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Saturday, 2 October 2010
To diet or not to diet... that is the question!
After a dull summer of getting by with the usual required amount of vests, cropped trousers, skirts, dresses and sandals I was suddenly agape at my wardrobe.
Why? Rain. Wind. And anything else Mother Nature chose to throw our way.
The sudden realisation that I couldn't go out in my 'baggy stuff' hit home and I grabbed my jeans, boots and cardi from the wardrobe.
All went well - button done up, zip decided to strain a little but I thought 'hey, at least I don't have to lie horizontally and use a coat hanger to cover the belly'. Anyway, boots next. And therein lay the problem... sitting down, ie bending. I thought I was going to be drawn and quartered, well cut in two at least. As I heavy breathed, I managed to get the boots on and decided it was infinitely safer to stand up straight until it was time to go out.
Luckily at that point in time, all I had to do was walk the school run and make my way home. Which I did, until I got about 200 yards from the front door. I felt like a lost Legionnaire stumbling across the desert who had spotted an oasis in the distance. An oasis that was there, but so far away. My front door was that oasis and I was panting for breath just like my imaginary Legionnaire, stumbling up the path.
Water, water. Unzip, unzip.
My beautiful oasis provided me, not with water, but with my comfy leggings and baggy top. Not to mention my slipper socks.
And the hardhitting thought that if I don't buy new clothes or diet I could be embarassing my kids at the school gates. I mean no child wants to see their Mum in black socks and sandals, do they?
4 comments:
Hi there, Me,Myself,MoiReplyDelete
You and how many others are doing exactly the same thing - respect!
I am fortunate that I don't do the school run but still have this problem by the time autumn comes around.
You just have to face it : the answer is remove three things from your diet.
Mine are potatoes, bread and sweets. I don't bother about pasta because I don't like it but believe me when I say it - pasta is fattening.
I expect to be vilified for this - I always am - because people tend to think pasta is healthy.
Great blog site - love the colour - green's my favourite.
Hi Angelique,ReplyDelete
Well I started today and have actually been very good! We'll see how long it lasts... I think I'm in the right frame of mind.
Thanks for your comments and advice, please come back again. It gets very quiet in here lol!
Me.Myself. Moi,ReplyDelete
Hello again- very good- you've started already. I'm way behind I have already succumbed to a 'tiger bap' and wouldn't you know it, a black cherry sundae topped with cream. Huh, so a black mark for me today.
Water, drink lots of filling water! It makes you feel full.
When I was a child, I used to live on a farm and spent most of my childhood playing in fields. Idyllic when I look back compared to what the children of today in the UK experience. I used to refuse lots of food my parents gave me, like meat, milk, eggs. I lived mainly on what I could eat from the wild - docks, wild potatoes and the like. I was really a vegetarian spent a lot of mealtimes eating tomatoes either with or without sugar. As I got older my diet has changed and I don't think it has really helped me. I didn't cook vegetables either I used to eat them raw. Very strange child.
I am fascinated by the way people here in the UK join diet circles - weight-watchers and the like. But whatever helps has got to be good I suppose.
Well, First Good Behaviour Point to you then - I failed miserably!
Will come over and chat again
Hi Me. Myself, MoiReplyDelete
How's your diet going - mine's not doing very well - although I must say, instead reaching for the doughnuts - I have started eating raw potatoes again. Which is a good sign.
I hope you are drinking lots of water, so good for you - washes out the system and supposedly puts a bloom on your skin that Loreal would envy.
Sadly it doesn't seem to be working for me - just my luck.
I remember Boots did a diet a while ago which meant you starved for 2 days and drank their special brand of some liquid or other. I think it died a natural death, and probably a few dieters felt as though they might die too. But not seen it about lately.
You know, we started this dieting at the wrong time of year - it's the worst time to do this because the weather is now getting cold in the UK. This is the time when you should be putting on the pounds not taking them off because we need to keep warm. Shall we cancel and start again just before summer ?
What do you think ?
Are you thinking of anything other than food ? (joke)
We can pat ourselves on our backs and say we did try but forgot winter was coming!


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Steiner Sports scores big victories in crowded sports marketing industry
NetSuite - Tuesday, February 13, 2018.
Adding Collectibles Business to Unique Sports Experiences Drives Growth for Leader in the Field
Continue reading at the original source >>
About NetSuite
Netsuite develops business management software for small and mid-size companies. Their main products include CRM, ecommerce, Web site management and employee productivity. Netsuite was founded in 1998.
Their main competitors include Salesforce, Siebel and Microsoft. Lawrence J. Ellison co-founded Netsuite and is the majority owner.

subset: commoncrawl


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Mele Kalikimaka is just the thing to say on a bright and sunny Hawaiian holiday – especially when you're relaxing at the perfect resort, the Fairmont Orchid, Hawaii! And be sure to ask your travel advisor about the fabulous December Festive Season offer featuring Holiday Best Available Rates plus special Virtuoso amenities when you travel between December 20, 2012 and January 2, 2013. Rates start at just $499 per night based on double occupancy for a delightful Fairmont Garden View Room, or choose a stunning 1-Bedroom Ocean Front Suite for $2,549 per night. There's also an upgrade based on availability at check-in, a welcome amenity, and even an early check-in and late check-out. With new non-stop service from New York and Washington D.C. to Honolulu, even east coast travelers can be ringing in the New Year – and celebrating the spirit of Aloha – before you know it!
The Fairmont Orchid, Hawaii


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What happened, Miss Simone? Tome.
The first model to walk out was black. So was the second. And the third. Pearls were clutched as a gaggle of white women sitting in front row wondered why Tome dared to not only open with one woman of colour, but with three. This had to be my favourite moment of the week thus far, putting into question the entitlement that many white women felt that evening as women of colour were the focus of the show.
The Tome show was inspired by 'What happened, Miss Simone?', a documentary (which I am sure you can binge on Netflix), chronicling the ups and downs of the incredible Nina Simone. Her beauty and elegance was reflected in the earthy shades of the 60s, complemented by some wild prints and edgy cuts.
Click through below.
Andre ThillaiTome, NYC, Australia, MBFWA, mercedes benz fashion week australia, blogger, sydney, sydney fashion week, sydney fashion, carriageworks, tamil, tamil fashion blogger, racism, what happened miss simoneComment


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Top 10 WordPress Plugins for Affiliate Marketers
As you might already know you can download so called "plugins" for WordPress. These are little extra scripts often written by freelancer and are available for free. With this post I will list the plugins I use on this post (I actually use 10).
Maybe the most used plugin, since it comes built in wordpress. Anyway – Akismet is working like a comment spam filter. If some bot is trying to make a spammy comment Akismet will automatic mark it as spam.
This tool is great for all bloggers that cares about SEO on their blog. AIOSP lest you create unique descriptions and titles on posts and pags. It can also help you with not getting dublicate content. (Disabling indexing of the the archives etc)
This is by far the most powerfull contact-form plugin I have found, and it works great. You can add as many input fields as you want and its really easy one click operations. You can see it in action on my contact page.
This plugin lets you display the recent comments in your sidebar as a widget. Great way to promote any discussion. You can see it in action on the right.
This is a light weight bookmark plugin, but it does the trick. Got a 40-something long list of bookmark-sites to choose from and they are displayed anywhere you want them to in your posts. I got mine on the bottom of each post. (The little images)
This is really a great plugin. It will rank your post after how popular they are. These numbers are based on alot of different term for example views, comments, trackbacks etc. You can choose whats the most important in the option. If you display the most popular posts on your main page you can make sure they are not forgotten when they get bumped down. I got my list showing on the top right. (Click popular)
A really small, but yet powerfull plugin wich ads a small line of text under each post which basically reminds the reader to subscribe to your RSS Feed. Mine says: "If you enjoyed this post, make sure you subscribe to my RSS feed!"
Give something back to your commentators. Give them a link. With this plugin you can display the commentators that have given the most comment on your site, and even let their name be a clicking link to their site. This might get readers to do more comments, since they get a "free" sitewide link". I display mine in the sidebar.
A really powerful statistic plugin for wordpress whch are redicilus easy to install. The plugin is just one .php file and all the operations are handled by a third party site. This plugin will give you information about your visitors like where they come from, what post they read and what link they click.
Yet Another Related Posts Plugin
Displays related post on the bottom of each post. Great way to keep your readers on your site and give them fresh posts which they might like.
There you have it. My favorite plugins so far. Do you have any good plugins on your blog? Make a comment!


