text:
The Bank of England is formally reviewing whether it should keep and publish transcripts of monetary policy committee meetings, in what would be a big departure from tradition.
The Bank has appointed Kevin Warsh, a former US central banker at the Federal Reserve, to consider whether permanent records of the interest rate-setting meetings should be made and released after a number of years.
It follows a request for records to be kept by Andrew Tyrie, chairman of the House of Commons Treasury committee, made to the Bank's governor, Mark Carney, at a hearing in March.
Under the current process, discussions at the MPC's monthly meetings are recorded, but no transcript is made and the recordings are erased once official minutes are published two weeks later.
This puts the Bank out of step with the US Federal Reserve, which publishes transcripts of its policy meetings five years after the event. Tyrie welcomed the review as "a welcome and essential step".
He said: "It was very concerning for the committee to discover that the Bank's current practice was to destroy these records. Any practice other than retention and eventual publication would take a lot of justifying. We did not hear an adequate explanation for the present practice at the hearing on 11 March."
Announcing the review on Wednesday, Carney said: "The Treasury committee has asked an important question and I am delighted that governor Warsh has accepted our invitation to undertake an independent review.
"I and my fellow governors look forward to gaining his perspectives on this important issue."


text:
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Match Report
Posted Sat 12 Oct 13 at 05:08 AM
Exciting game ends all square
United and Wolves came together for the first time since the late 80's in a rearranged Tuesday night fixture with the visitors looking to hit the history books with their first ever run of six consecutive away victories.
For the Cumbrians it was a case of looking to get back to winning ways following their disappointing and frustrating weekend away trip into Kent.
The home side started well and a chest down from Guy on the edge of the box found Buaben in space. He volleyed first time but Stearman stepped across to make the block.
Attractive one-touch passing on the right flank opened things up for a cross from Chimbonda as he linked with Buaben and Amoo. Matt Robson raced into the box but the delivery was slightly too high and his header skimmed away to safety.
The visitors dampened home spirits with their first meaningful attack with just 8 minutes on the clock when Griffiths fed a lovely pass through to the unmarked Bakary Sako. He took one touch and picked his spot with an unstoppable thunderbolt which sped into the bottom corner past the stunned Mark Gillespie.
Carlisle worked hard to get back into it, with Amoo patrolling the edge of the area with his movement, and Wolves remained dangerous on the break as they utilised Sako's considerable pace. A quickfire push from deep involving the mobile forward brought a last ditch clearance from debut boy Max Ehmer as he stretched to take the cross away from the late arriving Lee Griffiths.
A wayward midfield pass from Thirlwell allowed Wolves to come again but Griffiths wasted the opening as he went for glory from distance. His shot had plenty of power but it sailed high over the bar.
Hesitation from Prince Buaben brought another piercing attack from Sako as he skipped past two challenges to get into the danger area. One dip of the shoulder too many shifted his balance and his shot, when it came, screwed off the top of his laces and made its way apologetically for a home throw in.
Crunching tackles from Buaben and Robson lifted the volume from the home crowd and their players responded with a determined passage of play as they blocked two attempted crosses from Golbourne. The ball broke kindly and Prince Buaben took over deep inside the Wolves half with his back to goal. He spun on the spot and took everyone by surprise when he poked a lovely shot past Ikeme and into the back of the net.
The visitors attacked from the restart and Sako found the ball at his feet right on the edge of the box. Griffiths wanted it but the striker created space and crunched a low shot through a ruck of bodies. Gillespie was beaten but it rattled against the upright and straight into the path of the unmarked Kevin Doyle. He had the goal at his mercy but he needed too many touches and Gillespie recovered to make a fine reaction save at his near post.
Another flowing move put James Henry through the back line but his ambitious spin and shot brought howls of despair from Sako and Doyle as it bobbled past the target.
Quick thinking from Guy sparked another Carlisle attack when he let the ball run for Buaben. Robson called for it and his cross got a touch from Guy as he volleyed for goal. Buaben picked up the loose pieces and put it on a plate for Noble but the instant shot was scuffed into the side netting right in front of the relieved visiting fans.
United were on top and a dinked delivery from Townsend was met by Guy on the six-yard line. His nod down was inviting but Evans was there to hook it away. Amoo pulled off his man and shouted for it and he was a whisker away as his piledriver skimmed off a thigh before shaving the post.
The home side were made to pay for the miss when Sako again raced forward towards the byline. Chimbonda stopped him in his tracks but Doyle followed up to send it to the far post. Lee Griffiths held his position and nodded it over the line via both posts after an agonising wait.
Another Griffiths shot tested Gillespie at his near post and Wolves ended the half in control as they sent men forward. Sako thumped a sizzler of a set piece, which just needed the slightest of touches, but Doyle and Griffiths pulled out and the moment was gone.
Wolves survived loud appeals for a penalty early in the second half when Amoo appeared to be clipped inside the area but the officials waved play on following the briefest of consultations.
The Cumbrians kept up the pace of their game and a half clearance was fed to Amoo as he came under pressure. Golbourne slipped and that allowed the wide man to pull the trigger as he searched for the far post. A deflection wrong-footed Ikeme but he did enough to make the save low to his right.
United got the goal their play deserved on 53 minutes when Townsend overlapped on the left. His cross picked out Buaben and a push from behind from Lee Evans left Mr Mathieson with no choice on this occasion but to point at the spot. Liam Noble did the rest with a confident penalty finish.
Matt Robson was next to test the target with a dipping free kick from wide on the angle, and confusion at the back from a Townsend grass-cutter brought a corner which caused all kinds of problems as Guy flicked it on with his heel. Robson peppered the box with a string of decent deliveries but Wolves survived as they brought every man back to defend.
Carlisle were again the team calling the shots but they were reminded that there was work to do when O'Hara came forward in support of his strikers. His cross spun up off Townsend and Griffiths could do little else but hook it on and into Gillespie's hands.
The response from United was immediate with a quick ball out to Robson who had found a yard on the half way line. He took three paces and let one fly and it needed a touch from Ikeme to keep it away from his net.
A beautiful pass from his own half from Noble set Amoo on a path to the edge of the area and his cross had the crowd on its feet as Lewis Guy opened his legs to try to make the touch. He lunged at it, with Ikeme beaten, but it was just too far away and he couldn't quite stab it home.
Carlisle had an even better chance to take the lead on 76 minutes when Buaben battled his way through two tackles. His first shot was saved by the prostrate Carl Ikeme and he was left with his head in his hands as he prodded the rebound wide with the width of the target to aim at.
Substitute Jake Cassidy almost found a gap when he wormed his way past Townsend on the United left and Gillespie had to get a touch as it threatened to find its way in.
Symington and Robson had long range free kick efforts which failed to trouble the target and a neat turn from Sigurdarson brought a moment of panic as he ran on and fed it inside. Gillespie dropped low as O'Hara tried to find a touch.
And Wolves were close again with 90 seconds to play when Sako cushioned the ball on his chest. He found Sigurdarson and a volley from O'Hara somehow stayed out as it ran the full length of the goal line before being cleared to safety.
Both sides went for it as the clock ticked into time added on but it was a share of the spoils from what was an extremely entertaining fixture.
Today's Match Sponsor
Today's Match Ball Sponsor
United - Buaben (29), Noble (53 pen)
Wolves - Sako (8), Griffiths (41)
Wolves - Evans (52)
Carlisle United - Gillespie, Chimbonda, Ehmer, O'Hanlon, Townsend, Thirlwell, Noble, Buaben, Amoo, Guy (Symington 74), Robson. Subs - Fleming, Livesey, Gillies, Potts, Beck, Berrett.
Wolverhampton Wanderers - Ikeme, Stearman, Batth, Henry, Davis, Griffiths (Cassidy 75), Sako, Evans (O'Hara 57), Ricketts, Golbourne, Doyle (Sigurdarson 75). Subs - Edwards, Forde, Ebanks-Landell, McCarey.
Referee - Mr Scott Mathieson
Attendance - 5,369 (1,335 away fans)
Latest Match Reports
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A new study shows many other states are full of happier people than Minnesota.
MPR News Reflections and observations on the news
Archives for December 17, 2009
A man robs the same bank branch three times.
The Vikings add more sketches to the scrapbook of stadium proposals past.
The unemployment story falls short of 'glass-half-full' status once you look beyond the headline.
Insurgents hack into U.S. drones' data.
Walking the fine line, Cash for Clunkers for wealthy folks, the resilience of people, remembering Panama, and what is the speed of thought?


