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Tuesday, February 17, 2009
And all the classic Rocker gear is represented; the Goldies, Bonnies, Dommis, dustbin fairings, even a Norvin, and at the end, a couple of Japanese lightweights.... (Above - Bonnie, Goldie, Bonnie)
There was always a bit of real racing to inspire the 'go faster' look of the Rocker boys; these shots (above and below) of a racing Dominator 88 were taken at Mallory Park. A very tasty machine indeed, and worthy of imitation.
Nothing will make your Norton Dominator 99 go faster than a leopard seat cover and Goldie muffler! The two-in-one exhaust was an optional extra from Norton, and the flat 'bars are standard. It was sporty to begin with... you can tell it's an early '60/'61 model by the two-tone paint job (standard) and the Norton 'button' on the timing cover - of course it's a Slimline Featherbed frame as well.
Another Norton, which is being used to its limits, complete with a Peel fairing, which could use a little tucking in, as the fiberglass will shortly be ground away on the tarmac, or, if you're really unlucky...
...it will find a bump in the road and lift the rear wheel off the deck, pitching itself and the rider off the road completely. This machine is an early Wideline Norton, can't tell if it's a single or twin-cylinder, but it has the '58/'59 type chrome panel on the petrol tank; the 'ace' bars have Doherty alloy levers, very racy, and the rear valanced mudguard has had the removeable rear section... removed! Much of it would have needed repair after this getoff, but it seems the rider never had to bother, as the notation says "he survived this spill but wasnt' so luckly later when he died on his way back from London on this bike...".
Not all Nortons were Dominators, Atlases, or Internationals; this is the only photo I've ever seen of a Café Norton Navigator! The 350cc little twin (below) was never a great performer, and certainly didn't live up to the hotrod reputation of it's bigger brothers. I've owned four of them (don't ask), and the timing chest sounded like a cast iron stove being run over cobblestones... not Norton's best effort. But, they are compact and tidy looking, and share forks and wheels with the big twins...
Not all Rocker-worthy machines were British, either; this NSU Supermax 250cc single is a rare before-and-after study -
of an attempt to lighten and sportify what was already a very good machine. The inspiration must have be the pukka racing NSU Sportmax, one of most beautiful motorcycles of all, but the impecunious young owner could only manage to lose the front mudguard and add 'ace' handlebars... improvement or desecration?
Regarding clip-ons; for the seriously racy crouch, the rule was, 'the lower the better' - just above the lower fork clamp seems to have been the goal. Inspired by racing practice, it became Fashion, and the utility distorted out of the equation... no racer had 'bars that low! The fellow on the second machine has inverted some fairly high handlebars to really get down to it.
This Triumph Tiger 90 with 'bikini' rear enclosure, ca.'62-'64, has met its cornering limit fairly quickly - the centerstand and footrests are being shaved away by tarmac. This bike is very standard though - rearsets would be useful for such scratching! Undoubtedly, the rider needed the bike to take him to work or school the next day, so practicality ruled the hour...
Here's another rarity; a Royal Enfield Super 5, their sportiest 250 in 1962/3, with short leading-link forks, 5 speeds, and a 20hp engine, giving about 84mph top whack. This is a '62 model with deeply valanced front mudguard - amazingly the bike is completely standard, with 'ace' bars as per catalogue spec. R.E. had a clue; in 1964 they introduced a rare factory-built Café Racer from a British maker; the Continental GT. The other ones? You tell me - prizes for correct answers.
Another fantastic period machine, and an early example at that; a Norvin, the immortal combination of a Vincent 1000cc v-twin in a Norton Featherbed chassis, which according to the notes 'had only three speeds', but still went like stink! This machine falls into the Barely Legal category, with no head or taillamp in the first photo.
But later on, it was completed, and our lad can be seen 'hanging off' at the notorious bend which ate the Norton above. Note the number of spectators lurking on the outside of the bend - the Rockers must have been the best thing going on a sunny weekend day, and clearly this was a corner worth watching.
Another corner worth watching; here a Goldie tears around the bend, while the fellow in the plaid jacket records the proceedings on his portable tape player! I can hear it now - the classic Gold Star muffler has been replaced with a short megaphone (actually a factory racing item), and it was LOUD. The rider is very well tucked away and leaning a lá Phil Read into the bend. Nice technique.
Another shot of our B.S.A. Gold Star hotrod, with clip-ons a bit lower than the Factory set them...the tank is patterned on the 'Lyta' large-capacity racing item, although his might be a fiberglass copy - much cheaper, and money was certainly tight in the 60's. Phis Read had only recently introduced the 'knee hang' on GP circuits; it would be a few years yet before racers would hang completely off the seat. The lad had good style, this is one of the best 'action' shots of the group.
"Into every ride a little Trouble must fall"... and if you've ditched your center stand for more ground clearance, a kerb is a handy thing.
Even a Learner could ride a hot Royal Enfield Clipper 250cc, as this fellow has, while waiting for his pal on the Norton with Peel fairing to sort out his issue. Note the four-wheeled competition driving away; truly, motorcycles ruled the road in the 1960s in England. That little Hillman (?) saloon would be hard pressed to make 70mph, and certainly wouldn't get there quickly.
And if you've got a bike, and your mate's is down, give the lad a ride...no holding onto the rider though! A very nice Norton Domi 88 or 99, with optional tachometer, but driven from where? Perhaps it's just for show - I only see one cable - or maybe it's an 8-day clock!
And now, the Trojan horses appear... so unassuming in these early days, and so small. And while the 125cc SOHC Honda CB92 Benly had tremendous performance for it's capacity, it was still only a 125... and if the rider was a big bloke, it would take a while to achieve the 70mph max - no passing Hillmans then. Note the fellow's '59' Club patch; Father 'Bill' Shergold's club for motorcyclists, and you had to visit his church in Hackney Wick, London, to get a patch. It was the largest motorcycle club in the world during the 1960s.
By the time this Yamaha YDS1 250cc two-stroke twin appeared, all bets were off, and Honda had already won a string of TT victories. Yamaha and Suzuki were pressing hard on the Island as well as on the GP circuits, scoring victories over their exotic DOHC counterparts from Italy and Germany... Britain had long ago given up a credible threat in this class, although 'special' builders continued to shrink Velocette KTTs and BSA Gold Stars for something competitive.
Cue 'The End' by the Doors please, as this was the smoky perspective soon to be seen by all the leaky, unreliable, cobbled-up, badge-engineered, head-in-the-sand British Café Racers in the very near future. More's the pity, and they are missed.
All photos courtesy Adrian Manktelow, and copyright D.G.Manktelow. Images used by permission.
13 comments:
- Coyote Man said...
Very nice pics, the navigator racer superb, ans also Norton 88 and 99, my actual racing bike!
Many thanks for this fabulous post!
- February 18, 2009
- david said...
Great post, Paul. I'd like to see even more of the "lifestyle" and people shots that Manktelow did.
It's always as interesting as the machinery!
btw, my first bike was one of those Yam YDS's. Mine was a '65 YDS-3, 305cc , a Calif.-only model.
In '68-'69 people were surprised how quick the little things were.
When I saw the last pic on this post, I could almost
smell the smoke and hear that particular "Ring-a-Ding"sound !
- February 18, 2009
- William said...
beyond excellent!!
- February 18, 2009
- R.Dress said...
Hi Paul,
Wow as always great photos! I think it's worth mentioning that in 1961, Honda shall we say "broke on through to the other side" with Englishman Mike Hailwood at the helm taking first in the 125, 250, 350, and 500 cc Isle of Man. It must have been a chilling and sobering message to the British motorcycle empire. Below is a link to hear the venomous sound of a Honda 250/6. God Speed.
- February 18, 2009
- vintagent said...
Lifestyle, location, and more bike shots will arrive in Part 2. Adrian is looking through his dad's archive; there is a rumor of an 8mm film! Keep your fingers crossed!
