more likely to take time off work, with negative repercussions in respect of a broader societal perspective that also considers the importance of higher work absenteeism and greater overall societal cost.
There is clear evidence from our data that patients issued sickness certificates are different to those who are not issued certificates. The former were more likely to be male and have manual occupations. Patients issued sick certificates had significantly greater severity of pain and psychosocial obstacles to recovery at baseline. Upon crude (unadjusted) review of 6-month follow up health outcomes, patients issued sickness certificates still had significantly worse pain, psychosocial and general health outcomes. However, through sequentially adjusting for the differences in baseline characteristics we were able to identify differences in baseline levels of pain and disability as key reasons for the difference in 6-month outcomes between study groups. One significant association remained in the fully adjusted model—the association with HADS anxiety. This needs to be viewed cautiously given the observational design of our study and the heightened issue of multiplicity given the fact that several statistical tests were performed. The covariates included in the (adjusted) outcome model cover a range of baseline demographic and clinical factors that are known to be prognostic of outcome—and therefore of interest as potential confounders in the relationship between study group and clinical outcomes. Other (unmeasured) variables, notably work-specific variables may well explain additional variance though could not be accounted for in estimating the true study group difference. Unmeasurable factors may also play a part. Together, these unmeasured factors could potentially explain the residual difference between study groups in respect of health outcomes at 6 months.
There were differences in costs—most notably costs related to productivity loss through absenteeism. For the main analysis, productivity costs were calculated using the most commonly used approach—the human capital approach (HCP), which assumes the cost is lost throughout the full period of absenteeism. An alternative approach to this is the friction cost approach (FCA) whereby long-term absentee losses have a fixed horizon (which denotes time it takes to replace the skills of the absentee). Productivity costs for these individuals are applicable up to the 'time of replacement' with 3 months a justifiable friction period [46]. We assessed the robustness of the findings to the difference in evaluative approach and found consistent results showing significantly higher societal costs for patients issued sickness certificates.
Strengths and Limitations
This is the first study to investigate outcome and cost consequences of sickness certification in a primary care population with low back pain. It was based on a large cohort of primary care consulters; low back pain is most commonly managed in primary care. About 98 % of patients in the UK are registered with an NHS GP [47]. Linking questionnaire data with electronic medical record downloads allowed for examination of patients' self-reported clinical status within the SC and N-SC groups. The medical record data have been verified to be accurate [33], ensuring that sickness certification is measured objectively, thus reducing the potential for recall and ascertainment bias. Key prognostic variables were collected at baseline making it possible to carry out an adjusted comparison of the two study groups.
However, there were several limitations. The data were collected about 8–10 years ago and there have since been important UK developments, including changes to the sick certificate (now referred to as 'fit note'), in improving primary care management of patients with back pain affecting their work ability since the time of the study. There was large attrition—though this was fairly similar in both study groups. Also, responder/non-responder baseline clinical characteristics were similar—so there was little concern regarding imbalances in important prognostic variables. Both these issues imply that an analysis based on complete cases would not yield biased between-group comparisons [48]. Employment questions did not distinguish full-time and part-time work; so we calculated all costs on the basis of full-time work. Job satisfaction was assessed, but no other measures of physical job demands or organizational support were assessed; these factors are also likely to have a major role in the decision-making of clinicians on issues of sickness certification. Hospital admissions and/or length of stay (which are important cost drivers) [49], were not readily accessible from the electronic GP databases, though hospital admission is a rare occurrence in back pain patients so the impact will be limited [50]. Medical record data do not provide information about the duration of each certificate; the most common duration is reported to be 10 working days or 2 weeks [51, 52, 53, 54], and this was the interval we ascribed to each certificate in our study. A further limitation is that we cannot be sure that the issued sickness certificate was for the episode of back pain that the patients consulted with. A previous study, using the same methods as in our study, matched self-reported absence for low back pain with sickness certificates in the electronic medical records and found that 95 % of records matched [33].
Comparison with Existing Literature
The significant baseline differences in pain, disability, anxiety, depression, fear of movement, and pain self-efficacy between those who did and did not receive a sickness certificate suggest that those receiving certificates are the more complex patients who present with greater pain and disability as well as greater related psychological distress. Morris and Watson [55] also found that patients who receive sickness certificates reported significantly more pain, perceived disability and fear avoidance beliefs about work than those not receiving sickness certificates. Patients with common mental health problems, such as anxiety, consult more frequently and receive more sickness certificates than those without common mental health problems [56], and the rates of certification in the UK confirm this [57].
