text:
Physician and patient perceptions of surgical procedures for osteoarthritis of the knee in the United States, Europe, and Japan: results of a real-world study
N Fukui1,
PG Conaghan2,
K Togo3,
N Ebata3,
L Abraham4,
J Jackson5,
M Berry5,
JC Cappelleri6 &
H Pandit7
Osteoarthritis (OA) is the most common form of arthritis, with the knee being the joint most frequently affected, and symptomatic knee OA affecting around one quarter of the general population. For patients who do not respond to non-pharmacologic or pharmacologic treatment, surgery is a recommended option. The objectives of this study were to compare the willingness of patients with knee OA to undergo surgery, together with reasons for delaying surgery, and factors affecting successful outcomes.
A point-in-time survey was conducted in 729 primary care physicians, rheumatologists, orthopedic surgeons, and 2,316 patients with knee OA across three geographical regions: Japan, the United States (US), and Europe (EUR: France, Spain, Italy, Germany, and the United Kingdom), in order to garner their perceptions of knee surgery. Regression models were used to identify factors that might affect patients' and physicians' perceptions of surgery, including severity of OA (mild/moderate/severe), number of affected joints, surgery status, and willingness to undergo or delay surgery.
Baseline demographics were similar between US and EUR, although patients in Japan were more likely to be female, older, and only 7% in fulltime employment. We found that few patients with end-stage knee OA, across all regions, but particularly Japan, were willing to undergo surgery (Japan 17%, US 32%, EUR 38%), either through fear, or the lack of awareness of the risk/benefits. Moreover, surgeons are prepared to delay surgery in elderly or unwilling patients, due to their dissatisfaction with the outcome, and may defer surgery in younger patients due to the need for future revision. We also identified a disconnect between physicians, of whom over 80% consider improved functioning to be the most important outcome of surgery, and patients, who seek pain relief (Japan 60%, US 35%, EUR 14%). Since physicians across all regions considered pain reduction to be an indication of surgery success (Japan 27%, US 47%, EUR 43%), this may indicate a need for improved communication to patients on the potential benefits of surgery.
Managing the expectations of patients undergoing surgery remains an important goal in the treatment of knee OA and may help guide physician choice.
OA is strongly age-related and the most common cause of disability in the elderly, limiting their ability to carry out daily tasks and activities, and impacting their overall quality of life [1, 2]. Effective treatment options are limited, and international guidelines for the management of OA recommend initial pharmacologic and non-pharmacologic approaches, followed by appropriate surgical intervention for those who do not achieve adequate pain relief and functional improvement [3,4,5]. In Japan, non-surgical treatment, such as exercise programs, weight management, and pharmacotherapy, are considered the most appropriate treatment in 90% of patients with knee OA [6].
Surgical management for knee OA involves a spectrum of interventions, ranging from arthroscopic debridement, cartilage regeneration techniques, high tibial osteotomy, to focal resurfacing and unicompartmental or total knee replacement (TKR) [7]. Arthroscopic debridement of the knee may only provide short-term symptom relief [8], while TKR is now one of the most common orthopedic surgeries for patients with end-stage knee arthritis, with reproducible return to daily activities, good survival rates, and overall functional improvement over a longer time period [9].
Although TKR improves quality of life, relieves pain, and improves function, a significant proportion of patients still experience pain, loss of function, deficient muscle strength, and/or reduced walking speed [10]. In addition, if performed at a younger age, the need for revision surgery is significantly higher, which is costly, associated with higher morbidity and mortality and at times sub-optimal clinical outcomes [11].
Worldwide estimates of knee surgery show huge variation across countries, with an average of around 135 TKRs performed per 100,000 population [12]. The variation in the uptake of TKR surgery for patients with OA has been well documented [13]. For example, in Germany, France and Italy, the rate of knee replacement in 2017 was more than twice as high as others, even after age-standardization, with Germany having amongst the highest rates of TKR at 223/100,000 population, and Japan amongst the lowest at 65/100,000 [14], while the prevalence of TKR among the total United States (US) population in 2010 was reported to be 1.52%, higher among women, and increasing with age [15].
Potential reasons for this variation have not been fully explored, although fear of associated morbidity / mortality contributes to the reluctance of some patients with knee OA to undergo surgery [13]. At present, to our knowledge, there are no large multi-national studies that examine physicians' and patients' perceptions about surgical management of knee OA.
The objectives of this multi-national survey were to compare the willingness of patients with knee OA to undergo surgery, together with reasons for delaying surgery, and factors affecting successful outcomes across Japan, the US and five major European countries (EUR): France, Spain, Italy, Germany, and the United Kingdom (UK).
Data for this study were abstracted from the Adelphi Osteoarthritis Disease Specific Program (DSP™), a point-in-time survey conducted from 2017 to 2018 in primary care physicians (PCP), rheumatologists, orthopedic surgeons, and patients with OA across the three geographical regions (Japan, EUR, and the US). Physicians were recruited through publicly available lists, and the data collection setting was in primary care or secondary care rheumatology services (public or private hospitals, clinics, or offices). To be invited to take part in the DSP survey, physicians must have been involved in patient treatment decisions for a minimum of 10 patients with OA per calendar month.
Physicians included in the survey were invited to complete an online patient record form (PRF) questionnaire for 6–10 eligible patients who consulted for routine care. This consisted of information on patient demographics, any previous surgery for OA, type of surgery, success of surgery, how success was defined, and reasons for wishing to delay surgery. Patients were also invited to complete a Patient Self-Completion form (PSC) on a voluntary basis. This included information on their willingness to undergo OA surgery, reasons for not wanting surgery, success of their surgery, and how they defined success. Patients were excluded if they were diagnosed with OA in the hip, ankle and/or foot. All study materials were developed in English before being translated into the local languages by a certified translation agency.
Since this study was intended to be exploratory, with the aim of generating hypotheses for further research, the analyses were mostly descriptive in nature and no causal relationships could be established with confidence. Categorical variables were described by counts and proportions of respondents, while continuous numerical variables were described by their means and standard deviations [16].
Binary logistic regression models were used to identify statistically relevant differences between binary dependent variables and independent variables, by estimating probabilities using a logistic function [17]. Multinomial logistic regression was used to model nominal outcome variables (three or more categories or levels), in which the log odds of the outcomes were modeled as a linear combination of the predictor variables, with 95% confidence intervals derived via a modified Newton–Raphson algorithm. Relative risk ratios (RRR) were used to describe the probability of an event occurring in one category relative to a control category.
Covariates used in the regression models included region, age, sex, body mass index (BMI), anxiety and/or depression, employment status, current severity, number of affected joints, patient- or physician-reported satisfaction with medication. Stata version 16.1 or later (Stata Statistical Software, College Station, TX: StataCorp LP) was used to perform the analyses; for all regressions, a p-value < 0.05 was considered statistically significant.
A total of 729 physicians (Japan 87, US 153, EUR 489) provided demographic and clinical data for selected patients with OA. The sample included 373 PCPs (Japan 26, EUR 266, US 81), 147 rheumatologists (Japan 11; EUR 101; US 35) and 219 orthopedic surgeons (Japan 60; EUR 122; US 37) who provided data for 2,316 patients (Japan 302, US 527, EUR 1,487). Of these, 1,243 patients completed a PSC form (Japan 230, US 283, EUR 730) which recorded personal perceptions of surgery.
Baseline demographics were similar between the US and EUR with respect to age, gender, habitation, and employment (Table 1). However, patients in Japan were more likely to be female, older, have a lower BMI and different habitation compared to those in the US (Table 1). Only 7% of patients in Japan were in fulltime employment, with almost half being homemakers, and one quarter retired. In comparison, more patients were in fulltime employment in the US and EUR, and approximately half were retired. Patients were diagnosed by physicians with mild (Japan 41%; US 33%; EUR 22%), moderate (Japan 51%; US 47%; EUR 55%), or severe (Japan 8%; US 20%; EUR 23%) OA of the knee (Table 1).
Table 1 Patient demographics
Surgical history
There were significant differences in surgical history across the regions, with approximately 10% of patients in Japan having undergone previous OA surgery, and a greater proportion in the US and EUR (21% and 17%, respectively, Table 2). There were also some significant differences in procedures across the regions, with TKR being the most frequent intervention (Table 2), but higher usage in patients in Japan compared to the US and Europe (Japan 85%; US 46%; EUR 48%). In contrast, arthroscopic debridement was performed in approximately one third of patients in the US and EUR (US 38%; EUR 28%), but not at all in Japan. Patients with severe OA, as adjudged by their physician, were four times more likely to have had surgery than those at a milder stage (OR 4.09; 95% CI 2.08–8.04, p < 0.001, Table 3).
Table 2 Surgical history
Table 3 Regression data -characteristics (having had surgery vs. not having had surgery)
Willingness to undergo surgery, and reasons for delaying surgery
Significantly fewer patients in Japan were willing to undergo surgery than in the US and EUR (Japan 17%, US 32%, EUR 38%, respectively, Table 2; RRR 0.00016; 95% CI 0–1.27 p = 0.056, Table 4). Overall, female patients were more willing to agree to surgery than men (RRR 0.68; 95% CI 0.45–1.02 p = 0.065, Table 4) while patients with severe OA were almost five times more willing to agree to surgery than patients with milder disease (RRR 4.71;95% CI 2.42–9.17 p < 0.001, Table 4).
Table 4 Regression data -willingness to have surgery (yes/no)
Whilst approximately half of patients reported that they felt well and that they had no need of surgery (Japan 41%, US 56%, EUR 50%; Fig. 1), many patients reported their fear of surgery as a reason for wanting to delay surgery (Japan 49%, US 39%, EUR 36%; Fig. 1) especially women compared with men (OR for male vs. female 0.50 95% CI 0.29–0.89, p = 0.017). The cost of surgery was considered to be a potential reason for delaying surgery only by a few patients (13%) in Europe (Fig. 1). This was similarly reflected in physician data, where the majority of physicians across all regions responded that delaying surgery was often the aim when treating their OA patients. Patient reluctance was reported to be the most common reason for delaying surgery across all regions (Japan 79%, US 74%, EUR 69%; Fig. 2) as well as patient health status and age, while the cost to the patient was a consideration by approximately one third of physicians in Japan and the US, but seldom (7%) in EUR physicians (Fig. 2).
Reasons for patients not agreeing to undergo surgery
Reasons for physicians delaying surgery
Determinants of recommendation of surgery
The main factors driving a decision to recommend surgical intervention for patients with knee OA were lack of mobility (Japan 18%; US 68%; EUR 53%; Table 5) and degree of pain at rest (Japan 34%; US 29%; EUR 45%; Table 5). Other factors included failure of pharmacotherapy, degree of joint damage, and patient request, which was more frequent in Japan (45%) than in the US or EUR (20% and 16%, respectively; Table 5).
Table 5 Main factors in active recommendation of surgery for a patient with OA
Definition of surgery success
Improved functionality was reported by physicians to be the most common indicator of surgery success across all regions (Japan 81%; US 91%; EUR 86%; Table 6). Physicians in Japan and the US were more likely to consider pain reduction a sign of successful surgery rather than patients being completely pain free (pain reduction vs pain free: Japan 81% vs 34% of physicians; US 76% vs 50%; EUR 59% vs 53%; Table 6). Approximately two thirds of physicians in each region (Japan 68%; US 62%; EUR 66%) considered patient satisfaction to be a successful outcome, while the ability to perform activities of daily living was also considered an important factor by over half of physicians, particularly in the US and EUR (Japan 49%, US 68%, EUR 68%; p = 0.002; Table 6).
Table 6 Physician and patient considerations of successful outcomes of surgery
Reduced pain was also the most common determinant of surgery success reported by patients in the US and EUR (Japan 27%; US 47%; EUR 43%; Table 6), although Japanese patients were more likely to define surgery success as having no more pain, than US and EUR patients (Japan 60%; US 35%; EUR 14%, p < 0.001; Table 6). Other factors contributing to patients reporting a successful outcome included improved function/mobility and wellbeing (Table 6).
OA of the knee is a relatively prevalent debilitating condition that can progress to a point where the patient's quality of life is adversely affected due to pain and decreased function. When non-pharmacologic and pharmacologic treatments provide insufficient pain relief and/or improvement in function, surgical options are recommended, the most common being TKR [18]. The attitudes and beliefs of patients with knee OA about surgery are generally based on personal experiences, expectations, and fears, and are influenced by their social environment [19]. A recent systematic literature review found that patients had a fear of surgery, fear of anesthesia, concerns over postoperative pain or complications, and concerns regarding long-term outcomes [13].