- February 18, 2009
that came over pretty good , almost a web page by itself, although you failed to point out the Austin Atlantic ? a typical rockers car bondo patches and all lol , but well done and we might even forgive you if the standard drops on the next article (the fooking ell we will) lol dave
- February 18, 2009
Dear Paul,
Still can't make the comment function on the blog work, so I'll hazard this
reply to your post with the wonderful photographs by D. G. Mankletow on '60s
cafe racers. To wit, no one else seems to have picked up on your challenge to
name the two other factory-produced variants, after the RE Continental, and take
you up on your prize (?). This is tricky, as presumably you've excluded, by
including in the story, the DBD34 Gold Star, the Clubman's edition which would
technically qualify. So what's left? Of course, my beloved Velo Thruxton. But
after that, if we're sticking with English product? Hard to say, depending on
how you define "factory." Some might claim the Rocket Gold Star hits the mark,
others the late series AMC CSRs (especially with the Atlas engine). If you don't
confine things to "Made in England," how about Honda's delicious GB 500 TT,
though it's really intended as a 7R homage more than anything else. Or, sticking
with things British, how about the G50CSR, aka the Matchless Golden Eagle, even
if only a handful were produced and all, apparently, were sent to the States?
Am I missing something you're thinking of on the Triumph end (Meriden, not
Hinckley)? Lots of friends turned their Daytonas and Bonnies over to cafe-racer
specs, but those, I suspect, don't qualify. So, please, come clean, after the
Conti and the Thruxton, what are you thinking of?
- February 19, 2009
Jim, I didn't exclude the Gold Star just because it was in the post - so that and the Velo Thruxton are in my humble opinion the only other proper Cafe Racers produced for general sale, with the Connie GT - clip-ons, rearsets, alloy rims, big GP carb, fast, mildly anti-social, totally desireable then and now. You win!
Other bikes came close, but didn't have all the right bits, even if you could add/order them.
- February 19, 2009
i was thinking about defining the average cafe racer , and why so many late comers and overseas people misunderstand the genre, here's my first guess, it was about education. at the time mid fifties to late sixties, if you failed or passed the eleven plus exams more or less decided your career , class ,steam for life , taken at eleven years of age. put you in one of two streams - fail secondary modern , pass grammar school , second mod meant you were factory fodder , pass you went to grammar school a direct lead into university , but here's the catch - secondary modern means you could get a apprenticeship , five years and at the time part of that was one week a month you went to a technical college on full pay , thank you labor party , so when you came out of the apprenticeship tunnel , you had four years of work and one of technical collage , the grammar school grads were driving bmw,s but could not fix them
- February 19, 2009
What a unique set of high quality photographs. Wouldn't it be great if they were issued in book form. Is Mr. Manktelow still with us? Could you tell us some more about his life?
- February 21, 2009
- vintagent said...
Watch this space! I'm working on some biographical/historical information about D.G. and the riders in the pix, plus some local context...
- February 22, 2009
Outstanding photos! (Just wondering if that Norton 'Naviracer' was the one I towed home, back in '65?)
That Goldie with the alloy tank, looks very similar to the one owned by 'Mad Johnny' (John Davine).
I was a member of the Johnson's Motorcycle Club- out by Brands Hatch, from '65-'67, and had many friends among the guys who hung out there!
Thanks again, for taking me back!
- April 22, 2009
- Kunal said...
Very Informative and attractive blog created by the blog owner. I am very thankful for this blog owner for post information like that. I would like to come on this blog again and again. Honda Seat Covers & Suzuki Seat Covers
- February 02, 2011


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Okay so I"m running a hyperthreaded processor, with two 10,000 rpm disks on a hardware controller RAID 1. Now I could have had 7200 rpm disks in my tummy, but Susan said she doesn"t consider anything less than 10,000 rpms as "Server quality". Which reminds me… I was kinda hanging out in the SBS newsgroup the other day and someone wanted to use a beefy desktop to run a SBS 2003 server for an office.
People. When you expect a piece of machinery to "serve" you, you have to spec out hardware that is ready to serve.
I think I"m up for the task.
I can have all the good software in the world, but if Susan didn"t go with reasonable stuff, I wouldn"t be able to properly handle these blogs like I"m doing. So let"s get down to talking about all this prodding and poking that folks have been doing to me to make sure I"m in good shape.
- App pool
First off my excellent keeper Vlad Mazek, CTO of OwnWebNow, wonderous being, fabulous guy, extreme all around good guy [I"d say Vlad rocks but it"s been seen that "rocks" is too much of a buzz word around here,so I"ll refrain for now],noticed that my page file use kept ticking up a bit, which was the same symptom I had before at my old home that kept killing the blogs. So for now until we get up to Community Server we have a routine where the App pool is cycled. So for now we"re going to let that handle that issue until we can get updated to the CS engine once the version 2.0 releases.
- Perf Mon testing
So remember the other night they were doing testing on me? Here"s some of the comments I overheard… now I didn"t catch everything…but I jotted down a few things…..
…..This data looks pretty good. smlogsvc is down to half a %….this is goodness…… Sqlservr – No surprise here W3wp – again, no major surprise. From an I/O perspective, I"m quite happy with things. You"re averaging <50 IOPS (read+write), and on a 2 spindle 10K RPM RAID1 with a little cache, this is just fine. You definitely have headroom to spare.
Goodness… hey that"s sounds pretty good. I got "goodness". I must be performing okay. So I think I heard them say they are going to take that test on me again next week as with the holidays they didn"t think I had a full load hitting me and then again if/when they start changing things. Some of the things I heard them say was …..
I"m interested to see another 6 hour snap after you make any of the following changes:
– SQL upgrade
– .Text -> CS
– gzip enablement
– conditional GET enablement
– TTL changes
– any other change that might affect the load profile of the server
<ANY EM server
It sounds like they want to do more testing on me. So I"ll keep you guys posted if I overhear them say anything else of interest.
Oh yeah…I know…since I moved to Vlad"s home town of Orlando I"ve been losing the accent… as sometimes these days I sound more like Vlad does in case you are wondering…
May the force be with you…..


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text: Next Story > Risk & Compliance Journal. The Morning Risk Report: Hart, Chertoff Join Compliance Hiring Stampede By Nicholas Elliott Nicholas Elliott The Wall Street Journal CANCEL BiographyNicholas Elliott May 7, 2013 7:44 am ET Two well-known figures have found new roles at compliance-related companies, according to news released Monday that provides yet more evidence of a booming market for compliance services, staff and expertise. To Read the Full Story, Subscribe or Sign In Previous Jury's Out on How Hard Planned Cyberattack Will Hit U.S. Next Boardroom With a View


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Seasoned PC gamers with a nostalgic leaning toward point-and-click adventure games from the '90s — such as Myst, The 7th Guest and Day of the Tentacle— will likely enjoy clicking through Big Fish Games' Mystery Case Files: Return to Ravenhearst.
This fifth chapter — part of a popular series that has sold more than 2.5 million copies — includes some of the game-play elements found in its Mystery Case Files predecessors, yet has made considerable strides when it comes to production values and story, as well as puzzles that hark back to the classic head-scratchers from a decade ago.
In Return to Ravenhearst, you play as a detective called back to the mysterious 19th-century mansion constructed by Charles Dalimar as a token of affection for his love, Emma Ravenhearst. The queen of England, no less, asks you to once and for all solve the mystery of the now-decrepit dwelling and decipher the odd happenings inside it. At the start of the game you arrive at the gates and must find a way onto the locked property, and then figure out how to get into the mysterious mansion.
The game play is basically divided into two parts. As with past Mystery Case Files titles (which are free to try and cost about $20 to keep playing after the hour-long trial), the first kind of puzzles involve "hidden object" tasks, where you are presented with a busy scene and must find a dozen or so items listed at the bottom of the screen (curiously, the items are usually unrelated to the location or story).
Once you find the items by scouring the screen, you click on them, which crosses them off the list. Items you find will be added to your inventory, which leads to the second type of puzzles. As in the adventure games of yesteryear, you will need to use an item in order to manipulate it. Some are fairly easy tasks, such as using a crowbar to pry open a loose floorboard early in the game, but eventually you will be faced with tougher Myst-like lever, dial and number puzzles. Clues on how to solve these conundrums can usually be found in your case files notebook, accessible at anytime within the game.
It would be remiss not to mention the high production values in Return to Ravenhearst, such as the moody and highly detailed graphics, the live-motion sequences with real actors to help push the story along and the original classical music soundtrack performed by the Berlin Film Orchestra (a small beef, however, is the music isn't tied to what's happening on the screen, as is the case with many other games with dynamic scores).