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This is the full research report for 126.96.36.199, which is an IP address.
Richard Tattersall
TalkTalk Communications Limited
Northbank Industrial Estate, Irlam
Telephone: 44 161 2222000
Fax: 44 161 2222008
Richard Tattersall
TalkTalk Communications Limited
Northbank Industrial Estate, Irlam
Telephone: 44 161 2222000
Fax: 44 161 2222008
22.214.171.124 is the IP address you have a ran a report for on May, 29, 2017.
If you meant to use another IP other than 18.104.22.168, then enter above and try again.
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text:
ED Magedson – Founder
Ripoff Report
JIT, Superior Concepts, Granton Marketing, SmartCircle101 Park Avenue Suite 345 Oklahoma City, Oklahoma U.S.A.
Does your business have a bad reputation?
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Corporate Advocacy Program™
This report was posted on Ripoff Report on 02/17/2009 03:50 AM and is a permanent record located here: http://www.ripoffreport.com/reports/jit-superior-concepts-granton-marketing-smartcircle/oklahoma-city-oklahoma/jit-superior-concepts-granton-marketing-smartcircle-brainwash-scam-in-okc-it-has-arriv-424932. 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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text:
poetry chapbook contest for L/G/B/T poets
Expand Messages
- SEVEN KITCHENS PRESS announces the 2009 ROBIN BECKER CHAPBOOK PRIZE for an
original, unpublished manuscript in English by a Lesbian, Gay, Bisexual or
Transgendered writer.
Prize: $100 plus 25 copies.
Submission deadline: Postmarked between March 1 and May 15 of each year.
Eligibility: Open to all L/G/B/T/Q poets writing in English (no translations,
PLEASE NOTE THE FOLLOWING CHANGE TO THIS YEAR'S COMPETITION: Two manuscripts
will be selected as CO-WINNERS of the 2009 Robin Becker Prize: one by a writer
with no previous book or chapbook, and the other by a writer with previous book
or chapbook publication.
Please read the guidelines carefully; the complete guidelines are posted on the
Seven Kitchens site (see URL below) and we are not responsible for other
versions that may be posted, in whole or in part, elsewhere.
Any poet who identifies as L/G/B/T/Q is eligible to submit to the Robin Becker
Chapbook Prize.
• The manuscript itself need not address L/G/B/T/Q themes, though such work is
• The final judge for this year's series is Ruth L. Schwartz.
Submit a paginated manuscript of 16-24 pages (not including front matter).
• Include two cover pages: one with the manuscript title, author name,
address, e-mail and phone number; the second cover page should have the
manuscript title only.
• Include a table of contents page.
• Include, if applicable, an acknowledgments page for work previou
• Please include, on a separate page, a brief (100-150 words) biographical
note, including a statement of any previous or pending book or chapbook
The author's name must not appear in the manuscript.
• All manuscripts will be blind judged, meaning all identifying material will
be separated from the manuscripts as they are logged in.
• Manuscript titles and their log numbers will be posted on the WEB SITE
[http:// sevenkitchens. blogspot. com] (remove spaces from URL) as they are
Simultaneous submissions are accepted, but please notify us promptly if your
manuscript is accepted elsewhere.
• Submissions must be posted between March 1 and May 15, 2009.
• The winning manuscripts will be announced on or before August 15, 2009.
• Manuscript finalists will also be announced, and may be eligible for
publication in the chapbook series.
Manuscripts will not be returned. E-mailed submission is preferred, but you may
send via regular mail.
• If you are sending by mail, do not staple or bind your manuscript; please
use a binder clip and mail flat in an 8.5 x 11 envelope.
• If you are sending by e-mail, please send one document in Microsoft Word
format (.doc, .docx or .rtf files are ideal); you must include the words "Robin
Becker Chapbook" in the subject line of your e-mail.
• Include a $12 reading fee with each manuscript you submit (
submissions are welcome). IMPORTANT: Checks should be made payable to Ron
Mohring. Online payment may be made via PayPal to sevenkitchens at yahoo dot
• Each entrant will receive one copy of the winning chapbook, to be published
during winter of 2009.
• Each co-winner will receive $100 and 25 copies of her or his chapbook.
Additionally, the publisher will distribute ten review copies and will solicit
online reviews of each chapbook.
Send your manuscript:
• by e-mail, as a Microsoft Word attachment, to: sevenkitchens at yahoo dot
com; or
• by mail to Ron Mohring, Publisher; PO Box 668; Lewisburg PA 17837.
Ruth L. Schwartz is the author of four award-winning books of poetry and a
memoir: Dear Good Naked Morning, selected by Alicia Ostriker for the Autumn
House Poetry Prize (Autumn House, 2004); Edgewater, selected by Jane Hirshfield
as a 2001 National Poetry Series winner (HarperCollins, 2002); Singular Bodies
(Anhinga Press, 2001), winner of the 2000 Anhinga Prize for Poetry; Accordion
Breathing and Dancing (University of Pittsburgh Press, 1996), winner of the 1994
Associated Writing Programs Award; and Death in Reverse: A Love Story (Michigan
State University Press, 2004).
Ruth has won over a dozen national literary prizes, including two Nimrod/Pablo
Neruda Awards, two Chelsea Magazine Editor's Awards, the North Carolina Writer's
Network Randall Jarrell Prize, and the New Letters Prize in Poetry. She has20
received grants from the NEA, the Ohio Arts Council, and the Astraea Foundation.
Her poems have been anthologized in The World in Us: Lesbian and Gay Poetry of
the Next Wave (St. Martin's Press, 2000), American Poetry: Next Generation
(Carnegie-Mellon University Press, 2000), The New Young American Poets (Southern
Illinois University Press, 2000), and elsewhere.
This chapbook series honors Robin Becker, whose continuing accomplishments as a
poet, professor, and mentor of lesbian and gay writers deserve wider acclaim.
Becker serves as poetry editor for the Women's Review of Books and is a
professor of English and Women's Studies at Pennsylvania State University. She
is the author of six collections of poems, including Giacometti's Dog (1990),
All-American Girl (1996), The Horse Fair (2000) and Domain of Perfect Affection
(2006), all from the University of Pittsburgh Press, and of the chapbook
Venetian Blue (Frick Art & Historical Center, 2002).
Becker's honors include individual fellowships from the Bunting Institute, the
Massachusetts Cultural Council, and the National Endowment for the Arts. She won
the 1996 Lambda Literary Award for All-American Girl, and the 1997 Virginia
Faulkner Prize for Excellence in Writing from Prairie Schooner Magazine. In
1998, Becker was a visiting Scholar at the Center for Lesbian and Gay Studies at
the City University of New York. In 2007, she was the Sandra and Gary Sojka
Visiting Poet at Bucknell University. She has served as final judge for
national poetry competitions including the Astrea Awards, the Benjamin Saltman
Prize from Red Hen Press, The Idaho Prize from Lost Horse Press, the John Ciardi
Prize from Bk Mk Press, and the Prairie Schooner Book Award in Poetry. Becker's
column on poetry and the poetry scene, "Field Notes," appears in the Women's
Review of Books.
[Non-text portions of this message have been removed]
Your message has been successfully submitted and would be delivered to recipients shortly.


text: NEW YORK, Feb. 28, 2014 /PRNewswire/ -- Pomerantz LLP has filed a class action lawsuit against AmTrust Financial Services, Inc. ("AmTrust" or the "Company") (NasdaqGS: AFSI) and certain of its officers. The class action, filed in United States District Court, Southern District of New York, and docketed under 14-cv-736 is on behalf of a class consisting of all persons or entities who purchased or otherwise acquired securities of AmTrust between February 15, 2011 and December 11, 2013, both dates inclusive (the "Class Period"). This class action seeks to recover damages against the Company and certain of its officers and directors as a result of alleged violations of the federal securities laws pursuant to Sections 10(b) and 20(a) of the Securities Exchange Act of 1934 and Rule 10b-5 promulgated thereunder. If you are a shareholder who purchased AmTrust securities during the Class Period, you have until April 7, 2014 to ask the Court to appoint you as Lead Plaintiff for the class. A copy of the Complaint can be obtained at www.pomerantzlaw.com. To discuss this action, contact Robert S. Willoughby at firstname.lastname@example.com or 888.476.6529 (or 888.4-POMLAW), toll free, x237. Those who inquire by e-mail are encouraged to include their mailing address, telephone number, and number of shares purchased. AmTrust, through its subsidiaries, underwrites and provides property and casualty insurance in the United States and internationally. The company operates in four segments: Small Commercial Business, Specialty Risk and Extended Warranty, Specialty Program, and Personal Lines Reinsurance. The Complaint alleges that throughout the Class Period, Defendants made materially false and/or misleading statements regarding the Company's business, operational and compliance policies. Specifically, Defendants made false and/or misleading statements and/or failed to disclose that the Company: 1) manipulated its loan loss reserves in order to inflate reported earnings; 2) manipulated its deferred tax liabilities; 3) underestimated the discount rates for its life settlement contracts in an effort to inflate the Company's reported assets and total stockholder's equity; 4) the Company lacked adequate internal and financial controls; and 5) as a result of the foregoing, the Company's statements were materially false and misleading at all relevant times.