Implications for Practice
There are clear implications not just in terms of the clinical time but also the skills required to manage complex patients in the return to work process. GPs frequently report that they feel under-skilled in managing occupational health issues [51, 58], despite current courses from the Royal College of General Practitioners [59], and advice aimed specifically at GPs and patients [60, 61]. Furthermore, it is unclear to what extent issuing a sickness certificate is helpful to patients in managing their episode of back pain. It is possible that certification contributes to a cycle of disability for some patients, such as that represented by the fear avoidance model [62], reinforcing the unhelpful message that patients with back pain should avoid their usual activities.
On the other hand, issuing of a sickness certification may be viewed as a token for providing considerate, patient-centred care. In this context, emphasis is on expression of empathy and compassionate care, to potentially reduce unnecessary suffering, or symptom exacerbation, or to avoid embarrassment and stigmatization at work. For example, for a patient who is barely able to sit or stand comfortably, who is experiencing a high level of emotional distress, with an uncooperative employer and few social supports and coping resources, it may seem inhumane for the GP to recommend immediate return to work. Also, against the backdrop of encouraged return to work, is the unknown quantity of how going back to work affects an individuals' work performance and his/her interactions with co-workers and employers. Contrasting ethical/moral issues against clear societal productivity and cost losses is a challenge faced by clinicians and policymakers in making difficult decisions about the care of low back pain patients.
The new 'fit note' (issued in the UK in 2010) is an adaptation of the traditional sick-note to help encourage and mediate the process of return-to-work with emphasis on doctor assessment and provision of recommendation regarding the patients' capacity (and extent) to work, whether this may be "not fit for work" or "may be fit for work" under certain specified restrictions that should be taken into account by the employer. This gives the GP more options than the traditional sickness certification whereby 'sick leave' was dichotomous i.e. sick leave or not. Through fit notes, GPs record details of the functional effects of their patient's condition so that patients and their employers can consider ways to help the patient return to work. In this way, GPs can effectively manage patients' expectations about their capability for work; give a clear clinical assessment to guide the patient about the impact of their condition on their fitness for work; help sustain relations between the patient and employer by allowing communication to take place around work adaptation and support at work. In all, the revised 'fit-note' certification offers greater flexibility and could help improve clinical outcome as well as potentially reducing the burden of lost productivity and societal cost.
Our findings have shown that GPs' issuing of sickness certificates is unlikely to be associated with positive cost consequences, particularly from a societal perspective. After adjusting for several potential baseline confounding factors, sick certification on average resulted in higher healthcare costs and significantly greater costs related to work absenteeism. It is the difference in productivity loss between the two study groups that generated the greatest differences in cost. This is not a surprising finding because the issuing of a sickness certificate will in itself result in about 10 days lost from work [51, 52, 53, 54]. If all participants who were given a sick certificate were to then recover and go back to work without any further problems, the expected total number of absent days would be about 10 days. However, the observed figure was approximately three times that amount, and the disparity between the SC group and the N-SC group in terms of days absent from work was considerably greater than the 10 days advocated in the original certificate.
In conclusion, this study has provided no clear evidence that issuing of sickness certificates confers any major advantages or disadvantages in respect of patient improvements in clinical outcomes or healthcare costs. However, from a broader societal perspective, primary care clinicians and policymakers may wish to consider the higher societal costs as well as the ethical/moral issues of sickness certification within patient care. In general, primary care providers need more treatment options and resources for managing back disability (other than writing sickness certificates).
We thank Ms. Tracy Whitehurst and Dr. Elaine Thomas for their time and effort in aiding the data collection process for this study, and Dr. Annette Bishop for coordinating the BeBack study. The BeBack study was funded by a Programme Grant awarded by Arthritis Research UK (Grant: 13413) and by the North Staffordshire Primary Care Research Consortium. Gwenllian Wynne-Jones is funded by a National Institute for Health Research (NIHR) Postdoctoral Fellowship (PDF-2009-02-54). Nadine Foster is funded by a National Institute for Health Research (NIHR) Research Professorship (NIHR-RP-011-015). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Conflict of interest
All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.
Informed consent
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 [63]. Informed consent was obtained from all patients for being included in the study.
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Copyright information
Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.