Another small issue is when you return to the same spot to search for items, many of them have been clicked on before, so you know exactly where they are the second time around. The new items are also in the same spot, which you probably saw when combing the screen previously. Therefore, playing through the same area multiple times becomes too easy.
Minor shortcomings aside, Mystery Case Files: Return to Ravenhearst is an excellent sequel that should satisfy both fans of the series and those with a soft spot for the once-popular point-and-click adventure games.
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MSc International Health Technology Assessment, Pricing and Reimbursement (Distance Learning)
School of Health and Related Research, Faculty of Medicine, Dentistry and Health
We tackle some of the world's greatest health challenges to improve the health and care of people across the globe.
|September 2016 start
Course description 2016
This course is dedicated to the practical application of mathematical modelling to inform healthcare decision making. It bridges the gap between the underlying theory and application of mathematical modelling for decision making and more traditional health economics.
Governments, insurers, health care organisations and the pharmaceutical industry need to analyse the costs and benefits of health-related strategies.
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The programme is suitable for those who wish to pursue careers as applied economists in the health sector or as the basis for doctoral research.
Core modules
Optional modules
As a distance learning (DL) student, you do not attend the University in person. You study at your computer in your own time.
Course duration
2-4 years part-time (online)
|September 2017 start
Course description 2017
You'll gain an understanding of markets, pricing and customers needed for new product development in the health technology industry.
If you're already working or aspire to work in the field of health technology assessment, this course will give you the training you need to progress your career or gain a post as a health technology evaluator or commissioner.
This course is taught entirely online. You'll study part-time over two to four years. You do not need a UK study visa to take this online course.
Core modules
Examples of optional modules
Choices include:
Teaching and assessment
You will not attend the University in person. The course is taught entirely online, and you study at your computer in your own time.
The course is a mixture of online learning and independent study. We use customised online rooms within our Virtual Learning Environment to deliver course materials in an accessible and engaging format, including live online webinars allowing interaction with course tutors and other students.
Assessment is by coursework and project work.
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2-4 years part-time (online)
Entry requirements
Minimum 2:1 honours degree from a recognised university in a numerate subject.
Relevant subjects include economics, operational research, mathematics, statistics, industrial engineering, management science, physics or systems control.
English language requirements
Overall IELTS grade of 6.5 with a minimum of 6.0 in each component, or equivalent.
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What are the causes of floaters in the eye?
Eye floaters can be a nuisance, but they are not usually a serious medical problem. Floaters may appear to look like cobwebs, specks or dark spots inside the eye.Loose VitreousFloaters are small pi...
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What are the causes of floaters in the eyes?
Eye floaters, those drifting specks or strings that mar your vision, are a fairly common visual ailment. Many people are able to learn to ignore them; however, understanding their causes is importa...
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Laser eye treatment, or Lasik, surgery helps people see better without glasses. Some people have reported that after surgery, they have floaters--sometimes visible, moving flecks or spots in their ...
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Eyes are filled with a gel-like substance called vitreous fluid. As the eye ages, the vitreous fluid begins to slowly breakdown and become a liquid. Sometimes pieces of the vitreous fluid detach th...
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Breaker! Breaker! [DVD] [1977]
- Release Date: 12/05/2000
Best Buy is dedicated to always offering the best value to our customers. We will match the price, at the time of purchase, on a Price Match Guarantee product if you find the same item at a lower price at a Designated Major Online Retailer or at a local retail competitor's store.Here's how:
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Exclusions apply including, but not limited to, Competitors' service prices, special daily or hourly sales, and items for sale Thanksgiving Day through the Monday after Thanksgiving. See the list of Designated Major Online Retailers and full details.
Ratings & Reviews
A typical Chuck Norris vehicle from the late '70s, Breaker! Breaker! is neither the first nor the last Hollywood attempt to translate the wide appeal of trucking into big-screen profits. Alhough, it is probably the least successful. In this "modern" Western, a small California town is ruled by the nefarious Judge Josh. Using CB technology, the Judge and his gang of henchman lure wayward truckers into their town in order to do them bodily harm. Eventually their evil ways catch up to them in the form of J.D. Dawes (Norris), who comes in search of his brother. What he finds, however, is nothing a little Tae Kwan Do and a case of dynamite can't fix. ~ Brian Whitener, Rovi
Cast & Crew
- George Murdock - Judge Trimmings
- Terry O'Connor - Arlene Trimmings
- Don Gentry - Sgt. Strode
- Ron Cedillos - Deputy Boles
- Michael Augenstein - Billy Dawes
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- Free High-Speed Internet
- Reduced mobility rooms
- Wireless internet connection in public areas
- High-speed internet in room
- Air-Conditioning
- Wheelchair accessibility
- Free parking
- Suites
- Shuttle bus service
- Room service
- Continental Breakfast
TripAdvisor Reviews Grand Hotel Villa Tuscolana Frascati
Travel Blogs from Frascati
Day in Rome
We returned from Florence to Rome for a day and are now ready to head for the Amalfi coast. Again we walked for miles exploring Palentine Hill, the Forum, and the Travestera neighborhood yesterday. We are having beautiful weather with a slight welcome ...
The way of the Italians
... killing massive numbers of animals and gladiators (slaves) who were in cages, rooms below what would have been the floor. 50,000 people could be accommodated in the stadium, the poorer you were, the higher up the stadium you sat. With all these sites the one thing that stuns me is the fact that buildings that were built 2000 years ago are still standing, way past the 6 years building guarantee that we so value in Australia today! ...
Heading for Rome
Tried to find some Glass blowing in Nice, bought another bag, and headed for Rome, good drive to Rome though lots of tunnels and looking down on all the beautiful towns scattered alone the coast line. Found our way to the Pratti Residence with only one wrong turn. Nice but getting a little old now but plenty of room to spread ourselves ...
Borghese Gallery and Appian Way/Catacombs
... of chains, one that held Peter in Mamertine prison and one from when Herod jailed Peter in Jerusalem, miraculously joined when they were brought together, and they are on display in the church. After lunch, we went to meet our tour guide (Sergio) for our group tour to the Appian Way and Catacombs - when we got there, he was holding a sign with our name instead of a sign for the tour company. As it turned out, we were the only ones signed up for the ...
Steph's Happy birthday weekend
... Nemi The Romans flock to Nemi (32km/20 miles from Rome) in droves, particularly from April to June, for the succulent strawberries grown here, acclaimed by some gourmets as Europe's finest. In May, there's a strawberry festival. To reach Nemi by bus, go to the Anagnini Metro stop in Rome. From here, take the CoTral bus heading for Genzano. At Genzano, change buses, taking the one marked NEMI. Service is about every 30 minutes during the day. Nemi was also known to the ancients. ...


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Originally posted on The Nats Blog old | Last updated 12/14/12
Throughout the offseason, The Nats Blog will look back at every player's 2012 season to summarize and analyze his performance, and we'll look ahead to his possible role in 2013. We'll go from #1 Steve Lombardozzi all the way to #63 Henry Rodriguez with about two posts per week until Spring Training. Enjoy. When your team wins 98 games, you don't get to talk about useless or impactless players from that season very often. This is absolutely one of those exceptions. Xavier Nady Nady was pulled off of his couch in spring training with virtually no opportunity to make the team. He was even signed to a minor league deal. But enough injuries allowed the veteran journeyman to make it onto the Nats Opening Day roster in 2012. He's never been an exceptional defender, and his offense had declined steadily over the past three to four seasons. Nevertheless, Nady found his way into 40 games for the Nationals before being released in late July. During that time, he mustered a pitiful .157/.211/.275 slash line and 24 strikeouts in just 102 at-bats. The Nats merciful release of Nady turned out pretty well for him. He landed with the San Francisco Giants, who went on to win the World Series. That's right, folks. Xavier Nady, who amassed a -0.6 WAR last season, will be getting a World Series championship ring. Something isn't quite right with that. Next year: The 34-year-old Nady is still a free agent, but he will land with a team and serve as a fourth outfielder and bench player. It may not happen until spring training when teams really evaluate their needs, but it's only a matter of time. Next up: #22 Drew Storen
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Police have charged a 20-year-old man in connection with an alleged burglary in September.
According to police, Alden Gines, who does not have a local address, removed items from the garage of an Aiea residence on September 27.