In our study, fear was an important reason for postponing surgery, even for patients who received clinical advice to undertake the operation. Another factor that was considered is age, since older patients have been found to be more likely to postpone or refuse surgery, because they feel too old, suffer from severe comorbidities, or prefer other treatment options, such as medication or physical therapy [20]. Conversely, physicians may prefer to delay surgery in younger patients until they are older, in order to avoid the need for revision surgery.
In Japan, OA is a leading cause of years lived with disability, with the average age of patients around 70 years [1], similar to patients with OA in the US [2] and EUR [21]. In our study, the patients in Japan were, on average, older than those in the US and EUR, predominantly female, with milder severity of OA and greater reluctance and fear, possibly driven by concerns around safety risks associated with surgery. The greater reluctance to undergo surgery might also be related to the fact that TKR, which is almost the only surgery performed for knee OA in Japan, is a more invasive procedure that requires a longer hospital stay compared to arthroscopic debridement. Since approximately 20% of patients remain dissatisfied post-TKR, patients who are offered TKR, always have a dilemma about whether to undergo major and invasive surgery or bear the pain. Various non-medical factors and beliefs can contribute to the decision of a patient to proceed with a major surgical intervention. Whilst these concerns are likely to vary widely between patients, we hope that raising awareness of the role that fear plays as a barrier to surgery will encourage physicians to probe this in-depth during discussions with patients, enabling them to address any specific fears in advance.
Physicians across all regions were more likely to report pain reduction as an indication of surgery success than patients, suggesting that, although pain relief and improved physical function should be the main aims of OA surgery, expectations should be explicitly addressed before surgery [22]. Indeed, patients have been reported to opt for premature surgery because of unrealistic expectations of positive outcomes, undervaluation of the risk of negative outcomes, and lack of awareness of alternative treatments [23], which may indicate a need for improved communication to patients on the expected benefits and risks of surgery.
It is interesting to note that no patient in Japan underwent arthroscopic debridement, unlike a significant proportion of patients with knee OA in the US and EUR. Although the overall number of patients undergoing any surgery are small (particularly in Japan), the differences in the trends regarding type of surgical treatment are obvious. Arthroscopic surgery for knee OA was (and still is) often used as a temporary measure to delay joint replacement by performing lavage or debridement to help alleviate OA symptoms. Various studies have confirmed the ineffectiveness of such interventions [24]. Factors other than patient symptoms and severity of knee OA may play a role in the reported variation in practice.
Although no specific single leading factor has been found, patients' expectations, higher functioning before surgery, lower stage of arthritic disease, complications, poor resolution of pain, and lower improvement in knee function, are more common in dissatisfied patients [25, 26]. Patient satisfaction is thus an important outcome measure because of the well-documented discrepancy between clinician and patient ratings of pain intensity and its impact on quality of life and overall wellbeing [27,28,29]. Identifying the causes of dissatisfaction is also important in order to improve patient selection for OA surgery, adjust treatment strategies, and to support or treat dissatisfied patients with any residual complaints [22]. There is clearly an unmet need in the management of OA, and future research could focus more on improving patients' satisfaction with their treatment. Managing the expectations of patients undergoing surgery therefore remains an important goal, recognizing the value of well-informed patients in shared decision making.
Limitations and strengths
A number of limitations exist given the study methodology. This was a non-interventional study, with physicians providing data on differing numbers of patients depending on the number of patients with knee OA at each site. Moreover, the DSP™ is not a true random sample of physicians or patients, and participation is influenced by willingness to complete the survey, with participants encouraged, but not required, to complete all forms, such that the base sizes fluctuate across different variables [30]. Moreover, patient opinion was based around information from those patients who volunteered opinions and may, therefore not be a true representation of all patients' feelings about surgery. Finally, the survey addressed OA surgery in general, while many respondents in Japan may have focused specifically on the more common TKR, with debridement being the predominant focus in the US and EUR. Caution should be exercised when interpreting data on surgery in Japan since physicians only provided data on the relatively low number of patients who had undergone surgery.
The strength of the study is that it reflects real-world clinical practice and provides an insight into the acceptance of knee surgery by both physicians and their patients. Since this study involved a relatively high number of physicians from different geographical regions, the sample is likely to be representative of the overall population of patients with facing knee surgery in those countries.
Although surgery is frequently recommended for patients with knee OA, some patients are reluctant to undergo invasive surgical procedures due to fear of the operation and its outcomes. This was particularly significant in Japan, possibly due to the higher average patient age and the trend for patients to choose non-surgical therapies. Physicians aiming to delay surgery were influenced by patient reluctance, particularly in Japan, while potentially higher costs were only a factor in Europe. Since physicians across all regions were more likely than patients to report pain reduction as an indication of surgery success than patients, this may indicate a need for improved communication to patients on the potential benefits of surgery.
All data, i.e. methodology, materials, data and data analysis, that support the findings of this survey are the intellectual property of Adelphi Real World. All requests for access should be addressed directly to James Jackson at James.Jackson@adelphigroup.com. James Jackson is an employee of Adelphi Real World.
BMI:
DSP:
Disease Specific Programme
OA:
PRF:
Patient record form
PSC:
Patient self-completion form
RRR:
Relative risk ratio
TKR:
Akazawa M, Mimura W, Togo K, Ebata N, Harada N, Murano H, et al. Patterns of drug treatment in patients with osteoarthritis and chronic low back pain in Japan: a retrospective database study. J Pain Res. 2019;12:1631–48.
Schepman P, Thakkar S, Robinson R, Malhotra D, Emir B, Beck C. Moderate to Severe Osteoarthritis Pain and Its Impact on Patients in the United States: A National Survey. J Pain Res. 2021;14:2313–26.
Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578–89.
Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72(7):1125–35.
Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72(2):220–33.
Kito N, Ozawa J, Kanemura N. Clinical Guidelines for Physical Therapy of Knee Osteoarthritis. Physical Therapy Japan. 2016;43(2):204–9.
McCormack DJ, Puttock D, Godsiff SP. Medial compartment osteoarthritis of the knee: a review of surgical options. EFORT Open Rev. 2021;6(2):113–7.
Totlis T, Marín Fermín T, Kalifis G, Terzidis I, Maffulli N, Papakostas E. Arthroscopic debridement for focal articular cartilage lesions of the knee: A systematic review. Surgeon. 2021;19(6):356–64.
Batailler C, Swan J, Sappey Marinier E, Servien E, Lustig S. New Technologies in Knee Arthroplasty: Current Concepts. J Clin Med. 2020;10(1):47.
Reynaud V, Verdilos A, Pereira B, Boisgard S, Costes F, Coudeyre E. Core Outcome Measurement Instruments for Clinical Trials of Total Knee Arthroplasty: A Systematic Review. J Clin Med. 2020;9(8):2439.
Okafor CE, Nghiem S, Vertullo C, Byrnes J. Cost of Revision Total Knee Replacement: A Protocol for Systematic Review and Meta-Analysis. Pharmacoecon Open. 2021;5(2):331–7.
OECD. Health at a Glance,. OECD Indicators. Paris: OECD Publishing; 2019. p. 2019.
van der Sluis G, Jager J, Punt I, Goldbohm A, Meinders MJ, Bimmel R, et al. Current Status and Future Prospects for Shared Decision Making Before and After Total Knee Replacement Surgery-A Scoping Review. Int J Environ Res Public Health. 2021;18(2):668.
Katano H, Ozeki N, Kohno Y, Nakagawa Y, Koga H, Watanabe T, et al. Trends in arthroplasty in Japan by a complete survey, 2014–2017. J Orthop Sci. 2021;26(5):812–22.
Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, et al. Prevalence of Total Hip and Knee Replacement in the United States. J Bone Joint Surg Am. 2015;97(17):1386–97.
van Belle G, Fisher LD, Heagerty PJ, Lumley T. Biostatistics: A Methodology for the Health Sciences. 2nd ed. Hoboken, New Jersey, USA: Wiley; 2004.
Hosmer DW Jr, Lemeshow S, Sturdivant RX. Applied Logistic Regression. 3rd ed. Hoboken, New Jersey, USA: Wiley; 2013.
Thambiah MD, Nathan S, Seow BZ, Liang S, Lingaraj K. Patient satisfaction after total knee arthroplasty: an Asian perspective. Singapore Med J. 2015;56(5):259–63.
Suarez-Almazor ME, Richardson M, Kroll TL, Sharf BF. A qualitative analysis of decision-making for total knee replacement in patients with osteoarthritis. J Clin Rheumatol. 2010;16(4):158–63.
Yeh WL, Tsai YF, Hsu KY, Chen DW, Chen CY. Factors related to the indecision of older adults with knee osteoarthritis about receiving physician-recommended total knee arthroplasty. Disabil Rehabil. 2017;39(22):2302–7.
Salaffi F, Di Carlo M, Carotti M, Farah S, Giovagnoni A. Frailty prevalence according to the Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI) definition, and its variables associated, in patients with symptomatic knee osteoarthritis: findings from a cross-sectional study. Aging Clin Exp Res. 2021;33(6):1519–27.
Verhaar J. Patient satisfaction after total knee replacement-still a challenge. Acta Orthop. 2020;91(3):241–2.
Papakostidis C, Giannoudis PV, Watson JT, Zura R, Steen RG. Serious adverse events and 30-day hospital readmission rate following elective total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2021;16(1):236.
IQWiG. Does arthrosscopy help in osteoarthritis of the knee: Institute for Quality and Efficiency in Health Care; 2021 [Available from: https://www.informedhealth.org/does-arthroscopy-help-in-osteoarthritis-of-the-knee.html.
Gunaratne R, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW. Patient Dissatisfaction Following Total Knee Arthroplasty: A Systematic Review of the Literature. J Arthroplasty. 2017;32(12):3854–60.
Nakano N, Shoman H, Olavarria F, Matsumoto T, Kuroda R, Khanduja V. Why are patients dissatisfied following a total knee replacement? A systematic review Int Orthop. 2020;44(10):1971–2007.
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010;468(1):57–63.
Janse AJ, Gemke RJ, Uiterwaal CS, van der Tweel I, Kimpen JL, Sinnema G. Quality of life: patients and doctors don't always agree: a meta-analysis. J Clin Epidemiol. 2004;57(7):653–61.
Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients' versus general practitioners' assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 2001;51(473):995–7.
Anderson P, Benford M, Harris N, Karavali M, Piercy J. Real-world physician and patient behaviour across countries: Disease-Specific Programmes - a means to understand. Curr Med Res Opin. 2008;24(11):3063–72.
EphMRA. European Pharmaceutical Market Research Association (EphMRA) Code of Conduct 2019. 2019. Available from: http://www.ephmra.org/Code-of-Conduct-Support.
Medical writing support was provided by K Ian Johnson of Harrogate House Consultancy on behalf of Adelphi Real World and funded by Pfizer and Eli Lilly & Company. Philip G Conaghan and Hemant Pandit are supported in part through the United Kingdom National Institute for Health and Care Research (NIHR) Leeds Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
This study was sponsored by Pfizer and Eli Lilly & Company.
University of Tokyo, Tokyo, Japan
N Fukui
Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Biomedical Research Centre, Leeds, UK
PG Conaghan
Pfizer Japan Inc, Tokyo, Japan
K Togo & N Ebata
Pfizer Ltd, Surrey, UK
L Abraham
Adelphi Real World, Bollington, UK
J Jackson & M Berry
Pfizer Inc, New York, USA
JC Cappelleri
University of Leeds, Leeds, UK
H Pandit
K Togo
N Ebata
J Jackson
M Berry
All authors contributed to the conception of the study/analysis plan. Authors from Adelphi conducted the study, including collection and analysis of data. All authors contributed to the interpretation of data and drafting of the manuscript. All authors approved the final version to be published and agree to be accountable in ensuring questions related to the accuracy of any part of work are appropriately investigated.
Correspondence to J Jackson.
This study complied with all relevant market research guidelines and legal obligations and data were collected according to European Pharmaceutical Marketing Research Association [31]. Ethical approval waiver was granted by Western Institutional Review Board, Inc. and Freiburger Ethik Kommission International, official independent bodies that reviewed the Disease Specific Programme™ (DSP) methodology in the United States and European Union markets. No identifiable protected health information was extracted during the course of the study. Using a checkbox, patients provided informed consent to take part in the survey. Data were collected in such a way that patients and physicians could not be identified directly.
Naoshi Fukui acted as a paid consultant and/or speaker for Pfizer Japan Inc. and Ono Pharmaceutical Co., Ltd. Nozomi Ebata, Kanae Togo, Joseph Cappelleri and Lucy Abraham are employees of Pfizer with stock and/or stock options. Mia Berry and James Jackson are employees of Adelphi Real World who are paid consultants to Pfizer and Eli Lilly & Company in connection with this study.
Fukui, N., Conaghan, P., Togo, K. et al. Physician and patient perceptions of surgical procedures for osteoarthritis of the knee in the United States, Europe, and Japan: results of a real-world study. BMC Musculoskelet Disord 23, 1065 (2022). https://doi.org/10.1186/s12891-022-05954-x
DOI: https://doi.org/10.1186/s12891-022-05954-x
Real-world; survey