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2015.08.20 503BTS, Jim is talking and rehearsing with Chris… or dancing? :)
Chris's expression to Jim is always fond and with lots of pleasure.
Video by my friend Alice, who'd love to share~ Thank you as usual dear Alice!
Parafuso de aço inoxidável. Lmh12luu. Od110*8mm. Diameter * thickness = 50.8mm * 410um. Inside diameter: 50mm. Diameter*long =60*150mm. Standard parts. M3*25. Lmk16luu. Lmh12uu. Diameter * thickness = 50.8mm * 200um. 62 x 38mm / 2.4" x 1.5" (d*h). 00inch. Diameter * thickness = 24.5mm * 400um. Quartz. 2.5*0.5mm
Diameter * thickness = 50.8mm * 400um. F608-zz. Od*id*length=10*3.5mm*100mm. Flange 34. Long * wide * high=17.5*8*15. 8.0*5.0mm. F683zz. Gt28 flange de aço. Od1*id0.6*l300mm. 3mm x 8mm 4mm.
Od*l=80*1200mm. Diameter*long =95*100mm. 16mm/0.629". Biografias. Size:250x150mm: 90g/pc. Tampas de bing. 10*6.5. Od1*id0.3+*l300mm. Length: 30mm*1mm. Whether imports: 3.2~3.5mm.
25mmx40mmx58mm. 6mmx12mmx19mm. 0.7kg. 51ml 3570. 13x23x61mm. Rolamento de esferas 3 7. Tendo 25 52. 2 pcs 24mm linear rolamento de esferas. Diameter*height=20*30mm. Acessórios do banheiro do aço. Isolation level: Wholesale hbm z6fc3.
2015.08.20 503BTS, Jim is talking and rehearsing with Chris… or dancing? :)
Chris's expression to Jim is always fond and with lots of pleasure.
Video by my friend Alice, who'd love to share~ Thank you as usual dear Alice!
Dico enjoying a peaceful Sunday. #Dico #MyCat #MyPhotography #iPhone6s
hi dico with the big pouty kitty eyes!
Coach Bob Ladouceur/Jim Caviezel Appreciation Post - My Gifs.
From When The Game Stands Tall.
Too bad he wasn't a math teacher, I would love to have him help me with that….
NICE…&helli p;……..been missing your artwork! Lovely!
Finch & Reese ~~ Car Moments
(dedicated to follow-voice)
Jim in NYC & Philadelphia for Pope Francis visit at Festival of Families on 9-25-15 and 9-26-15.
So wonderful.
#JohnReese #PersonOfInterest #GimmeReese #GimmeJim #JimCaviezel
(Source: fabulousmemories)
John Reese/Jim Caviezel Appreciation Post - Fanart/Edited Pics/My Edits
Original Picture is NOT mine.
Credits go to Vital Agibalow/vitalphoto.com for the original pic :
Just beautiful.
Ella and her friend Pyrène. My princesses. #Ella #Pyrene #MyDogs #MyPrincesses #MyPhotography #iPhone6s
sweet soulful faces!
Looks like some serious talk going on in the top photo and Jim and Amy talking between takes.
Inside the Market Diner on 11th Ave., between 43rd and 44th St. 10-2-15
BTS S5E07 Chris Fisher, no title still.
My personal photos please do not crop or remove my watermark. Thank You