Gines was arrested in Waipahu this morning and later charged with first-degree burglary. His bail was set at $11,000.


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"We play sounds with worldwide appeal. You can drop them from Portugal to Australia to Japan. It's soulful house music with a global vibe." Stalwarts of the house scene for almost a decade, London based DJ/production duo Sam Holt and Gavin Mills - aka Copyright - are about to jump to the next level with the release of their debut album, 'Voices and Visions'. An assured collection of soulful house, classic song writing, with latin, afrobeat, disco, funk and tech influences and outstanding vocal performances from a stellar cast of collaborators, 'Voices and Vision's' is set propel Copyright into the super league of global house players. Having their first proper release on the hugely influential US label Soulfuric back in 2000, the boys proceeded to put out a slew of quality tracks on that and several other labels (including their own imprint, Copyright Recordings) in the early noughties.
Tracks like 'Good For You' feat Angie Brown, 'Bulo' with longtime friend and percussion collaborator Shovel and 'Release Yourself' set the pace, while their move to Defected in 2005 saw them jump up a gear with tracks like 'He Is', 'Bring Me Love' and 'I Pray'. The international recognition they received from these releases culminated in Defected boss Simon Dunmore asking Copyright to mix the 2007 'Miami In The House' compilation. Distilling the Copyright sound while showcasing their mixing prowess and nose for what makes a great party, it went on to sell more than 30, 000 copies globally. Which begs the question, with so much success, how come it's taken them so long to finally deliver their debut long player? "I think we wanted to wait until the time was completely right," says Gavin. "We were quite happy developing our sound, gaining production experience and honing our DJing. Then out of the blue Simon said 'you guys should do an album. Why don't you give us three maybe four new tracks, we'll put it together with some of the stuff we've released before.' It evolved and we've ended up with about eight new tracks." And it's been more than worth the wait.
Sublimely blending their trademark soulful sound with a host of other influences, the album is a reflection of their varied and universally-appealing DJ sets. "There are tracky parts, classic song writing, percussive stuff, deep elements and even some hip house!" enthuses Sam. The hip house comment refers to the inclusion of original acid and hip house pioneer K.C. Flightt, alongside new school rapping sensations Mr V and Miss Patty and old school don, the inimitable Jazzie B. "We wanted to represent a bit of UK flavour. It's great to have an English accent on a house record. We went down to Brixton and came back with that iconic sound," says a wide-eyed Sam of the band's experience of working with the Soul II Soul legend. Elsewhere, longtime cohorts Shovell, Imaani and Tasita D'mour make an appearance, ensuring continuity for the original Copyright fans, while all brining something new and unique to the mix as the Copyright family pushes the sound forward. In keeping with their global ethos, expect to see the boys DJing around the world to promote the album in 2008, including a number of live performances with the album's guest artists - cementing 'Voices and Visions' position as a key release for 2008 in Britain and overseas. At a time when the UK's reputation abroad isn't all that. It's good to see some of Her Majesty's subjects doing their bit to spread the love.


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The Prime Minister has decided that the job is no longer required as it overlaps with the Mayor's responsibilities. The move to axe the ministerial post is part of a trend to cut costs and devolve power to City Hall and comes days after it emerged that the Government Office for London is also to close.
But Labour has warned that the move is a retrograde step which will remove a voice for London in Whitehall and mean Londoners have less clout across the Lib-Con Government on issues such as Crossrail and other projects.
Ironically, at the same time as abolishing the post, Mr Cameron has decided to boost other cities across the country with their own "city minister".
Senior Downing Street sources confirmed that the Prime Minister had opted to get rid of the Minister for London post because it duplicated some of the functions of the Mayor.
The Conservatives are keen on devolving more power to City Hall and believe that having a separate ministerial post has been an "anomaly" since the Mayoralty and Greater London Authority were first created 10 years ago.
It is understood Stephen Hammond, the Tory MP for Wimbledon and a former shadow transport minister, would act as an informal "point man" for London issues.
There are several ministers in Government who represent London seats. Chipping Barnet MP Theresa Villiers is the current Transport Minister in charge of the Crossrail project, while Bob Neill is Local Government Minister.
Some Tories believe privately that the decision to scrap the post is an error because the minister could have acted as a counterweight if Labour win back the mayoralty in 2012.
Mr Cameron did appoint successive shadow ministers for London, with Justine Greening - now a Treasury minister - seen as having made her name in the job. John Major created the post in 1994.
Under Labour, a string of ministers had the job, from Nick Raynsford to Keith Hill to Tony McNulty and then Tessa Jowell. Ms Jowell had Cabinet rank for the post, which was combined with a responsibility for the 2012 Olympics. The decision to axe the post has not been formally announced and only became clear after repeated questioning from the Standard.
Former Minister for London Jim Fitzpatrick said: "London generates at least 18 per cent of the nation's wealth and it's frankly ridiculous for this city not to have its own minister liaising between the Mayor and the Prime Minister and rest of Whitehall.
"It's dead sneaky for David Cameron to slip this out. Whatever happened to open government?"
Another former incumbent, Tony McNulty, added: "Now, more than ever, London needs a strong voice in the Government. It's quite outrageous."
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"As all of you should know, one of the girls in the ninth grade was taken to hospital from here on Monday morning, and I am very sorry to have to announce that last night, she passed away."
It was not unexpected to me, but it was a shock for the words to be projected across the gym. A thousand students were witness to the conviction of spoken tragedy; there was no lie.
I had been taking a message to the secretary's office on Monday when the ambulance had arrived, and was promptly shooed back to class by a bevy of blank-eyed secretaries.
A whispering coterie of Seniors in the canteen told me they'd seen Alisha Carson carried off on a stretcher from her Geography lesson, in which she'd apparently collapsed.
There was a letter the following day, casually informing parents that there had been a problem, or, I suppose, reassuring the minds of those other fourteen-year-olds who had been in her lesson and had seen her 'keel over'.
I said the announcement in the gym was not unexpected; when my tutor, Mr Morse, told us at register that the swimming sports house meetings had been cancelled in place of an unforeseen whole-school assembly, I knew instantly what was coming.
But it's always a shock when a misfortune is confirmed definitely, fore-shadowed though it might have been.
I heard little more of what the headteacher had to say to us. She mentioned something about the girl's family, and then something more about trusting her students to keep it quiet.
I was aware all this time of a mild sobbing a few rows behind me, and it was the only sound. Not a cough or a wriggle, as in the normal school assembly, when the young ones are restless and the elder ones scornful. I could not bring myself to turn to see the origin of the sobbing; all I and everyone else wanted was to be still.
"In a few minutes you will go back to your tutor rooms for the duration of this lesson," the soft voice of Miss Seymour spoke through the stillness. "At ten o'clock, you will go to your second lesson. There are counsellors in all day in Room Forty, the art room with no windows, and if you need anyone to talk to please tell your tutor. That is all. Today is to be a quiet day."
She bade Mr O'Ryan to dismiss us from the back door, and I heard the sobbing fade down the corridor. I knew it was Shani, but I couldn't go after her till Mr O'Ryan dismissed the line in which I sat.
"Is Shani okay?" I asked several people. "Did she know the girl well?"
They all shook their heads. "No; she didn't have a clue who she was; I asked her," replied one girl in a low voice. "She's vanished now. I expect she'll be okay in a minute."
I hoped so. Kind-hearted Shani to cry for a girl she didn't know. Permit me to say that I myself wasn't all that upset as I made my way back to my registration room.
I didn't recognise the name 'Alisha Carson' and no face came to mind. But she was a ninth grade girl; maybe she was one of the girls Colby accidentally shunted that day he returned from the physio. God, I hoped not. The thought made me feel ill. But I was so grateful I hadn't actually known her. It doesn't bear thinking about what her friends might be feeling.
I was solemn, but I wasn't really all that upset. It was horrible, but it didn't directly affect me. Of course Shani was crying. Shani has such a soft heart, silly girl. I only hoped the sun would shine again in her pretty face before the day was over – how I was to regret that wish.


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Yes. No. Maybe. I don't know. Can you repeat the question?