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World Stamp Show in New York
New York will be hosting an International Stamp Exhibition that is held once every ten years in the United States. This year, the show will be held May 28th through June 4th, 2016 at The Javits Center in New York. The last International Exhibition in New York was in 1956 (which I attended.)
Admission is free and the Show will be a treat for every one of the 250,000 people expected to attend. About 200 of the world's most notable dealers will be selling and buying philatelic material of all kinds, 70 philatelic societies and stamp clubs will be represented and 50 foreign governments will set up postal facilities offering their stamps at face value truly taking you on a trip around the world. There will be more than 70,000 pages of competitive stamp exhibits along with a Court of Honor and Invited Exhibits that will display priceless rarities; and the exhibits will show almost any way stamps can be collected. The U.S. Postal Service will issue new stamps every day of the show along with commemorative show postmarks.
Stamp collecting is a fantastic and wonderful hobby that can provide many hours of pleasure and education and enables you to meet or correspond with collectors with similar interests, some from all over the world. I am a member of the Collectors Club of New York with its own building at 22 East 35th Street. If you live in the area and think you might want to expand your collecting interests you should consider joining this club. They will be having an open house Monday through Friday May 30th to June 3rd from 10:00 am to 5:00 pm. You are welcome to visit and take a peek at our facilities and meet with some of our members. When you attend the show, stop at the Collectors Club mega booth on the show floor and find out more about this world renowned club.
Everyone that has ever put aside any type of philatelic material is a collector, though perhaps not serious at all. If you are able, come to the show, spend a few hours and see if you want to expand your interests.
For additional information go to their Website: http://www.ny2016.org/


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Each generation has experienced its own brand of mini-tech booms, spurring start-up companies, providing jobs, producing capital and propelling us further down the road for the next innovative wave. We prospered because we embraced policies of supporting critical research without stifling free-flowing market growth. We promoted public and private partnerships without picking winners and losers. That was the path that led us into the 21st century. Yet, some of the most recent technological strides made have been in spite of, rather than because of, government forces.
In the clamor for increased R&D spending in today's struggling economy, it is important to note this public-private balance holds the key for future successes. Perhaps nowhere is this more evident than with current NASA operations. Even in the face of slashed budgets, NASA is balancing development of our next-generation rocket system and the Orion Multi-Purpose Crew Vehicle while supporting commercial cargo launch efforts to the International Space Station. Developing a mutually beneficial relationship between NASA and commercial industry can enable commercial providers to carry human crews to low Earth orbit in the near future.
This will have major impacts for our nation's space presence in the world alongside the emerging space tourism industry, which promises to be a billion-dollar economy within the next decade. This is good news at a time when we depend on Russia's space program to send astronauts to the International Space Station, and as China emerges as a space leader. We cannot cede hard-earned American leadership to other nations due to our own neglect.
Some would say that our decreasing investment relative to competing nations threatens our place as a technological leader and hinders the kind of economic growth we so desperately need right now. And others would say the government has a responsibility to stimulate that kind of growth using federal dollars to pave the way. However noble our intentions might be, we must ensure that we invest wisely in a way that promotes real economic growth, rather than pushing a pointed agenda using taxpayer dollars. Yes, investment means risks, but allowing a politically motivated agenda to drive R&D dollars to unproven technologies is no investment at all. It is simply bad policy that costs us more in the long run. I'm all too convinced that the story of Solyndra represents the current administration's rule rather than the exception.
The economic benefits of a technological boom are undeniable, as is the need for increased R&D investment. But we need so much more than increased spending — we need responsible R&D investment driven by organic, marketplace solutions, with real promise, carefully balanced between public and private capital and influence. Only then can we ensure the best chance for economic success and lasting recovery. Otherwise, we risk continuing down the path of playing the Solyndra game of government picking winners and losers. And we all know how that ends.
Rep. Palazzo (R-Miss.) serves on the House Armed Services Committee and the Science, Space and Technology Committee, where he also serves as chairman of the Space and Aeronautics subcommittee. In addition, he serves as assistant Republican whip.


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I ran into Amee and her boyfriend Jesse on July 30th at Kym + Jack's wedding and she mentioned that she had been thinking of having some portraits taken but didn't know which photographer to go to. Lucky for her, this is my specialty; not only that but I just *happened* to be toying with the idea of shooting at the local fair after dark and needed a happy couple to model for me. We had a vague arrangement worked out in minutes, and got in touch promptly after the wedding to figure out the details.
We decided on August 11th, set up a time to meet and it was a date! Then, out of the blue...
"Hi Christina! It's Jesse, Amee's boyfriend. We spoke to you at Kym's wedding about a photo shoot. So here's the thing, I have this idea and I want to propose to Amee and get it all on camera.. she doesnt know this so please don't mention it to her. I want it to be a complete surprise..."
My response was something along the lines of "OMG OMG OMG!!" followed by squeals of happiness! I'd always wanted to capture a proposal and this was the PERFECT opportunity--since Amee set up the shoot with me herself, there was no way she would ever suspect a thing! Muahahahahahaaaa... uh, I mean YAYYYY!!
Jesse and I agreed on a verbal cue that I would give him when I figured out what would be the best little area to pop the question. I got to the fair early and walked around a little bit. I knew Jesse didn't want to propose in front of a huge crowd, so I decided that the Midway was the best place since the lower end of the fairgrounds was super busy and jam packed full of people arriving for that night's musical act. We walked up and down the Midway, took a few photos just to get things rolling, and then I gave Jesse his verbal cue: I told him that I needed to get a great big smile out of Amee and asked him to whisper in her ear all the things that he loved about her. I don't know exactly how he worded it, but it must have been good!!
Mission accomplished!! Amee didn't suspect a thing.
Finally the sun had set, and the real fun began! Now it was an engagement shoot, and there was no light! I had been looking forward to this challenging bit of night time portraits, and brought my flash setup and wireless triggers for some dramatic images after dark. My new friend Lauren of Lauren Reber Photography was my sidekick on this shoot, and directed my light for me as well as doing a bit of second shooting. THANK YOU Lauren, sooo much for taking the time to help a gal out! These images wouldn't have been possible without you!
I'm lovin' this haunted house image of Amee and Jesse in a casual snuggle.
My goal for these night shots was to incorporate the colorful lights from the carnival rides as a background element, and to capture a bit of motion blur from the fast-moving thrill rides in the distance. The results were even better than I had imagined they could be!
Thank you so much to Amee and Jesse for being my models for the evening, and for sharing your special moment with me and Lauren! Congratulations, and I can't wait for your wedding next year!


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MGE Carpentry proudly serves the Clarkston, MI area for all of it's decking needs.
Clarkston, MI is on the northern outskirts of the Detroit suburbs. Its charming downtown area has been registered as a Historic District on the National Register of Historic Places. The homes in Clarkston reflect this quaint historic element, and its residents enjoy small town life with the convenience of being near the city. All this and more is why Clarkston was recently named as Forbes Magazine's Top Suburbs to Live Well.
MGE Carpentry is proud to serve Clarkston, MI residents for all their decking needs. Whether you are designing a new project from scratch or updating/replacing an old deck, let MGE Carpentry help you with your deck project in Clarkston, MI. With an annual average of 181 sunny days, there are plenty of reasons to get outside and enjoy a custom-built deck at your home in Clarkston, MI.