subset: commoncrawl


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A successful street team starts first with its members. If you want to have a street team that is successful in marketing and promoting your music, then you have to find the best people for your team.
The best people to have on your street team are people who are go-getters! You do not want people who are lazy. You want people who will get the job done and take initiative. You want team members who are eager and excited to market and promote your music. Your members should have an internal motivation and determination for completing your tasks.
You also want self-starters and self-finishers. You will not be around your team to micro-manage them and make sure they are doing their job. So you need members who will finish the job on their own. You want individuals who can work independently and who are persistent to finish what they start.
You also want team members who are well mannered and courteous. Your team members are representing you, so you need to find people who can represent you well. You do not want someone who will damage your image.
You should also look for members who work well in a team and who are honest and full of integrity. When they are talking to people, you want to feel confident that your team members have an ability to be honest with other people and fulfill their promises. You should also look for people who are capable of leading others because you may want to get street team managers to help you run and manage your team.
To learn more about how to build a team full of the right people who are capable of marketing your music, and to learn 10 action steps to take to build your own street team, sign up here for the free 4-day, How to Build a Street Team E-course: Build Street Team


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FireFly Media Server (formerly mt-daapd) › Firefly Media Server Forums › Firefly Media Server › Setup Issues › SB + Firefly / mt-daapd (Ubuntu Edgy) fails to connect now? › Reply To: SB + Firefly / mt-daapd (Ubuntu Edgy) fails to connect now?
@Binary Jay wrote:
I forgot to mention that I previously (when researching through existing posts on the board) tried to disable RSP in mt-daapd by removing it from the plugins list in the conf file. I didn't however rename/move the rsp.so file. Is removing it from the plugins list not good enough to accomplish what you suggested to force mt-daapd into DAAP only mode?
That works for the version roku distributes (based on svn-1359). It was changed to load all plugins present in the plugin_dir around 1400 or so. It was done to make it easier for distros to modularize it… specific plugins that would drag in large dependancies could be packaged separately, and by just dropping the plugin in the plugin_dir and the plugin would automatically get activated.
I'll try the rename when I'm home from the office this evening to see if that does any good. Failing that, unless you have any other suggestion, I'll take my chances with the 2.7b4 firmware. I assume the firmware can be rolled back to 2.5x if I choose to, somehow?
I seem to remember you could do that, but I don't remember the details. It's something to root around for in the roku forums, I think.
Ah, it's in the manual: unplug the device, and plug it in while pressing any button on the remote. The logo should appear with "safe mode" superimposed on it, and you should be taken directly to the system configuration menu with options limited to checking for software update and resetting factory defaults.
Stored settings won't be recalled, though, so in safe mode you'll have to connect via wired, or go through the process of setting up a network and wep key.
So it's doable to recover, just painful. 🙁


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Business Connections
This is where we feature other businesses and individuals in the Bothell area. We support and are supported by these folks and wish to acknowledge the interconnected nature of our community. Think of this as a resource page to other businesses. They come with our wholehearted recommendation.
Green Gates at Flowing Lake, A lovely venue!
(360) 563-9200
An emerging wedding and event venue, Green Gates recommends Phillips agents for wedding venue insurance. We are thrilled to do business with Green Gates and their customers. The venue can be described as turn-of-the-century Craftsman style with a Tuscan flair. 250 guest capacity. Weddings, Receptions, Reunions, Business off-site.
Jon Norris, Big Picture Image, Graphic design
(206) 323-1058
Jon has helped us with many web design questions. His knowledge and expertise make him a great resource.
Urban Coffee Lounge, a cozy hangout in Juanita and Kirkland
(425) 820-7788 and (425) 285-9114
Our clients, the Minors, have created a warm and cozy atmosphere in their coffee shops, mixed with clean industrial design elements. These features make Urban Coffee Lounge an ideal place to hang out and enjoy good food and coffee!
Greater Bothell Chamber of Commerce, the best chamber ever!
(425) 485-4353
If you are in need of any services the Chamber has a great directory for local businesses.


text: Happy Wedding Week! It's Kelsey and Garrett's wedding week! I'm so excited! Lakyn HayesSeptember 18, 2017kingsport tn wedding photography, kingsport tn wedding photographer, kingsport tn photographer, kingsport tn photography, johnson city tn wedding photography, johnson city tn wedding photographer, johnson city tn photographer, johnson city tn photography, bristol tn wedding photography, bristol tn wedding photographer, bristol tn photography, bristol tn photographer, bristol va wedding photography, bristol va wedding photographer, bristol va photography, bristol va photographer, knoxville tn wedding photography, knoxville tn wedding photographer, knoxville tn photography, thomas farm wedding photographyComment Facebook0 Twitter 0 Likes


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Alzheimer's disease
Alzheimer's disease is the most common form of dementia, accounting for 60% -80% of cases according to the World Health Organization (WHO). It involves a deterioration of memory, intellect, behavior and ability to perform activities of daily life. This disease has an impact, not only on those who suffer from it, but also family and caregivers who are subjected to great physical, emotional and economic stress.
It is currently estimated more than 35 million people worldwide suffer from Alzheimer's, and this figure is continuing to grow. The WHO estimates that, by 2030, the number of detected cases will have doubled.
Grifols and Alzheimer's
Since 2004, we have led a broad range of research initiatives on Alzheimer's.
The AMBAR hypothesis
AMBAR is an innovative treatment proposal aimed at slowing the progression of Alzheimer's disease through periodic plasma exchange.
The AMBAR
AMBAR is an international and multicenter clinical trial designed by Grifols in collaboration with Fundació ACE in Barcelona, Spain; and the Alzheimer Disease Research Center in Pittsburgh, PA, U.S.
The results
The new results of AMBAR, an innovative treatment approach for Alzheimer's disease (AD) using plasma science, show that both mild and moderate patients improve after treatment.


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Tag: Tin Sheds Gallery
Art Essays
Jim Anderson / Phillip JusterSaturday, February 26th, 2011 Australian Art, Sydney Morning Herald Column,
"I have tried too in my time to be a philosopher," said Dr. Johnson to his biographer, Boswell, "but I don't know how, cheerfulness was always breaking in." Seeing the exhibition, Lampoon: An Art Historical Trajectory 1970-2010, I thought these lines were oddly appropriate for Jim Anderson. In a retrospective at Sydney University's Tin Sheds […]
Sydney Morning Herald Column
Ken Unsworth & Paul SelwoodSaturday, July 11th, 2009 Sydney Morning Herald Column,
As a by-product of last year's flawed Biennale, Sydney was introduced to an extraordinary new venue. Cockatoo Island is an old naval shipyard, an industrial fantasia, only fifteen minutes by ferry from Circular Quay. Over the past six months the island has been used as concert venue and as a drawing camp for students from […]


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Dr. Capers emphasizes that"unconscious bias does not equalracism nor does it mean that youhave discriminated. However, yourunconscious bias can affect behavior."And, understanding these biases canchange people's behaviors. Afterthe 2012-2013 admissions cycle, 71percent of the admissions committeemembers said the IAT might be helpfulin reducing bias, 48 percent wereconscious of their individual resultswhen interviewing candidates in thenext cycle, and 21 percent said theirown results had an impact on theiradmissions decisions in the next cycle.
"The next class of medical students
that were enrolled following the IAT
exercise was the most diverse in our
College of Medicine's history, at that
time," Dr. Capers says.
Meanwhile, enrollment at OSUCOM
continues to diversify. In fact, the
college is one of the most diverse in
the nation and tied for ninth place for
highest number of black students—67
among 756 enrollees for the 2015-16
school year—according to a U.S. News
Published in Academic Medicine
in fall 2016, the study's findings are
already being used as an opportunity
to educate the larger Ohio State health
sciences workforce.
Since January 2017, Dr. Capers has
led educational workshops across
the seven health sciences colleges
aimed at helping faculty, students and
staff develop a greater awareness
of how their experiences, attitudes
and perceptions may affect how they
Benjamin Wright, a rehab safety care associate at Dodd Rehabilitation Hospital, plans to apply to medical school. He says the workshop takeaways will
help him strive "to become the best provider that I can be."


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Treize à table Crowned Canadian Winner of the Gourmand World Cookbook Awards
The Gourmand World Cookbook Awards, an international competition that honours the best food and wine books, revealed its winners by country this week. We are pleased to announce that Treize à Table, a collection edited by Chrystine Brouillet and Geneviève Lefebvre, is the Canadian winner in the "...
Incompatibility with macOS 10.14
Apple is preparing to release a new edition of its operating system for Mac, called macOS 10.14 Mojave. As is the case every year, this edition adds new protections to the system, designed to improve its security. This year, however, the new restrictions are very rigorous, causing communication...
The 2018 Antidote Scholarship Awarded to Sarath Chandar
As part of the Druide Fund for Research in Text Analysis, created through a donation from Druide informatique, the Mila Laboratory has chosen the winner of its 2018 Antidote Scholarship. The lucky recipient of the $20,000 scholarship is Mr. Sarath Chandar, a Ph.D. student under the joint supervision of professors Yoshua Bengio et Hugo Larochelle.
Druide Raises $67,000 for the Fondation Paul Gérin-Lajoie
On June 5, Druide informatique and its subsidiary Éditions Druide held their tenth annual Golf Classic for the Fondation Paul Gérin-Lajoie. The event and the campaign that followed raised $67,000, bringing the total contributions to the PGL foundation to nearly $440,000 since the Druide Classic...
A New Look for Typing Pal – School Edition
Druide informatique is pleased to announce the rollout of a new version of Typing Pal – School Edition, its web-based typing tutorial application for educational institutions. As well as an entirely modernized and unified look, this update boasts an even richer, more diversified set of content.


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Check the BBB when buying security systems
Does the low bidder on your security system have an F grade with the BBB?
Find out before you buy
Several of my customers have mentioned another companies name which I will not mention but today just for kicks I looked up their www.BBB.org report on the Better Business Bureau and found that this particular company has had over 3200 complaints in the last 3 years. Granted any large company is bound to have complaints. The company where I work has over 270 employees so it is not a small company but give me a break, thousands of complaints may be a red flag. Also if there is an ALERT on their report that is not a good thing either.
Many of those complaints cannot be resolved with that company because they have sold the contract to another company which is a common practice in the security industry. PEAK ALARM DOES NOT SELL THEIR CONTRACTS. Peak Alarm owns their own UL listed Central Station which handles all the Peak Alarm accounts.
So I looked up PEAK ALARM on the BBB and found 4 complaints in the last 3 years and they have all been resolved. I checked online and there are some complaints but several of them appear to be the same person. I also spoke with the CEO and President of Peak Alarm and they take valid complaints seriously and strive to use that information to make positive needed changes at Peak Alarm. This attitude of listening impressed me.
I then looked up several of my competitors and found hundreds and thousands of complaints have been filed. The one company that has over 3200 complaints has changed their name a couple of times and they also created a separate company name as their installation company. When you have an issue and call them after they have sold the account you now have to deal with the new company that did not do the installation. This makes the experience a difficult one.
1. Ask your security company salesman and installers to show you their UTAH DOPL LICENSE (DIVISION OF OCCUPATIONAL LICENSING) It is a blue and white license and they must carry it on their person. This insures that they have been through the FBI background check and have been fingerprinted. Many companies hire people to sell for them and they don't get licensed. Two such salesmen knocked on my door two days in a row a few years ago when I happened to be serving as the Chairman of the Alarm Systems Commission with the State of Utah. They knocked on the wrong door. They both had shinny new company ID card but those cards are not licenses.
2. Look up the company on the www.bbb.org web site and that company that I am referring to has a F GRADE and an alert on their BBB Report.
3. On eBay when the satisfaction rating is like 70% most people will not buy from those companies even when the prices are lower especially when you read the complaints. My 16 year old son is smart enough to pay a bit more and get his electronics from a company that has a 99% rating


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Currency Displayed in
This item is from Wyeast's Private Collection of seasonal yeasts and availability is subject to change. Please check back later for updates!
Beer Styles: Saison, Belgian Specialty Ales, American-style Sour & Wild Beer, Strong Golden Ale
Profile: A blend of Saison yeast and Brettanomyces creates a dry and complex ale. Classic earthy and spicy farmhouse character meets tropical and stone fruit esters; aging brings elevated Brett flavor. Expect high attenuation with this blend.
Alc. Tolerance 12% ABV
Flocculation low
Attenuation 80-90%
Temp. Range 65-80°F (18-27°C)
All prices are in USD.


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Hopkinton Town Library News
Monday, February 4, 2019
Punxsutawney Phil had his way
By the feel of the air, Puxsutawney Phil's prediction that Spring is on its way seems on target. It was great to be able to walk over to the library without bundling up, especially since I found therein PAINTERS!! This is an exciting development. The puzzle pieces are falling into place. And I am sending list upon list of items that were lost post lightning strike to our insurance company. What a process. The below are from last week's walk through with our insurance adjuster.
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Juan Esperanza
Brookings Harbor High Class of 2004
Personal Info
- Name:
- Juan Esperanza
- Graduation Year:
- 2004
Register to view Current location, Gender, Birthday, Relationship Status, Children, Employer, Military, College, and Interests
Memories of Juan Esperanza
What I'm doing now:Register to see what Juan Esperanza is up to now!
Juan Esperanza's Latest Activity:
|- Registered as a BHHS Class of 2004 alumni. 2011
|- Added photos to their personal photo gallery. 2011