For six years, America watched the highly-dysfunctional yet loving Wilkerson family; the family with five sons were just trying to hold the unit together as much as they could although they usually despised each other and often drove each other to screaming breakdowns. Hopefully, we thought while watching dad Hal crying in the busted down family car or witnessing mom Lois screaming rants at her coworkers, we're not that bad. Malcolm and his crazy family let us believe that there's always somebody worse off out there.
While the show only ran for six seasons, it was one of our favorite family-centric sitcoms because families aren't always as happy as in the shows with laugh tracks. Sometimes you just want to ring your siblings necks! So whatever happened to the most maladjusted family on TV? Find out here!
Whatever happened to Malcolm and his brothers?


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|Quick Glance
|Screen Size (inches)
|22 in
|Response Time
|5 ms
|Screen Size (inches)
|22 in
|Aspect Ratio
|Response Time
|5 ms
|300 cd/m?
|Dot Pitch
|0.282 mm
|Horizontal Viewing Angles
|Vertical Viewing Angles
I did this and it's pretty cool: http://www.instructables.co... I actually used tape to fix the lamp to the back of one of my displays. :P
morsch, I was just about to post exactly the same link! I also have a cheap daylight bulb behind my Samsung T240 as a bias light, it is brilliant and I feel it's really helping to reduce eye-strain.
I think TR should capitalise on this idea and do a guide soon; I'd link to it!
Pointless bling.
I wouldn't call it a gimmick, it's made me think about getting a small light behind my monitor to reduce eye strain. But I do think that paying a premium will put many people off.
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Related quotes
"Bearing false witness is not just one of the Ten Commandments. The Bible has numerously repeated warnings against slander, false testimony and just plain old lying. Interestingly, it has been a socially acceptable form of oppressing minorities and the poor for centuries: slander, sensationalism, hearsay, innuendo, half-truths, insinuations, rumors, myth, and outright lies. We should learn these words, and call it what it really is . . ."
"Truth always rests with the minority, and the minority is always stronger than the majority, because the minority is generally formed by those who really have an opinion, while the strength of a majority is illusory, formed by the gangs who have no opinion -- and who, therefore, in the next instant (when it is evident that the minority is the stronger) assume its opinion... while truth again reverts to a new minority."
"The negative side of democracy is that the position of ideological minorities is not in power. However, the ideological minorities are often smarter than the herd."


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Rupert Murdoch's News Group suspended one of the most senior journalists at the News of the World last night following a "serious allegation" of phone-hacking, placing renewed pressure on the Conservative director of communications, Andy Coulson, the former editor of the newspaper.
The shock suspension of Ian Edmondson, who is assistant editor (news) at Britain's biggest-selling Sunday paper, follows the allegation that he was involved in hacking into the phone of the actress Sienna Miller, who is suing News Group.
Lawyers acting for Ms Miller have filed in to court a 20-page document which claims that notes compiled by the disgraced private investigator Glenn Mulcaire indicate that Mr Edmondson instructed him to intercept her voicemail and to target her friends and family, including her partner Jude Law.
Mulcaire and the former News of the World royal correspondent Clive Goodman were jailed for phone-hacking in 2007 after a court heard that they conspired to intercept the voicemails of members of the royal household.
Yesterday News Group issued a statement saying a "serious allegation" had been made about a member of the News of the World staff. "We have followed our internal procedures and we can confirm that this person was suspended from active duties just before Christmas," it said. "The allegation is the subject of litigation and our internal investigation will take place in tandem with that. If the conclusion of the investigation or the litigation is that the allegation is proven, appropriate action will be taken. The News of the World has a zero-tolerance approach to any wrong-doing."
The suspension of Mr Edmondson increases the pressure on Mr Coulson, who has assured MPs that Goodman had been a rogue operator within his newspaper and that there had been no culture of phone-hacking. "Goodman deceived the managing editor's office and he deceived me," Mr Coulson told a committee of MPs when questioned in 2009.
News Group has determinedly supported that line but it has become clear that the phone-hacking story is not going to go away as individuals have continued to come forward with legal claims against the News of the World's publishers.
Mr Murdoch's organisation has reached out-of-court settlements in cases brought by Gordon Taylor, the chief executive of the Professional Footballers Association, and Max Clifford, the publicist.
Allegations against Mr Edmondson, a long-standing News of the World journalist who worked under Mr Coulson, have been raised in a number of recent cases. The documents filed in the Miller claim state that in several cases Mulcaire's notes "were marked 'Ian' in the top left-hand corner, which the claimant infers to be Ian Edmondson".
In a judgment made in November in respect of a separate claim brought by Nicola Phillips, Mr Clifford's personal assistant, Mr Justice Mann made several references to Mr Edmondson and upheld Ms Phillips's application for Mulcaire to be compelled to reveal who at the News of the World had asked him to investigate Mr Clifford.
One of the questions that Ms Phillips wanted Mulcaire to answer was: "Did Ian Edmonson request him to investigate individuals connected with Max Clifford?"
The Independent has seen a judgment made in October relating to a claim brought against News Group by Andy Gray, the Sky Sports commentator, another branch of Mr Murdoch's empire. Mr Gray also claims his phone was hacked by Mulcaire on behalf of the News of the World.
Mr Justice Floyd rejected News Group's attempts to stop the commentator gaining access to documentation held by the office of the Information Commissioner, who investigated the unlawful trade in confidential information in 2006, after the commissioner's office said it believed the material related to "illegal activities" and was "likely to be helpful" to Mr Gray.
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The 2015 political donations were out this week and they contained some numbers that should cause a bit of unease. It's not just the 2015 amounts that are of interest, it's the running totals as well. Since 2005, the B.C. Liberal party has raised more than $107.8 million -- $70.2 million of that from businesses and corporations.
B.C.'s proposed Prosperity Fund is meant to capitalize on the future opportunities from natural gas development. If done correctly, the fund could be a huge benefit to both current and future British Columbians. As with many things though, the devil is in the details. Thankfully there are lessons to be learned, and avoided, from our neighbours, Alberta and Alaska.


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ED Magedson – Founder
Ripoff Report
Sprint WirelessNationwide USA
Sprint Wireless Deceptive Contract Practices and a series of covered up lies Overland Park, KS Nationwide
Does your business have a bad reputation?
Fix it the right way.
Corporate Advocacy Program™
I have just completed seven hours on the phone over the past three months with Sprint regarding a phone bill that is three times the amount that I was quoted in the store. The facts are:
So here is the Ripoff, they have misrepresented the bill amount, hidden behind a flabby piece of thermal paper that they rush you through, promised one thing and then the next representative was wrong but they can do anything, and I would have to pay in excess of $900 to cancel them!! Plus buy three new phones else where.
Oh yeah, they also do not have a publish consumer affairs line. Off to my state's attorney general I go!!
This report was posted on Ripoff Report on 08/17/2014 09:22 AM and is a permanent record located here: http://www.ripoffreport.com/reports/sprint-wireless/nationwide/sprint-wireless-deceptive-contract-practices-and-a-series-of-covered-up-lies-overland-par-1170329. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.
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#1 Author of original report
There is always more
SUBMITTED: Wednesday, February 25, 2015POSTED: Wednesday, February 25, 2015
Again thank you for your feedback and questions. The fact of the matter is that I probably should have provided far more detail than I did. Candidly I did not expect so pointed responses from individuals not associuated with the bank.
Regardless, I did use soft language regarding Citizens who actually made my life absolutely miserable for three weeks over this and they did in fact close the account. I suppose concilliatory tone weakened my comments.
Ultimately, what I did not say is that we endured the loss of our home and a family member and had to deal with relocating and recovering all at the same time as this. That was the reasin fir the delay in both cases.
Also, I have made sure that I have paid every fee and dollar amount that applied to items that they did clear. As for the other items, they had been outright rejecting all items for the weeks prior and I had no reason to expect that they would open the flood gates once the account was closed (that just does not make sense).
Anyway, again, thank you for your feedback as it is what makes this forum work.
Are you an owner, employee or ex-employee with either negative or positive information about the company or individual, or can you provide "insider information" on this company?
#2 Author of original report
Update on Sprint
SUBMITTED: Monday, August 18, 2014POSTED: Monday, August 18, 2014
Not sure if Stacey -() is an employee of some sort or just thinking that they are high and mighty. You never know who you are dealing with in real life.