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Optimizing the Management of Rotator Cuff Problems
In the absence of reliable evidence, it is the opinion of the work group that surgery not be performed for asymptomatic, full thickness rotator cuff tears.Although there is a growing awareness that a large proportion of our population can have full thickness rotator cuff tears that are asymptomatic, we were unable to find quality literature that addressed the issue of operative vs. non-operative treatment for such patients. The issue of appropriate treatment of asymptomatic full thickness tears is potentially important given the high prevalence rate, concerns regarding prrogression in the form of an enlarging tear, or deterioration into a symptomatic process. Given the potential importance of this patient population, the work group felt that a consensus opinion would be appropriate in light of a paucity of published evidence. The opinion that surgery not be performed for asymptomatic, full thickness rotator cuff tears was based on the following considerations:
- Asymptomatic rotator cuff disease is highly prevalent in the older population. A large percentage of our population will have full thickness rotator cuff tears without any apparent difficulties. Thus, the presence of a tear in and of itself is not clinically significant for many people as they have no pain or apparent lack of function.
- For patients with bilateral asymptomatic shoulders, there is no reliable evidence that surgery prevents long-term clinical deterioration of a rotator cuff tear.
- Post-surgical healing rates are inconsistent in elderly patients - the patients most likely to have asymptomatic rotator cuff tear.
- Surgical repair of the rotator cuff has peri-operative morbidity and risks, including pain and loss of use of the arm for a significant time period, infection, deltoid injury, implant failure, and arthrofibrosis. The morbidity and risk are probably not warranted in absence of symptoms.
- Currently, the primary indication for rotator cuff repair is significant pain or dysfunction affecting quality of life; neither indication is present in patients with asymptomatic rotator cuff tears.
Rotator cuff repair is an option for patients with chronic, symptomatic full thickness tears.Our systematic review identified one Level III study46 that compared conservative to surgical treatment of rotator cuff tears. In this study, sixty patients treated without surgery were compared to seventy-seven with rotator cuff repair. Per this study, in group A, tears were non-traumatic in 73% of cases and traumatic in 27% of cases. In group B, tears were non-traumatic in 32% of cases and traumatic in 68% of cases. Statistically significant less pain on shoulder range of motion and at night was seen in those patients who had surgery as compared to those with conservative treatment. Eighty-one percent of the surgical patients reported excellent results as compared to thirty-seven percent with conservative treatment although the authors did not report statistical significance in this comparison. Because there was only one Level III study to support this recommendation, we also examined Level IV articles.
We identified multiple Level IV articles47-52 on the influence of advanced muscle disease on rotator cuff repair. Six studies47-52 assessed MRI tear characteristics of fatty infiltration and/or muscle atrophy on outcome. One study47 reported that patients undergoing open, mini-open or arthroscopic repairs of full thickness tears had fatty atrophy or infiltration of the infraspinatus that led to lower ASES scores. Atrophy and infiltration of the supraspinatus did not correlate with ASES scores. Another study51 reported that the degree of preoperative supraspinatus atrophy correlated with postoperative Constant-Murley scores. Constant-Murley scores in patients with greater atrophy were associated with poorer outcome. Another study48 did not show a statistically significant correlation between preoperative fatty infiltration and postoperative Constant-Murley score. A final study50 showed positive correlation between decreasing postoperative UCLA scores and greater preoperative muscle degeneration as assessed by MRI. While these studies in total suggest that greater post operative functional deficits may occur in the presence of more significant muscle disease, the overall positive outcome of the surgery still suggests that operative treatment of chronic rotator cuff tears is an option.
Because this recommendation is supported by a single Level III article and several Level IV articles, the strength of the evidence that supports it is limited.
We cannot recommend for or against exercise programs (supervised or unsupervised) for patients with rotator cuff tears.When the patient and physician select non-operative management of a rotator cuff tear, the primary objectives are to decrease pain, increase function, and enhance activities of daily living (while mitigating potential long term adverse outcomes). We found no quality evidence that demonstrated a specific impact of an exercise program, compared to the natural history of disease without other interventions. Similarly, we found no reliable evidence demonstrating that the efficacy of an exercise program is predicated upon a specific form of education, supervision, or exercise environment.
Although reliable evidence was not found to definitively support a positive impact, we also found no such evidence to suggest that there are adverse impacts of exercise programs upon rotator cuff disease.
One Level IV study53 addressed a physical therapy program. This study observed statistically significant improvement on the Oxford shoulder disability questionnaire and the SF-36 for General Health at three months in a cohort of ten patients treated with a physical therapy-supervised program for massive irreparable cuff tears. It is not possible to generalize this study across patients with different severities and durations of rotator cuff tears.
A second Level IV study54 reported inconsistent results on the Simple Shoulder Test (SST) but did observe improvement at an average of 2.5 years in three scales with a home exercise program in a larger group of patients with chronic rotator cuff tears.
We cannot recommend for or against subacromial injections for patients with rotator cuff tears.One level II study55 found no statistically significant difference in pain or tenderness up to six weeks after injection of steroid with lidocaine compared to lidocaine injection alone.
In contrast, three Level IV56, 57, 58studies noted short term improvement with corticosteroid injection compared to baseline status, without comparison to a placebo control. We found no specific, compelling evidence to provide evidence-based recommendations concerning an ideal / absolute / safe number or frequency of subacromial corticosteroid injections in the setting of a rotator cuff tear. While it is logical for clinicians to consider potential adverse effects of corticosteroid injection upon rotator cuff tendon biology and healing capacity with rotator cuff repair (based upon general concerns across other areas of orthopaedic practice), there was no quality evidence to guide recommendations in this regard. Because the evidence that addresses this recommendation is limited and conflicting, the strength of this recommendation is Inconclusive.
We cannot recommend for or against the use of NSAIDS, activity modification, ice, heat, iontophoresis, massage, Transcutaneous Electrical Nerve Stimulation (TENS), Pulsed Electromagnetic Field (PEMF), or phonophoresis (ultrasound) for nonoperative management of rotator cuff tears.In symptomatic patients with full thickness rotator cuff tears, treatment objectives are decreased pain, increased function, and enhancement of activities of daily living. Although we found no specific evidence demonstrating treatment efficacy, neither did we find evidence that the following modalities were ineffective non operative treatment alternatives for rotator cuff tears: NSAIDS, activity modification, ice, heat, iontophoresis, massage, TENS, PEMF, phonophoresis (ultrasound).
We suggest that patients who have rotator cuff-related symptoms in the absence of a full thickness tear be initially treated non-operatively using exercise and/or non-steroidal anti-inflammatory drugs.Several Level II studies 59, 60, 23 report the beneficial effects of exercise in decreasing pain and improving function in patients with rotator cuff related symptoms without a full-thickness tear. One study23 reported on 24 patients undergoing an exercise program and noted significantly improved pain scores on the VAS [visual analog scale] after 8 weeks of treatment; post hoc pairwise comparisons of the two groups in this study showed significantly more improvement in the exercise plus manual therapy group using a composite pain measure. Another study59 reported patients had significant improvements in pain at rest, pain at night and Constant-Murley scores after 3 months of a home exercise program. A third study60 randomized patients between a group undergoing exercise and a control group. The group undergoing exercise had statistically significant improvements in pain levels at rest, pain with movement and upper extremity function (DASH-Laborers subscale). No statistically significant difference was reported in patients who participated in supervised and unsupervised exercises.
Our systematic review also identified two Level II studies61, 62 that found better results with non-steroidal anti-inflammatory medications than with placebo in the treatment of rotator cuff-related symptoms in the absence of a full-thickness rotator cuff tear. The first study63 was a prospective, double-blinded placebo-controlled study in which 20 patients treated with oral diclofenac had significant improvements in pain (VAS) and shoulder function at four weeks compared to patients taking a placebo. The second study 64 reported significant improvements in shoulder function VAS scores in 10 patients treated with naproxen compared to 10 patients receiving a placebo.
We cannot recommend for or against subacromial corticosteroid injection or Pulsed Electromagnetic Field (PEMF) in the treatment of rotator cuff-related symptoms in the absence of a full thickness tear.We found one Level I study63that evaluated the effect of subacromial corticosteroid injections on patients who had previously had 6 weeks of unsuccessful physical therapy and 2 weeks of NSAIDS for rotator cuff-related symptoms in the absence of a full-thickness tear. The authors reported no differences at 3 and 6 months in ASES scores, DASH scores or pain with impingement testing between groups. However, five Level II studies61, 64, 65, 66, 67 report conflicting results for the effect of subacromial steroid injections for durations between 2 and 6 weeks. These studies report various results for outcomes of pain and function and also vary in that some studies report results for one steroid injection while others report results for multiple steroid injections. The work group's overall assessment of this evidence was conflicting. Because of these conflicting results, this recommendation is supported by inconclusive evidence.
Two Level II studies68, 69 also examined the use of pulsed electromagnetic field (PEMF) in patients diagnosed with rotator cuff related symptoms. One study69reported no statistically significant differences in pain or Constant-Murley scores in patients treated with PEMF as compared to those treated with sham-controls. In the second study68 the authors measured pain on the VAS scale and found a statistically significant difference in favor of PEMF. Based on these conflicting results, the work group does not have sufficient evidence to provide specific treatment recommendations in regard to PEMF.
We cannot recommend for or against the use of iontophoresis, phonophoresis, transcutaneous Electical Nerive Stimulation (TENS), ice, heat, massage, or activity modification for patients who have rotator cuff related symptoms in the absence of a full thickness tear.There were no studies identified examining iontophoresis, phonophoresis, TENS (transcutaneous electrical nerve stimulation), ice, heat, or massage as non-operative treatments in patients with rotator cuff-related symptoms.
Early surgical repair after acute injury is an option for patients with a rotator cuff tear.Rotator cuff tears are a common cause of shoulder pain and dysfunction.64 The prevalence of rotator cuff tears, even asymptomatic tears, increases with advancing age.6, 7 Treatment options for traumatic rotator cuff tears include a number of non-operative options as well as surgical repair. Delaying repair of acute traumatic rotator cuff tear may lead to the development of pathology associated with chronic rotator cuff tears including tendon retraction, and fatty infiltration and atrophy of the rotator cuff muscles with associated detrimental effects on upper extremity function. In earlier surgery after acute injury, the surgeon is more likely to encounter healthier tissue with better healing potential which may lead to better outcome.
Our systematic review did not identify any quality literature that addresses the issue of timing of surgery after acute rotator cuff injury. The evidence that we considered included five level IV case series70, 71 (limited evidence) of rotator cuff repair that focused on early surgical repair of rotator cuff tears. One study70 reported on a series of subjects with a history of a significant acute injury that were treated with surgery within three months of injury. This cohort represented less than 10 percent of the repairs that they performed in their overall experience, thus demonstrating that acute rotator cuff injuries are relatively uncommon. The patients repaired within 3 weeks of injury had better results than those repaired after 3 weeks. The second study71 reported the results of rotator cuff repair in a series of 26 patients who had a history of trauma with an acute onset of symptoms and a full thickness rotator cuff tear. All of the repairs were performed within 3 weeks of the injury. Similar to the findings of the first study, these cases only represented about 5 percent of the cases of full thickness rotator cuff tear that the authors treated. Although they reported a high rate of successful results (20 excellent, 4 good, 1 fair, and 1 poor) they did not determine whether the timing of surgery affected the outcome.
A third study72 reported the outcome of repair of traumatic anterior superior rotator cuff tears with combined subscapularis and supraspinatus tears. The patients had open repair at an average of 4.5 months after injury. Outcome assessment demonstrated restoration of subscapularis related function. The authors did not find a correlation between outcome and duration of symptoms. Two additional studies73, 74 addressed repair of traumatic anterior superior rotator cuff tears with combined subscapularis and supraspinatus tears. One study reported on thirty patients with a traumatic tear who had open repair at an average of 4.5 months after injury and the other reported on twenty-four patients of which twenty-two recalled a specific incident at which the injury occurred. (See Table 26 for the summary of these results.) One study reported there were no significant correlations between outcome and a number of preoperative factors including duration of symptoms. The other study did not provide statistical analyses.
