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LIMA — Beginning June 1, Putnam County residents can recycle their glass containers, removing about 155 tons of refuse from being deposited in landfills.
The Ohio Environmental Protection Agency awarded Putnam County a $100,000 grant to purchase glass collection bins and roll-off containers and to upgrade the transfer station as part of a county-wide recycling initiative. The county also will be working with Rumpke Recycling, who will be transporting and processing the glass.
"The grant money is solely to get our glass program up and running," Community Recycling Coordinator Ashley Siefker said, "and we will be able to sustain it once we get all these improvements made."
She said the county intends to contribute $24,000 to help with the purchase of recycling bins and to assist with any other costs.
Putnam County deposited about 140 tons of recycled glass in the Hancock County landfill during the past year, Siefker said, and the county spent about $9,000 per year in labor, transportation and fees to dump the glass at the landfill.
Commissioner Vincent Schroeder said county officials have been working hard on trying to find a market for recycled glass during the past year and "it was a constant problem that the Ohio EPA actually helped us solve."
When the program is fully operational, she estimates they should be able to remove more than 155 tons of glass from the county's waste stream and Putnam County Solid Waste Management District workers intend to actively seek recycled beverage containers and other types of glass from residents, restaurants, taverns and other sources to reach a greater level of glass recycling.
Within four years, Solid Waste officials anticipate glass recycling in Putnam County will surpass 200 tons annually.
"We are trying to be good stewards of the environment," Commissioner John Love said. "Our goal was to take a product, like glass, out of the waste stream and not to add to it. This offers a long-term solution."
The Solid Waste District is partnering with Rumpke Recycling to have the glass transported from the county for free. The recycled glass will be taken to Rumpke's glass recycling site for processing.
"Improvements in technology have made this transition possible," Commissioner Travis Jerwers said. "We no longer have to be selective about separating colors or size. Sophisticated machinery will do all the sorting in the Rumpke glass recycling facility in Dayton."
The county already recycles cardboard and paper, which includes newspapers and magazines, glass, plastic, and aluminum and other types of metal to reduce refuse reaching the landfill. In 2004, the county's recycling rate was 11 percent while the latest data shows the recycling rate for the county at 61 percent.


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3:41 pm
Mon November 9, 2009
Of 34 H1N1 deaths in Mich. this year, 4 had asthma
By AP
LANSING, MI – Michigan health officials urge people with asthma to get the seasonal and swine flu shots as soon as possible.
Chief medical executive Greg Holzman of Michigan's Community Health Department said Monday a third of those hospitalized nationally this year with H1N1 symptoms have had asthma.
He says four Michigan residents who had underlying asthma are among the 34 H1N1 patients who've died in the state since April.
He says those with asthma should see a doctor promptly if they get flulike symptoms so they can receive Tamiflu.
State health officials say since Sept. 1, 28 Michigan residents have died and 801 have been hospitalized. About 46,272 have shown signs of a flu-type illness this week.

subset: commoncrawl


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Dr. Lindsay Pope provides time-tested (fad-free) dental procedures and excellent care that lasts. She treats every patient like a member of her own family, doing everything possible to keep them feeling comfortable and secure
The post Dr. Lindsay Pope provides dental care for all ages appeared first on Fayette Woman.
An orthopaedic specialist, women's health specialist, and Pilates expert, Karyn Staples has helped people improve physically for more than 15 years. She is an engaged, active advocate for fitness and wellness and a member of the Pilates Method Alliance and the American Physical Therapy Association.
The post Karyn Staples is ProHealth, pro fitness, pro you appeared first on Fayette Woman.
Single on Valentine's Day? