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Addressing obesity in the management of knee and hip osteoarthritis – weighing in from an economic perspective
BMC Musculoskeletal Disorders volume 17, Article number: 233 (2016)
Obesity is one of the only modifiable risk factors for both incidence and progression of Osteoarthritis (OA). So there is increasing interest from a public health perspective in addressing obesity in the management of OA. While evidence of the efficacy of intereventions designed to address obesity in OA populations continues to grow, little is known about their economic credentials.
The aim of this study is to conduct a scoping review of: (i) the published economic evidence assessing the economic impact of obesity in OA populations; (ii) economic evaluations of interventions designed to explicitly address obesity in the prevention and management of OA in order to determine which represent value for money. Besides describing the current state of the literature, the study highlights research gaps and identifies future research priorities.
In July 2014, a search of the peer reviewed literature, published in English, was undertaken for the period January 1975 – July 2014 using Medline Complete (Ebscohost), Embase, Econlit, Global Health, Health Economics Evaluation Database (HEED), all Cochrane Library databases as well as the grey literature using Google and reference lists of relevant studies. A combination of key search terms was used to identify papers assessing the economic impact of obesity in OA or economic evaluations conducted to assess the efficiency of obesity interventions for the prevention or management of OA.
14 studes were identified; 13 were cost burden studies assessing the impact of obesity as a predictor for higher costs in Total Joint Arthroplasty (TJA) patients and one a cost-effectiveness study of an intervention designed to address obesity in the managment of mild to moderate OA patients.
The majority of the economic studies conducted are cost burden studies. While there is some evidence of the association between severe obesity and excess hospital costs for TJA patients, heterogeneity in studies precludes definitive statements about the strength of the association. With only one economic evaluation to inform policy and practice, there is a need for future research into the cost-effectiveness of obesity interventions designed both for prevention or management of OA along the disease spectrum and over the life course.
Obesity poses one of the greatest contemporary global public health challenges. Worldwide, the number of overweight or obese individuals has more than doubled since 1980 . With rising prevalence rates in adult populations, the consequential growth in obesity-related chronic disease, including osteoarthritis (OA), is inevitable. Globally, the prevalence of OA, particularly of the large weight-bearing joints such as the knee and hip, is also predicted to grow , spurred on as a result of an ageing population but also an ageing population that is getting heavier .
There is well established evidence associating obesity (BMI ≥ 30 kg/m2 ) and OA, with obesity being identified as a major but modifiable risk factor for both OA disease incidence and progression [4–6]. The issue with obesity and OA is that the two conditions often coincide, working synergistically to perpetuate poor function and a greater likelihood of sedentary lifestyles which inevitably lead to higher levels of disability and a reduction in quality of life . Furthermore, the need for total joint arthroplasty (TJA) surgery for the treatment of severe OA in knees and hips is more likely to arise in the obese  and earlier in life . Changulani et al. 2007 reported that patients with a BMI of >35 kg/m2 who were treated by knee replacement were, on average, 13 years younger than their normal weight counterparts; the authors alluded to the potential implications of younger age for lifetime management of OA . Wang et al. 2013 also highlighted that weight gain and persistent excess weight from early adulthood increased the risk of TJA of the hip and knee for OA .
Knee and hip OA is one of the leading causes of global disability and was ranked as the 11th highest contributor to global disability in the most recent Global Burden of Disease study in 2010 . As such, OA as a disease results in large indirect costs to society, mostly driven by impacts on productivity . These indirect costs, when coupled with rapid growth in direct healthcare related costs associated with management of the disease and specifically TJA as a major cost driver , mean that the economic burden is huge. Furthermore, it is likely to be exacerbated by the aforementioned growing obesity and OA prevalence. Despite TJA being a very effective and cost-effective treatment option for end stage hip and knee OA, 2013 data from the Organisation for Economic Co-operation and Development (OECD) highlights continuing growth in the number of procedures being carried out with faster growth in knee replacements (TKA) particularly in countries with higher rates of overweight and obesity such as Australia, USA and the UK. It has been estimated that in 2007 in Australia, allocated health care expenditure on OA alone was approximately AUD 2 billion . However, given that obesity rates are likely to continue to rise, this will potentially lead to substantial increases in the prevalence of OA and an even greater burden on health care expenditure .
There is now a substantial body of evidence focusing on the relationship between obesity and OA from a variety of perspectives. This includes investigation of the causal relationships of obesity and OA through biomechanical , physiological  and inflammatory mechanisms  and quantification of the impact of obesity on OA outcomes . Attention has also been afforded to the benefits of weight loss in OA populations including a systematic review which concluded that a 10 % reduction in body weight is likely to have positive clinically meaningful effects on OA symptoms such as pain and disability . A recent review focused on addressing obesity in knee OA, identified 9 randomised controlled trials of weight loss interventions in people with knee OA. It concluded that there are several strategies likely to be successful in the management of knee OA . However, the evidence base is far from definitive in terms of what is the most efficacious type of intervention, who it should specifically target and when along the treatment pathway it should be offered. There are the usual challenges of whether obesity interventions can achieve long term weight maintenance and prevent weight regain , particularly in a population where OA symptoms may hinder physical activity efforts. There is also some concern that interventions that target weight loss alone may lead to muscle weakness and some bone density loss , meaning that an intervention that targets both weight loss and appropriate physical activity simultaneously is likely to be more favourable. This is reflected in current treatment guidelines recommending that weight maintenance and exercise in combination are suitable for managing OA symptoms [21, 22], although, in reality, it is often difficult to determine compliance with these recommendations.
Despite this apparent research momentum, it is not clear what the contribution of research from a health economics perspective has been in terms of supporting the use of obesity interventions in the prevention or management of OA. The discipline of health economics is fundamentally concerned with the allocation of scarce healthcare resources in an environment of competing demands with the goal of maximising a society’s welfare in the process . Health economists typically carry out two different types of studies designed to achieve different purposes. Firstly, they describe and predict the economic impact of a disease or risk factor in order to quantify its cost burden (commonly known as cost of illness studies); secondly, they evaluate the incremental costs and benefits of alternative options to current practice (cost-effectiveness studies)  to inform resource allocation decisions. The latter essentially addresses the main objective of economics per se, that being efficiency, or maximising the benefit from available resources.
The goals of this study are two-fold. Firstly, it aims to identify and review the published economic evidence that is focused on describing and quantifying the economic impact of obesity in OA populations. Secondly, it reviews economic evaluations of interventions designed to explicitly address obesity in OA populations in order to prevent the onset of OA or improve OA clinical outcomes and potentially health related quality of life (HrQoL), to determine which interventions represent value for money. In doing so, the study also highlight gaps in the literature and identifies future priorities for this burgeoning area of research.
Literature search strategy
A systematic search of the published peer reviewed literature was conducted in July, 2014 by the lead author. The search was limited to full text literature published in the English language from January 1975 – July 2014. Six electronic databases were searched: Medline complete (Ebscohost), Embase, Econlit, Global Health, Health Economics evaluation database (HEED) and all Cochrane Library databases using the same search terms and Boolean operators in each database. Key words used and search combinations were as follow: osteoarthritis or arthritis or joint replacement or joint prosthesis or arthroplast* or knee arthroplasty or hip arthroplasty AND obes* or obesity or overweight or weight gain or weight loss or BMI or body mass or weight* or weight control AND prevention or treatment or primary prevention or secondary prevention AND economic* or economic evaluation or price or cost or cost-effectiveness analysis or economic benefits or cost benefit analysis or cost burden. A targeted Google search of the grey literature using the search terms was conducted, plus the reference lists of all relevant articles were searched for further studies.
All relevant abstracts obtained from each database were exported to ENDNOTE, X7 (Thomson Reuters) with duplicate articles removed. Titles and abstracts were searched and relevant full -articles, extracted and reviewed (see flow chart, Fig. 1). For inclusion, studies had to fulfil one (or more) of the three following broad criteria:
A costing or cost of illness study which evaluates the association of obesity in any OA study population with healthcare or other societal costs.
A partial economic evaluation study which assesses either the costs alone or the costs and outcomes of an obesity intervention in any OA study population but without comparison to an alternative healthcare pathway (cost description or cost-outcome description) or where the costs of alternatives are examined but without consideration of outcomes simultaneously (cost analysis). An obesity intervention was defined as any intervention that included a component that addressed weight loss or weight maintenance in order to impact on OA symptoms and outcomes.
A full economic evaluation study such as a cost-effectiveness analysis, cost utility analysis or cost benefit analysis which assesses both the costs and benefits of an obesity intervention against a known alternative or usual care in any OA study population.
The three criteria were purposely broad given that this is a scoping review designed to find any relevant studies and highlight gaps in the literature.
Figure 1 identifies all steps in the search process and the resulting studies extracted. In the first instance, 2048 citations were retrieved from searched databases (1997) and other sources (51). After removal of duplicates and irrelevant citations, 215 abstracts of candidate articles were screened of which 71 full text articles were assessed for eligibility. The search yielded 12 costing studies (Table 1) and one full economic evaluation (Table 2).
Impact of obesity on resource use studies in TJA populations
Settings and target group
There were twelve studies identified as cost burden studies; they all included analysis of the association between the presence of obesity in total joint replacement populations used as a predictor of healthcare costs [25–36]. Nine studies were set in acute care hospitals with a focus on THA [26, 31, 36] or TKA recipient populations [30, 33, 35] or included both THA and TKA recipients [25, 32, 34]. The remaining three studies were set in inpatient rehabilitation hospitals with two studies focusing on TKA recipients [27, 29] and one on THA recipients . Table 1 summarises the main characteristics of the identified studies. They included a mix of studies focusing on primary or index TJA surgery only [25, 26, 30–33] or inclusion of both primary and revision types of surgeries [27–29, 34–36]. This highlights the heterogeneity between studies in relation to the specific populations under study, with each having its own unique set of patient inclusion and exclusion criteria. Nearly all studies were conducted in the USA with only one study conducted in Australia .
All studies, regardless of setting, were conducted retrospectively from a narrow healthcare perspective and were restricted to the collection of direct medical costs or charges specific only to that setting. All studies relied on hospital administration data. While this enabled most of the studies to have near complete data, the downside was that the costs reported in each study were limited and did not reflect the total cost burden. As an example, the studies conducted in the acute care setting took no account of costs of the resources consumed in rehabilitation, supportive nursing facilities, outpatient and ambulatory care services or costs borne either by other sectors or by patients themselves. Methods used for identification, measurement and reporting of cost outcomes were heterogeneous and not always transparent; some studies provided little detail about their costing methodology including the selection or specification of cost items included in reported aggregate resource use [27, 28, 32] or the reference year used for the costing [27, 28]. Some studies only presented hospital charges rather than costs per se [26–29], the former usually reflecting an element of profit as well as a method of recouping uncompensated costs. If this profit is considered above and beyond the societal opportunity cost, then adjustments should be made with cost to charge ratios . However the choice of ratio applied (eg. the use of an overall hospital ratio versus a department specific ratio) varied between studies and introduced an element of uncertainty in the estimates obtained. The timeframe over which resource use was measured also varied greatly between studies. Some studies only accounted for hospital resource use during inpatient stay post -surgery [25–29, 32]. Others sought to capture resource use related to potential readmissions by measuring up to 30 days [30, 31, 34] or three months post -surgery [35, 36]; only one study followed patients for 12 months post- surgery in order to capture a picture of the annual hospital resource use as impacted by the presence of obesity .
The studies varied in terms of ascertaining and classifying the presence of obesity in the study population. In Epstein et al , the earliest study, obesity was measured as the relative weight to normal weight which is now considered an outdated method for classifying obesity; all the other studies used Body Mass Index (BMI) categories and/or BMI as a continuous variable although there was variation between studies as to the number and cut offs for the BMI categories used. Nearly all identified studies used recorded height and weight data obtained from medical records as the basis of BMI calculations. However the Kim et al. study that analysed a sample of 229 001 TKA recipients and 497 001 THA recipients captured in the US Nationwide Inpatient sample (NIS), used hospital administration coded data to determine the presence or absence of obesity rather than the height and weight recorded body measurements of patients per se . This opened the study to misclassification bias and it has also been suggested in the literature that administrative data underreports the presence of obesity .
The main variation in analytical approach between studies was whether an analysis conducted accounted for the presence of obesity related co-morbidities as a potential mediator or confounder between obesity and hospital costs. More recent studies were more likely to present results of both unadjusted and adjusted analyses using well known comorbidity indexes to show both the mediated and independent effect of obesity on hospital costs. Kremers et al , stated that obesity is a risk factor for several costly comorbidities and, therefore, controlling for co-morbidities may result in underestimation of the true incremental cost of obesity because costs attributable to comorbidities theoretically can be considered attributable to obesity.