Defining whether a rotator cuff tear is acute has relevance to this discussion. In evaluating patients, the surgeon should attempt to properly identify patients with acute tears as opposed to patients with pre-existing chronic tears that become symptomatic after an injury event. A discrete traumatic event is more suggestive of acute tear. Physical examination findings including supraspinatus and infraspinatus muscle atrophy as well as internal and external rotation lag signs may be indicative of larger and more chronic rotator cuff tears.
Evaluation of rotator cuff muscle quality with CT or MRI is an important consideration. Six Level IV case series47-52 addressed the MRI findings of fatty infiltration and muscle atrophy in relation to the outcome of rotator cuff repair. Chronic and larger tears are associated with muscle atrophy and fatty replacement, both of which correlate with inferior functional outcome after rotator cuff repair. It is thought that early repair of acute rotator cuff tears might mitigate the development of chronic tendon and muscle pathology and improve functional outcomes (see Recommendation 2: Full Thickness Tears and sympTomatic Patients: Supporting Evidence- MRI Tear Characteristics:
Tables relevant to this recommendation are: Table 7 through Table 10
Figures relevant to this recommendation are: Figure 4 through Figure 6
MRI Tear CharacteristicsTables relevant to this recommendation are: Table 24 through Table 25
Figures relevant to this recommendation are: Figure 61 through Figure 66
We cannot recommend for or against the use of perioperative subacromial corticosteroid injections or non-steroidal anti-inflammatory medications in patients undergoing rotator cuff surgery.After a systematic search of the literature, we found no clinical data that supported or refuted a negative or positive effect of subacromial corticosteroid injections on tendon healing or outcomes after rotator cuff repair. Therefore, the work group could not recommend for or against their use in the perioperative period as the evidence was inconclusive.
Non-steroidal anti-inflammatory medications have the potential benefits of limiting pain and swelling associated with rotator cuff repair surgery. While the clinical effects of NSAIDs have been evaluated in the non-operative treatment of patients with rotator cuff symptoms in the absence of a full-thickness tear, we found no evidence supporting or refuting their usage in the postoperative period after rotator cuff repair. Specifically, the work group was concerned about the possible negative affects of NSAIDs on tendon healing. There is no clinical data supporting or refuting a negative or positive affect on rotator cuff tendon healing therefore the group found that the evidence with regard to NSAIDS on healing was inconclusive. If NSAIDs are utilized, appropriate prudence should be exercised as this treatment modality is associated with potential adverse side effects including gastrointestinal bleeding, renal injury and platelet dysfunction.
It is an option for physicians to advise patients that the following factors correlate with less favorable outcomes after rotator cuff surgery: Increasing AgeIncreasing patient age has been identified as a potential factor influencing outcomes and healing after rotator cuff surgery. Healing and strength (as indirectly measured by the Constant-Murley score) are critical factors in evaluating surgical success. Several studies determined that the Constant-Murley score (as a measure of shoulder strength) was negatively correlated with increasing age after rotator cuff repair.75, 51, 47, 54, 76 Similarly, numerous authors concluded that age was a negative predictor of posterosuperior rotator cuff healing after repair.77-79
Age has also been shown to correlate with subjective outcomes after rotator cuff repair although the associations are not as strong as those for healing and strength. A number of studies have found increasing age to be negatively associated with clinical outcomes after rotator cuff surgery.47, 76, 80, 79, 51, 77, 75, 81, 82, 83 However, some studies found no effect of increasing age on clinical outcomes49, 72, 73, 84, 85, 86, 87, 88, 89, 90-92, 93
Out of all 23 studies included, one author reported a negative correlation between increasing age and a patient-reported outcome measure.81 This study reported on 80 patients at 2 years after rotator cuff repair and concluded that older age was associated with worse DASH scores. The authors did perform a multivariate analysis confirming the relationship; therefore, this should be recognized as a significant finding. One other author82 reported VAS pain and reported age ranges for comparison groups. The findings are statistically significant but the authors do not define the size or direction of the effect. A third author reported "Treatment Response", but this outcome is a composite of pain and internal/external rotation. It is therefore a composite of a patient-oriented outcome and a surrogate measure making it difficult to interpret.
It is an option for physicians to advise patients that the following factors correlate with less favorable outcomes after rotator cuff surgery: MRI Tear CharacteristicsRotator cuff muscle quality has been implicated as having a direct effect on the ability of a repair to heal and the functional outcome after a repair. Both fatty degeneration (comparative amount of muscle tissue to fat as determined by MRI or CT scan) and muscle atrophy (volume of rotator cuff muscle as determined by MRI or CT scan) have been evaluated in regards to their effects on tendon repair healing and outcomes. Based upon six Level IV studies48, 47, 49, 50, 51, 52 it is an option for a surgeon to advise a patient undergoing rotator cuff repair about the negative affects of supraspinatus and infraspinatus muscle atrophy and fatty degeneration on both tendon healing and clinical outcomes.
One study48 evaluated 38 patients prospectively who underwent a rotator cuff repair with MRI and outcome scores (ASES score, Constant-Murley score) at baseline and at 1 year postoperative. The authors reported that worse infraspinatus muscle atrophy and fatty degeneration were correlated with worse ASES and Constant-Murley scores. Also, worse fatty degeneration correlated with poorer infraspinatus healing. Worse supraspinatus atrophy correlated with worse ASES scores, Constant-Murley scores and tendon healing. Finally, worse supraspinatus fatty degeneration correlated with worse tendon healing.
A second study50 evaluated twenty-eight patients who underwent repair of a massive rotator cuff tear at 44 months postoperative with UCLA scores. Preoperative fatty degeneration of the infraspinatus correlated with inferior postoperative UCLA scores.
Several authors focused their evaluation on the correlation of just supraspinatus muscle quality to tendon healing and outcomes. One study evaluated twenty-seven47 patients after a mini open rotator cuff repair for an isolated supraspinatus tear with an MRI and Constant- Murley score at an average of 67 months postoperative. This study determined that preoperative supraspinatus muscle atrophy correlated negatively with postoperative Constant-Murley scores. Another study49 evaluated 53 patients after isolated arthroscopic supraspinatus repair with Constant-Murley scores and MRI at an average of 26 months postoperative. Preoperative supraspinatus fatty degeneration and muscle atrophy correlated with worse healing rates. A final study51 prospectively evaluated 30 chronic rotator cuff tears of varying sizes, which underwent an open rotator cuff repair, with an MRI at an average of 21 months postoperative. The authors determined that preoperative supraspinatus muscle atrophy correlated with poorer healing rates.
Based upon these studies, preoperative infraspinatus fatty degeneration and muscle atrophy correlated with worse outcomes and healing. Preoperative supraspinatus muscle atrophy correlated with worse outcomes and healing. Finally, preoperative supraspinatus fatty degeneration was correlated with worse healing, but not necessarily worse outcomes.
It is an option for physicians to advise patients that the following factor correlates with less favorable outcomes after rotator cuff surgery: Worker's Compensation StatusSeveral authors94, 95, 96 have evaluated the effect of Workers' compensation on surgical treatment for rotator cuff disease including acromioplasty for tendonitis and repair of full-thickness tears. Based upon one Level II study96and two Level III studies,97, 98 the work group has determined that it is an option for physicians to advise their patients that workers' compensation status correlates with less favorable outcomes after rotator cuff repair.
One study96 prospectively evaluated 107 shoulders (23 of which were receiving workers' compensation) at an average of 45 months postoperative from an open rotator cuff repair with the UCLA score. Both groups were comparable with regards to patient age, sex, tear size, preoperative strength and active motion. At final follow-up, patients receiving workers' compensation had significantly worse UCLA scores compared to those not receiving workers' compensation. Another study94 prospectively evaluated 106 patients (40 of which were receiving workers' compensation) at an average of 32 months after arthroscopic acromioplasty for rotator cuff tendonitis with the ASES score, the Simple Shoulder Test and a VAS pain scale. The authors report no statistically significant differences between groups with regards to each of these outcomes although the AAOS work group re-calculated the statistics and found workers' compensation patients had significantly worse SST and VAS pain scores than those not receiving a claim. The last study95 prospectively evaluated 24 patients (12 receiving workers' compensation) at an average of 3 years postoperative from an open acromioplasty for rotator cuff tendonitis with UCLA scores. At final evaluation, workers' compensation patients had significantly worse improvements in pain compared to those not receiving Workers' compensation.
Based upon the above data, shoulder function as evaluated by the UCLA score, the Simple Shoulder Test and VAS pain scores were all inferior in workers' compensation patients treated surgically for acromioplasty for rotator cuff tendonitis or rotator repairs compared to a non-workers' compensation group. This data supports the option of advising patients that workers' compensation status correlates with less favorable outcomes after rotator cuff surgery.
We cannot recommend for or against advising patients in regard to the following factors related to rotator cuff surgery: Diabetes, Co-morbidities, Smoking, Prior Shoulder Infection, Cervical Disease.Various patient-related factors may influence clinical outcomes after rotator cuff surgery. These factors may affect functional outcomes or tendon healing, hence the work group systematically searched for data on diabetes, smoking, co morbidities, prior shoulder infection and cervical disease.
Two Level III studies97, 98 compared the outcomes of diabetic and non-diabetic individuals after rotator cuff surgery. One study98 found no statistically significant difference between the two groups on postoperative stiffness using the Constant Murley Score at 46 months. The second study97 found a statistically significant difference and possible clinically important difference in the ASES score favoring patients without diabetes. This study found no statistically significant difference in the occurrence of infection between the two groups of patients. Since these studies assessed different outcomes with varying results, the work group found this evidence inconclusive.
One Level IV study73 assessed the effect of medical co-morbidities in patients undergoing open repair of traumatic anterosuperior rotator cuff tears. The authors reported no statistically significant correlation between medical co-morbidities and outcome. They did not provide significance values or define "outcome." Again, the work group evaluated this as a single study that contained limited evidence. They concluded overall that the evidence is inconclusive concerning the presence of medical co-morbidities and patient outcomes.
There were no studies found that addressed the effects of smoking, prior shoulder infection, or cervical disease as they relate to rotator cuff surgery outcomes.
Although we found no specific evidence demonstrating a significant effect for any of these factors, neither did we find evidence that the above factors had no effect on clinical outcomes after rotator cuff surgery. Therefore, the work group found there to be inconclusive evidence regarding the affects (either positive or negative) of these factors on outcomes after rotator cuff surgery.
We suggest that routine acromioplasty is not required at the time of rotator cuff repair.Acromioplasty and release of the coracoacromial ligament is often included as part of a rotator cuff repair. Theoretical benefits of an acromioplasty in the setting of a rotator cuff repair include increasing the subacromial space available to facilitate the repair and also relieving extrinsic compression on the repair after completion. Despite these theoretical benefits, one quality study101 suggests that an anterior acromioplasty has no effect on final outcomes after rotator cuff repair. Two studies89, 81 reviewed the results of removing acromial bone (Bigliani type II and III acromions) and did not find any benefit in postoperative functional results.
One Level II randomized prospective study89 performed a comparison of 47 patients treated with an arthroscopic rotator cuff repair plus an associated anterior acromioplasty and coracoacromial ligament release with 46 patients who underwent rotator cuff repair alone. All patients had isolated supraspinatus rotator cuff tears with Bigliani type II acromion. The patients were evaluated preoperatively and an average of 15 months postoperatively with the American Shoulder and Elbow Surgeons Score. The authors reported no significant difference between groups of both final ASES scores and improvement from baseline. While these results suggest there was no difference in ASES scores between groups, this study was not sufficiently powered to detect the minimally clinically important improvement.