We believe in the one, triune God, as he has revealed himself in the Scriptures.
God exists in three persons, but each person of the Trinity is fully God.
The persons of the Trinity are God the Father, God the Son, and God the Holy Spirit.
All human reasoning fails to comprehend this reality. We are unable to adequately describe the Trinity when we try, however, this does not make it logically inconsistent or contradictory; the Triune nature of God is a mystery.
From creation to salvation to sanctification and redemption, the Godhead works in perfect harmony to accomplish whatever they have willed. In fact, there is no way to live a life in relationship to the Triune God without all three members of the Trinity being involved.


To judge by his victory speech after the Potomac primaries, John McCain expects to be fighting Obama in November.
Hope, my friends, is a powerful thing. I can attest to that better than many, for I have seen men's hopes tested in hard and cruel ways that few will ever experience. And I stood astonished at the resilience of their hope in the darkest of hours because it did not reside in an exaggerated belief in their individual strength, but in the support of their comrades, and their faith in their country. My hope for our country resides in my faith in the American character, the character which proudly defends the right to think and do for ourselves, but perceives self-interest in accord with a kinship of ideals, which, when called upon, Americans will defend with their very lives.
To encourage a country with only rhetoric rather than sound and proven ideas that trust in the strength and courage of free people is not a promise of hope. It is a platitude.
A well crafted line, aimed precisely at Obama's weakest spot. Note that McCain does not disdain hope and inspiration: he celebrates them, yet still turns the line against Obama. I wonder if Obama is ready for the possibility that McCain will be harder to squash than Hillary.


text:
Q: Get the name of the table column referenced by a (auto updatable) view column (PostgreSQL) Given the folowing view definition
create or replace view projects as
select id, client_id as clientId from data.projects

Is it possible, knowing the view name and the view column to get the name of the original table and column names?
I know about information_schema.view_column_usage but it does not provide the column to column relation.
My thinking is that although it might not be possible to find out using a query, the information is available somehow since the column clientId is autoupdatable and PG needs to somehow translate it to an insert on the original table.
Is there a public function similar to pg_column_is_updatable that would return the oid of the referenced column?
EDIT:
The best i could come up with is this https://gist.github.com/ruslantalpa/2eab8c930a65e8043d8f

redpajama_set_name: RedPajamaStackExchange


text:
' Copyright (c) Microsoft.  All Rights Reserved.  Licensed under the Apache License, Version 2.0.  See License.txt in the project root for license information.

Imports System.Threading
Imports Microsoft.CodeAnalysis.Organizing.Organizers
Imports Microsoft.CodeAnalysis.VisualBasic.Syntax

Namespace Microsoft.CodeAnalysis.VisualBasic.Organizing
    Friend Partial Class VisualBasicOrganizingService
        Public Class Rewriter
            Inherits VisualBasicSyntaxRewriter

            Private ReadOnly _nodeToOrganizersGetter As Func(Of SyntaxNode, IEnumerable(Of ISyntaxOrganizer))
            Private ReadOnly _semanticModel As SemanticModel
            Private ReadOnly _cancellationToken As CancellationToken

            Public Sub New(treeOrganizer As VisualBasicOrganizingService,
                           organizers As IEnumerable(Of ISyntaxOrganizer),
                           semanticModel As SemanticModel,
                           token As CancellationToken)
                Me._nodeToOrganizersGetter = treeOrganizer.GetNodeToOrganizers(organizers.ToList())
                Me._semanticModel = semanticModel
                Me._cancellationToken = token
            End Sub

            Public Overrides Function DefaultVisit(node As SyntaxNode) As SyntaxNode
                _cancellationToken.ThrowIfCancellationRequested()
                Return MyBase.DefaultVisit(node)
            End Function

            Public Overrides Function Visit(node As SyntaxNode) As SyntaxNode
                _cancellationToken.ThrowIfCancellationRequested()

                If node Is Nothing Then
                    Return Nothing
                End If

                ' First, recurse into our children, updating them.
                node = MyBase.Visit(node)

                ' Now, try to update this new node itself.
                Dim organizers = Me._nodeToOrganizersGetter(node)
                For Each organizer In organizers
                    node = organizer.OrganizeNode(_semanticModel, node, _cancellationToken)
                Next

                Return node
            End Function
        End Class
    End Class
End Namespace

redpajama_set_name: RedPajamaGithub


Mistakes tend to cost time, money or both. When a small mistake means unemployed Canadians face a month's wait for income they need to live, however, the burden of error falls squarely on the government.
The applicant, meanwhile, is left wondering where their next meal is going to come from, or worse. This is an online system that was launched five years ago and was supposed to improve service delivery. In response, the federal department of Human Resources says more automation at Service Canada will solve the problem. It's hard to imagine it getting much worse.
We tend to expect better from an enterprise as large as the Government of Canada, but similar snafus crop up in all kinds of small and medium-sized businesses (SMBs) which have been bolting together applications they've either purchased or created over long periods of time. Think of all the online order forms that seem to send information into thin air, internal sales leads that go missing or benefits changes that can't seem to get made no matter how many times employees enter them. None of those consequences are as potentially dire as EI delays, but they can affect not only a company's performance but its reputation with customers, staff morale or, depending on what goes wrong, a ton of expenses. Service Canada may be this week's poster child for IT failure, but few SMBs can afford the kind of disgruntled users that are more or less stuck with the government.
It's interesting that the headline for the online version of the Globe's story was "Unforgiving computer system causes long waits for EI payments." Consciously or not, the headline invokes a key principle in user interface (UI) design. Forgiveness refers to an approach to creating something that takes into account the most likely errors a user will make, and providing functionality that attempts to fix them before much damage is done. An example might be the auto-correct features in most word-processing programs that address common typos, or the "cancel" button that gives you an out before you submit something wrong online.
The concept of forgiveness is something the IT industry typically assigns to the vendors that make products and services, but the Service Canada EI debacle proves it needs to start with the customer. Anyone who has worked in the government managing EI claims for any length of time would know the five or 10 most common mistakes applicants make. Similarly, SMBs should be close enough to their users to identify the areas where things are most likely to go awry. As they become more mature users of IT, this may become the ultimate SMB decision-maker's skill set. Yes, to err is human. But to be able to pinpoint where forgiveness needs to be built in is divine.


Baba Yaga will sell players five battlestaves a day after completion of Lunar Diplomacy. Simply use Moonclan Teleport to teleport to the city, then walk into her moving house to the north, and buy the five staves unnoted. This method works well with buying battlestaves from Zaff—because of the low buying limit for battlestaves on the Grand Exchange, many crafters will pay above-market price to get them in bulk, so players could accumulate battlestaves over the course of a few weeks and make extra money by selling them all at once.


The quintessential evening accessory, this captivating Y Ligne clutch from Saint Laurent is fashioned from satin-smooth calfskin and embellished with a beautifully contrasting gold-tone Y closure, for a precious effect as dazzling as a night in Paris.
Features: Smooth black calfskin leather exterior; antiqued gold tone hardware; top flap with magnetic dome closure to main compartment; tonal suede lined interior with 1 x flat pocket.
Measurements: 28 cm (length) x 16 cm (height to body) x 4.5 cm (width).
Condition: Great condition. The leather exterior is in great condition, showing very light wear only. The hardware shows light hairline scratches. The suede lined interior is clean and in great condition, showing very light wear including light rubbing.


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text:
announcing: MichaelShermer.com
announcing: Michael's latest book, The Mind of the Market
announcing: the book tour schedule
MICHAELSHERMER.COM
The Work of Michael Shermer
Happy New Year 2008! We are pleased to start the year off with an announcement of our new website: www.MichaelShermer.com . Dr. Michael Shermer is the Publisher and Editor of Skeptic magazine and the co-founder of the Skeptics Society. This site features the writings and work of Michael Shermer, including FREE posts of:
his lecture schedule & touring information
his monthly Scientific American column
excerpts & reviews from his 11 books, plus how to order
essays & book reviews that have appeared in Skeptic magazine, Los Angeles Times, Washington Post, Science, Scientific American, Toronto Globe & Mail, American Scientist, and elsewhere
video from his many media appearances, including clips from his 13-hour TV documentary series on science and the unknown
Each column, article, book review, essay, video is available to leave a comment on or to discuss online. Please do leave your thoughts on the topics — we'd like to hear them.
Check Back Weekly!
We've started off by posting content in reverse chronological order (oldest to newest) and will continue to add three new FREE items (articles, columns, videos) every week throughout the year!
Support the work of Michael Shermer, an activist and essayist, much of whose work is available free online. Link to us using these resources we've created for you.
You can also subscribe to the website's RSS feed which will be automatically updated with all new additions, or to our eSkeptic newsletter which will also list the new additions of the week.
VISIT www.michaelshermer.com
Michael's latest book
The Mind of the Market
How did we evolve from ancient hunter-gatherers to modern consumer-traders? Why are people so emotional and irrational when it comes to money and business decisions? Bestselling author Michael Shermer believes that evolution and evolutionary psychology provides an answer to both of these questions through the new science of evolutionary economics.
Drawing on research from neuroeconomics, Shermer explores what brain scans reveal about bargaining, snap purchases, and how trust is established in business. Utilizing experiments in behavioral economics, Shermer shows why people hang on to losing stocks and failing companies, why business negotiations often disintegrate into emotional tit-for-tat disputes, and why money does not make us happy. Employing research from complexity theory, Shermer shows how evolution and economics are both examples of a larger and still somewhat mysterious phenomenon of emergence, where one plus one equals three.
Along the way, Shermer answers such provocative questions as, Do our tribal roots mean that we will always be a sucker for brands? How is the biochemical joy of sex similar to the rewards of business cooperation? How can nations increase trust within their borders? Finally, Shermer considers the consequences of globalization and what will happen if nations allow free trade across their borders.
Throughout this entertaining and surprising book Shermer considers the morality of markets in a discussion of what he calls virtue economics. Although we are selfish and altruistic, cooperative and competitive, peaceful and bellicose, in the main the balance is heavily on the side of good over evil. For every random act of violence that makes the evening news, there are 10,000 nonrandom acts of kindness that go unrecorded every day. Markets are moral and modern economies are founded on our virtuous nature. The Enron model of business is the exception and the Google motto of "Don't Be Evil" is the rule. The Mind of the Market will change the way we think about the economics of everyday life.
Get it autographed!
Michael is happy to personally autograph your copy of the book. Simply, place your order in Shop Skeptic and in the "comments" section of the checkout process, tell us you'd like it signed. If you want the autographed personalized, just say so!
READ the New York Post
review of the book
READ other reviews & endorsements
READ an excerpt from the book
Michael's North American book tour
for The Mind of the Market
January 8, 2008 at 7 pm
January 11, 2008 at 12 pm
January 12, 2008 at 7 pm
REFER to the latest schedule for updates

redpajama_set_name: RedPajamaCommonCrawl


text:
Parina
Literature, economics and more...
Fiction, non fiction, intellectual, trite or bawdy, Writing is not a career, it's not a vocation it's not even a compulsion.
It's something like breathing. You do it because you are alive and you are alive because you do it.
Or, as Johnson is reported to have said, Writing is like prostitution. At first you do it for yourself, then you do it for some friends and then you do it for money.
But whatever we write it's always fiction, non fiction, intellectual, trite and bawdy all mixed up together…
A selection of Parina's books
A collection of short stories, a personalised biography of the shipping magnate Stavros Niarchos in Greek, A Fantasy Fiction novel and a satirical view of how the Economy works, in English. Diversity of subjects, form and language
Parina home
Vanguard Press
EUROPA (a short story)
Granny Stories Soon to be Forgotten
CASSANDRA?
© 2021 Parina


text:
Add parallel Share Print Page Options Listen to Malachi 1:6-14
Breaking Covenant Through Blemished Sacrifices
6 "A son honors his father,(A) and a slave his master.(B) If I am a father, where is the honor due me? If I am a master, where is the respect(C) due me?" says the Lord Almighty.(D)
"It is you priests who show contempt for my name.
"But you ask,(E) 'How have we shown contempt for your name?'
7 "By offering defiled food(F) on my altar.
"But you ask,(G) 'How have we defiled you?'
"By saying that the Lord's table(H) is contemptible. 8 When you offer blind animals for sacrifice, is that not wrong? When you sacrifice lame or diseased animals,(I) is that not wrong? Try offering them to your governor! Would he be pleased(J) with you? Would he accept you?" says the Lord Almighty.(K)
9 "Now plead with God to be gracious to us. With such offerings(L) from your hands, will he accept(M) you?"—says the Lord Almighty.
10 "Oh, that one of you would shut the temple doors,(N) so that you would not light useless fires on my altar! I am not pleased(O) with you," says the Lord Almighty, "and I will accept(P) no offering(Q) from your hands. 11 My name will be great(R) among the nations,(S) from where the sun rises to where it sets.(T) In every place incense(U) and pure offerings(V) will be brought to me, because my name will be great among the nations," says the Lord Almighty.
12 "But you profane it by saying, 'The Lord's table(W) is defiled,' and, 'Its food(X) is contemptible.' 13 And you say, 'What a burden!'(Y) and you sniff at it contemptuously,(Z)" says the Lord Almighty.
"When you bring injured, lame or diseased animals and offer them as sacrifices,(AA) should I accept them from your hands?"(AB) says the Lord. 14 "Cursed is the cheat who has an acceptable male in his flock and vows to give it, but then sacrifices a blemished animal(AC) to the Lord. For I am a great king,(AD)" says the Lord Almighty,(AE) "and my name is to be feared(AF) among the nations.(AG)
Malachi 1:6 : S Lev 20:9; Mt 15:4; 23:9
Malachi 1:6 : Lk 6:46
Malachi 1:6 : S Dt 31:12; S Isa 1:2
Malachi 1:6 : Job 5:17
Malachi 1:6 : S ver 2
Malachi 1:7 : ver 12; Lev 21:6
Malachi 1:7 : S Eze 23:41
Malachi 1:8 : S Lev 1:3; S Dt 15:21
Malachi 1:8 : S Ge 32:20
Malachi 1:8 : S Isa 43:23
Malachi 1:9 : Lev 23:33-44; Ps 51:17; Mic 6:6-8; Ro 12:1; Heb 13:16
Malachi 1:9 : S Jer 6:20
Malachi 1:10 : 2Ch 28:24
Malachi 1:10 : S Hos 5:6
Malachi 1:10 : Lev 22:20
Malachi 1:10 : ver 13; Isa 1:11-14; Jer 14:12; Mal 2:12
Malachi 1:11 : S Isa 24:15; 56:6
Malachi 1:11 : S Isa 6:3; S 12:4
Malachi 1:11 : S Ps 113:3; S Mt 8:11
Malachi 1:11 : Isa 60:6-7; Rev 5:8; 8:3
Malachi 1:11 : S Isa 19:21; Heb 13:15
Malachi 1:12 : S Eze 41:22
Malachi 1:12 : S ver 7
Malachi 1:13 : Isa 43:22-24
Malachi 1:13 : S Nu 14:11
Malachi 1:13 : S ver 10
Malachi 1:13 : S Dt 15:21
Malachi 1:14 : Ex 12:5; S Lev 22:18-21
Malachi 1:14 : Ps 95:3; S Ob 1:21; 1Ti 6:15
Malachi 1:14 : Jer 46:18
Malachi 1:14 : Ps 72:8-11


text:
Robert Heffernan (* 20. Oktober 1917; † 22. Juni 1943) war ein australischer Hochspringer.

Bei den British Empire Games 1938 in Sydney gewann er Silber mit 1,88 m.

Weblinks

 Athletenporträt bei Athletics Australia

Hochspringer (Australien)
Australier
Mann
Geboren 1917
Gestorben 1943
Teilnehmer an den Commonwealth Games (Australien)

redpajama_set_name: RedPajamaWikipedia


Do not struggle anymore with the head-banging question, do I love him? Keep reading to find out what are the signs that you are really in love with your boyfriend and that it is true and unconditional love.
In a certain point of a relationship, or even in the process where you are trying to get a guy, but you're not quite there yet, you are bound to stop and wonder 'Why do I love him so much?'. Women tend to question themselves, their decisions, feelings, and actions to the point where they distort the initial feeling to begin with.
If you're having doubts about the man you are seeing and wondering 'Do I really love him', than join us in the reading of this article and we are sure you're bound to discover what's inside of your heart.
How do you know if you have strong feelings for him? The truth is that it is hard, darn hard. So hard that you know... you end up overthing things. Luyckily enough there are ways to find out. Here are the signs you do.
In today's world of fast speed dating, it's not that easy to recognize love. You have a difficult task of distinguishing true love from just desire. That is why if you ask yourself, do I really like him, think about what you liked about him when you first saw him.
Did you like him because of his looks or did you get attracted because you have many things in common? You don't have to settle for a guy that you have nothing in common with, just because he looks like a macho stud. On the contrary, if you realize that you still adore the things that you loved about him in the first place, then it probably is true love.
Got butterflies in the stomach?
If you are asking yourself, 'Do I love him?' That's easy. Think about what you are feeling the moment you are about to see him. Are you excited and happy? Maybe your heart is beating as it's about to jump right out of your chest and into his arms? Or are you indifferent and you only seeing him just because he is your boyfriend? Once you sort this issue out in your mind, you will have a clear picture in your mind. Love is all about the flutters in your stomach and happiness when you see his face. If you don't feel that, than you are far away from love.
Is he on your mind?
This might be a foolish thing to reconsider, but think about how much you are actually thinking of him. Do you remember him only when he sends you a text message or calls you, or is the 90 percent of your daily conscious thinking devoted to him? If the last one is true, than you are definitely in the love lane. Enjoy the springtime, because springtime is in the love lane is the best season ever. It's when your life is filled with fluttering emotions and the love with your partner blooms.
This might sound silly, but's it's actually not. If you really like or love someone, you will forget about the pride, and text them or call them first. You won't wait for his message and you'll want to talk to him first. This is a sign of thinking more about him and less about yourself, which is a definite indicator of being in love. So if you're still wondering 'Do I love him?' Yes, you probably do.
Do you mention him often?
This is something you that can help if you are nagging yourself with the question 'Do I still love him?' If you find a way to insert his name or his actions into your conversation with others, that means he is in your mind and probably heart. Once you love someone, you will constantly find ways to talk about them, because he preoccupies your mind and makes sure everyone knows about it. It's just nature and you can't escape it!
When you really love someone, you want him to feel good and be happy. You even sacrifice your well-being to make them feel nice. This is how love affects people. If you put his needs first, and think about his happiness more than you think about yours, then it's love. It can't be anything except pure love, unconditional love, and that's the best kind. Putting someone in the first place is a unselfish act full of true emotions, that you can't evade even if you wanted to.
Are you there when the times are rough?
One of the definite signs of love is being there for him when he has a rough time. Or if your relationship is on the down slope, you are still positive and working it out. That means you love him, and don't ask further. We only care for things we love, invest in them, and stick through the bad times because of the strong feelings we nourish for that particular person.
You know you love someone if you don't think of him only when you want your urges to be fulfilled, you know what we mean? When you're in love sparks are flying all over the place, and you can't wait for that first time, but once you are really in love, you look at other qualities and find other ways to enjoy in your partner, not just consume your relationship physically.
Are you a love bug?
In the end, if you go through all these and discover that you really are in love, don't struggle with the next big question, and that's 'How do I tell him I love him?' There are a million different ways you can express your emotions, and whichever you go with, I'm sure that your sincerity will do the trick. After all, if you are so deeply in love, chances are high that he feels the same.
There is a difference between true love and lust, and it takes a lot of introspection to recognize one from another. Signs that you are falling in love or have already fallen in love are various, but the common denominator is the fact that you feel good around the person you are with.
It is really hard to find true love but once you have found it is even more difficult to recognize it and make it last long. If you find al 7 signs of true love in your relationship, consider yourself lucky because you have definitely found it and all you have to do is enjoy it and make it last a long time!
Being ignored by your ex is never easy to cope with, especially if you have to ask yourself does my ex-boyfriend miss me. Him ignoring you might mean that he isn't over you yet. How does that make you feel? Do you want him back? Are you willing to give him another shot? First, try to understand his reasons.
Getting into a relationship is not the only problem women have to deal with. Once you have a decent guy for a relationship what is next? Then you are tortured by the question does he really love you, or is it just a phase. Stay tuned for signs that a guy really likes you and you are in a successful relationship.
It is a must for women to know how their partner feels about them. If you are asking does he really love me, we come to your aid with a list of 8 signs that can tell you he is really into you. If he doesn't fulfill these requirements, you might want to reconsider wasting your time with him. He might not be worthy of it.


text:
Male Circumcision and HIV
Genital Integrity – HIV Prevention – Informed Consent
The CDC/AAP Project [Archived]
← NOTEBOOK: Influencing the Discussion on Male Circumcision and HIV
Council on Foreign Relations Takes Up Male Circumcision and HIV →
Early, consistent treatment followed by a new class of drug could cure HIV
Posted on May 16, 2007 by David Wilton
I used to think a series of three shots to the abdomen to treat rabies after a wild animal bite was extreme. But this treatment, if it works, would be rabies treatment hell-on-wheels.
Dr. Anthony Fauci, Director of the NIH, recently co-authored a paper published in the Journal of Infectious Disease that appeared to show eight years of treatment when begun early followed by a new class of drug at very high levels could result in a cure. That's right. A cure.
So much focus has been on prevention by way of a vaccine that it has hardly occurred to most in the last 10 to 15 years that a cure would ever be possible. Still, eight years followed by what is likely to be an unpleasant level of dosing is not an easy way out. Moreover, the treatment only contemplates a narrow class of individuals.
Yet, this is better for the narrow group it might work for than a lifetime of drugs, but less preferred than preventing infection altogether. Therefore, don't expect the hoped for results from the coming trials to take male circumcision off the table.
Bloomberg News article, next page.
Top U.S. Scientist to Use New AIDS Drugs Seeking Cure (Update2)
May 15 (Bloomberg) — AIDS may be cured in a select group of patients who now have extremely low levels of virus in their bodies by aggressively dosing them for a year with new HIV drugs from Roche Holding AG and Merck & Co., according to the top U.S. infectious disease scientist.
Research released yesterday suggested that 7.7 years of combination therapy might cut HIV to very low levels in those treated early and faithfully. The next step is to see if aggressive treatment with new drugs for a year will cure the disease, said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.
Patients are already being lined up for the new study. If doctors get the virus to levels where it seems to disappear, they'll stop treatment, Fauci said in a telephone interview yesterday. Patients will then be monitored so therapy can quickly resume if the virus reappears, he said.
"The first step is to see how far we can push the envelope," said Fauci, who co-authored the study published yesterday in the Journal of Infectious Disease. "We now have a scientific basis to feel that it's at least worth pursuing it in some select patients."
The shares of Merck, based in New York, rose 42 cents to $52.50 at 10:49 a.m. in New York Stock Exchange composite trading, while Roche's shares rose $2.10 to $228.90.
HIV, the human immunodeficiency virus which causes AIDS, infects about 40 million people worldwide, and 1 million in the U.S. The virus mutates constantly to elude the body's defenses as well as drugs, such as Bristol-Myers Squibb Co.'s Sustiva. It can also hide in immune cells, called resting T-cells, where it is relatively safe from treatments.
Early treatment can keep the virus from reaching high numbers within those T-cells, Fauci said. He and NIAID researcher Tae-Wook Chun followed seven HIV patients for three- and-a-half to four-and-a-half years, measuring the number of resting T-cells in which HIV remained as time went on.
They found that early treatment with drugs from three classes, each of which hits the virus at a different point of vulnerability, brings down viral levels quickly. With this treatment, the number of infected resting T-cells can be halved every 4.6 months, the study said. The study will be published in the June 15 issue of the Journal of Infectious Diseases.
Based on that finding, they and colleagues at the University of Washington in Seattle estimated that 7.7 years of three-drug therapy would all but eliminate HIV in patients who
began treatment early.
While the number of patients who got the three-drug regimen early, kept it up for years, and have low levels of virus may be small, studying them "will be of considerable value in assessing the feasibility of eradication of HIV," Fauci and his coauthors said in the journal article.
Treatment in the next group of patients will probably include Roche's Fuzeon, which prevents the virus from attaching to immune cells, and Merck's Isentress, which stops HIV from adding its genes to the cell's genome. Isentress is in the final stages of development.
Each drug attacks a part of the virus untouched by other classes of medications. Such drugs might give the best chance to eradicate HIV because the virus is unlikely to have mutated to develop defenses against the new medications, Fauci said.
The proposed study might also help doctors decide when and how to use currently available HIV drugs, some of which have been associated with complications such as heart disease after long-term use, Fauci said.
Stronger Treatment
If doctors have a chance of getting patients completely off drugs, it may be worth the risk of stronger treatment, he said.
Another risk is that measurement of low HIV levels isn't always accurate. If the virus actually takes longer than eight years to eliminate, or can't be driven out, patients who think they are cured may be taking a chance by halting HIV drugs, said David Margolis and Nancie Archin of the University of North Carolina in Chapel Hill, in an editorial in the same journal.
"The few infected cells remaining might be enough to reignite infection," they said. "And, of course, the possibility exists that HIV may rarely persist in cells other than resting T-cells."
Patients will be closely monitored to make sure that treatment resumes quickly if viral levels begin rising again, Fauci said.
The U.S. government recommended expanded testing for HIV last year to try to diminish spread by making infected people aware of their status. The strategy might also get more people into treatment early, offering the possibility that they could be cured, if aggressive, early treatment works.
Lauerman, John. Top U.S. Scientist to Use New AIDS Drugs Seeking Cure (Update2). Bloomberg News. May 16, 2007.
http://www.bloomberg.com/apps/news?pid=newsarchive&sid=a.0x1mlV37Qw#
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This entry was posted in Medicine and tagged AIDS, circumcision, Fauci, Fuzeon, HIV, Infectious Disease Journal, Isentress, Merck, NIH, Sustiva, Tae-Wook Chun. Bookmark the permalink.
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Voluntary Medical Male Circumcision Project (VMMCProject)
What is an intactivist?
in·tac·tiv·ist [in-tak-tuh-vist]
1. an especially active, vigorous advocate of children's rights, especially the right to genital integrity or the right to be free from genital cutting (circumcision).
2. of or pertaining to intactivism or intactivists: an intactivist organization for the right of male, female, and intersex children to be free from genital cutting.
3. advocating for children by vigorously opposing genital cutting (circumcision), especially the cutting of children who lack capacity to consent: Intactivist opponents of the American Academy of Pediatrics picketed their annual conference in New Orleans.
Parallels: Comparing Tattoos and Circumcision
Straight From Facebook: Inside the Circumcision Room
Parallels of Opposition to the Metric System and Male Intactness in America
The Crimson Joins Harvard in Filing "Motion to Dismiss"
Harvard Responds to Eric Clopper with a "Motion to Dismiss"
September 2020 in a Nutshell
Must-See Video on YouTube Regarding Normalization
AFRICA: Two Boys Die Post-Circumcision Despite Thoughts and Prayers
FACEBOOK: Another Hemorrhaging Baby Post-Circumcision
Clinical Trial: Music as Analgesia for Male Infant Circumcision
His Body, His Rights – Bonobo3D
Interview with Vladislav Sobolev - Hugs Over Masks
Interview Vladislav Sobolev - Hugs Over Masks
No New Normal Rally & March - Vancouver, Sept. 27/20
Vladislav Sobolev - Hugs Over Masks
No New Normal Protest - Vancouver
Ted Kuntz - Vancouver Freedom Rally
A Celebration of Freedom! Vancouver - Sept 13/20
Equal Rights for Boys
Save the Next Generation
Circumcision - Reinforces Harmful Stereotypes
Circumstitions News
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Juarez City News
Law Office of David Wilton


text:
using StardewValley;
using System;
using System.Collections.Generic;
using TehPers.FishingOverhaul.Api.Content;
using TehPers.FishingOverhaul.Api.Weighted;

namespace TehPers.FishingOverhaul.Api.Events
{
    /// <summary>
    /// Event data for after fish chances are calculated.
    /// </summary>
    public class PreparedFishEventArgs : EventArgs
    {
        /// <summary>
        /// Information about the <see cref="Farmer"/> that is fishing.
        /// </summary>
        public FishingInfo FishingInfo { get; }

        /// <summary>
        /// The chances of finding fish. The weights are not yet normalized.
        /// </summary>
        public IList<IWeightedValue<FishEntry>> FishChances { get; set; }

        /// <summary>
        /// Initializes a new instance of the <see cref="PreparedFishEventArgs"/> class.
        /// </summary>
        /// <param name="fishingInfo">Information about the <see cref="Farmer"/> that is fishing.</param>
        /// <param name="fishChances">The chances of finding fish.</param>
        /// <exception cref="ArgumentNullException">An argument was null.</exception>
        public PreparedFishEventArgs(
            FishingInfo fishingInfo,
            IList<IWeightedValue<FishEntry>> fishChances
        )
        {
            this.FishingInfo = fishingInfo ?? throw new ArgumentNullException(nameof(fishingInfo));
            this.FishChances = fishChances ?? throw new ArgumentNullException(nameof(fishChances));
        }
    }
}


text:
History of NDSU
Buildings List
Historical Facts
NDSU Presidents
Institute for Regional Studies Archive Collection
Databases and Indexes
Genealogy and Biography
Service and Fees
Class Visits and Tours
University Records Transfer
NDSU Libraries
NDSU History
North Dakota Women's Suffrage items added to Digital Horizons
The meeting minutes for the Votes for Women League, Fargo Chapter between the dates of their founding on February 4, 1912, to April 11, 1919, has been digitized and uploaded onto Digital Horizons.
https://cdm16921.contentdm.oclc.org/digital/collection/ndsu-histor/id/2272/rec/111
The Votes for Women League of North Dakota (also called North Dakota League for Votes for Women) was organized on February 4, 1912 in Fargo at the home of Mrs. Mary Darrow Weible. It appears that it was organized in conjunction with the appearance of Miss Sylvia Pankhurst, a note English suffragist, in Fargo for a public talk. A formal organization was established with its activities confined to securing female suffrage. Shortly thereafter other chapters were organized throughout the state with the headquarters being in Fargo. The Fargo group remained active into World War I and the rise of the Nonpartisan League that also helped enact limited suffrage in North Dakota in 1917. Thereafter with the enactment of the Federal Amendment appearing imminent, the League helped out the boys at Camp Dodge, Iowa, did Red Cross work, and supported the Council for Defense. By 1919, active work by the League had declined and it began discussing the formation of a civic league to replace what might become the defunct League.
Also uploaded is the first Votes for Women League president, Clara Darrow's booklet entitled "I want to vote" : an appeal to the voters of North Dakota delivered at the Grand Theatre, Fargo, October 25, 1914
https://cdm16921.contentdm.oclc.org/digital/collection/ndsu-histor/id/2215/rec/2
Digital Horizons
Archives Site Search
NDSU Press book, "Girl on a Float", added to collection
New NDSU Press book, "His Feathers Were Chains" added
New book "Mammals of North Dakota" added to collection
Archives Open by Appointment Only
New family history book "Fjord to Flatland" added
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Archives - West Building
3551 7th Ave N
NDSU Archives Libraries
NDSU Dept #2080,
Fargo, ND 58108-6050
Email: ndsu.archives@ndsu.edu
Connect With Us --
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© 2023 NDSU Libraries || All rights reserved.


Juniperus Pfitzeriana Plant – King Of Spring 3.5 out of 5 based on 20 ratings.
Where are Plant Finder & Plant Selector? We have combined these two powerful search tools into a single Find a Plant service searching over 250,000 plant records. Virtually all of the features of the old searches are still available and in addition we have added several new features to create a more comprehensive and user friendly search experience.
Looking beyond junipers for evergreen ground covers – Overplanted for years, the "tam" junipers or 'Pfitzer' (Juniperus sabina 'Tamariscifolia' or J. chinensis 'Pfitzeriana') make darling children.
Talking with a plant expert will help. November's a f.
In U.S. Department of Agriculture hardiness zones 7 through 11, flowers appear from spring through fall. Companion plants that can fill in below.
"Daub's Frosted" juniper (Juniperus x pfitzeriana ".
The eastern red cedar (Juniperus virginiana) grows to 40 feet tall with.
pendulous orange and red flowers that bloom in spring. For summer color, plant the monarda (Monarda spp.), a 3- to 4-foot-ta.
1 x 7.5 litre potted juniperus plant (T68103) 2 x 7.5 litre potted juniperus plants (T68104P) Water Juniper plants regularly throughout the growing season until fully established.
By the spring, this still-bold foliage has almost a white color and looks striking when combined with an evergreen, like Eastern red cedar (Juniperus.
different plants, from the highly decorative A.
Juniperus Pfitzeriana Plant – King of Spring Juniperus × pfitzeriana 'King of Spring' is a compact evergreen shrub with vibrant golden foliage, borne on gently arching stems. Ideal for ground cover as well as a stand alone specimen adding colour to your garden even in the dark winter months.
Juniperus × pfitzeriana 'King of Spring' is a compact evergreen shrub with vibrant golden foliage, borne on gently arching stems. Ideal for ground cover as well as a stand alone specimen adding colour to your garden even in the dark winter months.