text:
Accessory Boutique
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Hair Accessories
TAYLORS BRIDAL - Accessory boutique, has everything you need to complete your bridal look, including veils, tiaras, hair combs, bridal jewellery, special occasion hats and fascinators and more!
Specialising in veils, which we make at our in-house studio attached to the boutique, we have a range of ready-made styles for you to try on in store, and also offer a bespoke service, giving you full flexibility on style. We can make a veil to your specific requirements in any shape, size or colour. So if you dream of acres of chantilly lace, or mountains of Swarovski crystals, then visit us today and we'll help make that dream a reality.
And it's not just veils that get the bespoke treatment at TAYLORS BRIDAL! We also have a fantastic tiara designer who hand makes designs exclusively for us, which can be requested in any colour from the Swarovski crystal chart! So whether you want to go vintage-chic, or ultra modern, we're sure we can accommodate your every wish.
Don't forget to check out our blog page (which you can also follow by liking us on Facebook) for regular updates on new stock, designs and special offers!
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text:
The summer transfer window is open, and agents and club representatives are plotting their next moves as the World Cup unfolds in Brazil.
It'll be a busy summer, with teams looking to strengthen after a surprising 2013/14 Premier League season.
Get the latest transfer news, gossip and rumours from the Daily Mirror and plenty more newspapers and websites below..
Transfer news from today's Daily Mirror
Liverpool's Luis Suarez has finally said sorry over his World Cup bite shame - under orders from transfer suitors Barcelona.
Frank Lampard will play for Manchester City's A-League side Melbourne City in Australia next season, ahead of the ex-Chelsea midfielder's move to the Etihad club's Major League Soccer franchise New York City FC.
Barcelona have slapped a £32million price-tag on Liverpool-target Alexis Sanchez.
Southampton's Adam Lallana will complete his £25million move to Liverpool in the next 24 hours - and Reds manager Brendan Rodgers promises there will be more signings. The Anfield club's summer splurge could top £100m as they strengthen for Champions League football next season.
Newcastle will ask for a double-their-money £12million if a trio of clubs - Arsenal, Paris Saint-Germain and Monaco - step up their interest in right-back Mathieu Debuchy.
Manchester City are closing in on making Malaga goalkeeper Willy Caballero their third summer signing.
New Tottenham boss Mauricio Pochettino is close to landing Argentine compatriot Esteban Cambiasso on a free. The 33-year-old midfielder is looking for a club after a decade with Inter Milan.
Manchester United are refusing to give up hope of prising Thomas Vermaelen away from Arsenal. The Gunners rejected a £6m bid from their Old Trafford rivals last week, but Louis van Gaal is determined to add the Belgium defender to last week's captures of midfielder Ander Herrera and left-back Luke Shaw.
Leeds striker Ross McCormack is joining Championship rivals Fulham in a £10m deal
Kaka has agreed to return to Brazil to play for Sao Paulo, the club he starred for before moving to Europe with AC Milan. The 33-year-old playmaker will join on loan for the rest of the year and is expected to join new MLS team Orlando City in the spring.
Brighton striker Leo Ulloa will tell boss Sami Hyypia he wants to be allowed to leave. The Seagulls have already rejected a £7million bid from top flight new-boys Leicester.
Atletico Madrid are moving to ward off admiring glances from Manchester United and Barcelona by extending the contract of Uruguay World Cup defender Jose Maria Gimenez.
Other stories from today's Daily Mirror
Leeds have launched a cost-cutting exercise under new owner Massimo Cellino that sees players forced to wash their own training kit and bring in packed lunches because the training ground canteen has been closed. They must also agree to money being taken out of their salaries to wash their kits on matchdays.
Luis Suarez has been offered a chance to keep himself fit during his 4 month FIFA ban by Hajvalia, a team in Kosovo - which is not yet a FIFA member.
Transfer news and rumours from other papers
Liverpool didn't have any involvement or prior knowledge about Luis Suarez's bite apology. (The Independent)
Arsene Wenger is set to launch a swoop for £23million Sami Khedira to help bring out the best in Mesut Ozil. (The Sun)
Arsenal have also hadn an enquiry for Roma's Alessandro Florenzi turned down. (Metro)
Crystal Palace are ready to pursue Cardiff defender Steven Caulker. (Telegraph)
Real Madrid are set to offer £25million for Bayern Munich's (and former Manchester United target) Toni Kroos. (Daily Mail)
Tottenham will join Arsenal in the race for Ivory Coast's Serge Aurier. (Daily Mail)
Fraser Forster is being linked with an £8million move to Atletico Madrid. (The Sun)
The Spanish club are also keen on signing Manchester City's Alvaro Negredo. (Daily Star)


text:
Hi All,
I'm really struggling with a niggling little issue with my right leg that is affecting my rides, was hoping someone may be able to help?
I bought a new road bike back in November which I had correctly fitted at my LBS, now I continued riding through the unpleasant last UK winter but obviously the miles have risen dramatically since March.
For the last 4 weeks, I've been struggling with what feels like a right hip/groin and then during the ride seem to drive a tightness down the whole leg. It doesn't stop the ride or overly affect my times other than a feeling that my leg doesn't have the power it had. After the ride, the leg feels a little tight but not injured as such.
I've been performing a lot of active "yoga" based stretching but it doesn't seem to be improving it?
I have wondered if it's a trapped nerve?
Anyone any thoughts??


text:
Results 1 to 7 of 7
Thread: Software/Tuners in Australia
Threaded View
11-19-2013, 05:04 PM #1Guest Vendor
- Join Date
- Nov 2013
- Location
- Melbourne, Australia
- Posts
- 11
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Software/Tuners in Australia
I am seriously considering purchasing a C63 Coupe (pre-owned, probably a MY12). Been looking for a while but not found one I like with the performance package that is in my budget.
I am coming from a GM background & have limited experience of the MB/AMG world. Most of my experience has been with the likes of HP Tuners software.
- What software is available for scanning?
- Is there any software for OBDII re-flashing, or are they all ECU-chip-swap?
- Any recommendations for workshops in Australia, ideally Melbourne?
Any & all help is appreciated.


text:
ED Magedson – Founder
Ripoff Report
relatieplanet.nlInternet USA
company posing as relatieplanet.nl relatieplanet proofreading job scam Internet
Does your business have a bad reputation?
Fix it the right way.
Corporate Advocacy Program™
A company pretending to be Relatieplanet solicits proofreaders for their English communications and offers good pay per a certain number of kilobytes. This is a Russian scam that resurfaces every few years.
You might actually receive assignments, but communication will lapse or drop off completely if you ask specific questions about the manner in which they will eventually pay you.
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Travel Blogs from Hüttwilen
Jungfraujoch: Top of Europe Day Trip from Zurich
... bus. In defence the roads were extremely windy.
Words cannot describe today, It was probably the best tour so far on this trip, actually probably the Best Tour we have ever done, Our Guide "Kid" was amazing and the Views were beyond belief. I thought we had some beautiful places in Australia but they cannot compare to the Views on top of the Swiss Alps for natural Beauty.
A lot of what we saw looked like it came straight out ...
Around my elbow to get to my thumb
... till we get rid of thousands of gallons of fuel. We not only cruise for hours but the pilot says not to be alarmed when the gasoline pours out of the wings . As I took pictures I wondered what was happening below where it was raining gas. Finally we touched down in New York at JFK and waited for hours for another plane. An 11PM departure put us in Zurich shortly after waking up from my coma.
Jesse was ...
Why visit North Korea?
... watching tours, special interest tours for aviation and train lovers, but none of that is as fascinating as experiencing the real North Korea, with carefully arranged visitor impressions and mass games and hotels where people keep you from strolling out to the streets.
Some reading and viewing before the trip
- Japanese Sushi chef works for Kim Jong-il and betrays him ...
My last stop in Europe.....
... a bit of trouble finding the entrance. There was a Starbucks and a restaurant in the front, so I had to ask a couple of people and they pointed in the direction of the back of the building. Once I found the entrance, check-in went smoothly. Although the building looks a bit old and plain from outside, I found a far different picture inside. The Hotel has obviously had some significant renovations, as the interior and the rooms are extremely modern and look ...
20 Hours in Zurich.........
... tram all over the city from one end to the other four times. It was amazing to see the kids navigate and take turns leading the way. We did this for four hours. We would ride the tram, see something that interested us, hopped off, and then hopped back on. We walked along the lakeshore to the boat docks, saw the swans, ducks, and other birds. Sadly it was overcase the entire time, but we still had a great day!


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Home > Find A Doctor > Doctor Profile
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NOW that's what you would call a fairway to go!
BBC Radio Two DJ Chris Evans and golf star Lee Westwood team up for a VERY
quick round.
Chris, 46, was spotted taking Lee, 39, for a spin in his £2million 1956
Ferrari 860 Monza at the gates of Berkshire's Sunningdale course.
The golfer also gave Chris a few tips with his clubs. After that, the least
Evans could do was give the world No 3 a Ryder home…


text:
"What, did you really think you were Daddy Dearest's only bastard?"
Down here, on all fours and staring at the floor while wheezing like an asthmatic, it's hard to say what I had believed. If I was being honest with myself, I'd have to admit to not giving the subject much thought. Before tonight anyway.
"I guess… I was too busy… staying alive… to think about it," I manage to squeeze out between agonizing breaths; he really caught me with a good one.
It makes sense though – the old man bedded (or couched, or dark alleyed…) any woman that would have him. He watched over me until diabetes finally overwhelmed him when I was six, but for as much of those years as I can remember it was a revolving door of disinterested pseudo step mothers.
"If I wasn't the only one," I ask as the pain begins to recede, "why did he only look after me? Did he know about the others?"
"Oh, he knew," Tommy says with disgust, "but you were the only boy." I begin to laugh – it hurts but I can't stop. "What's so fucking funny?"
"What was I," I gasp, rolling onto my left side, shaking with laughter, "the heir to his trash can kingdom? His poverty palace?"
"He wanted a son to carry on his name," Tommy says as I collapse onto my back and howl with laughter. This is all too much; I've even almost forgotten about the gun in his hand. "What is it now you lunatic?"
"That was a noble cause, to be certain, but he's failed to achieve even that much," I tell him. "I don't know my last name!"
"No problem there," he says. "She does."
This brings me up short. I lay still for several moments, letting this new tidbit bounce around in my head. Do I want to know? Does it matter anymore? Did it ever?
I push off the floor and return to my feet. The gun follows me up but I try to ignore it. I'm starting to see a way out of this but I need to concentrate. If I approach this the wrong way I'll set Tommy off and the gun would surely follow his lead.
"So pops made some attempt at taking care of me but he abandoned the girls," I say in a thoughtful tone. "I bet they weren't too happy about that."
"You think? Two of them died before their first birthday and a third didn't make it past five," Tommy snaps at me. "Ashley is the only survivor."
"Why didn't you tell me about Ashley? How long have you known her, known all this?"
"It doesn't matter. Oh, she prefers to be called Ashes," he says. "As in: rising from the."
"Cute," I mutter as I trace out my next steps. "I think it does matter how long you've known her though, so could you at least tell me that?" Tommy sighs and looks annoyed, but he tells me.
"I dunno, like three months?"
Three months are like three years on the street; you trust people after that much time together. I decide to assume they're sleeping together instead of asking for confirmation – there's no need to have that fresh in his mind when my next words arrive.
"So Ashes carries this grudge around all her life, then one day meets you," I say. "She gets to know you, finds out you and I are tight; you tell her all about your buddy J and she figures out who I am. Sound about right so far?"
Tommy scowls, he glares, but he nods, the slightest twitch of his head.
"So she hangs around, gains your trust," I continue steadily. "She's found a way to get some revenge but she needs you on her side first. So she tells you all about our 'Daddy Dearest', how lucky I was -"
"Enough!" Tommy shouts, the gun shaking in his hand. But I can't stop now.
"And then finally she has her chance – she laces your dope with God knows what, steals your stash and puts the blame on me! I have to admit, that's pretty impressive -"
"Enough," Tommy mumbles, the gun falling to his side. "No more."
"Tommy," I say gently as I move slowly towards him, "I think it's time for a family reunion."


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|Reviews for Sing to Us
| suns and stars chapter 1 . 9/10/2010
lol made me laugh but it ws funny and sweet
| Sparkle chapter 1 . 10/25/2009
Wow. Good. I loved this movie and the actors and this captured the emotions entirely.
| Mrs Max McDowell chapter 1 . 6/5/2009
That was wonderful and it brought tears to my eyes.
| brookemopolitan chapter 1 . 3/10/2009
this is really interesting... on a side note, its crikey, not crickey... but thats not so important
i find the drover's thoughts particularly interesting, especially because all through the film he was very supportive of Nullah going walkabout, because he understands exactly what it entails... its interesting to see his perspective now that Nullah actually has gone..
| Bobbie chapter 1 . 3/10/2009
well done! please write more!
| fiction-is-my-addiction chapter 1 . 3/9/2009
This is a great one-shot. you are a really good writer. I hope you write more fanfics for this topic. I'm dying for more. Loved the story!


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Sonic Universe Volume 12: Chaotix Quest
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|This article contains information about a canceled object.
As a result, the content of the article may have been canceled or replaced by another subject.
Sonic Universe Volume 12: Chaotix Quest was the intended eleventh volume in the Sonic Universe Graphic Novel series. This volume contains reprints of stories from the "Chaotix Quest" story arc from Sonic Universe #46-#49. The volume was intended to be released but was later removed from listings entirely after numerous delays, presumed cancelled.
Official solicitation
- SONIC UNIVERSE is the hit spin-off series to Archie Comic's wildly successful SONIC THE HEDGEHOG comic book series! Explore the characters, worlds and dimensions of Sonic's universe!
- The Chaotix are a team you can count on! All for one and one for all! That's why they're on the case to track down their missing friends and overcome anything in their way!
- Vector, Espio and Charmy will brave medieval forests, gruelling deserts, and hordes of Dr. Eggman's goons to rescue Mighty and Ray! Along the way they'll discover the tragic truth to Mighty's secret past, and maybe save him from himself!


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Shoal It's cool.
Pamela Please, sit down. We're just about to eat—hopefully.
Grey What kind of food did they serve on the road?
Pamela Canned things, mostly. Non-perishables.
Grey Sounds satisfying.
Pamela I'm starving.
Grey Well, then, you're in for a treat. Miller is the best chef I've ever met. He keeps the whole colony up and running—don't know how we'd get by without him.
Shoal I don't know how you get by waiting so long for the food to show up.
Pamela Shoal, don't tell me you left your manners back at the Capitol.
Grey [laughing] Hey, tonight's meal is meant to be cooked in celebration. For the sake of the best things you'll ever taste, it's worth the extra wait.
Pamela Just be patient, all right, love?
Shoal Yes, Mom.
Grey So, does the head architect know what's on the checklist for Advancement?
Pamela Not exactly. Mr. Debars is the one with all the plans.
Grey Mm, I understand. But if you had to take a guess, what would you say?
Pamela Well … the buildings are the most in need of restoration.
Grey Sure.
Pamela I'd say full demolition and overhaul is tempting. Most of the foundation work doesn't meet the requirements anymore, especially in a landscape like this. The structures are hardly sound enough for expansion, and the ceilings are all higher than the current standard, besides that. The furniture doesn't function very well with the space; we could certainly be more efficient in that regard. As for myself, I think the basic layout of the public areas and the housing provisions feels like it was planned in a rush, so if it were up to me I'd redo most of the colony's design. I haven't been out to see your generators and turbines yet, but I assume the largest issue in safety is the lack of protection from the sun—it isn't on the minimum requirement list, but I'm sure Debars will want to have added a ceiling to the enclosure by the end of this Advancement. I'm sure it would be on the list next time, anyway.
Grey Ah…
I see.
Shoal Look! The food is coming!
Enter cooks carrying platters of food
Grey Well, listen, I hate to run but I promised Chief Foster I'd get a few things taken care of before heading off to bed. It was great meeting you both.
Pamela Likewise, Mr. Grey. You have a lovely son.
Sailor Can I stay and eat?
Grey Sure, little man. Be back home by dark.
Sailor Okay.
Pamela We'll see each other tomorrow, I'm sure. We've got a big day of work ahead.
Grey Evidently. Have a good night.


text:
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After a foreclosure in Alabama, if you do not move out of your home then the mortgage company will sue you to eject (or evict) you from your home.
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text:
Cost-effectiveness of general practice care for low back pain: a systematic review
- First Online:
- Received:
- Accepted:
DOI: 10.1007/s00586-010-1675-4
- Cite this article as:
- Lin, CW.C., Haas, M., Maher, C.G. et al. Eur Spine J (2011) 20: 1012. doi:10.1007/s00586-010-1675-4
- Citations
- 1.8k Downloads
Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves.
KeywordsLow back pain Cost-effectiveness analysis Primary health care Systematic review
The direct (healthcare) and indirect (loss of productivity) costs of low back pain (LBP) have been estimated for several countries, in a number of studies, with each study reporting staggering costs [1]. For example, the conservative estimates for direct and indirect costs of LBP in United Kingdom were £1,632 and £3,440 million in 1998 [2]. These figures are likely to be higher today. In the United States, healthcare costs among people with spinal pain increased by 65% from 1997 to 2005, more rapidly than the overall healthcare costs, and accounted for 9% of the total healthcare costs in 2005 [3]. Studies like these illustrate the need to efficiently use available healthcare budgets when managing LBP.
An economic evaluation takes into account the costs relative to the effects (outcomes) in a systematic comparison of two or more treatment alternatives [4, 5]. It does not necessarily answer the question of what the cheapest intervention is. If an intervention is more effective than another intervention but associated with higher costs, the intervention may still be cost-effective if the ratio of costs and effects is acceptable. Hence, economic evaluations are designed to inform policy makers, clinicians and consumers about the relative efficiency (value-for-money) of treatment alternatives.
Care from a general practitioner (GP care) is one of the most frequently utilised healthcare services for LBP [2, 6]. The role of a GP working in primary care is to triage and provide first-line care to manage LBP. In managing LBP, GPs may be the sole provider of care or, in about 20% of patients [6, 7], GPs refer patients for additional healthcare services (e.g. physical therapy). The purpose of this systematic review was to critically appraise and summarise current evidence, retrieved from economic evaluations conducted alongside randomised controlled trials, on the cost-effectiveness of GP care compared to other treatment options for non-specific LBP.
We followed the method guidelines of the Cochrane Back Review Group [8, 9], Campbell and Cochrane Economic Methods Group (http://www.med.uea.ac.uk/research/research_econ/cochrane/cochrane_home.htm), and the NHS Economic Evaluation Database Handbook [10]. Full economic evaluations (i.e. cost-minimisation, cost-effectiveness, cost-utility or cost-benefit analysis) undertaken from any perspective conducted alongside randomised controlled trials were included in this review. Studies which collected data on costs and/or utilisation but did not relate this information to a measure of benefit, or did not make inferences about the relative efficiency of the treatment alternatives, were excluded. Studies that recruited adults with non-specific LBP of any duration and included GP care in at least one intervention group were eligible for this review. We defined GP care as care provided by a general practitioner or doctor working in primary care. There was no restriction on the type of comparison group used. Studies that recruited multiple musculoskeletal conditions (e.g. neck or LBP), or investigated interventions implemented after spinal surgery were excluded. In addition, studies had to report costs and effects of the interventions, or an incremental cost-effectiveness ratio (ICER). There was no language restriction.
We used the Cochrane Back Review Group's search strategies to identify randomised controlled trials in LBP (http://www.cochrane.iwh.on.ca/pdfs/CBRG_searchstrat_Sept08.pdf). Economic search terms (e.g. economics, costs and cost analysis) were developed from search strategies used by the NHS Economic Evaluation Database (NHS EED) (http://www.york.ac.uk/inst/crd/nhseedfaq02.htm). The following databases were searched from inception to 1 June 2010: Medline (via OvidSP), EMBASE (via OvidSP), CINAHL (via EBSCO), Cochrane Central Register of Controlled Trials (CENTRAL, via The Cochrane Library), PsychINFO (via OvidSP), PEDro, the American Economic Association's electronic bibliography (EconLit), NHS EED, and European Network of Health Economic Evaluation Databases (EURONHEED). The reference list of relevant systematic reviews and included studies were also searched. See Table 6 of Appendix for an example of a full search strategy.
Two reviewers independently screened first the titles, then abstracts (if available), and then full papers. For each included study, we used the criteria recommended by the Cochrane Back Review Group [8, 9] to assess the risk of bias of the trial design, where studies with a score of 6 or more out of a total of 11 would be considered as having a low risk of bias [11]. Studies were also rated using the Consensus on Health Economic Criteria (CHEC-list) [12] for the quality of the economic evaluation. Studies were included in the analysis regardless of their risk of bias or quality of economic evaluation. Data were extracted using a customised data extraction sheet which was piloted on a cost-effectiveness study [13] before use. Two reviewers independently performed rating and data extraction. Publications related to the included studies (e.g. published protocol or clinical outcomes paper, listed in Table 7 of Appendix) were used to assist these processes. Throughout the review, disagreement between the two reviewers were resolved first in discussion, and then by an independent third reviewer if necessary.
Data extracted from each study included: (a) the type and perspective of the economic evaluation, (b) characteristics of participants, (c) treatment comparators, (d) year, length, country and currency of the study, and (e) identification, measurement and valuation of costs and outcomes used in the economic evaluation, and (f) results of the study. Information on the relative cost-effectiveness of the interventions was used as the primary outcome in the review. This is usually reported as an incremental difference in costs relative to an incremental difference in effects, e.g. the ICER. Alternatively, where one treatment incurs lower costs and generates higher benefits compared to a treatment comparator, an ICER is not necessary and the treatment is said to be dominant.
For data analysis and presentation, studies were grouped first according to intervention, then by the type of economic evaluation conducted. In addition, regardless of the interventions investigated, studies reporting ICER using generic outcomes [e.g. cost per quality-adjusted life-years (QALYs) gained] from the same perspective were compared after adjusting for cost differences across countries and time. We used the cost-effectiveness threshold of the British National Institute for Health and Clinical Excellence (NICE; GBP20,000 to GBP30,000 per QALY gained) as an indicator of cost-effectiveness [14, 15]. That is, if a treatment has an ICER lower than the NICE threshold when compared to an alternative, the treatment is said to be relatively cost-effective.
Study characteristics
Study ID, type and perspective
Study details
Hollinghurst et al. [24]
Type: CEA/CUA
Participants randomised (n): 435a
Usual GP care ± exercise and behavioural counselling
Perspective: healthcare sector, patients, societal
Duration of LBP: chronic or recurrent
Massage ± exercise and behavioural counselling
Length of follow-up: 12 months
Alexander technique (6 lessons) ± exercise and behavioural counselling
Setting: United Kingdom 2002–2004
Jellema et al. [25]
Type: CEA/CUA
Participants randomised (n): 314
Usual GP care
Perspective: societal
Duration of LBP: <12 weeks
Minimal psychosocial intervention (delivered by GP)
Length of follow-up: 12 months
Setting: The Netherlands 2001–2003
Johnson et al. [26]
Type: CEA/CUA
Participants randomised (n): 234
Usual GP care
Perspective: not stated
Duration of LBP: >3 months
Exercise and education using a cognitive-behavioural approach
Length of follow-up: 15 months
Setting: United Kingdom 2002–2003
Type and perspective: not stated
Participants randomised (n): 164
Usual GP care
Duration of LBP: >4 weeks but <3 months
Usual GP care plus advice, education and exercise
Length of follow-up: 24 months
Usual GP care plus advice, education and exercise, plus worksite visit
Setting: Finland 1998–2000
Kominski et al. [18]
Type: CMA
Participants randomised (n): 681
Usual GP care
Perspective: not stated
Duration of LBP: mixed
Usual GP care plus physiotherapy
Length of follow-up: 18 months
Chiropractic care
Setting: United States 1995–1998
Chiropractic care with physical modalities
Kovacs et al. [16]
Type: CEA/CUA
Participants randomised (n): 104
Usual GP care
Perspective: not stated
Duration of LBP: ≥14 days
Usual GP care plus neuroreflexotherapy
Length of follow-up: 12 months
Setting: Spain, years not specified
Loisel et al. [20]
Type: CEA/CUA and CBA
Participants randomised (n): 130
Usual GP care
Perspective: insurance provider
Duration of LBP: >4 weeks absent from work due to LBP
Clinical rehabilitation (back pain specialist, back school ± multidisciplinary rehabilitation)
Length of follow-up: mean 6.4 years
Occupational intervention (occupation physician and ergonomics intervention)
Setting: Canada 1991–1993
Clinical rehabilitation plus occupational intervention
Ratcliffe et al. [27]
Type: CEA/CUA
Participants randomised (n): 241
Usual GP care
Perspective: healthcare sector and societal
Duration of LBP: 4–52 weeks
Length of follow-up: 24 months
Setting: United Kingdom 1999–2001
Seferlis et al. [19]
Type: CMA
Participants randomised (n): 180
Usual GP care
Perspective: not stated
Duration of LBP: <2 weeks on sick leave due to LBP
Manual therapy
Length of follow-up: 12 months
Exercise training
Setting: Sweden, years not specified
Skouen et al. [21]
Type: CBA
Participants randomised (n): 211 (195 completed follow up)
Usual GP care
Perspective: societal
Duration of LBP: sick leave for at least 8 weeks, or sick-listed for at least 2 months a year for the last 2 years
Light multidisciplinary treatment
Length of follow-up: 24 months after the end of treatment
Extensive multidisciplinary treatment
Setting: Norway 1996–1997
UK BEAM Trial Team [17]
Type: CEA/CUA
Participants randomised (n): 1,334 (1,287 included in analysis)
Guideline-based GP care
Perspective: healthcare sector
Duration of LBP: at least 4 weeks
Guideline-based GP care plus exercise
Length of follow-up: 12 months
Guideline-based GP care plus spinal manipulation
Setting: United Kingdom 1999–2002
Guideline-based GP care plus combined treatment (spinal manipulation followed by exercise)
The majority of the studies conducted a cost-effectiveness and/or cost-utility analysis. There were also two cost-minimisation [18, 19] and two cost-benefit [20, 21] analyses. One study, which had one- and two-year results published in two separate papers [22, 23], did not clearly specify the type of economic evaluation conducted, but the type of outcomes reported suggested that it was a cost-effectiveness analysis. Of the 11 included studies, all studies were conducted in Europe except for one conducted in the United States [18] and one in Canada [20].
We grouped studies into three groups: GP care alone versus other treatment (eight studies), GP care plus other treatment versus other treatment (one study), and GP care alone versus GP care plus additional treatment (five studies). Two studies [18, 24] had multiple comparisons and appeared in more than one treatment contrast. Most studies evaluated "usual GP care", i.e. they did not specify whether the treatments followed a protocol or guideline but provided care that included advice, exercises, rest and prescription of medications with or without referrals to other services [16, 18, 19, 21]. A number of studies did not describe details of the GP care, except that it was the normal or usual care provided by a GP [20, 24, 25, 26] which may include referrals to other services [22, 23, 27]. The exception was the UK BEAM Trial [17], which provided training to GPs to deliver guideline care in the management of LBP ("guideline-based GP care").
Risk of bias of the trial design (Table 2)
Risk of bias score (/11)
CHEC-list (/19)a
Hollinghurst et al. [24]
17 (1)
Jellema et al. [25]
18 (1)
Johnson et al. [26]
12 (1)
13 (0)
Kominski et al. [18]
11 (4)
Kovacs et al. [16]
15 (1)
Loisel et al. [20]
14 (0)
Ratcliffe et al. [27]
19 (0)
Seferlis et al. [19]
7 (5)
Skouen et al. [21]
14 (1)
UK BEAM Trial Team [17]
17 (1)
Quality of the economic evaluation (Table 2)
Five studies collected costs appropriate to their chosen perspective [17, 20, 24, 25, 27]. One study undertook the economic evaluation from the societal perspective, but collected only costs associated with the study treatment and loss of productivity and not the costs of other treatments [21]. Five studies did not state the perspective adopted for the economic evaluation [16, 18, 19, 22, 23, 26]. Most studies measured costs using diaries, questionnaires, or practice or insurance records, and valued costs appropriately using published sources. Where appropriate, most studies conducted an incremental cost-effectiveness analysis. The length of follow-up was at least 1 year for all of the studies. In three of the five studies in which the length of follow-up was more than 1 year, discounting was undertaken [21, 22, 23, 27]. Just over half the studies conducted a sensitivity analysis to account for uncertainties in their estimates of costs and effects [16, 17, 20, 24, 25, 27].
GP care alone versus other treatment (Table 3)
GP care alone versus other treatment
Study ID and perspective
Incremental cost-effectiveness ratio (in cost per one unit of effect gained) or cost-benefit outcome
Cost-effectiveness/cost-utility analysis
Hollinghurst et al. [24]
Perspective: healthcare sector, patients, societal
Compared to GP care alone from healthcare sector's perspective only, in 2005 GBP
•Disability (RMDQ) = 448
•Pain-free day = 26
•QALY gained (EQ-5D) = −34,473 (less effective and more costly)
Alexander technique (6 lessons):
•Disability(RMDQ) = 113
•Pain-free days = 13
•QALY gained (EQ-5D) = 5,899
Jellema et al. [25]
Perspective: societal
Minimal psychosocial intervention compared to GP care alone 2002 Euro:
•Disability (RMDQ) = 690
•Recovery rate (% recovered) = 239
•QALY gained (EQ-5D) = 47,348
Johnson et al. [26]
Perspective: not stated, but collected direct healthcare costs
Exercise and education using a cognitive-behavioural approach compared to GP care alone = 5,000 in 2003–2004 GBP per QALY gained (EQ-5D)
Loisel et al. [20]
Perspective: insurance provider
Compared to GP care alone, in 1998 Canadian dollars per days on full sickness benefits:
•Clinical rehabilitation = −67.6
•Occupational intervention = −88.4
•Clinical rehabilitation plus occupational intervention = −63.5
Ratcliffe et al. [27]
Perspective: healthcare sector, societal
Acupuncture compared to usual GP care, in 2002–2003 GBP per QALY gained (EQ-5D):
•From healthcare sector's perspective = 4,241 (95% CI = 191–28,026)
•From societal perspective and with intention-to-treat analysis, acupuncture dominant
Cost-benefit analysis
Loisel et al. [20]
Perspective: insurance provider
Compared to GP care alone, in 1998 Canadian dollars:
•Clinical rehabilitation = 16,176
•Occupational intervention = 16,827
•Clinical rehabilitation plus occupational intervention = 18,585
Skouen et al. [21]
Perspective: societal
Light multidisciplinary treatment in male patients compared to usual GP care alone = 7,240,900 for the male participants (n = 21) over 24 months in 1998 Norwegian kroner
Two studies conducted a cost-benefit analysis using sick-listed workers. Loisel et al. [20] showed that clinical rehabilitation and/or occupational intervention incurred lower healthcare and income replacement costs compared to usual GP care alone from the insurance provider's perspective. Skouen et al. [21] found similar results for light multidisciplinary treatment from the societal perspective, but interestingly only in male participants.
GP care plus other treatment versus other treatment
Only one study was included in this comparison [24]. This study found that usual GP care plus exercise and behavioural counselling was associated with lower costs than massage or the Alexander technique plus exercise and behavioural counselling from the perspectives of the healthcare sector and patient. There were no statistically significant between-group differences in disability, pain-free days or QALY outcomes. However, the ICERs for both treatment alternatives were low, suggesting that these treatments were cost-effective compared to usual GP care plus exercise and behavioural counselling (ICER for massage plus exercise and behavioural counselling = 5,304 per QALY gained, for the Alexander technique plus exercise and behavioural counselling = 5,332 per QALY gained, in 2005 GBP from the healthcare sector's perspective).
GP care alone versus GP care plus additional treatment
Cost-effective/cost-utility analysis comparing usual GP care alone versus usual GP care plus additional treatment
Study ID and perspective
Incremental cost-effectiveness ratio (in cost per one unit of effect gained)
Hollinghurst et al. [24]
Perspective: healthcare sector, patients, societal
Usual GP care plus exercise and behavioural counselling compared to usual GP care alone from the healthcare sector's perspective only (in 2005 GBP):
•Disability (RMDQ) = 61
•Pain-free days = 9
•QALY gained (EQ-5D) = 2,847
Perspective: not stated, but collected direct healthcare and indirect costs
Not conducted, but usual GP care plus advice, education and exercise with or without work site visit, incurred lower costs and was more effective compared to usual GP care alone.
Kovacs et al. [16]
Perspective: not stated, but collected direct healthcare and indirect costs
Not conducted
One study investigated the cost-effectiveness of guideline-based GP care, and found similar results to studies that investigated usual GP care [17]. From the healthcare sector's perspective, guideline-based GP care alone incurred lower costs compared to guideline-based GP care plus exercise and/or spinal manipulation. Adding spinal manipulation to guideline-based GP care was effective in managing sub-acute to chronic LBP (mean between-group difference = 0.04 QALYs), and the ICER was low (£4,800 in 2000 to 2001 GBP per QALY gained from the healthcare sector's perspective). In contrast, adding both spinal manipulation and exercise to guideline-based GP care did not statistically significantly increase the number of QALYs gained compared to guideline-based GP care alone, but would only cost £3,800 per QALY gained. This shows that the most effective treatment may not be the most cost-effective treatment, as cost-effectiveness analysis considers costs relative to effects.
Comparing cost-effectiveness across interventions (Table 5)
Comparing the incremental cost-effectiveness ratio (ICER) in cost per quality-adjusted life-year gained from the healthcare sector's perspective
Original currency
ICER in original currency
ICER in 2005 GBP (rounded to the nearest pound)
Usual GP care plus exercise and behavioural counselling [24]
Guideline-based GP care plus spinal manipulation and exercise [17]
Acupuncture [27]
Guideline-based GP care plus spinal manipulation [17]
Exercise and education using a cognitive-behavioural approach [26]
Massage plus exercise and behavioural counselling [24]
Alexander technique plus exercise and behavioural counselling [24]
Alexander technique [24]
Guideline-based GP care plus exercise [17]
Massage [24]
−34,473 (more costly and less effective)
In this systematic review, we identified 11 relevant studies, most of which examined the cost-effectiveness of GP care in sub-acute or chronic LBP. When considering costs from the healthcare sector's perspective, GP care was associated with lower costs than other treatment alternatives, and this finding was consistent across healthcare systems. However, if the costs associated with loss of earnings or changes in productivity were included, GP care generally incurred higher costs than other treatments. Most treatments appeared relatively cost-effective compared to GP care. In particular, adding advice, education and exercise to usual GP care or providing clinical rehabilitation and/or occupational intervention or acupuncture were dominant treatment alternatives (i.e. they incurred lower costs and generated more benefits) compared to usual GP care alone. Adding exercise and behavioural counselling to usual GP care, or spinal manipulation to guideline-based GP care, and using the Alexander technique were more effective and may also be more cost-effective, as indicated by ICERs below the NICE threshold of GBP20,000 to GBP30,000.
These findings have important clinical and research implications. They suggest that GP care alone may not be the most cost-effective treatment for LBP, yet currently only around one-fifth of patients with LBP presenting to GPs are referred to another healthcare service [6, 7]. In addition, evidence-based management of LBP is typically based on effectiveness outcomes from trials. Our review findings suggest that evidence of cost-effectiveness should also be considered by clinicians and researchers when making recommendations regarding the management of LBP. Compared to GP care, when alternative treatments incur lower costs and are more effective (e.g. acupuncture), or incur higher costs and are less effective (e.g. massage), the choice for the most efficient treatment option is straight forward. In the absence of a clear difference in treatment effects, the results of economic evaluations can provide information on the relative efficiency of treatment alternatives. Because both the incremental costs and the effects are taken into account in an economic evaluation, a treatment may be relatively cost-effective compared to an alternative treatment even if the difference in clinical effectiveness is small. Hence, future studies should consider including an economic evaluation in order to provide comprehensive information on both effectiveness and efficiency of treatments in managing LBP [28]. Conducting economic evaluations has recently been regarded as a research priority in musculoskeletal conditions such as LBP [29].
In all but one study the GP intervention was the usual care provided by a GP. In contrast, the additional or alternative services, such as exercise and advice, were usually delivered according to a defined protocol that represented best practice. Surveys of usual GP care reveal low compliance with care recommended in guidelines [6, 7]. Hence, comparing usual GP care to a best practice alternative potentially under-estimates GP care and needs to be borne in mind when interpreting the results of this review. A number of trials found that referring a patient for additional services was more cost-effective than usual GP care alone. It is acknowledged that some of the additional services, e.g. advice/education and exercise prescription, could be provided by some GPs who manage LBP. Our pragmatic interpretation of the results of our review is that GPs aiming to provide cost-effective care should ensure that their patients receive these additional services, either by referral (as occurred in the original trial) or by providing the services themselves.
Most economic evaluations identified by this review were conducted as cost-effectiveness or cost-utility analyses. While a cost-effective analysis provides data that may be more meaningful to clinicians (e.g. adding exercise and behavioural counselling to usual GP care would cost £61 in 2005 GBP per one point gained on the Roland Morris Disability Questionnaire) [24], a cost-utility analysis provides information using a generic outcome (most commonly cost per QALY gained) that can be compared across interventions and health conditions [4] and assist policy makers in making decisions on reimbursing existing or new treatments. In our review, we used the NICE threshold to assess the cost-effectiveness of LBP treatments. The NICE threshold has not changed since 1999. While controversies exist on the use of such a threshold and on whether the threshold should be altered [14, 15, 30, 31], most treatments for LBP have ICERs well below the current threshold. It needs to be highlighted, however, that the findings of this review are based on single studies as the heterogeneity of the included studies prevented the pooling of data. Only 4 of the 11 included studies had a low risk of bias. In addition, the findings may be limited to countries with similar healthcare systems, and, for cost-utility analysis, to populations where similar utility weights can be expected.
In our review we identified two cost-minimisation studies [18, 19]. Cost-minimisation analysis is used when treatment alternatives achieve the same outcomes in effectiveness, but the appropriateness of its use is controversial because the lack of a demonstrative difference between two treatments may be due to insufficient power rather than an absence of effects [32]. Hence, it may be only appropriate to conduct a cost-minimisation analysis where an equivalence trial has been conducted [33] or when the confidence intervals of the between-group treatment effects are narrow enough to rule out potential treatment effects. For example, Kominski et al. [18] conducted a cost-minimisation analysis based on the results of a randomised controlled trial, which showed narrow between-group differences in treatment outcomes [34]. Some authors do not recommend cost-minimisation analysis as they argue that economic evaluations should be used to provide estimates of the incremental difference in costs relative to the incremental difference in effects (i.e. the incremental cost-effectiveness) rather than hypothesis testing [32].
Six similar reviews have been published previously [35, 36, 37, 38, 39, 40]. Results of these reviews were either inconclusive [35, 36, 37, 39], failed to demonstrate economic benefits of interventions for LBP [38], or focused on the qualitative description of the economic design [40]. In contrast to these reviews, and due to an increasing number of available studies, we were able to selectively include randomised controlled trials which conducted a full economic evaluation. Compared to a previous review [40], there is a trend showing that the quality of economic evaluation has improved, particularly in the identification, measurement and valuation of cost, and conducting an incremental cost-effectiveness analysis and sensitivity analysis. It is important to note that the strength of this review is not that it gives an ultimate answer to the question which intervention is most cost-effective, but in the summary of all available economic evaluations for GP care in LBP.
The aim of our review was to investigate the cost-effectiveness of GP care in managing LBP. Therefore, while studies normally report a range of condition-specific clinical outcomes, we extracted only the outcomes used in the economic evaluation. For the treatments that were dominant compared to GP care or may be cost-effective when added to GP care, there is some evidence of small effects in the clinical outcomes not used in the economic evaluation [22, 23, 41, 42, 43, 44]. There is also some evidence of small or short-term effectiveness on condition-specific outcomes for acupuncture [45] and exercise [46] in systematic reviews of treatment effectiveness, but not so for spinal manipulation when provided in addition to GP care [47, 48].
Findings of this systematic review suggest that although GP care alone was often associated with lower treatment costs from the healthcare sector's perspective, it may not provide a cost saving for society if the costs associated with loss of earnings or productivity are taken into account. When considering costs relative to effects, GP care alone may not be cost-effective in managing sub-acute or chronic LBP. Adding advice, education and exercise to usual GP care, clinical intervention and/or occupational rehabilitation, and acupuncture appeared to dominate over usual GP care. Adding exercise and behavioural counselling to usual GP care, adding exercise and/or spinal manipulation to guideline-based GP care, and using the Alexander technique also appeared cost-effective. The cost-effectiveness of GP care can be improved by referring patients to receive additional services, such as advice and exercise, or by the GPs providing the additional services themselves.
CL and CM are funded by the National Health and Medical Research Council, Australia. LM is funded by Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG), Brazil.
Conflict of interest
Open Access
This 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 source are credited.


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Railway Cuttings
"We can do it! We can do it! We can do it!" puffed Simon the Strong Engine as he hauled the Express up the hill to the Big Station at the End of the Line.
All the passengers cheered. Two girls from he Village had come to wave encouragement to Simon as he went past.
"Peep! Peep! Peep!" he whistled back happily.
As soon as he had past, the two girls brushed the soot out of their hair and went back to the Village where they had always lived.
Their mother was there to welcome them.
"Now, what have you two been up to?" she asked.
"We've just waved at Simon," said Jemima excitedly.
"Yes, and he whistled back!" giggled Patricia, who was always laughing, for some reason.
"Now, you rest there and I'll get you some tea and cakes!" smiled their mother, disappearing into the kitchen.
She emerged again immediately with a big cup of tea and ten massive round cakes.
"Now, you enjoy this!" said the girls' mother.
"Ooh, thank you!" said the two sisters together.
They had ten current massive cakes each followed by six cups of tea, all from the same small teapot and jug of milk, both of which seemed to keep replenishing themselves.
Their mother took the crockery away and put it by the sink, from which it transferred itself instantly to the appropriate racks on the wall and hung there gleaming.
"Now, your father will be home soon. Why don't you go to meet him?" asked the girls' mother.
"Ooh, yes, let's!" they both chanted together.
They put their pale green coats with their dark green belts on and their pale green hats, too.
They hurried along the lane that led to the Little Station. They heard the sound of a whistle and saw steam rising above the hill.
When they arrived at the Little Station they had to sit down at once. Dear me, those poor girls had been rushing so much that they were quite out of breath!
By and by their father's train arrived - it was a Very Important Train for their father was the Deputy Head of the Railway.
They saw his brown moustache and brown tribly hat through the smoke as he pulled the window down, reached out and opened the door.
"Hello, girls!" he enthused and gave his daughters a hug. They smiled up at him. Each girl helped to carry one of their father's many cases. That made them feel Very Important.
On their way up the hill, Jemima had an idea.
"Father, why don't we take a train to the Big Station at the End of the Line?"
Her sister and father stopped in their tracks.
"WHAT?" thundered her father. Neither girl had ever been to the Big Station at the End of the Line before.
"I think it would be jolly interesting, I mean to say!" she said, her accent starting to develop a slight North-East London twang to it as the sentence progressed.
"That won't be possible," said their father, regaining his composure, "as we are working on more Railway Cuttings up there so it's not a safe place at all for Little Girls."
"Oh, of course, Father - how silly of me!" said Jemima, returning to her usual middle-class voice.
"Let's see what your mother's prepared us for dinner! Come on!" he chuckled and they all walked blissfully along the lane that led back to the Village.
When they arrived, their father kissed their mother, who had started up a welcoming fire, even though it was the middle of the summer. That didn't matter: nobody sweated in that household.
"Now, I've got your supper ready," smiled their mother.
The girls removed their green coats and hats to reveal their dark green skirts and their blazers, which were covered in dark purple and pale purple stripes.
All four members of the family washed their hands and then sat down to eat what the Deputy Head of the Railway's wife had prepared: eighty massive current cakes (no more than twenty each were allowed due to rationing) and as much tea as they wanted.
"My dear, you have surpassed yourself!" said the Deputy Head of the Railway delightedly. "That was the best supper I've ever eaten."
"Now," said his wife and, unable to think of anything else to say, she just said, "Now" again.
"Indeed," beamed her husband and they all went to sit on bright red seats that were even nearer the fire.
"Now, this is cosy, isn't it?" said the girls' mother. "Now," she continued, "I'll just get us some tea to wash down that meal with. It's good for the digestion. Now, you must have had an interesting day. Now, you tell us all about it. Now," said the Deputy Head of the Railway's wife.
"Well, my dear, Steph refused to pull a train today because she thought the people looked common and would mess up her nice green paint!" said the Deputy Head of the Railway.
"Now!" laughed his wife.
"And we're building more Railway Cuttings. I was telling the girls on the way here. It's a Very Important Project."
"OMG!" exclaimed Jemima.
Everybody stared at her.
"I mean goodness me," she corrected herself.
As their father talked pleasantly, the girls were delighted to hear the kettle whistling like Simon. Their mother brought them in some more tea and cakes to enjoy while their father was talking.
By and by it was seven o' clock and so time for the girls to go to bed.
On their way up, their mother gave them each a candle to light their way and a cake and a piping hot cup of tea each.
Despite the massive inrush of carbohydrates, the entire family stayed slim and nobody needed any indigestion remedies.
"Now, good night," said their mother, kissing them both and then returning to the Big Bedroom, where they could already see their father lying in his pyjamas, a pipe in his mouth and his glasses at the end of his nose while he read his newspaper.
"Patricia," asked Jemima. "Do you need the bog?"
"What's one of those?" giggled Patricia.
"The loo?"
No response but more confused giggling.
"The toilet?"
Again, nothing.
"The John? The head? The can? The dunny? The karzi? The WC? The restroom? The lavatory?"
She gave up at this point, impressed with herself for knowing any of those terms, let alone all of them, but noticing her sister's distress.
"It's just that we've eaten a lot today and it's like proper proper unhealthy, right, and yet we're all slim, right, and we never need to go to the toilet."
Patricia seemed on the verge of tears.
"Why are you talking like that? I hate it when you talk like that. Oh, please, Jemima - do talk normally. Talk the way we've always talked or I shall be fearfully upset."
"You're right," said Jemima, her personality returning to one suitable for this world. "Sorry, old stick. Sleep well."
"You too, Jemima," giggled Patricia, her temporary misery forgotten.
In the middle of the night the girls were woken up by Martha the Noisy Engine going past.
"PEEP! PEEP! PEEP! KEEP UP WITH ME! KEEP UP WITH ME!" she chanted to her coaltrucks.
"Patricia," said Jemima.
"Do you remember someone called Jeremy? Only I keep thinking I have a brother, not a sister, and that he's called Jeremy."
This brought fresh tears.
Jemima, correct voice back, said, "I say, Patricia, I've thought of a good wheeze: let's pop down and take a shufty at the New Railway Cuttings?"
Nervously Patricia agreed to join her sister. They climbed out of their window and jumped down onto the brilliant green grass. They weren't hurt at all, despited the long drop.
They crept along to the place where Martha had thundered past. They then hesitated before following the track along, making sure to stand next to it and never touching any rail.
By and by they came to the Little Station.
As they neared it Jemima hushed her giggling sister: for the Stationmaster was walking back and forth, back and forth, singing his old seashanty and with a red lantern burning in his hand.
Once they had evaded his constant patrol they ploughed on up the line, Patricia pleading to go home all the while.
By and by they came to the New Cuttings. There were workmen everywhere and engines huffing and puffing like anything.
"Oh!" laughed Patricia nervously. "I really don't think we're supposed to be here - let's go back to the Village, Jemima - PLEEEEEEASE!"
Jemima engineered it so that they detoured around the workmen and ended up just the wrong side to be able to go back home along the line.
Patricia complained and whimpered all the way but her sister was having none of it.
Eventually they reached the Big Station at the End of the Line.
They gasped when they saw it. It really was a Very Big Station indeed. It had many, many platforms, not like the Little Station that they knew, and a number of locomotives asleep, whisps of black smoke and dreamy steam pouring out of their funnels. They got up onto one of the platforms and sneaked quietly between a little 0-4-0 shunter and a massive Canadian Pacific with a cowcatcher shaped like a grey beard.
They looked beyond it. Maybe it was dark but there seemed to be... nothing. That can't have been right. They inched further towards the Place Beyond the Big Station at the End of the Line. Still nothing.
They got right up to it. Nothing. It felt like nothing, it smelled like nothing and it looked like... well, nothing.
Suddenly out of the nothingness a man appeared. He wore a black top hat, a black coat with a golden watch chain, yellow-and-black check trousers and a monocle and had something they'd never seen before: a big tummy.
"Crumbs!" said Patricia.
"Oh... my... days!" exclaimed Jemima.
"Well, well, well, Little Girls," said the Head of the Railway. "What am I going to do with you, ay?"


text:
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Even if you can't be at the Grand Prix in person, wearing Black Hublot Big Bang Replica Magic 301.CX.130.RX could give you a sense of what it might feel like to be there. Although it is a replica watches, but completely like the genuine one. This is a chronograph that's sure to get you noticed, and it's as close as you can come to wearing a race car around your wrist.
The water-resistant feature makes this fake watches a good option for an active man looking for a stylish and attractive way to keep time. The Hublot Big Bang Black Magic replica makes a bold statement with its 44.5 mm diameter black ceramic case, alternating between polished and brushed finishes. The extra-large bezel, also in black ceramic, carries 6 H-shaped screws, sunken, polished and blocked. It is equipped with faceted hands, as well as a trapezoid exhibition window between the 4 and 5 o'clock hours. The three sub-dials add to the functionality of the piece. There is a 30 minute sub-dial at the 3 o'clock position, a 12 hour sub-dial at the 6 o'clock position, and a running second sub-dial at the 9 o'clock position.
Inside this intriguing timepiece is the automatic clone HUB4100 mechanical chronograph movement.


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It's a mix of Cadbury chocolate and the famous gooey goodness that goes into Creme Eggs whipped up with McDonald's soft serve into a McFlurry frenzy.
That's right, McDonald's is now selling Cadbury Creme Egg McFlurries. In time for Easter and available for a limited time, you have until April 5 - or until stocks last - to try this latest frozen treat from Maccas.
Described by a McDonald's spokesperson as a "deconstructed" creation, broken up pieces of Cadbury chocolate and Creme Egg's gooey centre are blended in with McDonald's soft serve.
Around the world, McDonald's customers have taken to Twitter to share their thoughts on the Easter-themed flavour.
One user tweeted: "Just had a Cadbury creme egg Mcflurry here in Canada. Let me repeat that, A CADBURY CREME EGG MCFLURRY!!! #dreamsdocometrue."
THERE IS A CADBURY CREME EGG MCFLURRY— Sophie (@insopherable) February 26, 2016
Some were dubious about the combination, with one person suggesting the egg would have been better in a hot chocolate creation.
To be honest I'm not sure why Maccas did a Creme Egg McFlurry instead of a Creme Egg iced/hot chocolate— sleepy elf ?? (@cloudbeach) February 26, 2016
But the majority simply expressed their desperation to try it.
Somebody drive me to McDonalds so I can grab that creme egg mcflurry— Slippery Steve (@TheAlbinoPython) February 28, 2016
Trying to convince William to drive me up to Mcds to buy me a Creme egg McFlurry. Please. Please. Please ????— Tasha Hunkin (@tashhunkin) February 27, 2016
The bad news? The Easter-time McFlurry contains 383 calories per serve and 56 grams of sugar, which is more than double the daily intake recommended by the World Health Organisation.
Dare we suggest you share one?
- nzherald.co.nz