Another randomized, prospective study81 compared 40 patients treated with an arthroscopic rotator cuff repair, anterior acromioplasty and coracoacromial ligament release with 40 patients who underwent rotator cuff repair alone. All patients had a repairable full thickness tear and either a Bigliani type II or III acromion. At two years postoperatively, the authors reported no significant differences in final Constant-Murley scores or DASH scores. The Constant-Murley scores are suggestive that acromioplasty has no effect on outcome. The work group considered the DASH result a true negative because this study was sufficiently powered to show the nonsignificant result was also not clinically significant. These results suggest that acromioplasty has little or no effect on postoperative clinical outcomes; therefore it is not required for the management of normal acromial bone (including type II and III morphology at the time of rotator cuff repair).
Acromial spurs are independent from normal acromial bone. Spurs have been identified as acquired ossifications of the coracoacromial ligament on the undersurface of the acromion. This ossification is considered in excess of normal acromial bone and may have a pathological role in the process of rotator cuff disease. The work group recognizes that acquired acromial spurs are a topic of interest to many surgeons; however they are beyond the scope of the current guideline.
It is an option to perform partial rotator cuff repair, debridement, or muscle transfers for patients with irreparable rotator cuff tears when surgery is indicated.Five Level IV 99-103 studies addressed the use of operative debridement, limited repair, or muscle transfer for an irreparable rotator cuff tear. These studies found an improvement in pain and function after repair of a portion of a chronic full thickness rotator cuff tear when a complete repair can not be achieved.99 They also found clinically important improvement with arthroscopic debridement without partial repair of the rotator cuff with or without release of the long head of the biceps102 and improvement in pain and function with transfer of the latissimus or teres major for irreparable tears involving the supraspinatus and infraspinatus tendons.100 Comparative studies on the superiority of one surgical technique or option over another for surgical management of irreparable full thickness rotator cuff tears have not been reported. All studies reported intermediate term results 3-4 years after surgical treatment. Long term results were not reported. Complications reported after muscle transfer include temporary Complex Regional Pain Syndrome and cosmetic deformity of the biceps.
It is an option for surgeons to attempt to achieve tendon to bone healing of the cuff in all patients undergoing rotator cuff repair.While the primary clinical goal of rotator cuff repair surgery is improvement in pain, strength and function, a primary biological goal of the surgery is to achieve healing of the tendon to bone. Three Level IV 77, 83, 104studies addressed tendon to bone healing of the cuff in patients with full thickness rotator cuff tears. The first study77, 77, 83, 104 reported on MRI-confirmed status of the integrity of rotator cuff repairs in 63 subjects at two years from surgery. Patients with intact cuff repairs demonstrated improved outcomes over those found to have re-tears. The authors also reported a significant negative correlation with age but did not report magnitude of the correlation. Similarly, the second study104 reported superior outcomes, favoring intact cuffs over re-tears in a cohort of 49 subjects who underwent open repair with nonabsorbable suture at four year follow-up. In the last study, the rating of the tendon after repair was correlated with the UCLA score after surgery, but the authors did not report if the results were statistically significant for the outcome.
We cannot recommend for or against the preferential use of suture anchors versus bone tunnels for repair of full thickness rotator cuff tears.The primary technical goal of rotator cuff repair surgery is the stable fixation of the torn tendon to the tuberosity of the humerus. Numerous repair techniques have been described, the two most common of which rely upon the use of bone tunnels (trans-osseous technique) or suture anchors. We identified no studies that specifically compared suture anchor to bone tunnel fixation in rotator cuff repair surgery. Three studies105, 106, 107 address the use of suture anchors while one study83 addresses bone tunnel technique. Since no comparative studies were identified and since the four studies found were evaluated as limited evidence, we cannot recommend one fixation technique over another. Based on the available evidence, either fixation technique, when applied properly, can result in favorable outcomes.
We cannot recommend for or against a specific technique (arthroscopic, mini-open or open repair) when surgery is indicated for full thickness rotator cuff tears.A recent trend in rotator cuff repair surgery has been an apparent evolution from open repair techniques to "mini-open" repairs and, most recently, to arthroscopic repairs. The systematic review found no single comparative study that included all three techniques. One Level II 108and two Level III109, 110 studies address arthroscopic versus open rotator cuff repair in patients with full thickness tears.
The first study108 compared open acromioplasty and rotator cuff repair to arthroscopic subacromial decompression with mini-open repair in a randomized trial with 73 patients. This study found early results favoring the mini-open technique up to one year after surgery (ASES, Rotator Cuff – Quality of Life Scale, and Shoulder Rating Questionnaire), but no statistically significant differences at 2-year follow-up. The second study109 reported no statistically significant differences at 49 month follow-up on results of a non-randomized comparison of open and arthroscopic repair techniques. Lastly, in a non-randomized but controlled study comparing arthroscopic to mini-open repairs, the third author110 reported no differences at 36 months in the ASES and UCLA scores. The lack of comparisons between all three techniques makes it difficult to determine if any one technique should be preferred over another. Additionally, the apparent disagreement between the results of the included studies makes it difficult to recommend for or against a specific technique.
We suggest surgeons not use a non-crosslinked, porcine small intestine submucosal xenograft patch to treat patients with rotator cuff tears.One level II study111 and one level III112 study evaluated the results of open repair of medium to massive rotator cuff tears with and without the use of a non cross linked, porcine small intestine submucosal xenograft as augmentation to the primary tendon to bone repair. In these studies, there was less favorable outcome (pain and function) with the use of this graft when compared to primary repair alone. The complication rate of hypersensitivity reaction was approximately 20-30 % of cases with the use of this graft.114 Based on these results, the work group suggests that non-cross linked, porcine small intestine submucosal xenograft patches not be used to treat patients with rotator cuff tears.
We cannot recommend for or against the use of soft tissue allografts or other xenografts to treat patients with rotator cuff tears.The work group recognizes that different graft materials and different methods of graft processing have different biologic and mechanical properties which may result in differences in clinical effectiveness or complications between graft materials. Two level IV studies113, 114, one addressing the use of xenograft and one addressing the use of allografts, were included. In both cases the graft was used to close an irreparable rotator cuff defect. These studies had small treatment groups (n=10 and n=16 respectively) and were of low quality. Based on the evidence, the work group had insufficient data to make specific recommendations for or against the use of other xenografts or allografts to treat reparable or irreparable full thickness rotator cuff tears.
In the absence of reliable evidence, it is the opinion of the work group that local cold therapy is beneficial to relieve pain after rotator cuff surgery.One of the primary objectives of patient care is the alleviation of pain and suffering. Pain has been coined one of the 'vital signs' of patient management. It is therefore reasonable to encourage pain control methods, especially when there is broad experience with their application in general clinical practice across multiple specialties.
Cold therapy has been utilized in the postoperative setting for a variety of orthopaedic procedures, including shoulder surgery, to aide in pain control and possibly to decrease tissue swelling. Based on these observations, there may be beneficial effects of cold therapy after shoulder surgery; however, there is no compelling or strong, quality evidence that pertains specifically to rotator cuff repair. Studies evaluating the effect of cold therapy are limited by a lack of standardized methodology and by variability in the methods of cold application.
Based upon the expert opinion of the work group, local cold therapy is a reasonable treatment for pain control after rotator cuff surgery. Surgeons should be aware of the possibilities of local tissue injury and generalized hypothermia related to excessive cold application, although these complications are quite rare.
We found no quality studies to help decipher any potential clinical differences between intermittent crushed ice, continuous cold therapy, and other forms of cryotherapy after rotator cuff surgery.
We cannot recommend for or against the preferential use of an abduction pillow versus a standard sling after rotator cuff repair.After a systematic search, no clinical data was found supporting or refuting a negative or positive effect of a sling, shoulder immobilizer, abduction pillow, and/or abduction brace after repair of a full thickness rotator cuff tear on tendon healing or outcomes after rotator cuff repair. Therefore, the work group could not recommend for or against their use in the post-operative period.
We cannot recommend for or against a specific time frame of shoulder immobilization without range of motion exercises after rotator cuff repair.After a systematic search, no clinical data was found supporting or refuting a negative or positive effect of range of motion exercises (passive, active or active assisted) for post-operative rehabilitation after repair of a full thickness rotator cuff tear on tendon healing or outcomes after rotator cuff repair. Therefore, the work group could not recommend for or against the timing of range of motion exercises in the post-operative period.
We cannot recommend for or against a specific time interval prior to initiation of active resistance exercises after rotator cuff repair.After a systematic search, no clinical data was found supporting or refuting a negative or positive effect of active resistance exercises for post-operative rehabilitation after repair of a full thickness rotator cuff tear on tendon healing or outcomes after rotator cuff repair. Therefore, the work group could not recommend for or against the timing of active resistance exercises in the post-operative period.
We cannot recommend for or against home-based exercise programs versus facility-based rehabilitation after rotator cuff surgery.Our systematic search of the literature yielded two quality studies115, 116 providing data comparing the efficacy of a home based exercise program to referral to a facility based rehabilitation program following rotator cuff repair. Both studies reported large loss to follow-up at longer durations (24 and 52 weeks) and found conflicting results among the outcomes reported at shorter durations (6 and 12 weeks). Further, patient compliance was not measured in both studies. Based on the conflicting results and varied outcomes reported, the work group could not recommend for or against a specific post-operative rehabilitation protocol.
We cannot recommend for or against the use of an indwelling subacromial infusion catheter for pain management after rotator cuff repair.Post-operative pain control is an important objective for improving the patient's overall surgical experience. For this recommendation, we only considered studies of indwelling infusion catheters for the management of pain after rotator cuff repair. We did not consider evidence related to possible benefits of infusion catheters after shoulder procedures without rotator cuff repair.
One Level II study117 compared intravenous injection of fentanyl and ketorolac tromethamine with subacromial infusion of bupivacaine up to 120 hours after rotator cuff repair. There was no statistically significant difference in pain measured by visual analog score between the two groups. Impact on long term clinical outcome was not measured. The authors did not compare these treatments against a clinically-relevant control group (for example oral analgesic medications only). It is not possible to extrapolate the findings of this study to typical clinical situations, since intravenous fentanyl and ketorolac are not routinely used in general orthopaedic practice. Therefore, we can not provide specific recommendations about the use of subacromial indwelling infusion catheters, particularly in the setting of outpatient rotator cuff repair. The work group did not consider risks or benefits of infusion catheter utilization in other clinical conditions.
Guideline Work Group:
Robert A. Pedowitz, MD, PhD, Chair
Ken Yamaguchi, MD, Vice-Chair
Christopher S. Ahmad, MD
Robert T. Burks, MD
Evan L. Flatow, MD
Andrew Green, MD
Joseph P. Iannotti, MD, PhD
Bruce S. Miller, MD, MS
Robert Tashjian, MD
AAOS Guidelines and Technology Oversight Committee:
William C. Watters, III, MD, Chair
Council on Research, Quality Assessment and Technology:
Kristy Weber, MD, Chair
AAOS Staff:
Charles M. Turkelson, PhD, Director of Research and Scientific Affairs
Janet L. Wies, MPH, Manager, Clinical Practice Guidelines
Sara Anderson, MPH, Research Analyst
Justin St. Andrew, MA, Research Analyst
Laura Raymond, MA, Lead Research Analyst
Sara Anderson, MPH, Lead Research Analyst
Kevin Boyer, BS, Research Analyst
Patrick Sluka, MPH, Research Analyst
Richard McGowan, MLS, Medical Librarian
Guideline Work Group:
Robert A. Pedowitz, MD, PhD, Chair
Ken Yamaguchi, MD, Vice-Chair
Christopher S. Ahmad, MD
Robert T. Burks, MD
Evan L. Flatow, MD
Andrew Green, MD
Joseph P. Iannotti, MD, PhD
Bruce S. Miller, MD, MS
Robert Tashjian, MD
AAOS Guidelines and Technology Oversight Committee:
William C. Watters, III, MD, Chair
Council on Research, Quality Assessment and Technology:
Kristy Weber, MD, Chair
AAOS Staff:
Charles M. Turkelson, PhD, Director of Research and Scientific Affairs
Janet L. Wies, MPH, Manager, Clinical Practice Guidelines
Sara Anderson, MPH, Research Analyst
Justin St. Andrew, MA, Research Analyst
Laura Raymond, MA, Lead Research Analyst
Sara Anderson, MPH, Lead Research Analyst
Kevin Boyer, BS, Research Analyst
Patrick Sluka, MPH, Research Analyst
Richard McGowan, MLS, Medical Librarian