Be that as it may, Sprint apparently does read these reports and I was contacted in less than four hours by a corporate resource. As of 6:30 PM last evening, we spoke in detail about this matter and I have been promised a return call with results at 6:30 PM EST today. The individual I spoke with was courteous, professional, clearly understood the issues that I was contending and very result oriented.
I am hopeful and encouraged that this matter will be resolved. I will update as more develops.
Are you an owner, employee or ex-employee with either negative or positive information about the company or individual, or can you provide "insider information" on this company?
#3 Consumer Comment
Here is the policy
SUBMITTED: Sunday, August 17, 2014POSTED: Sunday, August 17, 2014
Activ. Fee: $36/line. Credit approval required. Framily Plan: Offer ends 8/31/14. Month to month term. Includes unlimited domestic Long Distance calling, texting and 1GB/mo./line on-network data allowance. Add'l data: 1.5¢/MB. 3rd party content/downloads are add'l charge. Int'l svcs are not included. Pricing may vary for existing customers. Max of 10 phone lines per group. Excludes existing accounts and discounted phones. Group members must agree to share their names, last 4 of phone numbers, Framily ID, group status, and that they are subscribed to Framily plan with group. To withdraw consent, member must enroll in a different service plan. Withdrawal does not affect ability to subscribe to other plans. Sharing Framily ID allows others to join group. All group members may invite others to join. Separate bills are per account. Discounts: Awarded $5-$30/mo./line off $55 base rate plan depending on number of members in the group. Discounts not prorated. Groups cannot merge. Pricing may vary for existing customers. Max of 10 phone lines per group. Excludes existing accounts and discounted phones w/term agmt. Group members must agree to share their names, last 4 of phone numbers, Framily ID, group status, and that they are subscribed to Framily Plan with group. To withdraw consent, member must enroll in a different service plan. Withdrawal does not affect ability to subscribe to other plans. Sharing Framily ID allows others who are eligible to join group. All group members may invite others to join. Discounts: Awarded ($5-$30/mo./line) within 2 invoices (timing may vary based on different invoice cycles for Group members). Discounts not prorated. Groups cannot merge. Usage Limitations: Other plans may receive prioritized bandwidth availability. Streaming video speeds may be limited to 1 Mbps. Sprint may terminate service if off-network roaming usage in a month exceeds: (1) 800 min. or a majority of min.; or (2) 100 MB or a majority of KB. Prohibited network use rules apply--see sprint.com/termsandconditions. Unlimited Guarantee: Available while line of service is activated on Sprint Framily Plan, Unlimited, My Way Plan or My All-in Plan. Applies to unlimited features only . Price and phone selection subject to change. Account must remain in good standing and non-payment may void guarantee. Non-transferrable. 3 GB Buy Up: Includes 3GB/mo. on-network data allowance. Add'l on-network data usage 1.5¢/MB. Does not combine or stack with other data. Unlimited Data and Annual Upgrade Buy Up: Req. min.12 consecutive payments, new Installment Agreement, acct. in good standing, & give back of current eligible device in good & functional condition. After upgrade, remaining unbilled installment payments are waived $350 Citibank Card Offer: Offer ends: 6/12/2014. Consumer, IL and CL lines porting to Sprint Framily Plan only. Amount based on ETF (Early Terminiation Fee) charged or remaining balance on install-bill device (excludes Prepaid devices). All lines must be ported from an active wireless line at another carrier and remain active and in good standing for at least 45 days to receive the prepaid card. Allow 12 weeks for your prepaid card to arrive. Register at www.sprint.com/switchtoframily. Excludes 11+Corporate-liable, upgrades, replacements, and ports made between Sprint entities or providers associated with Sprint (i.e., Virgin Mobile USA, Boost Mobile, and Assurance), and plans $10 or less. Not be combinable with other offers. Visa Prepaid Card: Cards are issued by Citibank, N.A., pursuant to a license from Visa U.S.A. Inc., and managed by Citi Prepaid Services. Cards will not have cash access and can be used everywhere Visa debit cards are accepted. Sprint Easy Pay: Req. 24 mo. installment agreement, 0% APR, & qualifying device & service plan. Credit approval req. Device pricing for well-qualified buyers. Monthly payment terms for all others will vary and a down payment may be required. Down payment, unfinanced portion and sales tax (on full purchase price) due at purchase. If you cancel wireless service, remaining balance on device becomes due. Tablet: Offer ends 7/10/14. While supplies last. Taxes and svc charges excluded. No cash back. May not be combinable with other tablet offers. Requires activation of a line of service on a Framily plan during the same transaction. Other Terms: Coverage and offer not available everywhere. The Nationwide Sprint Network reaches over 279 million people. The Sprint 3G network reaches over 277 million people. Sprint 4G LTE network reaches over 200 million people. See Sprint.com/coverage for details. You can view the Sprint privacy policy at Sprint.com/privacy. May not be combinable with other offers. Restrictions apply.
SO I suggest you talk to the individuals on your plan - sounds like someone went over their alloted time and text -
AND how does someone spend 7 hours on the phone with Sprint in three months?? Did you calculate this time?? Did you keep a journal?? Good luck with the State Attorney - I will almost guarantee this individual has alot more things on their plate than your pathetic complaint.
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Patient-Reported Outcome Measures for Chronic Obstructive Pulmonary Disease
- First Online:
DOI: 10.1007/s40271-013-0004-5
- Cite this article as:
- Jahagirdar, D., Kroll, T., Ritchie, K. et al. Patient (2013) 6: 11. doi:10.1007/s40271-013-0004-5
- Citations
- 1.5k Downloads
Patient-reported outcome measures (PROMs) are intended to reflect outcomes relevant to patients. They are increasingly used for healthcare quality improvement. To produce valid measures, patients should be involved in the development process but it is unclear whether this usually includes people with low literacy skills or learning disabilities. This potential exclusion raises concerns about whether these groups will be able to use these measures and participate in quality improvement practices.
Taking PROMs for chronic obstructive pulmonary disease (COPD) as an exemplar condition, our review determined the inclusion of people with low literacy skills and learning disabilities in research developing, validating, and using 12 PROMs for COPD patients. The studies included in our review were based on those identified in two existing systematic reviews and our update of this search.
People with low literacy skills and/or learning disabilities were excluded from the development of PROMs in two ways: explicitly through the participant eligibility criteria and, more commonly, implicitly through recruitment or administration methods that would require high-level reading and cognitive abilities. None of the studies mentioned efforts to include people with low literacy skills or learning disabilities.
Our findings suggest that people with low literacy skills or learning disabilities are left out of the development of PROMs. Given that implicit exclusion was most common, researchers and those who administer PROMs may not even be aware of this problem. Without effort to improve inclusion, unequal quality improvement practices may become embedded in the health system.
Key Points for Decision Makers
• Patient-reported outcome measures (PROMs) are health questionnaires asking patients to report on their symptoms and quality of life
• Normally patients are involved in the rigorous process to develop PROMs to ensure the questionnaires make sense and are relevant to them. However, this study demonstrates that people with low literacy skills and learning disabilities are generally left out of the development of PROMs so they may not be able to use these measures
• Increased involvement of these groups in research and specific efforts to ensure PROMs are accessible for them could prevent unequal access to further uses of PROMs, for example, in healthcare quality improvement
1 Background
Patient-reported outcome measures (PROMs) are quickly becoming an important part of healthcare quality improvement processes internationally [1]. Health professionals and authorities can use these questionnaires to understand the burden of disease from the patients' perspective and gather information to improve the quality of care they receive. Although PROMs are mainly used for acute conditions, expanding their use into long-term conditions is imminent [2].
Multiple stages involving patients and subject experts are required to develop PROMs so that they will produce meaningful data. Typically, developers first consult with the concerned groups about what to include in the PROM. Several forms of validation and reliability testing follow before the PROM is finalized. The development of a PROM does not stop at its conception; the process of development is ongoing, encompassing further validation and reliability testing of PROMs through use with different patient groups. The initial and ongoing development and validation are meant to ensure the items and tool are meaningful to clinicians and patients and that it is easy to administer [3]. Since patients are consulted, PROM development appears patient centered. But not all groups of patients may have an opportunity to offer their views on PROMs.