Given such heterogeneity in elements of study design, including study setting, sample size, population under study, measurement of key variables and the analysis performed, it is not surprising that results of those studies are somewhat mixed. Three studies suggest there is no difference between groups by BMI categories on hospital costs in the acute care setting [26, 30, 31]. The remaining six acute care setting studies found a statistically significant association between the presence of severe obesity (>35 kg/m2) and higher health care costs/charges with the difference mostly in the range of 5-10 %. Overall, the more recent studies, with larger sample sizes and longer follow up periods tended to present positive association results. The main driver of the cost difference was overall hospitalisation costs, although length of stay (LOS) related to the primary episode of care, was not always identified as a contributing factor to these higher costs.
Whilst Epstein et al. reported 30 % higher total charges and 35 % mean longer LOS for persons classified as extremely overweight (body weight ≥ 188% of ideal) compared to their normal weight counterparts , the costs presented were high and less relevant today given the recent introduction of more streamlined and efficient clinical care pathways.
The two single centre rehabilitation studies [27, 28] reported that severe obesity in both THA and TKA populations was associated with higher overall hospital charges. However, results of the much larger multicentre trial in the TKA population contradicted the results of the single site study by reporting that whilst the severely obese had the highest daily charges of all BMI groups (albeit modest at USD10-36 per day), total charges were highest in the non obese group. The authors cautioned interpretation of these results, given that the average non obese patient was 11.2 years older than those in the severely obese group, indicating that age-related changes could be driving the costs. The authors also reported a significant interaction effect between high BMI and revision surgery leading to prolonged and more costly inpatient care.
Results of the literature search revealed only one full economic evaluation. The latter was a within trial cost-effectiveness analysis (CEA) study by Sevick et al, 2009 , run alongside the ADAPT trial (Arthritis, Diet and Physical Activity Promotion Trial)  which followed 316 participants with moderate knee OA and baseline BMI of ≥ 28 kg/m2, randomised to one of 4 arms: healthy lifestyle control, diet alone, exercise alone or diet and exercise interventions delivered over 18 months. Key study design characteristics and results of this economic evaluation are summarised in Table 2.
The study provides evidence that a multimodal intervention incorporating both physical activity and diet components is the most efficient choice for improving self-reported function, pain and stiffness as measured using the 3 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).
Sub-scales at 18 months compared to a healthy lifestyle control or diet and exercise interventions alone. However, it was not the most efficient choice for weight loss alone or for functional measures of mobility alone. The authors suggest that the magnitude of change in WOMAC scores found in the exercise and diet group could be considered clinically significant in similar Knee OA populations . Despite the reported comparative efficiency of the multimodal intervention arm, the total costs of the ADAPT intervention arms were higher than other CEAs of exercise and other conservative interventions in general OA populations [40–43]; this reflects the resource intensive nature of the intervention design and delivery over the 18 month trial duration. While the authors concluded that both weight loss and physical activity are needed to achieve improvements in subjective physical function and pain, it is not clear whether a diluted approach would necessarily achieve the same results.
There are some limitations to this study that are acknowledged by the authors. Costing was performed from a narrow managed care as health care provider perspective. For example, it did not include patient out of pocket costs such as the cost of pharmaceuticals which are likely to be impacted, particularly if pain and function is improved by the intervention. Other costs that would be included from a societal perspective such as productivity impacts were likewise excluded. The time horizon was also limited to the duration of the trial. Longer term follow up of both costs and outcomes would have provided greater understanding of whether the intervention could maintain function in the long term, prevent disease progression and the associated impact on healthcare resource use over this time. The study population for this evaluation was overweight and obese patients with knee OA but not end stage OA with an average baseline BMI of ≥ 28 kg/m2. However exercise maybe more difficult in end stage OA populations and there is also debate about whether exercise is actually beneficial at higher BMI’s (≥35 kg/m2) until weight loss is first achieved .
Despite a growing body of literature highlighting the importance of addressing obesity in OA populations, this review highlights the current paucity of economic evaluation research conducted in this area. Therefore, it remains unclear as to whether it is efficient to address obesity explicitly for the prevention or management of OA, how to best do it, which population to target, and when along the disease spectrum this should occur.
Nearly all studies identified were cost burden studies in TJA populations conducted to assess whether obesity leads to higher healthcare sector costs. It should also be noted that all of identified the studies related to OA in knees and hips, despite the search of OA being much broader. All of the costing studies adopted the narrow perspective of the individual healthcare setting from which the main cost data were derived; therefore, they did not account for costs associated with the whole continuum of care for TJA and only provided a snapshot of the potential economic impact compared to if a societal approach had been taken. With greater streamlining of acute health care clinical pathways for joint replacement recipients, some of the traditional post-operative costs have shifted away from the acute care setting and onto inpatient rehabilitation, outpatient, community and ambulatory care settings as well as patients and families themselves. Ideally, resource use should be tracked throughout the whole episode of care, using database linkage to gain a broader understanding of the costs associated with the presence of obesity in TJA populations. A Canadian study by Tarride et al  which tracked total healthcare resource use in both hospital and ambulatory care settings (though not OA attributable costs per se), demonstrated that healthcare costs per year to OA patients were nearly double those of non OA control participants. A subsequent finding that was not the primary objective of the study was that costs were more than triple for obese OA patients compared to non-obese controls; this highlights that the co-existence of obesity and OA possibly augments the excess financial burden of OA.
Not all of the costing studies reviewed concluded that higher costs in TJA populations were due to obesity per se. However, the more recent studies with stronger methodologies trended towards showing significant differences in healthcare costs between the severely obese compared to other BMI categories, which suggests that there are potential health care cost savings to be realised if weight loss in the severely obese is addressed prior to TJA surgery. Yet focusing only on the cost side of the equation simply identifies a potential problem, but does not address issues of technical (“how to do”) or allocative efficiency (“what to do”) in terms of choosing alternate healthcare programme options; these can only be addressed by economic evaluation studies. Similarly, establishing and subsequently investing in interventions with proven efficacy alone without consideration of the cost implications will inevitably drive healthcare spending upwards . For example, there is increasing interest in the use of laparoscopic adjustable gastric banding surgery, for severely obese (BMI ≥ 35 kg/m 2) to achieve rapid weight loss prior to TKA  given some evidence of negative health outcomes post TKA for these patients such as higher rates of infection , higher rates of revision , and worse pain and function post operatively . Lap band surgery is highly efficacious [49, 50] and cost-effective [50, 51] as a weight loss intervention in the severely obese but it is also a very costly intervention. It remains to be seen whether the incremental cost of adding this procedure prior to TJA in this population is outweighed by the incremental benefits achieved through cost offsets and improved health outcomes including health related quality of life gains immediately post-surgery and over longer time periods. It is certainly worthy of further investigation however, given evidence of the association of pre-operative obesity predicting additional weight gain post TJA  which is only likely to further precipitate the ill effects of OA and obesity in combination.
Only one economic evaluation was identified in this review . This showed that despite a small but growing number of efficacy trials that have been conducted to assess the impact of interventions to address obesity in OA populations , published cost-effectiveness studies are still lacking as in many areas of obesity research. The Sevick et al study, provided some evidence that weight loss and exercise in combination was most cost-effective in improving pain and function in overweight and obese patients with moderate knee OA compared to only exercise or weight loss independently. Yet the study provides no indication of the intervention’s longer term cost-effectiveness beyond the 18 month trial duration. It would be of particular interest to a range of stakeholders (clinicians, funders and patients) to know if the intervention was able to slow disease progression, control symptoms and maintain function for longer in persons with obesity and OA and subsequently delay their demand for more intensive and costly healthcare that coincides with higher levels of disability. Longer term cost-effectiveness studies however are reliant on either longer duration efficacy studies being conducted or, alternately, extrapolation of outcomes through modelling; the latter can be very informative but are dependent on assumptions especially in relation to maintenance of program effect. It would also be interesting to see how changes in OA symptoms as a result of an intervention manifests in terms of the quality of life impact using a utility-based HRQoL measure that can be used in economic evaluation to produce a cost per Quality Adjusted Life Year (QALY). QALYs provide a common generic measure of benefit taking into account both mortality and morbidity impacts and importantly, within this context, may capture benefit from weight loss and exercise that extends beyond that of the effect on immediate OA related outcomes. This metric also facilitates comparison of the cost effectiveness of interventions within and across disease areas. Even if studies have not incorporated a generic utility based HRQoL measure, there are reliable mapping techniques available. For example mapping techniques have been used to map disease specific measures such as the WOMAC to HRQoL scores on measures such as the EQ-5D  and the Assessment of Quality of Life (AQoL)  for Australian populations, although there are some limitations to the applicability of such mapping exercises .
With only one published cost-effectiveness study to inform policy and practice in this area, it is evident that there is a need for more economic evaluations of interventions to be conducted. This is inherently reliant on a growing evidence base of the efficacy of such interventions which ideally would incorporate economic evaluation alongside such efforts. Modeling could then be utilised to predict longer term cost-effectiveness over the life course and OA disease progression; this would require explicit statements of the assumptions about maintenance of program effect and their testing in sensitivity analysis. Economic evaluation in addressing obesity in OA should ideally adopt a societal perspective given that both costs and benefits may be incurred beyond the heath-care sector and where possible, an incremental cost per QALY should be reported to provide comparison across disease areas.
The notion of intervening to alter disease progression, delay, avoid or reduce complications post TJA by addressing obesity explicitly is, prima facie, likely to have both downstream economic and health benefits to healthcare systems, individuals and society as a whole. In practice, guidelines identify the need to focus on obesity in the management of OA, however it is evident that there is a lack of data both from an efficacy and cost-effectiveness perspective to support and to guide to whom, how and when this should be conducted and whether it should be explicitly incorporated into clinical pathways and public health practice. More research is therefore warranted in order to guide clinicians, funders, decision makers and patients alike.
Overall, this review has demonstrated that while the presence of obesity in OA populations, and in particular severe obesity, has been shown to have significant health and economic impacts, there is a dearth of evidence from an economic perspective to guide resource decisions about whether addressing obesity explicitly is considered value for money.
AQoL, assessment of quality of life; AUD, Australian dollars; CEA, cost-effectiveness analysis; HRQoL, health related quality of life; ICD-9 M, international classification of diseases – 9th revision; LOS, length of stay; NIS, Nnationwide inpatient sample; OA, osteoarthritis; OECD, organisation for economic cooperation and development; THA, total hip arthroplasty; TJA, total joint arthroplasty; TKA, total knee arthroplasty; USD, United States dollars; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index
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Sevick MA, Bradham DD, Muender M, Chen GJ, Enarson C, Dailey M, Ettinger Jr WH. Cost-effectiveness of aerobic and resistance exercise in seniors with knee osteoarthritis. Med Sci Sports Exerc. 2000;32(9):1534–40.
Tarride JE, Haq M, O'Reilly DJ, Bowen JM, Xie F, Dolovich L, Goeree R. The excess burden of osteoarthritis in the province of Ontario. Canada Arthritis Rheum. 2012;64(4):1153–61.
Williams I, Bryan S, McIver S. How should cost-effectiveness analysis be used in health technology coverage decisions? Evidence from the National Institute for Health and Clinical Excellence approach. J Health Serv Res Policy. 2007;12(2):73–9.
Groen VA, van de Graaf VA, Scholtes VA, Sprague S, van Wagensveld BA, Poolman RW. Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients: a systematic review. Obes Rev. 2014.
Kerkhoffs GM, Servien E, Dunn W, Dahm D, Bramer JA, Haverkamp D. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am. 2012;94(20):1839–44.
Dowsey MM, Gunn J, Choong PFM. Selecting those to refer for joint replacement: Who will likely benefit and who will not? Best Practice and Research: Clin Rheumatol. 2014;28(1):157–71.
Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev. 2009;15(2):Cd003641.
Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, Clegg AJ. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13(41):ix–214.
Lee YY, Veerman JL, Barendregt JJ. The cost-effectiveness of laparoscopic adjustable gastric banding in the morbidly obese adult population of Australia. PLoS One. 2013;8(5):e64965.
Dowsey MM, Liew D, Stoney JD, Choong PF. The impact of pre-operative obesity on weight change and outcome in total knee replacement: a prospective study of 529 consecutive patients. J of Bone And Joint Surgery British Volume. 2010;92(4):513–20.
Wailoo A, Hernandez Alava M, Escobar Martinez A. Modelling the relationship between the WOMAC Osteoarthritis Index and EQ-5D. Health Qual Life Outcomes. 2014;12:37.
Ackerman IN, Tacey MA, Ademi Z, Bohensky MA, Liew D, Brand CA. Using WOMAC index scores and personal characteristics to estimate assessment of quality of life utility scores in people with hip and knee joint disease. Qual Life Res. 2014;23(8):2365–74.
Dr Dowsey holds an NHMRC Early Career Australian Clinical Fellowship (APP1035810).
Professor Moodie is supported by an NHMRC Centre for Research Excellence in Obesity Policy and Food Systems grant (APP1041020). To undertake this study, Ms Flego was supported by a small internal grant provided by Deakin Health Economics.
Availability of data and materials
All data supporting the findings is contained in the manuscript or the publications referenced.
AF, MM and MD all contributed to conception of research question, and search methodology. AF conducted all the searches independently including all citation extraction, screening and full text article reviews. All authors (AF, MM, MD and PC) contributed to interpretation of findings, and to writing and review of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent to publish
This study draws on published literature, and did not entail the recruitment or participation of humans or animals. Ethics clearance was therefore not required.
About this article
Cite this article
Flego, A., Dowsey, M.M., Choong, P.F.M. et al. Addressing obesity in the management of knee and hip osteoarthritis – weighing in from an economic perspective. BMC Musculoskelet Disord 17, 233 (2016). https://doi.org/10.1186/s12891-016-1087-7