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You've probably heard the term affiliate marketing, or maybe you've even seen an ad in a magazine or Facebook for how to make money with a blog or a website?
Affiloblueprint is hands down the best affiliate marketing training program I have used. Affiliate marketing is a great way to make full-time income or part-time extra cash.
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You can learn how to make money with affiliate marketing Here.
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After you sign up and are approved, you are given a link with a special code that tells the network you referred the customer. When the customer clicks the link,they are taken to the company's website.
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Before you get started with affiliate marketing, you need to learn how to make money blogging first. If you don't learn the proper steps, you may never make a cent online. You are sure to get frustrated and quit too soon. Don't be one of the many dot com failures.
You write high quality articles or product reviews, and put the links to the product in your content. Don't forget to add images!
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These images also have your link embedded in them, so when someone clicks the banner or image, this also directs them to the company's website where you can buy the product.
Even if the customer clicks a link and goes to the website, but buys something else other than the product you are marketing, you still get the commission for the sale.
Not a Get Rich Quick Scheme
Affiliate marketing is not a get rich quick scheme. It is not the affiliate marketing of the 1990's when you could throw up a website with little or no high value content, and people would flock to it and money would magically flow into your bank account.
The search engines are smarter, affiliates are smarter, consumers are smarter, and advertisers are smarter.
The tactics of the 90's would probably get you banned by either the search engines, the advertisers or both today.
Have no fear, with AffiloBlueprint from Affilorama, which is a web based affiliate marketing training program, you will learn everything you need to know how to start making money with a blog, including:
- Setting up a blog
- How to set up WordPress, the leading blogging software
- Finding products to market on your blog
- Finding keywords people are using to find your product
- How to write articles and product reviews
Can You Really Make Money with Affiliate Marketing?
When I tell people I am an affiliate marketer, and explain to them what I do. The first question I get is, you can really make money with a blog. I also get, wasn't affiliate marketing big in the 1990's?
They are surprised when I tell them, yes and that affiliate marketing is bigger than ever. Industry revenue is over $3 Billion USD, and per Mthink, affiliate marketing is expected to top $6.8 Billion USD in the next five years.
Yes, you can really make money with affiliate marketing. Depending on the industry you're targeting, how competitive the industry is, the products you promote and how often you blog, you can make anywhere from a few hundred dollars a month, to several thousands of dollars a month.
Just to be clear affiliate marketing is not a get rich quick scheme. Buyers are more savvy, and they can smell an affiliate a mile away. They know when someone is just trying to make money, and not interested in trying to solve your issue or answer their questions.
You Want to Solve Your Reader's Problems
The affiliate marketers who understand their readers issues, writes high quality content, and promote products or services the reader is looking for, will make money with affiliate marketing.
AffiloBlueprint is one of the best affiliate marketing training programs on the market today.
Started by Bark Ling, he is one of the original affiliate marketers from the beginning. He is now a 7-figure earner. He holds nothing back, and takes you step-by-step how to get started in affiliate marketing, and making your first dollar online.
You can take years and trial and error to find everything for free that Mark teaches you on the internet
I think it would it be better to have a mentor who will guide you past the pitfalls,and prevent you from making the errors he made so many years ago?
Latest posts by Ken (see all)
- How to Create a Landing Page in WordPress - 03/25/2019
- InstaBuilder 2.0 WordPress Landing Page Builder Review - 03/13/2019
- How to Start a Blog in less than 15 Minutes? - 03/07/2019


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Duties include:
- Assist with public relations efforts such as writing press releases, conducting media outreach, researching speaking opportunities and tracking media coverage.
- Write and distribute weekly internal newsletter
- Support and inform social media efforts
- Assist with creating and distributing email campaigns and online surveys
- Contribute ideas and stories for external newsletters
- Manage submissions for the My Life page of the St. David's Center Web site
- Assist with event planning and implementation
- Support administrative function within communications and events
This is an unpaid internship; 10 - 15 hours per week; flexible scheduling. Internship would begin June 1; length is negotiable.
- Completed or currently pursuing Bachelor's degree in marketing, communications, public relations, journalism or related field
- Proficient in Microsoft Office products and knowledge of the Internet and social media
- Familiarity with FrontPage is a plus, but not required
- Strong interpersonal and communication skills, both written and verbal
- Excellent organizational skills and the ability to handle multiple tasks
- Must be able to manage a project with goals and deadlines


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What is Math Really?Por Camilo Arcaya • 26 abr, 2018 • Sección: Leyes
Anthony Rizzi
Abstract: Modern mathematics is known for its rigorous proofs and tight analysis. Math is the paradigm of objectivity for most. We identify the source of that objectivity as our knowledge of the physical world given through our senses. We show in detail, for the core of modern mathematics, how modern mathematical formalism encapsulates deep realities about extension into a system of symbols and axiomatic rules. In particular, we proceed from the foundations in our senses to the natural numbers through integers, rational numbers, and real numbers, including introducing the concept of a field. An appendix shows how the formalism of complex numbers arises.
arXiv:1804.05955v1 [math.HO]
History and Overview (math.HO)