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We know you love to spoil them but they already have enough stuff.
You love seeing their eyes light up after unwrapping a much-coveted gadget. Their parents, however, insist that today's hottest toy is tomorrow's clutter. So what can you give the grandkids that'll never end up in the donation pile? Experiences, for one. And knowledge, thanks to fun educational toys. Another good bet? Any activity that brings you closer together as a family. Keep scrolling for ideas.
Admission to an upcoming concert by their favorite artist or to a kid-friendly stage performance like Disney on Ice gives them something to look forward to—and studies show anticipating a fun experience is its own kind of enjoyment. Check out more family-friendly shows coming to an area near you on Ticketmaster.
Bedtime stories aren't what they used to be. None of the heroines in Volumes 1 and 2 of Good Night Stories for Rebel Girls dream of marrying a prince. Neither does Harriet Tubman, star of the "lyrical biography" for children Before She Was Harriet, a notable title among children's booksellers polled by Publisher's Weekly, along with hits like Wonder and Windows.
Annual family passes to kid-friendly institutions like natural history museums, nature centers, or botanical gardens typically pay for themselves within a few visits, but even single-day tickets will pique the curiosity of young minds.
Encourage their extracurricular interests with subscription services like Kiwi Crate ($20/month) which sends monthly boxes filled with all the supplies needed to do a fun science project. Other niche subscriptions include Bitsbox (starting at $25/month), which teaches coding; JustLikeMe! ($28/month), featuring books with African American protagonists; and Sensory Theraplay ($40/month), a selection of therapist-recommended toys for children with autism and developmental delays. You can find even more fun and educational kids' subscription boxes at Crate Joy.
Give them a healthy outlet for all of their natural energy with a gift card for an indoor playground or trampoline center. Better yet, give their parents the day off and spend some quality time bonding with your grandkids from the ball pit.
An afternoon of family togetherness at the bowling alley, skating rink, or an indoor rock climbing gym will get everyone's endorphins flowing.
Support their passion by pitching in to help pay for the necessary gear and travel.
Encourage problem-solving and a healthy sense of competition with a good old-fashioned board game—just be prepared to play a round or two with them.
RELATED: Your Favorite Board Games Just Got a Rustic Makeover
You already know they're talented—help them show the world their musical gifts with an instrument and lessons. Check out Amazon for all kinds of deals on musical instruments.
Craft stores like Joann offer lessons in baking, crocheting, sewing, and more geared towards older kids and teens.