I am David Segura, a Houston based Windows Deployment Specialist. I currently work for a large Enterprise supporting 40,000+ clients, for over 13 years, so much of what I write on my blog is used in an Enterprise Production environment.
The blog is a two way commitment . . . it allows me to share what I do, while also giving me a way to document my processes. The added benefit is that I get to share this knowledge with you. I am open to questions, but keep in mind, I am not a Consultant, or an Instructor. I don't make any money from what I post here, not even Ad Revenue, so this is my gift to you. If you find anything I post helpful, please Rate the post, Add a Comment (even to say Hi), and Share it out.
Much of my knowledge has come from the Guru's, Johan Arwidmark and Mikael Nystrom after attending one of their Geek Week training sessions in Redmond. If you are not fortunate enough to attend one of their sessions, you can always get a Deployment Fundamentals book.
I just discovered this blog and just started reading your posts. Great seeing how you've progressed over the years. I'll post more once I've had a chance to read more.
I use Microsoft DaRT which has File Explorer, but there is a cost for businesses to use that. Do you have an alternative?
Just wanted to say that iv been going through your Blog for a Deployment im on and would just really like to thank you. Its helped me out loads.
If im ever in Houston, il shout you a beer or 3.
Thanks Dan. I'm working on something quite big for Windows 10 customizations. Care to test it out?


Every woman should have a basic and essential makeup that makes her look beautiful and presentable at all times. This makeup is for both formal and informal events. Also you can use it both in the day and at night adding a few changes. These are six shades that you can use for different looks and occasions.
The discretion provided by neutral tones allows you to create different levels of intensity, texture and depth in your face. So, just add some cool shades or add contour and illuminator transform a natural look into another loaded one. For that reason, it is advisable that you get a palette with these shades.
The golden tones are very favorable for the brown and dark skin as it enhances the tone of your skin; as well as its features. Use this tone with some more tenuous, like hazel and beige; that way your makeup will be balanced and sophisticated.
This color is good with both whiter and warmer skins. Therefore, it is perfect to create a natural look that you can use either as a shade or on some lipstick. You could even use it as a blush.
The peach or coral colors not only apply on the cheeks or on the lips, these also look spectacular on the eyelids. One advantage is that it will enhance the color and shape of your eyes, giving them natural warmth.
Some red shades look perfect for your eyes to look spectacular day by day. The key is to combine it with brown colors to give depth to the eye socket and balance the intensity of the red. As for lipsticks, it is essential that you find the red that best suits you as it is a classic and sensual color that every woman should have.


In case the the update is still stucked. Try to redownload the updates.
1. Press "windows + R" on your keyboard.
2. Type "supporttool" and press enter.
3. It will open the Trend Micro Diagnostic Toolkit and go to "Uninstall" tab.
4. Click on "5. Stop all components" and wait till it finish stopping all components.
5. Click on "2. Delete Now" and "3. Delete Now".
6. Click on "4. Start all components" and the Trend Micro Main Console will open.
7. Look for a small human icon at the top-right corner of the main console, click on it and select "About this software".
8. Wait till it checks and downloads the latest updates.


Rachel completed her B.S. in Agricultural Science in 2016 in her home state of New York. After graduating she sought to challenge herself by conducting research in dryland agricultural systems of Eastern Washington. She began her research in Dr. Tao's soil fertility program in Spring 2017. She was fascinated by the Palouse landscape and was inspired to study how restrictive layers in the soil, such as Fragipans and Argillic horizons, impact wheat growth and nutrition.
Rachel's joy for the inland Northwest extends beyond her research. In her spare time Rachel enjoys backpacking, painting, and cooking with others.
I grew up here in Pullman and attended WSU, where I majored in Environmental Science and Spanish. I am interested in studying ecosystem services.
I come from a small farming community nested in the "hill country" region of central Texas, but completed my undergraduate education in Reno, NV. At the University of Nevada, I graduated with a B.S. in environmental science, and focused on soil science, environmental chemistry, biofuels synthesis/production, environmental policy and regulations, and community outreach. After working with indigenous groups impacted by environmental degradation through large-scale mining, in both Nevada and western Africa, I ultimately decided soil science and resource conservation were the logical foundations to center my studies on for my Ph.D.As part of the Low Impact Development research program at WSU, my research will focus on the use of iron-gluconate amended compost and its ability to mitigate the impacts of agricultural land runoff through the adsorption of xenobiotics, excess nutrients, and arsenic, with the main focus being the speciation, fate, and transport of arsenic.
As I was born and raised in the Great Lakes state, I've always been aware of the importance of environmental conservation and sustainability, as well as the stunning beauty that nature has to offer. My interests led me to receive a bachelor's degree in chemistry, with two minors focusing on environmental sustainability, technology and policy at Michigan State University. While finishing my last year of school, I worked in the MSU Soil and Plant Nutrient laboratory where I was exposed to the fascinating world of soil and crop science. Now that I am at WSU, I plan to maximize the experience of my unique background to make advancements in soil health and fertility in the Pacific Northwest.
Growing up on a farm in rural Minnesota has made a substantial impact on my academic interests. With my life-long experience in agriculture, and the passion for biological sciences I accrued during my undergraduate education, I decided to devote my future studies towards microbiology in agriculture. This led me to a M.S. in Animal Science with an emphasis in ruminant microbiology at South Dakota State University. To broaden my skills and education, I decided to attend WSU starting in the fall of 2017, and focus my doctoral research on rhizosphere microorganisms and their effect on crop productivity. Specifically, I will be working on characterizing metal and micronutrient transformations by the rhizosphere microbiome and phytobiome that enhance plant nutrition and crop yield.
I was born in a small town in Nanyang, China, a city full of history and beautiful scenery. My passion for plants and nature lead me to higher education regarding natural resources management for both of my Bachelor degree (Northwest A&F University) and my Masters degree (Institute of Soil Science, Chinese Academy of Sciences). What I observed during my courses field trip in 2012, impressed me so much because it is so difficult to find a clear river without pollution caused in most part by the unsustainable development of the crop lands. I came to WSU to Dr. David Huggins's Lab in the Fall of 2014 to focus on my research interest of carbon and nitrogen cycling in soil and try to find some practical and meaningful solution for sustainable agriculture development. I like drawing, playing badminton, running and reading, and sometimes I like cooking, but it depends on my mood.
Marissa Porter is a Soil Science Master's student at Washington State University. She completed her undergraduate studies at Marist College in New York, receiving a Bachelor of Science in Environmental Science. Before beginning at WSU in Fall of 2017, she spent the summer working vegetable farm in Colorado. Her research focus is on nitrogen use efficiency of canola, a relatively new crop in the region. Her project will improve the fertility knowledge of canola, helping to integrate it as a rotational crop in the winter-wheat summer fallow cropping system that dominates eastern Washington.
After finishing my B.S. in Microbiology and chemistry at BYU, I started my M.S. Degree in Soil science at WSU in Aug. 2014 with Dr. Dave Huggins. My work there focused on evaluating site-specific nitrogen fertilizer management in dryland winter wheat. After completing my masters in Aug. 2016, I went directly into my Ph.D. program with Dr. Markus Flury.
My research with Dr. Flury examines the potential for and impact of plastic pollution in sewage-sludge (biosolids) amended soils. We are looking at the accumulation and potential for movement of nano- and micro-sized plastic particles in agricultural soils. Additionally, we are looking at the accumulation and molecular associations of silver nanoparticles in these same soils over time.
As part of the WSU-PNNL Distinguished Graduate Research Program, I collaborate with researchers at Pacific Northwest National Laboratory in Richland, WA, where I live with my wife and two children.
I was born and raised in Minnesota where I grew up loving just about anything to do with the outdoors. The most influential experiences from my undergrad include the semester I spent in Costa Rica conducting research on an organic cocoa farm. That semester provided the springboard to further research in agricultural systems once back in Minnesota, which transformed into another influential experience as I developed relationships with local farmers and organizations to promote on-farm research trials.I am interested in studying various practices that can make agriculture more sustainable, especially as related to nitrogen management. My research is focused on introducing organic quinoa as an alternative crop for the inland Pacific Northwest. Specifically, I will examine the ecological and economic impacts of incorporating quinoa into organic rotations with other crops common to the region.
I will begin my PhD program in soil science under the supervision of Prof. Markus Flury at WSU. My research project will focus on transport of nano- and microplastic particles in unsaturated porous media. In this project, I will explore how nano- and microplastic particles will move through porous media and what the effect of the air-water interface is on transport of these particles.
I have obtained a Master's degree of Science in Hydrogeology from China University of Geosciences-Beijing and a Bachelor's degree in Hydrology and Water Resources Engineering from Shandong University of Science and Technology.
I had been a lab technician at China University of Geosciences-Beijing from June 2016 to April 2018, under the instruction of Pro. Qiulan Zhang. During that period, I had worked on designing and improving colloid transport experiment, and analyzing and recording test data to issue reports using charts, graphs and narratives.
In my spare time, I love reading novels, especially historical and science fictions. I also like swimming and playing table tennis.