People with low literacy skills or learning disabilities may be excluded from PROM development and ultimately from the uses of PROMs, countering national and international policies. The causes of learning disability and low literacy vary greatly, and people with low literacy and those with learning disabilities are not usually grouped together. Nevertheless, the functional difficulties (e.g., reading ability and comprehension) they face can be similar and both groups may find help in processing written material and managing health interventions useful [4]. Together, these groups form a large proportion of people in the UK, where one in five adults have low literacy skills [5] and there are approximately 1.5 million people with learning disabilities [6]. Literacy difficulties are associated with general exclusion from trials and research [7]. If people with low literacy skills or learning disabilities are left out of the development of PROMs specifically, they may struggle to complete them since patient involvement is crucial to ensure appropriate wording, format, and other needs are met. When PROMs are then used in further healthcare initiatives, they may face exclusion again. This exclusion would counter the UK Government's policy for the NHS to achieve full inclusion [8]. It also violates the principles outlined in the United Nations Convention on the Rights of Persons with Disabilities [9].
To prevent people with low literacy skills and/or learning disabilities from possible exclusion from PROMs initiatives, knowledge of the extent and nature of exclusion in the development of PROMs is required. There is little previous research on this issue in the PROMs literature. Others have, however, acknowledged the potential for the exclusion of people with low literacy skills and learning disabilities from PROMs initiatives. Devlin and Appleby [10] write that gathering PROMs data from people with "cognitive deficits" (p. 12) is difficult. Mencap, a leading charity in the UK for people with learning disabilities, say their clients are at risk of being left out of efforts to gather health information from patients [11]. But neither describes the current extent of exclusion from the development of PROMs in the first place.
Chronic obstructive pulmonary disease (COPD) is a good exemplar case to investigate potential exclusion. This long-term condition causes significant burden to over 3 million people in the UK [12]. It is also more prevalent in lower socio-economic groups where lower levels of literacy are also more common. This study examines the most commonly used PROMs for COPD to investigate whether there is systematic exclusion of people with learning disabilities and/or low literacy from PROM use and, if so, aims to suggest how PROMs can be developed more inclusively.
2 Method
Our methods had two phases.
Inclusion and exclusion criteria for the papers identified in Phases I and II
Inclusion criteria
Exclusion criteria
Phase Ia
Study with primary research involving patients or members of the public
Included PROM only to validate another PROM that was not relevant to our study
Inclusion of one or more of the following PROMs:
Condition specific:
• Chronic Respiratory Disease Questionnaire (CRQ)b
• Short-Form Chronic Respiratory Disease Questionnaire (SF-CRQ)b
• St George's Respiratory Questionnaire (SGRQ)c
• COPD-specific St George's Respiratory Questionnaire (SGRQ-C)c
Systematic reviews
Phase IId
Study with primary research involving patients or members of the public
Included PROM only to validate another PROM that was not relevant to our study
Inclusion of one or more of the following PROMs:
• McGill COPD Quality of Life Questionnaire
• Functional Assessment of Chronic Illness Therapy (FACIT)-Dyspnea Scale
• Disability Related to COPD Tool (DIRECT)
• Capacity of Daily Living during the Morning Questionnaire
• Visual Simplified Respiratory Questionnaire (VSRQ)
• Living with COPD Questionnaire
• COPD Assessment Test (CAT)
• EXAcerbations of Chronic Obstructive Pulmonary Disease Tool (EXACT)
Systematic reviews
Study was published between 2009 and 2012
In Phase II, we updated the search to identify papers describing PROMs developed from 2009 to 2012. To identify these papers, we used a pragmatic approach based on the search strategy provided to us by one of the authors of Davies et al. [14], searching in MEDLINE. We were not in a position to recommend which of the newly identified PROMs were suitable for population use, as was done in Fitzpatrick et al. [13] and Davies et al. [14], so we included all PROMs that were used with COPD patients, were in English, and were not too narrowly focused (for example, focusing only on one or two specific symptoms such as breathlessness). We also included two PROMs that were identified, but had only just been developed, at the end of Davies et al.'s [14] systematic review in 2009: the COPD Assessment Test (CAT) and the EXAcerbations of Chronic Obstructive Pulmonary Disease Tool (EXACT). The inclusion and exclusion criteria for this phase are also summarized in Table 1.
- 1.
The aim of the study
- 2.
The PROM(s) used
- 3.
The participant recruitment and data collection processes (if stated)
- 4.
The inclusion and exclusion criteria for research participants (if stated)
- 5.
Any mention of people with low literacy skills or learning disabilities
We distinguished between 'explicit' and 'implicit' modes of exclusion. Studies were classed as having 'explicit exclusion' if they excluded people with low literacy skills or learning disabilities 'explicitly' or immediately as a result of the study's eligibility criteria. While we did not consider a specific category of disability severity, the terms considered to imply the potential exclusion of groups with low literacy skills or learning disabilities included those who were 'unable to read,' or 'unable to complete or comprehend the questionnaire,' or those with 'cognitive deficits,' 'cognitive impairments,' or 'cognitive limitations.' Studies that used literacy-dependent methods for recruitment or data collection (e.g., unassisted self-completion of the PROM) were classed as leading to 'implicit exclusion.'
A second researcher in the team checked the data extraction for 20 % of the articles. Finally anything else in the study set-up that could impact the inclusion of these groups was recorded.
3 Results
- 1.
The McGill COPD Quality of Life Questionnaire
- 2.
The Functional Assessment of Chronic Illness Therapy (FACIT)-Dyspnea Scale
- 3.
The Disability Related to COPD Tool (DIRECT)
- 4.
The Capacity of Daily Living during the Morning Questionnaire
- 5.
The Visual Simplified Respiratory Questionnaire (VSRQ)
- 6.
The Living with COPD Questionnaire
Data extraction results
PROMs involved
Explicit exclusion
Implicit exclusion
Unclear or no evidence of exclusion
Aaron et al. [15]
• Excluded those with cognitive impairments
Aguilaniu et al. [37]
• Self-administration
Aiken et al. [19]
• Proxy responses not accepted
Ashmore. et al. [38]
• Self-administration
Berry et al. [39]
• Recruited through media advertising
• Self-administration
Bauldoff et al. [40]
• Excluded those with inability to read or cognitive impairments
Benzo et al. [41]
• Self-administration
Brightling et al. [42]
Brown et al. [43]
• Self-administration
Carr et al. [44]
• 19/234 were excluded due to cognitive impairments
• Self-administration
• Excluded those who could not communicate clearly
Carrieri-Kohlman et al. [45]
Coultas et al. [46]
• Recruited through postal mail-outs
Crockett et al. [47]
• Excluded those who were not mentally able to complete questionnaires
• Postal questionnaires
de Torres et al. [48]
• Excluded those who could not complete questionnaires
• Self-administration
Desikan et al. [49]
SF-36, SGRQ and CRQ
• Recruited through postal mail-outs
Dodd et al. [50]
• Self-administration
Eaton et al. [51]
• Excluded those who could not complete questionnaires
• Self-administration
Fan et al. [52]
Gross et al. [53]
Gupta et al. [54]
• Self-administration
Guyatt et al. [55]
Guyatt et al. [56]
Harper et al. [57]
• Self-administration
Hazell et al. [58]
• Self-administration
• Recruitment and questionnaire completion through the post
Hinchcliff et al. [59]
FACIT-Dyspnea Scale
• Self-administration
Johnson et al. [60]
Jones et al. [61]
Jones and Bosh [62]
• Self-administration
Jones et al. [63]
Jones et al. [64]
• Self-administration
Jones et al. [65]
Leidy et al. [66]
• Excluded those with an inability to read or cognitive limitations
• Self-administration
Mahler and Mackowiak [67]
• Self-administration
Maleki-Yazdi et al. [17]
• Self-administration
• Recruitment through media advertising
Martin [68]
• Self-administration
McGlone et al. [69]
• 4 were excluded because they were unable to read
McKenna et al. [70]
Living with COPD Questionnaire
• Excluded people who could not read or respond to questionnaires
• Self-administration
Miller et al. [71]
• Self-administration
Nagata et al. [72]
• Excluded those who could not read or understand the questionnaire
• Self-administration
Okubadejo et al. [73]
• Excluded those with an inability to read
• Self-administration
Pakhale et al. [74]
McGill COPD Quality of Life Questionnaire
Partridge et al. [25]
Capacity of Daily Living during the Morning Questionnaire
• Self-administration
Perez et al. [75]
Petrillo and Cairns [76]
• Self-administration
• 2 removed for lack of comprehension
Puhan et al. [77]
• 2 were excluded because they were unable to read
• Self-administration
Punekar et al. [78]
• Self-administration
Ries et al. [79]
• Self-administration
Ringbaek et al. [23]
• Excluded those who could not read
• Self-administration
Roth et al. [80]
Schofield and Mishra [16]
• Self-administration
• Recruitment through postal mail-outs
Schunemann et al. [81]
• Excluded those with cognitive limitations
• Self-administration
Schunemann et al. [82]
• Excluded those with cognitive limitations
• Self-administration
Schunemann et al. [83]
• Excluded those with cognitive limitations
• Self-administration
Sewell et al. [84]
• Self-administration
Sewell et al. [85]