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Visit to Retirement Village (Springvale)
A number of Year 2 students recently paid a visit to Lexington Gardens Retirement Village to meet and spend time with some of their residents.
The occasion began with an entertaining performance by our students. Residents were then presented with handmade cards and, in turn, students completed a colouring activity with them.
The visit is part of the Primary School's 'Respectful Relationships' program and complements a recent Inquiry Unit (Year 2) called 'Our Community'. The residents and our students really enjoyed the visit, which highlights the belief that "children and the elderly have a remarkable connection with one another".


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You get the following error message when you try to redeem a prepaid code on your Xbox 360 console:
Cannot enter prepaid code
Status code: 80070057
This may mean that you haven't completely filled in all your Xbox Live account information. If your account information isn't complete, you can't redeem a prepaid code.
To resolve this problem, enter any missing information in your account before you try again to redeem a prepaid code. Here's how:
If you keep experiencing the problem, contact Xbox Support.
Tak for din feedback!
Giv feedback om dette emne
Vil du kontakte support vedrørende problemet "Error 80070057 occurs when redeeming a prepaid code on Xbox 360 ", som du læste om, eller vedrørende et andet problem?


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September 24, 2016
Hiroshima and Miyajima – An unexpected surprise 0
My 3rd visit to Hiroshima started off really well. We arrived on a Friday night and as we get in to the city, we see lots of carnival style tents lining the roads. It turns out we had timed it perfectly and arrived right in the middle of the the Tokasan festival (aka Yakata festival), Jason and I took the hotel's bikes out and went for a ride to check out the festival while the girls all went to the peace memorial museum. While out and about, we stopped and bought some delicious takoyaki, which are octopus balls. They weren't the best ones I have had but they were certainly delicious.
One of the nights we were there, we went out of some okonimoyaki. Okonimoyaki is basically lettuce, bean shoots, spring onion, egg and a couple of other things mixed in to the shape of a pancake. There are 2 styles of okonimoyaki in Japan. One is the Osaka style, or traditional style which most of the country would have. The other is Hiroshima style, which obviously is a specialty of Hiroshima. My personal preference is Hiroshima style as they have noodles under the "pancake".
We were recommended a place nearby the hotel by the fantastic staff at the front desk (Super Hotel Hiroshima) and went to check it out. When we got there it was packed and we couldn't get a seat. They said they'd call us but we thought there was no hope of getting a table so we set off to find somewhere else. Luckily, after wondering aimlessly for 20 mins or so and nobody being able to decide on a place to eat, they phone Jason and said there's 1 table free. Let me just say that it was definitely worth the wait! The service there was excellent and the food just kept coming and coming. Every dish we ordered was delicious. If I'm ever back in H-town, then I will be hitting up that place again.
The night stopped there for everyone but Jason, Louise and I. We decided it would be a fun idea to go bowling. Who goes bowling randomly? We do. The first game I was getting smashed. I didn't bowl a strike and I think Jason may have won that one. I reckon I wasn't even half his score! I managed to come back and win the second 2 games, much to Louise's dismay.
That was not the end of the night for Jason and I though. We went for a walk to find a bar to have a couple more drinks and ended up stumbling across this tiny bar that seated about 8 people. The owner was a 34yo bachelor who had opened the restaurant only 3 years prior. His specialty, as we were to soon find out, was braised food that you cook on the table in front of you in a clay brazier. He actually turned out to be super cool and even invited his friend, an elementary school teacher who could speak English, to come and join us later on. Definitely one of the better experiences I've had in Japan!
The next day Louise, Anne and myself took a day trip to Miyajima, which is where the famous torii gate is located out in the water. It is one of the iconic symbols of Japan, however, I had actually never realised that it is was just outside Hiroshima.
Getting to Miyajima is a bit of a journey but I will say it's highly worth it. We also saved a lot of money as we had the Japan rail pass too. This entitles you to the free train ride (approx. 30 mins from Hiroshima station) and also a free ride on the JR ferry which goes across the inland sea.
On the island of Miyajima, there is also a beautiful temple that is set out on the water. I have included photos of it below. There is also a cable car that, due to my fear of heights, was not a very pleasant ride up. Just when you think you are at the top, you have to transfer to a second car that basically goes across what I called "death valley".
Anne did not join us for the cable car ride so after arriving at the top, Louise and I decided to take the hike up to the top of the mountain. It was only 1.1km but you had to go down 100m then up 300m in height. It doesn't seem like a lot on paper but it was ridiculously hot and took us about 2 hours round trip. I was wearing sneakers yet there were Japanese men in suits and women in heels. I don't know how they did it!


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Presentation software business Prezi has managed to raise further funds as it gears up for more market reach. The presentation design company has raised $14 million in finance from Accel partners and Sunstone Capital. Prezi presentation software is proving to be an effective online, or cloud-based, tool for presentation design and development.
It's one of a number of presentation software alternatives that has to compete with the likes of PowerPoint and Keynote. Of course, they often package these with other software titles.
Much of its effectiveness comes from its zooming capacity. Their product people define it as a zooming user interface (ZUI). And it's the zooming capability that's most commended by Prezi users. The ZUI allows presenters to show both the big picture and the detail in their presentations. Thus, they can explore presentation ideas, themes and thoughts in more detail, before they return to the big picture.
They sell Prezi as a service with annual licences. However, its two main packages require some attention, if you want to achieve the best deal for you and your business. But it's competitive. And it also has a good reputation among its users as their presentation tool of choice.
There aren't many presentation software titles that achieve that distinction. So, as such it's one of the real alternatives to PowerPoint.
So, when you are ready to boost your presentation skills, you can always read more presentation tips from Time to Market. All the presentation tips feature in our regular schedule of presentation courses. You can choose to join a public training course at one of more than 40 different presentation training centres. Or, of course, you can opt for a more personalised presentation skills coaching session. It's your choice. So, please don't hesitate to get in touch when you feel it's the time to give your skills a boost.
The Principal Trainer at training business Time to Market. Based in Oxford, I run presentation and public speaking training courses, coaching sessions and seminars throughout the UK. Andrew Ivey on Google+
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Please note: The University of Texas Health Science Center at San Antonio will now be called "UT Health San Antonio."
Working in collaboration with others can be a wonderful experience. Writing a journal article with a colleague, or working in a research team with people from other organisations, can be life-enhancing. Ideas build on ideas; tasks are allocated according to people's strengths and abilities; the results are loads better than anything you could achieve alone.
Collaborative working can also be a monumental pain in the neck. Misunderstandings, missed deadlines, and poor communication can sabotage a project, morphing it from a promising outset into a morass of time-consuming frustration and annoyance, sometimes with nothing to show for all the grief you've gone through. That can be particularly galling when you end up apologising for something that was not at all your fault and entirely outside your control.
And you know the really weird thing about working collaboratively? Nobody ever tells you how to do it; you're supposed to know. But my experience is that many people don't know how to collaborate well.
If you're happy to write a book chapter that you think will take you a week, but you don't have that much spare time till six months from now, say so. And if you think it will take you a week, allow a fortnight. Over-committing doesn't help you or anyone else.
From day to day and week to week, and at monthly and yearly levels too. Plan, schedule, re-schedule as necessary. Do what you say you're going to do, when you say you're going to do it – or explain why you can't at the earliest opportunity.
Problems arise in everyone's life. If you encounter a problem that will affect your ability to meet your commitments, tell everyone who needs to know as soon as you can, and give them a realistic revised date when you'll be able to get the work done.
If someone else is causing a delay, you may need to take control, particularly if you have contractual or other inflexible deadlines and the delaying person isn't communicating well – or at all. In that case, the best approach is to send a polite email with appropriate cc's so everyone knows where the delay originates. But do word your message carefully: the aim is to protect your own reputation without damaging anyone else's, so stick to the facts.
If you're collaborating with people who are missing deadlines and not answering your emails, chase them once or twice then stop. Don't stress about it, just focus on other work.
Accept feedback gracefully, even if it seems unpalatable at first. Don't take it personally because it isn't personal, even if it feels personal, even if it looks personal. It's an opportunity to learn things you'd be very unlikely to learn any other way, even if they're not the things you wanted to learn. So thank whoever gave you the feedback and make the best use of it you can.
Reflect on your collaborations – with your collaborators if possible, on your own if not. What went well? Why? What didn't go so well? Why? What would you do differently another time?
Make time to celebrate a collaboration that goes well, or even well enough. If you can meet up with your collaborators, so much the better: go for a drink or a meal together and congratulate each other in person. If not, celebrate online, in a private meeting or via email or social media. Or simply send a card to say 'thank you' or 'well done'.
Whether your collaborators are your colleagues, your students, your staff or your friends, be as professional with each of them as you would be with the most senior person in your field or in your organisation.
When you're planning a new collaboration, share these tips with your potential collaborators at the earliest possible stage and ask whether they're willing to sign up to them. If they're not, don't go ahead with the proposed collaboration.
Of course sometimes life gets in the way and things go wrong. But when you have a strongly functional collaboration, it is much easier to deal with unexpected difficulties. When unforeseen problems occur and your collaboration is floundering, life can be very miserable indeed. If you and your collaborators follow these ten top tips, none of your collaborations will be the 'pain in the neck' variety. They should all work smoothly, at the very least, and may well be wonderful and life-enhancing.
Dr. Helen Kara has been an independent researcher since 1999 and writes and teaches on research methods. Her most recent book is Creative Research Methods in the Social Sciences: A Practical Guide (Policy Press, 2015). She is not, and never has been, an academic, though she has learned to speak the language. In 2015 Helen was the first fully independent researcher to be conferred as a Fellow of the Academy of Social Sciences. She is also a Visiting Fellow at the UK's National Centre for Research Methods. Her next book will be Research Ethics in the Real World (Policy Press, 2018).
This article was originally published here and republished with the author's permission.
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Of the 790 Bosque Art Classic entries, 164 pieces were selected
by the judge, Tom Tierney. Only 9 artist were selected in my
entry category of Pastel Painting!
This is my first year of entering The Bosque Art Classic
and I am pleased to announce that
my floral pastel painting, "The Light Of Day"
has been accepted into the prestigious Bosque Art Classic in Clifton, TX.
The exhibit runs September 8 -30, 2012.
This white iris was photographed while I was exhibiting at the
"Dallas Blooms" Art Exhibit,Artscape at the Dallas Arboretum.
Each year before the exhibit opens I make a point of wondering the arboretum
grounds looking for new floral subject matter and inspirations to paint.
This year I was on a mission to photograph and later paint purple irises.
Unfortunately I could not find one purple iris on the entire property. On the last day
I took one final stroll of the grounds and stumbled upon one single iris!
It wasn't the purple iris I was hoping for but much better!
One single white iris standing alone under a huge pecan tree!
The light seemed as though it was shining directly over it!
It was nature saying, "Here I Am, Paint Me"! I was so captivated,
I immediately started taking several different photo reference
images of this white beauty. I am very pleased with the results,
because it is very rare that I paint a white
flower, since I love an overabundance of saturated color!
The gentle petals seemed to glow, this gave
me a very calm and peaceful feeling, and I learned a little lesson:
Sometimes on your way to
your goal...you get lost and find something better!
I also want to name a few of my favorite artist and friends who are also
accepted into the 27th Annual Bosque Art Classic
Drawing Category: The New Arrival Is Here" by Helen Bailey-McKinney, TX.
Helen is a wonderful artist and we have crossed paths at numerous award events and at
our local frame and imaging shop in McKinney, Imaging on the Square.
Oil/Acrylic Painting Category: Roadside Tapestry by Debbie Smith-Richardson,TX.
Debbie has such a beautiful and humble spirit,and she has shared tons of art tips and info with me personally!
Pastel Painting Category: Bandit by Rita Kirkman-New Braunfels,TX.
I took my first pastel workshop from Rita! A great instructor and artist.
Pastel Painting Category: An Iris In Bloom by Sangita Phadke-Colts Neck,NJ.
Looks like Sangita found my lost purple Iris! :) Although we have never met in person
our artwork has traveled together nationally!
Pastel Painting Category: The Light Of Day by Barbara J. Mason-Frisco,TX.
This is me!
Watercolor Painting Category: Sunflower and Crystal by Soon Warren-Fort Worth,TX.
As a watercolorist I appreciate Soon's attention to detail and photo realistic style. As I look
closer at this painting I noticed I have the same fabric that she used in the
background of this painting! Of course I'm love anything with dragonflies!!
Sculpture Category: I personally do not know any of the artist in this category,
but all of the sculptures are awesome and congratulations to all the accepted artist!
Congratulations to all of the accepted artist, good luck at the awards