A 'tsunami' of shoplifting crime is blighting the high street in Cambridge, businesses have claimed.
Small stores, large chains and even charity shops are victims of theft on a daily basis.
It is a crime that goes widely under-reported as staff lack confidence in the city's stretched police force to tackle the issue.
The worsening issue is affecting morale and profit margins – with claims it has put the futures of some businesses under threat.
Cambridgeshire Live investigated the scale of the problem in the city centre.
A situation 'out of control'?
"I would say you're looking at not even 20 per cent of shop theft gets reported to the police," claims Adam Ratcliffe, manager of Cambridge Business Against Crime.
The 150-member organisation works with the police and other parties to take a proactive approach to crime in the city.
This includes a running a secure information sharing network, an inter-shop radio system, and training staff.
Adam, a former police officer, is frustrated by what he sees as a problem that is "out of control".
"It's worse than it's been for a while," he explained. "The police don't have the resources to deal with low level crimes.
"Which has now lead to low reporting. Businesses don't have the time and resources to wait with detained people.
"This is not a dig at Cambridgeshire police. They police work tireless in the city."
Adam recently took to Twitter to highlight how great the problem of shoplifting was.
"Meeting today with a city shop that has at least five shop thefts PER DAY," he wrote.
"Stopped reporting to the police due to 'lack of response'. Even at an average, that is over 1,800 crimes in one store alone. Businesses are more vulnerable than ever."
This is not an outlier. Adam has plenty of alarming stories of the challenges faced by shop managers and owners.
He said: "One business said that he has people who will talk in take stuff of the shelves right next to him and walk out the door and when he challenges them they say what you going to do?"
"It's the same as being mugged down the street but people don't see it that way. They think 'oh it doesn't belong to anyone'.
"It's forcing businesses to close."
According to Cambridgeshire police, there were 1,040 shoplifting crimes recorded by officers between April 2016 and March 2017 in the whole of Cambridge city.
This rose to 1,263 record crimes between April 2017 and April 2018.
"Nationally the statistics suggest that shop theft isn't as bad as we say it is because we're not reporting it," said Adam Ratcliffe.
"We're seeing high value theft, we're seeing habitual theft, and it's on a relentless level. Whether it's to fund a debt or to fund a lifestyle."
Neil Mackay, who runs Mackays hardware store in East Road, is a longstanding campaigner against shoplifting, and objects to the use of that term.
"I see no good reason to differentiate the crime by calling it anything other then theft," he said.
"The very word shoplifting has been so devalued in the public's consciousness as to almost not be regarded as a crime."
Adam agreed: "We believe that shoplifting has lost all meaning, It's devaluing the crime."
Campaigning against the issue has taken Neil all the way to the House of Commons to discuss how to tackle it.
He said: "When I was on my way there as I walked from King's Cross I spoke to several managers in shops in London and to a man and woman they said there's not even any point in reporting it anymore.
"The statistics that are out are hugely under reported. I know it's the same in Cambridge."
Neil explained that preventing and responding to shoplifting comes at a cost to businesses – tagging items, installing CCTV, trawling through videos and reporting incidents to the police.
"In my opinion any level of shop theft is unacceptable," he said.
"At average retail margins it has been calculated that it takes 12 more sales of the item which was stolen, simply to get back to where the shop stood before the crime.
"That doesn't take into account the need to generate profits to pay staff, pay rates and all the other costs of running a retail environment."
Adam echoed that sentiment: "We're being told by businesses that they are finding it harder to afford to stay in Cambridge.
"If you imagine the level of stock loss on top of business rates and rent. They are struggling because they can't cope with the issue of stuff being stolen."
Neil has been so infuriated by the shoplifting strikes on his store that he has created a 'rogues gallery' of suspects caught on CCTV.
"Retailers have generally have lost faith that anything is going to be done about it," he said.
"We've got a tsunami of crime that's not being reported and not being recognised."
Neil's business is not alone in being targeted by thieves. Independent shops across the city are being hit by shoplifting.
Bill Ginn, manager at Black Barn Records on Burleigh Street said: "It's not happened massively regularly, we find empty sleeves pretty regularly.
The shop has suffered three or four large thefts since it opened of over £200, often involving people grabbing a handful of records worth between £15 or £20 each.
"Every time we've seen someone do it they've been caught every time. The police know who they are," said Bill.
He explained that the full toll of shoplifting was difficult to ascertain, but staff find empty sleeves every other day.
"It's always expensive sleeves," he said. Someone obviously swaps an expensive record into a cheaper sleeve. We got a guy on video swapping sleeves."
Bill said the incentives for shops to report crimes weren't there. One shoplifter they caught was only handed a small fine, while insurance pay-outs rarely cover the value of the lost stock.
He added: "The thing that's frustrating is were not selling bread and milk, not one's going to starve. You don't need to nick a record to survive."
In 2014, the Anti-social Behaviour, Crime and Policing Act 2014 changed the law in England and Wales around shoplifting.
It introduced a £200 threshold, under which anyone caught stealing goods less than that value could plead guilty by post or appear in magistrates' court.
The penalty would then be a fine or up to six months in prison.
The law has been blamed by businesses for a surge in shoplifting because police will not investigate the theft of items worth less than £200.
One worker at a supermarket in Cambridge city centre, who did not want to be named, said he constantly experiences shoplifting doing his job.
"At city centre shops it's terrible," he explained. "I put it down to being the level of homeless in Cambridge. They don't have the money, they've got to get something to eat.
"It's continuous petty theft. None of it's people robbing your tills. [It's] In the 10s every day. That's not saying they all get out.
"You can't grab people or chase them down the road but a lot of the time they get deterred by watching someone.
"The other week we had a guy come in take £40 worth of meat. We caught him at the door."
On another occasion someone swiped an entire shelf of baby milk worth £180.
The worker said all incidents get reported internally by his employer but police would not always respond to incidents.
"The reality is most of them are too small to waste police time. They are strained enough in the city."
"Shoplifting doesn't seem to be the priority at all. It's worse than anywhere else I've been."
Adam Ratcliffe said this lack of resource in the police was affecting how businesses responded to shoplifting, with some feeling more "vulnerable".
In February Cambridgeshire Live reported that, Cambridgeshire Constabulary has seen a 3.6 per cent reduction in neighbourhood police officers – from 528 in 2013 to 509 in 2017, a loss of 19.
Total officer numbers in Cambridgeshire were down by 38 since 2013 when the force had 1,383 officers. In February it was reported it had 1,345.
The force was gearing up to hire more than 50 new recruits, bringing the number of officers above the 2013 figure.
However, the 126 PCSOs the force employed was to be reduced by natural turnover with a commitment to retain a minimum of 80 posts.
Adam said: "Even security guards have to adapt the way they deal with people because they don't feel they have the support available to them if they call the police."
"People can be quite aggressive. When people are going in with items to cut tags off clothes, that's an intimidating factor.
"Security guards are very aware that they are the last ling of defence."
Carlos Da Silva, a security officer at Primark on Burleigh Street, said the store has one or two theft attempts a day which are all routinely reported to the police.
"Normally it's not that bad," he said. "From one to 10, you can put it at four or five. Saturday is the worst day, between three and five.
"If we catch someone, one of us stands outside, we invite the person to come inside we go into our room and we call the police.
"Some times the police come, some times they are too busy to come. Some times you feel a bit disappointed. Then you have different choices how to act with the shoplifter.
"Some times we don't have any choice just to recover the stuff and let them go."
But in stores without the protection of a security guard, staying on top of shoplifting is a great challenge.
One worker at a charity shop on Burleigh Street, who didn't want to be named, said she had a bag of stock taken just half an hour before being interviewed by Cambridgeshire Live.
"Obviously being a charity shop you generally don't have that many staff," she explained. "Paid staff tend to be on their own with a lot of work to do.
"You're constantly up and down trying to keep tabs on people. "You don't always know it's happening.
"Certain things you notice are not there anymore. Some times you do have incidents where you see them do it or you see someone come in and you have an inkling."
She estimated that the store experienced shoplifting on a daily basis, but it was hard to be sure without a proper stock count system.
"It's especially bad on this side of town I think," she added.
"It does get morale down. You work hard to do something good for a good cause and people are coming and taking the good stuff. Why? Because it's easier.
"When comes to clothes, personally I'm not that bothered. If people are homeless, low on funds, in one way you're helping.
"But people coming and nicking DVDs and stuff – that's not going to help anybody."
Adam Ratcliffe said that there needed to be a national change on how low level crime was dealt with, to lift pressure on businesses.
This included streamlining the reporting process and encouraging people to record incidents.
"Anecdotally, we're looking at bigger businesses being hit with double figures a day," he said.
"I think we are looking at a staggering statistic, if not higher, of one in 15 that is actually reported.
"My message is that shop theft and business related crime is being overlooked because if can be overlooked and until members of the public and the businesses themselves actually report anything that happens the true scope of the problem won't be seen."
A spokesman for Cambridgeshire police said: "We have a new reporting process for businesses which allows retailers to send relevant CCTV footage directly to us and allows us to prioritise those investigations which stand the best opportunity for successful investigative outcomes whilst filtering out those offences for which no reasonable lines of investigation exist."
Crimes can be reported to the force online through its website: www.cambs.police.uk/report/Report.
Sir Donald George Bradman: Who was Don Bradman? Why is Google Doodle honouring him today?


Welcome to Toyah's 60th Birthday week… The amazing Brave New World was released as a single 36 years ago today. Accompanied by the greatest visual imagery by ANY pop star EVER! Happy Birthday to a truly iconic 20th Century pop moment. View Official Toyah's Instagram post on this by clicking below.