You do not need an attorney to help you complete the forms. The forms are available at no cost to you by:
The Advance Directive Registry at the Arizona Secretary of State's Office is a free registry to electronically store and access your medical directives. The secure and confidential program grants peace of mind to registrants and their families, and easy access to all health care providers. To register your completed documents, make photocopies and send the copies to:
Arizona Secretary of State
Attn: Advance Directive Dept.
1700 W. Washington St.
Phoenix, AZ 85007
Additional filing information is available at the Secretary of State's Advance Directive Registry webpage.
© 2022 Arizona Supreme Court. All Rights Reserved.


text:
Although the SharpenAir is quick and easy to use it is helpful to read our instructions before your first use to ensure proper sharpening of your airbrush fluid needle.
SharpenAir contains four sharpening stones in its main compartment area where the logo is embossed. There are four "slots" or "channels" which run from the base of the sharpener vertically to the end of the sharpener.
Working your needle from right to left:
Step 1: Place the needle in the slot (far right) allowing the needle to reach the end of the slot. With minimal pressure begin rotating the needle in a clockwise direction; about 10-15 revolutions. Pull the needle out and check the tip. You may need to repeat this step a few times to achieve the desired straightness and/or until the burr is removed.
Step 2: This slot is at less of an angle than Step 1 and uses a less aggressive stone. Using the same amount of revolutions as step 1 (10-15), this step eases the angle even further in order to reach stock angle. This process will also help in removing some of the step one sand scratches. Step 3 and Step 4 are designed utilizing the same angle.
Step 3: contains a sanding stone consisting of a lower grit to quickly reshape the entire cone if needed. This step is optional. Smaller repairs may be completed at Step 2, however, a more damaged needle may utilize all steps in order to be completely sharpened.
Step 4: contains a higher grit sharpening stone and will further sand out the scratches from Step 3.
- If you have any further questions on how to operate your SharpenAir please feel free to contact us and we will be happy to help!
This little gadget is a marvel. I didn't even realize how bad my needles were until i put them through the SharpenAir and now it's the difference between night and day with the performance. I was also pleasantly surprised at how fast it arrived, within 3 days.
I wish I would have bought this years ago. There is nothing more frustrating than damaging a needle halfway through a project. Considering that new needles are 35 dollars this an economical alternative to buying a new needle every time you get to close or accidently drop your airbrush. If you have a drawer full of needles you have tried to salvage using pliers and honing stones, you can now fix them properly. I was surprised how well it restored the bent tip of my CM-SB. The needle still required a final polish to reduce tip dry, but this step is easy if you have adapted your electric erasure to hold a needle and have some 2000- 5000 grit wet dry sand paper.
Delivery was very quick! Product works great

domain: hobby


Our top class, quality 'Lú' Louth beanie hat is now available. Perfect to keep you warm while out and about, standing on the sidelines or cheering from the stands!
Sizing is regular.
Please note that as with all cotton items, they must be washed inside out, on their own, for the first wash. Only wash these items in a cold or 30 degree wash. Some minimal dye loss may occur on the first initial wash. Do not tumble dry. Do not dry clean.
Do not iron over or near the print as the heat may cause the design to lift.


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Dancing with the stars judge Len Goodman says goodbye to the ballroom competition series.
On Monday’s show, Goodman announced that this season would mark his finale as a judge.
“It will be my last season judging by Dancing with the stars. I have been with the show since it started in 2005 and it has been an immense pleasure to be part of such a wonderful show. But I have decided that I would like to spend more time with my grandchildren and my family in Britain,” Goodman said. “I can’t thank you enough. Dancing with the stars family. It has been such a wonderful experience for me.
After Goodman’s announcement, the judge received a standing ovation.
“You have inspired generations of dancers around the world with your passion, expertise and laser-focused eye and they will continue this commitment to excellence forever. Thanks a lot. A living legend,” said host Tyra Banks.
Goodman has been ABC’s celebrity ballroom pageant main judge since the show debuted on ABC in 2005. He has served as a judge alongside his fellow DWTS mainstays Carrie Ann Inaba and Bruno Tonioli. Dancing with the stars pro Derek Hough later joined as a judge.
Prior to DWTSGoodman previously served as Chief Justice on Come dance strictlythe original UK version of Dancing with the stars. He has also been a judge at the World and British Championships.
Goodman has been recognized for his achievements in dance, winning numerous awards including British Exhibition and World Exhibition Championship runner-up. Other awards include the British Rising Star Award, the Carl Allen Award and a Lifetime Achievement Award.
Goodman also runs the Goodman Dance Academy, a long-standing dance school in Kent, England.
Source : BBNWORLDNEWS

domain: news


Watch: There’s Gold to Be Found in New Discovery Series ‘Devil’s Canyon’ (VIDEO)
We’ve got a feeling that Discovery is going to start a legitimate gold rush to Devil’s Canyon, British Columbia, after viewers get a glimpse of the stars of the network’s latest treasure-hunting series, Devil’s Canyon (Tuesdays beginning June 6). It’s a reality series that fans of Discovery’s hit Gold Rush may want to check out.
The guys in Devil’s Canyon are extreme prospectors Boyce Goff, Ben van der Valk (featured in the video below) and John Belchik, who separately go into the remote canyon (where big mining companies can’t reach) with no camera crew and no help. The area is known for harboring the largest creekside gold deposit the world has ever seen, and the men are going old-school to pan-mine for gold with hopes of making a fortune.
It’s a classic man vs. nature test, as they’ve only got the food and supplies they carried on their back, and will need to survive the harsh terrain and imposing winter.
Check out an exclusive clip from Devil’s Canyon:
Devil’s Canyon, Tuesdays at 10/9c beginning June 6, Discovery Channel


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When you claim a rapper stole your song, make sure you still own the song in the first place. That’s the claim 50 Cent is making in court regarding a ’70s song he sampled in his 2009 track “Redrum,” which he made available for free online.
Robert Poindexter filed suit against 50, claiming he improperly used a song of his—”Love Gonna Pack Up And Walk Out” by the Persuaders, a band of which Poindexter was a member—and now 50 has filed court documents stating that Poindexter signed the rights to the song over to Warner Music Group, meaning he has no legal control over the song and thus no right to file the suit. Will WMG sue 50 for violating copyright laws now? Who knows. Either way, this is the most excitement a mellow ’70s jam has seen since James Taylor’s “Your Smiling Face” found its way onto a Girl Talk song. [TMZ]

domain: artistic


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Esophageal cancer is one of the most popular malignant tumors in China, which has high morbidity and mortality rate (1,2). Squamous cell carcinoma is much more frequently observed in Chinese esophageal cancer patients than adenocarcinoma. Depending on the location of tumor, Ivor Lewis or McKeown surgical approach is adopted for resectable esophageal cancer (3,4). These approaches are widely accepted with the advantages of mediastinal lymphadenectomy, low perioperative morbidity (5). The 5-year survival rate of esophageal cancer has been greatly improved to almost 40% through the surgical progress, early screening, and multidisciplinary treatment in recent decades (6). However, the perioperative morbidity and mortality remain unsolved problem as a result of enlarged lymphadenectomy, thorough en bloc dissection, and so on (7,8). In open surgery, post-operation pain might last a very long time and the perioperative morbidity including cardiopulmonary complications could reach as high as 30% (9,10).
Minimally invasive esophagectomy (MIE) has gradually become a standard surgical approach for esophageal cancer in recent years. It was first report by Dr. Cuschieri in 1993 (11) and implemented by many thoracic surgeons, such as Dr. Luketich. In 2003, a report of 222 cases of MIE was published (12), while another report of more than 1,000 cases of MIE was published in 2012 (13). A randomized multicenter clinical study by Biere et al. provided strong evidence of the short-term benefits of MIE for patients (14). Nowadays, MIE has been widely accepted in Japan, Europe, and America.
Esophageal cancer is one of the most common cancers in China (1,2). The incidence and morbidity of esophageal cancer remains very high in China nowadays. Early prevention and treatment for esophageal cancer is important and still a major task. MIE has emerged as effective alternative approach for open surgery in recent decades in China. Most of Chinese advanced esophageal centers, including Zhongshan hospital of Fudan University, The First affiliated Hospital of Fujian Medical School, Cancer Hospital of Chinese Academy of Medical Sciences, have adopted MIE as routine surgical approach for resectable patients. Our center performed the first case of MIE in China in 2004. From January 2004 to December 2015, we have successfully performed more than 1,300 cases of MIE. Since most esophageal cancer is squamous cell carcinoma and locates in the middle of esophagus, McKeown is preferred in our center.
Patients and surgical procedure
According to the NCCN guideline and Chinese Esophageal Cancer guideline, resectable patients in China are defined as follows:
- Age <80 y;
- T1–T3, without metastasis;
- without severe complications;
- without other malignant tumor;
- ECOG score 0–1.
Anesthesia and position
Combined general-epidural anesthesia and a single-lumen endotracheal tube are adopted before surgery. Commonly, we place patient in the left lateral prone position, but not the left lateral decubitus position or the prone position, which are common in western countries.
The thoracic port design and artificial pneumothorax
The observation port is selected in the 7th intercostal spaces of the posterior axillary line. Artificial pneumothorax is then set up through the trocar in the observation port, and the CO2 pressure is controlled between 8−10 mmHg. Other trocars are located: the 3rd intercostal spaces of the mid-axillary line, the 9th intercostal spaces of the subscapular line, and the 6th intercostal spaces of the subscapular line (Figure 1).
Thoracoscopic, laparoscopic and cervical procedure
The procedure of thoracic surgery is performed in standard manner as open surgery (Figure 2). (I) Opening the mediastinal pleura of the supra-azygos area, and cleaning the right para-laryngeal recurrent nerve lymph nodes; (II) clipping and cutting the arch of the azygos; (III) opening the mediastinal pleura of the sub-azygos area, and circumferential mobilization of the middle and lower part of esophagus; (IV) lifting the esophagus through a silk thread and cleaning the left para-laryngeal recurrent nerve lymph nodes; (V) total mobilization of the esophagus.
The procedure of abdominal and cervical part is performed as described by other surgeons (16). Patient is placed in supine position. Gastric mobilization is performed under laparoscopy (Figure 3). Then, a left cervical incision is made and the cervical esophagus is dissected and transected. A 4 cm middle abdominal incision is made, and the stomach and esophagus are retracted from this incision. A linear cutting stapler is used to make gastric tube. The anastomosis between gastric tube and cervical esophagus is performed through the cervical incision with circular anastomat.
Esophageal cancer is one of the four most common cancers in China, with high mortality. The pathological type of esophageal cancer in China is mostly squamous cell carcinoma, which is quite different from western countries. Treatment for esophageal cancer includes surgical therapy, radiotherapy, chemotherapy, and combined therapy. Open surgery was once the only choice for resectable patients before the emergence of MIE. MIE was first performed by Cuschieri in 1993 (11), and then introduced to China in 1994. As one of the largest esophageal cancer center in China, our center performed the first case of MIE in China in 1994, and the total number of our MIE cases has exceeded 1,300.
MIE has gradually become the standard surgical procedure for esophageal cancer because of its advantages in perioperative morbidity and mortality. In 2012, Lancet has published the report of a randomized controlled multicenter clinical trial in Europe, which supports that MIE reduces cardiopulmonary complications. However, the sample of this study is not large enough (14). Dr. Luketich also studied this topic with almost 1,000 cases (13). However, it’s still necessary to re-evaluate the benefits of MIE in China, because of the different pathological type and surgical approach. Experiences of our center support that MIE has better short-term outcome than open surgery. The incidence of perioperative complications is significantly reduced. However, data from our center shows the anastomotic leak incident does not vary with the operation approach. And the overall survival rate is also not influence by surgical approach. Similar results have been reported by other Chinese esophageal cancer center (18-20).
Two positions of thoracic surgery in MIE are commonly adopted by surgeons from western countries, including the left lateral decubitus position and the prone position. But in China, the lateral prone position is more popular (20). The left lateral decubitus position was firstly adopted in MIE, because of the anatomical similarity as open surgery. The prone position was then introduced in to MIE because of its clear exposure of mediastinal organs and structures. However, one main disadvantage of the prone position is that changing position is required in case of emergency. The lateral prone position with artificial pneumothorax not only provides clear exposure of surgical area, but also avoids the position change in case of emergency. At present, this position has also been accepted by many centers in the world.
Lymph node dissection is an important part of MIE surgery. 3FLD esophagectomy is not a routine surgery in China due to its high invasiveness. In the 2FLD esophagectomy, MIE always has a better lymph node dissection than open surgery, because of its enlarged view of surgical area by thoracoscopy and laparoscopy. The left para-laryngeal recurrent nerve lymph nodes are difficult to dissect under thoracoscopy through the surgical approach from right chest. Esophageal suspension is a good manner for the exposure and dissection of the left para-laryngeal recurrent nerve lymph nodes. The esophagus is lifted through a silk thread in order to pull the left-laryngeal recurrent nerve and its nearby structures into right chest. The incidence of nerve injury is reduced and the dissected lymph node number is increased with esophageal suspension in this way.
Since its first introduction to China in 1994, MIE has become widely accepted and developed in the past decades in China. Most advanced esophageal centers performed hundreds of MIE and accumulated abundant experiences. The benefits of short term outcomes of MIE are confirmed by studies in China. However, the long term survival and the anastomosis leakage results are still uncertain and need more research. Generally, MIE is safe, feasible and suitable surgical approach for resectable esophageal cancer.
Funding: This study was supported by the National Nature Science Foundation of China (Grant Nos. 81500568, 81370587).
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The study was approved by ethics committee of Zhongshan Hospital (No. B2013-115) and written informed consent was obtained from all patients.
- Zeng H, Zheng R, Zhang S, et al. Esophageal cancer statistics in China, 2011: Estimates based on 177 cancer registries. Thorac Cancer 2016;7:232-7. [Crossref] [PubMed]
- Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015. CA Cancer J Clin 2016;66:115-32. [Crossref] [PubMed]
- Chadwick G, Riley S, Hardwick RH, et al. Population-based cohort study of the management and survival of patients with early-stage oesophageal adenocarcinoma in England. Br J Surg 2016;103:544-52. [Crossref] [PubMed]
- Little AG, Lerut AE, Harpole DH, et al. The Society of Thoracic Surgeons practice guidelines on the role of multimodality treatment for cancer of the esophagus and gastroesophageal junction. Ann Thorac Surg 2014;98:1880-5. [Crossref] [PubMed]
- Ando N, Ozawa S, Kitagawa Y, et al. Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years. Ann Surg 2000;232:225-32. [Crossref] [PubMed]
- Shapiro J, van Lanschot JJ, Hulshof MC, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol 2015;16:1090-8. [Crossref] [PubMed]
- Jafari MD, Halabi WJ, Smith BR, et al. A decade analysis of trends and outcomes of partial versus total esophagectomy in the United States. Ann Surg 2013;258:450-8. [Crossref] [PubMed]
- Seely AJ, Ivanovic J, Threader J, et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010;90:936-42; discussion 942. [Crossref] [PubMed]
- van der Sluis PC, Verhage RJ, van der Horst S, et al. A new clinical scoring system to define pneumonia following esophagectomy for cancer. Dig Surg 2014;31:108-16. [Crossref] [PubMed]
- Yoshida N, Watanabe M, Baba Y, et al. Risk factors for pulmonary complications after esophagectomy for esophageal cancer. Surg Today 2014;44:526-32. [Crossref] [PubMed]
- Cuschieri A. Endoscopic subtotal oesophagectomy for cancer using the right thoracoscopic approach. Surg Oncol 1993;2 Suppl 1:3-11. [Crossref] [PubMed]
- Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 2003;238:486-94; discussion 494-5. [PubMed]
- Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 2012;256:95-103. [Crossref] [PubMed]
- Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012;379:1887-92. [Crossref] [PubMed]
- Lin M, Shen Y, Tan L, et al. Thoracoscopic procedures. The mobilization of the esophagus and the lymph node dissection are performed under thoracoscopy. Asvide 2016;3:317. Available online: http://www.asvide.com/articles/1074
- Palanivelu C, Prakash A, Senthilkumar R, et al. Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position--experience of 130 patients. J Am Coll Surg 2006;203:7-16. [Crossref] [PubMed]
- Lin M, Shen Y, Tan L, et al. Laparoscopic procedures. The mobilization of the stomach is performed under laparoscopy. Asvide 2016;3:318. Available online: http://www.asvide.com/articles/1075
- Zhu C, Jin K. Minimally invasive esophagectomy for esophageal cancer in the People's Republic of China: an overview. Onco Targets Ther 2013;6:119-24. [PubMed]
- Mu J, Yuan Z, Zhang B, et al. Comparative study of minimally invasive versus open esophagectomy for esophageal cancer in a single cancer center. Chin Med J (Engl) 2014;127:747-52. [PubMed]
- Li X, Lai FC, Qiu ML, et al. Minimally Invasive Esophagectomy in the Lateral-prone Position: Experience of 226 Cases. Surg Laparosc Endosc Percutan Tech 2016;26:60-5. [Crossref] [PubMed]
Cite this article as: Lin M, Shen Y, Feng M, Tan L. Minimally invasive esophagectomy: Chinese experiences. J Vis Surg 2016;2:134.

domain: medical


text:
Tim Allen is providing a hopeful health update on Jay Leno.
The 'Toy Story' actor spoke with paparazzi outside the Grossman Burn Center on Nov. 17, saying that Leno was feeling better after the comedian suffered burns from a gasoline fire.
Allen, in footage obtained by TMZ, said Leno appeared happy and in good spirits.
"He's feeling better," Allen said in the video. "We did some jokes, which is what we do. We commiserated."
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Allen said Leno's face won't be disfigured as of result of the burns, and joked that the former Tonight Show host will look like actor George Clooney once he's recovered.
"He's handsome and he's happy," Allen said. "The hospital is doing a great job taking care of him."
Allen's visit comes three days after Leno issued his own statement on Nov. 14 regarding the incident.
"I got some serious burns from a gasoline fire," Leno said in a statement. "I am ok. Just need a week or two to get back on my feet."
The Grossman Burn Center in Los Angeles also affirmed that Leno is fairing well following the burns.
"Jay Leno is in stable condition," the statement read, per KTLA, "and he's receiving treatment here at the burn center to his face and his hands from a gasoline accident in his garage over the weekend."
His doctor, Dr. Peter Grossman, told NBC Los Angeles that he expects the 72-year-old to make a full recovery.
"He's walking around and he's cracking jokes. I can tell you he's incredibly kind to our nursing staff," Grossman shared. "He's been appreciative of everybody here and he's an ideal patient, and one who understands the seriousness of his injury."

domain: celebrity


48 hours tied up in a utility white. After she was kidnapped on Monday in Nice, and then kidnapped, the millionaire Jacqueline Veyrac has been found safe and sound Wednesday. A happy ending, which, however, raises numerous questions on which the inquiry must address. Only one certainty: it has been released by a local resident intrigued by the registration plate is slightly dislocated from the vehicle.
READ more >> the Kidnapping of Jacqueline Veyrac: “I saw someone moving in the car”
The point on this case is fantastic and “mysterious”, according to the confession even of the prosecutor of the Republic of Nice.
Who is behind this abduction?
“It is not obvious that the performers are the same as the sponsors. It is in this investigation that the sorting can be done,” said Wednesday night Jean-Michel Priest. The testimony of the millionaire, shocked but unscathed, could give clues to trace their trail.
Le Parisien said on Thursday that a man speaking in broken English would be called the son of the millionaire, two hours after the abduction. “You have problems, you will have to pay,” he reportedly said. This is the only contact that has been established with the people hiding behind the abduction.
How many people were arrested?
Several people have been arrested and placed in police custody. But difficult to confirm a precise number. BFMTV reference to four people, AFP seven and Nice-Matin eight… “at this stage, the certainty is that two men, aged in their thirties have been arrested,” says The Express, a police source.
It’s about two people whose “suspicious behaviour” at a time when Jacqueline Veyrac has been released has attracted the attention of the police. The two men have indeed fled. “But there was nothing to say for the moment whether or not they are involved in the case,” says our source. Their custody in this case of kidnapping and forcible confinement in the purpose of the meeting is to allow the verification of their potential role. The suspects are at risk ten years of prison.
Le Parisien also refers to the arrest of a photographer-paparazzi suspected of having participated in the monitoring of the rich owner of the Côte d’azur. She was followed and photographed for several weeks to know the schedule of her appointments, adds RTL.
Why has it been removed?
“it Remains to specify the objective: a ransom? To impress?”, questions Jean-Michel Priest. The question of motive is of course central. For the prosecutor, “there is something that still remains very personal relationship with the victim, it remains the strong hypothesis”, he said, excluding a one-kidnapping for ransom as it may exist in eastern Europe or in Latin America.
Jacqueline Veyrac, 76 years old, is with his son at the head of the Grand Hotel of Cannes, a luxury hotel on the Croisette, and the famous restaurant in Nice, La Reserve. Described as a united family Veyrac has never made a display of its impressive heritage, became the source of tensions and conflict around the legacy since the death in 2002 of the father. Jacqueline Veyrac had already failed to be removed in the same manner near her home in 2013, but no formal link between these two cases has not yet been established.
“there are a lot of assumptions, no door is closed to understand what could push these people to remove this lady to get the money”, concludes AFP a source close to the case.


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text:
- Our list of the best things to do in Sherwood, Oregon, features the top 518 nearby activities — including 221 great attractions with user approval ratings of 90% or more!
- Sherwood, OR has a variety of great sights and experiences nearby. Top categories include: Outdoor Places, Food & Drink, Entertainment & Shows, and Museums & Galleries.
- The results below include the top 24 things to do within the city of Sherwood, OR , followed by 494 popular activities in nearby cities, including Portland, West Linn, Newberg, Dundee, Hillsboro, Vancouver, Carlton, Oregon City, Lake Oswego, Wilsonville, Beaverton, Molalla, Canby, Dayton, Tualatin, Gresham, McMinnville, Forest Grove, Tigard, Aurora, Gaston, Milwaukie, Estacada, Troutdale, Salem, Hood River, Keizer and Boring
A small park in a residential setting, Oregon Trail Park features a grass field, trees and a paved walkway through the center of the park. The park provides a children's play structure, park benches and dog waste bags.
Woodhaven Park is surrounded by trees and includes a playground for children with a sandbox, play structure and swings for toddlers and older kids. There are also benches, doggie bag holders, concrete walkways and a bike rack.
Sherwoodâ€™s Langer Park is maintained by the Sherwood Village Homeowners Association. The park features a fully equipped playground with toddler swings, paved walking paths, benches, and bags for visitors to clean up after pets.
Dedicated to World War II veterans, Veterans' Park has a marble statue with the names of local citizens who served etched into stone. In addition to the statue, the park has picnic tables and benches under the shade of trees.
20400 Southwest Cipole Road, Tualatin, OR 97062 MoreLess Info
Tualatin Island Greens is a golf practicing facility that can be enjoyed by golfers of all ages. The center offers a scenic driving range, private golf lessons and a miniature golf course enjoyed by the younger crowd.
Tualatin Indoor Soccer LLC is an indoor soccer facility with field turf for both youth and adult soccer. Tualatin hosts a variety of soccer leagues, offers soccer classes for kids, and is available to host parties and events.
Fielder's Choice is a baseball and softball performance center offering a variety of programs and camps for young baseball and softball players. Both individual and group lessons are offered with video analysis technology available to monitor a student's progress.
Not only does Ibach Park contain a playground for children, but the structures are interactive, meaning visitor's children can learn about the Native American and pioneer eras of the Tualatin area. The site also contains a teen play area.
99% 86 votes
Near Boones Ferry and Tualatin-Sherwood Road, Tualatin, OR 97062 MoreLess Info
With Uncorked Northwest Wine Tours, the traveler can get acquainted with some of the finest wines produced in the region and not only, since the tours are always customized by the client's needs and include complimentary foods, such as gourmet chesses and meats.
Guests can have a splashing good time in the 50 meter pool at the Tualatin Aquatic Center. Recreational swimming, lessons and camps, water aerobics, diving, lifeguard training, and more are available at the facility.

domain: geography


A stash of guns, ammunition and grenades have been uncovered by police in Essex during a search of a derelict building and surrounding land.
The search took place on Thursday afternoon in North Road, North Ockendon.
Police believe the items to include two AK47 rifles, a handgun, a sawn-off shotgun, ammunition and a number of high explosive grenades.
The MOD's explosive ordnance disposal unit was called to the scene.
Essex Police have stated that the weapons will undergo expert forensic and ballistic examinations, adding that there is no risk to the public.
Detective Superintendent Mark Hall, of the Kent and Essex Serious Crime Directorate, said:
"The investigation is at an early stage and I am maintaining an open mind as to the origin of these weapons, however from their condition they may have been in situ for some time.
"This is a significant seizure and clearly in the wrong hands these weapons could have caused very considerable harm.
“I am very pleased that we have been able to safely recover them."


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Anderson Cooper and Kathy Griffin: the truth behind their sunbathing photo
HollywoodNews.com: SHOCKER! Just kidding. We know the D-Lister and The Silver Fox are great buds and who better to help drum up some publicity for Anderson Cooper’s new daytime chat show than his pal Kathy Griffin?
Below is a video giving us a little sneak peek into their publicity stunt. While I admire Anderson the newsman, I gotta say, I really look forward to seeing him as the new Oprah!
Photo by PRPhotos
To read more go to GREGINHOLLYWOOD
Follow Hollywood News on Twitter for up-to-date news information.

domain: entertainment


Electromagnetic locks Co 103, Co 104
Co 103, Co 104 electromagnetic locks have the front strip, clamp and bolt made of stainless steel and a steel casing.
Both locks are equipped with bolt and door position sensors. Depending on the version, they can be controlled using a key or a handle and key. Key control (via a standard cylinder insert) comes in two variants: it allows temporary opening or allows complete locking / unlocking of the lock. The Co 103 lock is fail-safe (normally open), i.e. it needs power to close, unlike the Co104 lock fail-secure (normally closed), in which power is required to open. Locks are manufactured for 12 or 24 V supply voltage and allow for over two million opening-closing cycles without any maintenance. Co 103, Co 104 electromagnetic locks are available in surface and recessed versions and are adapted for horizontal installation. The exact technical data and the method of mounting the locks can be found in the PDF data sheet (located above for download).
EXAMPLES OF USAGE
Doors, windows, access control systems, sliding doors, revolving gates.
|Shear strength (non-destructive)|
|Shear strength (destructive)|
|Number of Bolts|
|Number of open / close cycles per second|
≥ 7 cycles
≥ 8 cycles
|Lock closing method|
|Lock opening method||latching|
|Manual control with a key|
|Manual control with a handle|


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Hi, how are you doing?
I've really not been feeling very well since the weekend, and haven't had the energy to do very much of anything....are you feelin' sorry for me yet? :)
My grandchildren are being raised to know how to share, and they do........which is how I got the stinkin' cold and sore throat!
Anyway, I did manage to drag myself into my craft room, yesterday ;D and created this card for somebody who has recently had a HUGE operation, and is now on the road to recovery....just a little "get well quicker" card........
I used scraps of paper from my still HUGE pile....got to make loads more cards before I even make a dent in it, lol......did a little handstitching on the blue spotty.....added some lovely green ric-rac.....coloured the little freebie nursie with Promarkers.....
used another freebie for the sentiment, which I lightly coloured (the white background looked too stark).....did more handstitching around the sentiment (so relaxing to do this)......
and added three little buttons.....and she's ready to send off to the invalid!
D'ya like the sentiment? Makes you think......mmmmmm......don't you agree?
Well, I'm hoping to get some crafting time tomorrow, but I'm not going to hold my breath.......got house guests, which I'll tell you more about, later :)
I'm entering this card here ilovepromarkers.blogspot.com Anything Goes
and here quirkycrafts.blogspot.com Spots, Stripes, Dots
Thanks for stopping by!


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Mama Gee arrested for human trafficking, 6 victims rescued. By Agency
Nasarawa State Police Command have arrested a 40-year-old woman, Rita Oti, aka Mama Gee, for alleged human trafficking at Nasarawa Eggon LGA of the state.
The command’s spokesperson, Ramhan Nansel, in a statement on Tuesday, October 6, said the suspect was arrested on September 29, when police intercepted a Volkswagen Sharon vehicle driven by one Godwin Yaasa with six occupants.
According to the police spokesman, the other occupants of the car were within the age range of 16 to 24, adding that they were heading for the Alagbado area of Lagos State.
Upon interrogation, the police discovered that the suspect lured the victims from Benue State under the pretext of giving them jobs without their parents’ consent.
Meanwhile, the Commissioner of Police, Bola Longe has ordered the transfer of the case to the State Criminal Investigation Department, Lafia for exhaustive investigation and reunite the victims with their families.

domain: law


Over the last few years, there have been several mysterious accidents that have occurred at oil rig platforms and gas stations. Over long-time periods of investigation, many of these accidents were discovered to be the result of pipeline explosions. Pipeline accidents are especially dangerous because they can develop into very serious disasters, such as oil spills, gas leaks, and overall severe injuries and fatalities. As a regular citizen or someone who works near pipelines, it’s crucial to know how these incidents can occur.
How Do These Accidents Happen?
Pipeline transportation was actually created in order to be a safer option. Oil pipelines have been found to be 70 times safer than trucks, which actually have killed four times as many people in a four-year time span compared to pipelines. Unfortunately, when pipelines fail, their consequences are much more catastrophic and can result in intense federal investigations. There are several ways that a pipeline could break:
- Equipment corrosion: The number one reason that pipelines fail is simply because they are too old. More than half of the country’s pipelines are at least 50 years old, and this aging can lead to big leaks and ruptures. A natural gas pipeline exploded in Allentown, Pennsylvania that had been installed in 1928.
- Construction worker carelessness: Many times, construction workers that are working on a digging project will accidentally hit a pipe with their heavy excavation equipment. This can be due to construction employees not having enough knowledge of the pipeline map of their location, and hence not realizing how close the pipelines are to digging tools.
- Natural disasters: Hurricane Sandy destroyed several natural gas pipelines on New Jersey’s barrier islands. Hurricanes in general are a danger to pipelines because heavy rains and flooding can loosen the surrounding pavement and expose the lines.
- Lack of safety regulation: The PHMSA (Pipeline and Hazardous Materials Safety Administration) has been criticized for lacking proper resources to properly monitor the millions of miles of pipelines that it has the duty to protect. Especially with the older pipelines, the PHMSA claims that it’s difficult to have enough employees to cover all proper regulations in the country.


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On Thursday, June 13, 2019, Princess, the Prince cover band featuring Gretchen Lieberum and Maya Rudolph, headlined Irving Plaza in New York, NY. There was an opening set by DJ Brainchild and more photos from the very fun show are now available on Irving Plaza’s Facebook page here.
On Wednesday, May 1, 2019, EELS headlined a show at Irving Plaza during their tour with Robert Ellis. Before last night, the previous time I saw EELS perform was in June 2006.
I covered the show for Live Nation/Irving Plaza and photos of both performances are now live on Irving Plaza’s Facebook page here.
On Tuesday, April 17, 2019, the tour featuring La Dispute, Gouge Away, and Slow Mass came to New York for a Saint Vitus presented show at Irving Plaza.
I covered the show for Live Nation/Irving Plaza and the full gallery featuring all three acts is now available here.
Commemorating the 20th anniversary of the release of his album, It’s Dark and Hell is Hot, DMX began his tour in his hometown of New York with a sold out show at Manhattan’s Irving Plaza on Monday, April 1, 2019.
He was joined by fellow rapper One Shot Dealz and DJs Funkmaster Flex and HR.
A full gallery from the show last night is now available on Irving Plaza’s Facebook page here and another sold out show occurs Friday night (April 5th) at the same venue as well.
On Thursday, January 31, 2019, Brooklyn’s Cautious Clay headlined a sold out, Governors Ball presented show at Irving Plaza with Sophie Meiers and Blanksy.
I covered the show for Irving Plaza/Live Nation and the full gallery is now available on their Facebook page here.
On Saturday, December 15, 2018, the reunited Philadelphia punk band The Dead Milkmen performed at Irving Plaza in New York, NY with support from rapper Sage Frances and Philly trio Gibbous Moon.
I covered the event for Live Nation/Irving Plaza and the full gallery is now available on Facebook here.
On Friday, December 7, Ministry headlined their second New York show at Irving Plaza in Manhattan. They were joined by Carpenter Brut (of France) and Alien Weaponry (of New Zealand).
I covered the event for Live Nation/Irving Plaza and the full gallery is now available here.
Touring in support of their newest album, Evil Spirits, The Damned headlines a sold out show at Irving Plaza with Radkey and The Darts.
I covered the show for Music Existence and the full gallery can be found here.
On Tuesday, April 9, 2018, Eric B. and Rakim's "The Technique Tour" continued with the first night of a two night stand at Irving Plaza in New York, NY. There were DJ sets by Technique the DJ and DJ Kid Nu, and live performances by Yo-Yo and Eric B. and Rakim. Rah Digga performed during Yo-Yo's set and Cynthia Nixon spoke to the crowd as she is currently running against Andrew Cuomo for Governor.
Full gallery now available on BrooklynVegan here.
On Friday, March 2, 2018, the sold out Governors Ball presented concert featuring Kelela, Tiffany Gouché, and Oyinda took place at Irving Plaza in New York, NY.
I shot the show for BrooklynVegan and the full gallery is now available on that site here.
In my current project of scanning film negatives, here's a set of images of taken of the now defunct Le Tigre during their November 1, 2003 show at Irving Plaza. The band performed just before the 2004 election and I recently photographed Kathleen Hanna's current band, The Julie Ruin, one day after the 2016 election, 12 years later. The aforementioned Julie Ruin images are available on Impose here.
On Wednesday, March 12th, Juicy J performed at Irving Plaza in New York, NY as a part of his "Never Sober Tour." The rapper reminded the audience that he's been around for twenty years, won an Academy Award and gave away three pairs of Air Jordan sneakers to three lucky people.


Why Gas Engines Are Far From Dead - Biggest EV Problems
- Published on: 2/5/2020
- Why Are Car Makers Still Developing Internal Combustion Engines?
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Why are car manufacturers still improving and spending money on combustion engines in the year 2020? Should all development research be going into electric cars and electric vehicle technology? Unfortunate news if you think ICE transportation is going away in the near future to be solely replaced by electric vehicles (EVs).
The internal combustion engine is still incredibly relevant today, and can still use further improvements in order to reduce global emissions. In this video we'll discuss scientific issues facing electric cars, environmental problems with ditching combustion engine research, how cost impacts customer decisions and manufacturer profits, and ultimately how consumer choice plays a large role in this industry. If you've ever wondered why combustion engines are still being developed, this video breaks down all the details.
Are EVs Actually Cleaner? - https://www.102tube.com/video/6RhtiPefVzM/video.html
Are Teslas Green? - https://www.102tube.com/video/2rywz73vwKw/video.html
Are Lithium Batteries Bad? - https://www.102tube.com/video/1mXSMwZUiCU/video.html
Living With An Electric Car - https://www.102tube.com/video/cXkRcuwoIm4/video.html
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Beaches, in New York City? That’s right, as great as gay New York is for its hustle and bustle, the beaches of the Big Apple and its surrounding area are well worth the required effort to reach them. Here’s our guide to the ones worth checking out.
The Island is notorious in gay culture and is certainly Gay New York's best beach. The sand on this island's shore stretch for miles.
Hot male bodies flaunt themselves in Speedos or less during the region's beach months, turning the island into a queer paradise. The gay scene here dates back to the 1930s and this beautiful locale welcomes people from all walks of life.
Getting to Fire Island requires a ride on the Long Island Railroad, a taxi ride, a ferry ride, and a walk to your accommodation, but it’s well worth the effort!
East of Fire Island, Jones Beach requires a longer ride aboard the Long Island Railroad. Once there, visitors can join the locals and let it all hang out at the so-called Beach Six, but, beware: you can get ticketed as nudity isn’t officially legalized on this beach.
Gay New York also loves a plot of federal land in New Jersey known as Gunnison Beach, one of the largest nude beaches on the East Coast. To find the gays, walk down to the southernmost section of Area G where being clothed makes you stand out more than being nude.
If all else fails, there's always good ol' Coney Island, just a trainride away. It's not strictly gay but there's a beach! Christopher Street Pier is also an option for hanging out and catching the rays on the grass outside.