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Owners of classic cars may believe that storing them away for the winter means that they are protected from damage from the elements, however, failing to prepare the vehicle before locking it way can cause even more problems.
The Daily Telegraph's classic car specialist Andrew English stated that maintaining classic cars is not a straightforward process and there are many things to do and products to use.
Motorists need to invest in car waxes, car polishes, car leather care solutions to ensure the vehicle is given the correct level of protection.
"Wash the coachwork, spray-clean the underside and leave the car to dry in the open air … then wax-polish the exterior and leave the wax on to help prevent paintwork from deteriorating," Mr English stated.
If the car is to be stored in a damp garage, the expert recommended using car leather care products such as car leather shampoo and conditioner to stop fungi growing on the seats and other surfaces.
Amanda, writing on behalf of Robert's Auto, stated in a recent entry on ClassicRallies.com that clay bars, microfibre cloths, car polish and car wax are all essential items when it comes to caring for a classic motor.
Posted by Anne Simpson


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Things are getting ugly in Bolivia. The positions are radicalizing even more as time goes on and the parties try to impose their views. For starters, the government is not backing down after its highly questionable move to approve the internal regulations code with a voting session without following the rules (see prior post). The opposition now, made up of not only the assembly members in the opposition, but also the civic committees of Beni, Pando, Santa Cruz and Tarija, and members of parliament from the same departments, have decided to strike on Friday. This decision was taken at a meeting yesterday in Santa Cruz, and they issued a document calling for the government to stop trying to control power and, as they put it, to carry an auto-coup-de-etat a la Fujumori.
As if things are not bad enough, various groups such as one of the national worker's union, an indigenous organization from the Eastern region, the Coca grower's union and the famous El Alto neighborhood associations, have decided to play police and travel to Sucre to assure the security of the assembly members, as well as to watch them closely.
For its part, the government a week ago, asked the same groups to go to Sucre. However, in recent days, it changed its mind and asked them not to go to Sucre. In response to the demands of the oppositon, Morales has asked the civic committees to form their own political party.
The main message is that the Constitutional Assembly is in serious crisis. There are calls from the separatists in Santa Cruz (la nacion camba) to form a regional assembly. The people in the Andes, are so worried that they decided to go to Sucre to make sure the assembly continues its work. They have threatened the assembly members with community justice if they don't do what the "people" want. The assembly itself is having trouble meeting and doing its work.
I think if the government does not negotiate and perhaps reconsider its actions, the process might even brake down. It might even be a better idea to stop interfering with the assembly and let the members (MAS) do their job. Last week I read a report, in a newspaper which is very supportive of MAS, La Razon, that the parties in the assembly were close to an agreement on the voting procedure and the nature of the assembly. The MAS group, after having meet with the government, changed positions and hardened its line. They were not ready to compromise anymore. As for the opposition, to regionalize the trouble will only contribute to the deep polarization that already exists as climate in Sucre. The civics and the parliamentarians should also stay away. Let the assembly do its work!


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So I left this post off with two WTF situations in full swing. I now have dramatic conclusions for both. DUN DUN DUN! If you don't know what I'm talking about then read the first post here.
Well wouldn't you know it, my VP said, "NO." The night of my first post, I got a call from my JTE saying that the VP had said no to my use of nenkyu because I cannot leave Japan until August 2nd which is when my new contract goes into effect. Wait, so now the issue is with my new contract and not the nenkyu? It's like they're just looking for reasons to keep me here! At this point my patience is running thin with this situation, so the next time I meet with my JTE, I remind him that I have already bought a plane ticket and explain again how I'm properly using the nenkyu. No go. He proceeds to ask me if my plane ticket is refundable to which I say, "I don't know" out loud and "Not a chance that's happening buddy" in my head, which is then followed by him "suggesting" for me to contact the Hyogo Board of Education for support which MIGHT sway the decision of the VP. Commence the emailing. Three days and ten emails later of catching the BoE up on the situation and explaining my reasoning, I am told that I am in the right. Thanks for confirming what I already knew, BoE. Back to my JTE. I print out the emails and although this particular JTE's English is pretty good, he sits there for a whole class period worth just burning holes through the paper trying to comprehend all the colloquialisms. Finally, he tells me that the VP is on a business trip so let's take it to the Principal. Now, this may sound like a worse situation, but my VP is new to the school whereas my Principal has known me since I got here and has always been pretty chill about my comings and goings. With emails in hand, my JTE explains the situation to the Principal. Pretty quickly it's met with a "those emails are in English, I can't understand them," (fair enough) "call the head of the BoE." In my head I'm screaming "DO IT! Resolve this non-issue already!" The call was made, the emails confirmed, case closed. My JTE turned and said to me, "Congratulations!" like I had won a court case. I smiled weakly because I wasn't looking for a fight in the first place and didn't feel like I had won anything. I was put through a lot of worry and stress about a situation I knew I had handled correctly.
The other situation with my neighbor escalated to involve two more JTEs and a big dose of American freedom fighting. Since the original post, I was approached again on two separate occasions. The first time was by a JTE who side-saddled up next to me as I was walking to the staff room and proceeded to ask about when I would give my neighbor the money. Although I knew it wasn't an official tax, I told him that my JET contract states that these kinds of extra taxes are covered for me or I'm exempt from them completely. He tries to tell me again that it's not a tax and that my neighbor ALREADY PAID FOR ME. -WTF?!- "Why did she do that??" I asked as calmly as I could. "Because it was due," he said. UGH. I told him I'm sorry she did that and voluntary tax or not, I don't have to pay. We parted ways once we got into the staff room.
Two days later (today) I am deliberately approached by just my neighbor. She has a receipt in hand and a pleading look in her eyes. Now, don't let the receipt fool you into thinking this is now an official tax. I even get a receipt for fruit I purchase on the street. So after three minutes of the most broken Japanese I've ever spoken because I am full of blind rage at being cornered like this, the JTE nearby finally comes over and tries to explain it to me again. Upset as I was, in a very calm, cool, and collected way, I cut him off and said, "I know this isn't a tax. I know she has already paid. Regardless, I am exempt from paying these kinds of fees and I don't appreciate these efforts to coerce me into paying them." My JTE looked taken aback and said "But don't you feel bad for her? Besides, this money goes into the community." I said, "I'm sorry, but I didn't ask her to pay for me." He and my neighbor have a brief discussion and she ends it with, "I should have asked her first. Daijoubu (It's ok)." She walks away and my JTE says to me with downcast eyes that he feels bad for her and I have a strong American mind. Yeesh. Well, as a woman with firm beliefs and strong sense of justice, I'm used to being called worse. So once again, I'm in the right and don't feel like a winner.
Next, I'm going for a trifecta of Japanese bureaucratic BS as I continue the process of getting my Japanese driver's license. Fun, fun, fun! Thanks to the BS, that story won't be complete for a while.