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Twenty-five years ago this month, the author opened the door on Area 51.
Area 51 is now permanently carved into the public consciousness. Area 51 is now the yin to Roswell's yang, and the UFO stories are never going to be divorced from the base itself.
The UFO crazies won the battle. Long live Area 51.
originally posted by: hellobruce
originally posted by: Springer
I can't deal with Lazar logically in my own mind, can anyone?
No... A simple question - when did he actually get his degree from MIT, and why is there no record of it anywhere?
No one remember him, no Professor there ever heard of him, he is in no yearbook...
originally posted by: seabhac-rua
I think that Stanton has some kind of axe to grind with the Bob Lazar story.
originally posted by: duaneology
Would you hire a proven theif to clean your house? Would you trust a proven liar to handle your investments?
originally posted by: duaneology
a reply to: chunder
C'mon, this wasn't an Arby's Lazar was applying to work at. Do you really believe that with the level of security clearance required they would have missed his lack of legitimate educational credentials? That's just plain silly.
originally posted by: Blue Shift
originally posted by: seabhac-rua
I think that Stanton has some kind of axe to grind with the Bob Lazar story.
I have always suspected that Friedman has his own "inside" sources, who have told him certain things in confidence over the years -- with the promise of more to come -- in order to keep him under a kind of control. Use him as a filter. I think that somehow the Lazar story originated with a different competing group and Friedman's group helped gather information for Friedman to help him discredit Lazar. It always struck me as a kind of power play between two shadow groups, with Lazar and Friedman as the public faces.
originally posted by: duaneology
It never ceases to amaze me how people will abandon logic and reason to avoid facing inconvenient evidence that contradicts their beliefs.


text:
A Dental Bridge is for patients who have had one or more their teeth removed and they would like to close the gap by installing pontics or false teeth to replace the missing tooth or teeth. The Dentist can create a bridge using the patient's healthy teeth on either side of the one or more teeth that were removed. If there is no healthy tooth to attach the pontics too, the dentist can install an implant to act as an anchor in their stead.
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There are many materials used in the producing of pontics or fake teeth. The bridge itself can be constructed from either porcelain or ceramic materials. Once installed no one but the patient and their dentist will know that they have a Dental Bridge installed.
The lifespan of a bridge depends on the patient's upkeep of their teeth, and regular visits to the Dentist are encouraged to improve the lifespan as well as the overall health of the remaining teeth and gums.
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Just as it is essential to care for your other teeth, so too is true of the Dental Bridge. Proper dental hygiene is required to maintain the strength of the supporting teeth or Implant that supports the bridge. Dr. Markowitz that the patient maintains a regular schedule of visits to the dentist to both prevent any further damage as well as help with the overall health of the patient's other teeth and bone.
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An 81st minute victor from Marcos Alonso gave Chelsea a 3-2 win on an afternoon of high drama, yet the holes in the defending at both ends contributed to a game that left both goalkeepers hopelessly exposed as chances aplenty were missed.
Ahead of matchweek two in the Premier League, we have searched the databases for five players you should definitely look to pick up to provide your team with a boost.
This is always the way, but it is clear that defensively we suffered three goals but also we had chances to do more goals.
According to the Sun, the England World Cup star will seek a loan move again if new boss Maurizio Sarri can not guarantee him regular match time.
But after opening his account in impressive style against Arsenal, Morata added that he expects Sarri's more proactive, expansive style of football to suit him better than the more orthodox target man role that predecessor Antonio Conte asked him to fulfil.
"Inside there were 15 minutes that were awful".More news: Taliban fighters kidnap over 100 people after buses ambushed
More news: New Zealand politician bikes to hospital before giving birth
More news: Kevin Spacey's 'Billionaire Boys Club' Earned Just $126 Nationwide on Friday
"We have good players, we can do something magic, so it's good to have this kind of manager".
"It was really very hard to answer about the last part of the first half. We were really in trouble".
"No, I needed half-time and the first half to end, not a cigarette", the Italian told reporters. "But in my opinion in this moment Kovacic, and Hazard, are not able to play for 90 minutes".
The 59-year-old Italian, a heavy smoker unable to satisfy his habit on the touchline due to the smoking ban, was grateful for Eden Hazard setting up Marcos Alonso's 81st-minute victor.
And two games into the Premier League season only champions Manchester City have scored more goals than Chelsea, who rank first in the division for completed passes, second for key passes and third for total shots per game.
"But we need to continue and press and press and press in the other half".


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read more +
Publisher's Description
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West Bend police arrest Racine man, accused of repeatedly sexually assaulting 15-year-old girl
WEST BEND — West Bend police on Sunday, February 12th arrested a 22-year-old man — accused of sexually assaulting a 15-year-old girl.
Around 1:30 a.m., an officer observed a vehicle parked at the entrance to Royal Oaks Park. The officer thought the vehicle was unoccupied, but soon, it was driven away by a male driver.
The officer stopped the vehicle and observed a 15-year-old girl in the back seat, "buttoning her pants."
An investigation revealed the Racine man had repeated sexual contact with the girl during the weekend, and he was arrested for repeated acts of second degree sexual assault of a child.
He was taken to the Washington County Jail and he's awaiting formal charges.