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All ages and abilities welcome, all kayaking tours are tailored to your needs.
Using stable sit on top kayaks we will venture out along the Pembrokeshire coast. Exploring the coastline as you kayak beneath towering sea cliffs and into sun dappled caves, looking out for seals and bird life along the way. Our experienced guides will keep you safe while Kayaking Pembrokeshire’s coastline and tell you the amazing stories that Fishguard bay has to offer about marine life, local history and much more…
The Pembrokeshire coast is a Marine Special Area of Conservation (SAC) designation recognizes that the area is one of the best in Europe for its marine wildlife. Our kayak guides, with years of experience, are well acquainted with the Pembrokeshire marine life and the local history of the Fishguard coast; knowledge which they are eager to share with you.
For a sample of Pembrokeshire’s marine life – Click here.
We teach your family all you need to know to stay safe and have fun while Kayaking Pembrokeshire’s coast. Starting with an explanation of how to use the adventure equipment we quickly progress to enjoying the coastline.
Kayaking Pembrokeshire’s coast is great for every age & level of fitness.
Explore the Pembrokeshire National Park coastline from a unique perspective.
Marvel at the towering coast.
Enjoy marine life in its natural habitat.
An ideal adult activity for Families, Stag, Hen and Corporate groups.

domain: biology


Please help us identify this person of interest who may be related to an incident at the Stadium Parkade. If you have any information, please contact us at 306-966-5555
U of S #INC-2016-000829 – Mischief Under $5,000, Stadium Parkade
Updated July 6th at 7:56am
These individuals have been identified and the file has been closed. Thank you to all who provided us with the identification and help in solving this file.
Protective Services is trying to assist a campus resident who had clothing taken from the laundry of Wollaston Hall. We do not suspect that this was intentional, but hope to track down those in the photo so the missing items can be returned.
If you know the persons in these photos, please contact us at 306-966-5555 and refer to INC-2016-000522.
*Updated July 12th, 2016: Thank you for your help! The individuals in related to this file have been identified and the file will be passed on to the Saskatoon Police Service.
If you recognize the individuals in these photos, please contact Protective Services immediately at 306-966-5555:
U of S INC-2016-000472 Theft Under $5,000 Laptop Computer from Place Riel
Updated January 27th, 1:41pm
Incident #2016-00980 – Mischief Birch Hall
This individual has been identified. Thank you for your assistance!
If you recognize this person, please contact Protective Services at 306-966-5555.
Update: This person has been identified so the photos were removed. Thanks! Please contact Protective Services any time you see suspicious activity on campus, 24 hours a day.
Protective Services is investigating an incident from the Campus Computer Store which occurred on October 5th, 2015. If you recognize the person in this photo, please contact Protective Services immediately at 306-966-5555
Incident 2015-13651 – Theft Under $5000 from the Campus Computer Store (Place Riel)
*UPDATED Thursday September 24th, 2:34PM*
Thanks to your assistance, we were able to positively identify the individual related to this incident.
Protective Services is looking for information related to a mischief call at Aspen Hall which occurred during the early morning of September 6th, 2015.
If you have any information, or know the identity of the person below, please contact Protective Services at 306-966-5555
U of S File 2015-12084 Mischief Under $5,000 (Aspen Hall) September 6, 2015
Incident 2015-09283: Robbery, Place Riel Student Centre, July 18th 2015
If you have any information with regard to this incident, please contact Protective Services immediately at 306-966-5555.
Update: Protective Services has received a positive identification for the suspect in this incident. Thank you for your tips.


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Target group: Civil Servants
Subject: Freedom of Movement and related rights
Type: E-learning (MOOC)
The IMPEU Online Course is for civil servants, local experts, and policy-makers The course enhances their knowledge, skills and competences to support the successful inclusion and participation of mobile EU citizens and their family members in the host EU country’s civic and political life and their participation in the democratic life of the EU. The course is available in 6 languages: Greek, French, Bulgarian, Italian, English, and Spanish.

domain: sociology


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Mallory Park Circuit
One of the UK’s shorter circuits; running races for cars, motorcycles, and rallycross.
Kirkby Mallory, Leicestershire LE9 7QE, approximately four miles north east of Hinckley.
1956 – 2013.
The track at Mallory Park lies within a former estate whose origins reach back to the Norman Conquest. For more than 700 years, the lands and building therein were occupied by a succession of wealthy and aristocratic families.
The main house on the estate, known as Kirkby Hall, was sold in 1941, and for the remainder of the Second World War was occupied by the Pioneer Corps. It was demolished in 1952; although workshops, the stable block and coach house still remain today.
After the estate had been sold, plans were laid to organise horse racing on the estate’s former pony trotting track. These did not come to fruition, and the track was instead leased to the Leicester Query Motorcycle Club.
In 1955, under new ownership, the present tarmac track was created; and the first races, for motorcycles and then cars, took place in May 1956. Further upgrades took place during the early 1960s, giving rise to both the full circuit, with the Shaws hairpin, plus the shorter oval circuit.
Amongst the stars who have raced at Mallory are Emerson Fittipaldi, Mike Hailwood, Denny Hulme, Henri Pescarolo, Jochen Rindt, Jody Scheckter, Jackie Stewart, John Surtees, and Jim Clark, who is commemorated at the circuit in a life-size statue.
In recent years, complaints have been made by local residents about noise levels at the track. In October 2013, following a two-year dispute and a successful prosecution for breaching agreed noise limits, the owners of Mallory Park went into administration.
• Motor racing circuits in England: then and now, Peter Swinger, Ian Allan, 2001.
• Motorsport Explorer, Julian Hunt, Haynes Publishing, 2012.

domain: history


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Criminal Defense Attorney in Weddington, NC
If you face criminal charges in the Weddington area, you have a lot at stake. The outcome of your Criminal Defense case could affect you for years. When risks should not be taken, trust the professionalism of Law Office of Todd E. Gonyer, PLLC to build a defense which can improve your chances. We have many years of experience and can apply the knowledge we have gained to your unique case, helping ensure the Weddington area courts properly observe your rights.
At Law Office of Todd E. Gonyer, PLLC, we know the law never sleeps. Criminal Defense charges in the Weddington area are not confined to the 9-to-5, so we do our best to shape our availability according to your needs. When you work with one of us, you are getting not just our many years of experience, but a highly-motivated team as well.
In our many years of working with clients, we have seen that most individuals who contact our Criminal Defense firm are first time offenders in the Weddington area. At Law Office of Todd E. Gonyer, PLLC, we know that good people are not exempt from being pulled into the chaos of the justice system. We want to help you through your Criminal Defense case.
Call Us Today to Receive Top-Quality Help with Criminal Defense Cases!
Our Criminal Defense attorneys here at Law Office of Todd E. Gonyer, PLLC in the Weddington area are waiting for the opportunity to help you exercise your rights. Trust us to increase your chance of receiving a reduced sentences or an acquittal when facing Criminal Defense charges. To reach us, give us a call at (704) 215-4924, or stop by our offices at 229 South Brevard Street near the Weddington area.
Law Office of Todd E. Gonyer, PLLC
229 South Brevard Street
Charlotte, NC 28202
Related Articles: Criminal Attorney Mint Hill NC, Criminal Defense Attorney Stallings NC, Criminal Law Attorney Stallings NC, Defense Attorney Mint Hill NC, DUI Defense Attorney Cornelius NC, Expunction Attorney Davidson NC, Misdemeanor Lawyer Pineville NC, Suspended License Lawyer Monroe NC, Suspended License Lawyer Stallings NC, Traffic Lawyer Cornelius NC,


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Chomsky’s views on society covered in UUFDC movie
A documentary look at an American philosopher and activist and his views on society is featured next in the Movies That Matter series at Unitarian Universalist Fellowship of Door County.
"Requiem for the American Dream" spotlights Noam Chomsky’s life and his perspectives on inequality in our society. In a series of interviews that took four years to film, Chomsky breaks down the political policies that have favored society’s “elite” and led us to this point in our history.
The Movies That Matter series is designed to examine a wide range of issues. Screenings are held on the third Tuesday of every month, with discussion following the movie. Admission is free, although donations are appreciated, and the public is welcome.
"Requiem for the American Dream" plays for the Movies That Matter series at 4:30 p.m. July 18 at Unitarian Universalist Fellowship, in the the Shops at Green Gables, 10341 Wisconsin 42, Ephraim. For more information, call 920-854-7559 or go to www.uufdc.org.