• Excluded patients with cognitive problems
• Self-administration
Singh et al. [18]
• Self-administration
Sprenkle et al. [21]
• Self-administration
• Done by postal recruitment/survey
Stapleton et al. [86]
• Excluded people with "mental status that precluded participation"
• Self-administration
Tashkin et al. [87]
Tonnel et al. [88]
Tsai et al. [89]
Viramontes and O'Brien [90]
Williams et al. [91]
• Self-administration
Williams et al. [20]
• Self-administration
Wilson et al. [92]
• Self-administration
Wyrwich et al. [22]
Xue et al. [93]
• Recruitment through media advertising
Yeo et al. [94]
• Self-administration
Yohannes et al. [95]
Yount et al. [24]
FACIT-Dyspnea Scale
• Self-administration
We also recorded other notable issues in the studies concerning people with low literacy skills and learning disabilities. Some of the studies' protocols may have given consideration for these groups. For example, Aiken et al. [19] used telephone interviews to administer the PROM, although they did not accept proxy responses. Williams et al. [20] provided an opportunity for participants to clarify the self-administered questionnaire at the end. Some studies also described the sample composition, which could give an indication of the prevalence of low literacy. In Sprenkle et al. [21], the majority of participants had minimum high school education, while 26 % of Wyrwich et al.'s [22] sample had a grade school education only. However, the latter study did use telephone interviews. Ringbaek et al. [23] found patients needed a lot of assistance to complete PROMs, particularly those with less education, and especially while attempting the SGRQ. Yount et al. [24] were explicit about their sample's high education level and used a touch screen to administer the FACIT-Dyspnea Scale. Technology was also used to send automatic alerts through an e-diary to support patients to complete the Capacity of Daily Living during the Morning Questionnaire [25].
4 Discussion
We have found that people with low literacy skills or learning disabilities are excluded from the development of PROMs for COPD in two distinct ways: explicitly through the study eligibility criteria and, of potentially greater significance, implicitly through recruitment or administration processes. These results indicate that these groups may struggle to complete PROMs. Healthcare initiatives like quality improvement for COPD that depend on PROMs may exclude people with low literacy skills or learning disabilities as a result.
Implicit exclusion is where researchers and readers may not realize exclusion takes place; we found implicit exclusion was most common largely due to the majority of studies' requirement for self-administration of the PROM. Almost all PROMs are only validated to be self-administered but their readability and administration may be more or less inclusive. For example, technology support or easy read formatting can enhance accessibility. While some studies did use technology [24, 25], none of the papers we reviewed included discussion of the groups they potentially excluded in the recruitment processes they described. This could partly reflect the word limitations imposed on authors, but at least to some extent indicates a lack of critical awareness of the potential for exclusion. Where the authors did highlight heterogeneity in their sample demographic [24], we could not find specific mention of approaches to include people who may have low literacy skills or learning disabilities. There was also a lack of description of efforts to accommodate specific support to complete PROMs, for example through assisted completion. While other authors have found substantial disagreements between self- and proxy reporting especially to collect subjective information [26, 27, 28], the valid provision of assistance in completing PROMs has proved useful in population survey research, for example in Kaye [29].
Identifying and distinguishing forms of exclusion in research to develop PROMs is a prerequisite for future research aiming to make PROMs practice more inclusive. We consider implicit exclusion to be more concerning than explicit exclusion because it implies a lack of awareness of the potential for inequality in resulting healthcare and research practices. Studies with explicitly stated criteria excluding people with low literacy skills or learning disabilities set a clear barrier preventing them from participating. This suggests awareness on the part of the researchers and gives clear notification to readers that the findings apply only to the included population groups, provided this caveat is not overlooked when discussing generalizability [30]. Implicit exclusion practices have a higher likelihood than explicit exclusion to result in barriers to inclusive participation without any realization. The more recent increased focus on equality and diversity issues in research may improve future development practices compared with those used to develop the PROMs we identified. Inclusion might be given a higher priority and researchers given more support to overcome inevitable time, skill, and funding constraints that can limit feasibility to include people with low literacy skills or learning disabilities in their work. But if we do not realize there are barriers, we will not recognize the need for efforts to be more inclusive. In a current policy environment with increasing interest in PROMs [10], the potential result is unequal access to quality improvement processes.
Specific efforts can support the inclusion of people with low literacy skills or learning disabilities in research to develop PROMs. Research funders can confront issues of inequality by attaching equality criteria as a condition for funding the development of a PROM (similar to the requirement from the National Institutes of Health in the USA [31] to justify not making efforts to include groups normally left out of research). Responsibility among researchers to think through the implications of their methods and practices for people's ability to participate in their study may also be helpful. This may involve consulting service users in the commissioning, design, and conduct of research to determine best practice options for PROM development including when (timeliness), where (setting), and how (visual assistance) they can be administered, and any required assistance [32]. Other literature outlines issues and provides guidance to conduct research with people with learning disabilities [33], and tools to aid communication also exist [34]. Guidance on increasing the accessibility of information including the need for ample white space and large font sizes [35] are also easily applicable to typical research documents like information leaflets, consent forms, and PROM design. Our findings also suggested some promising results to build on. The e-diary with automatic alerts used to administer the Capacity of Daily Living during the Morning Questionnaire [25] and the touch screen used to administer the FACIT-Dyspnea Scale [24] may be promising as technology-based methods to support PROMs administration for people with low literacy skills or learning disabilities. These are similar to previous efforts to administer PROMs to people with low literacy skills in a cancer setting using an audiovisual touch screen [36].
Our work is a first step in highlighting the presence of exclusive practices in the development of PROMs and it has limitations. The findings have to be interpreted in the light of word limits imposed on article length. We did not infer sample demographics, recruitment, or administration practices where they were not explicitly stated in the studies and authors' descriptions of these may have in turn been limited by journal word counts. The data extraction was partly subjective as we sometimes assumed terms used by the authors to describe people who are not eligible for their study (like excluding those with 'cognitive impairments') would exclude someone with low literacy skills or learning disabilities. However, the extraction was checked by a second researcher to ensure consistency. Finally, we recognize that although people with low literacy skills and learning disabilities should not be 'lumped together' as one group, both groups face similar practical and functional challenges with reading and understanding written material. Other groups may also face similar exclusion from PROM development and validation processes, and substantial difficulties with PROMs, for example people with dementia or people with acquired brain injuries resulting in cognitive impairments.
5 Conclusion
While the use of PROMs is growing as a major part of healthcare quality improvement internationally, we have demonstrated that, at least in relation to COPD, people with low literacy skills or learning disabilities might be left out because they are not included in the research to develop PROMs. Most exclusion is implicit, suggesting the potential for lack of awareness of exclusionary practices. To prevent this form of exclusion in the future, efforts on the part of funders and researchers and more research into validating PROMs to be used with support through technology-based accessible completion or assisted completion are important. Ultimately PROMs are a promising opportunity to involve patients in quality improvement for COPD healthcare but the exclusive nature of PROM development may further alienate people with low literacy skills and learning disabilities from healthcare practices.
The research on which this paper is based is funded by the Technology Strategy Board and Healthcare Improvement Scotland, UK.
Author Contributions
DJ conducted the initial search and data extraction and drafted the manuscript. KR, SW, and TK independently reviewed abstracts, verified data extraction, and edited the manuscript. All authors read and approved the final manuscript. SW acts as guarantor for the overall content.
Copyright information
Open AccessThis article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.


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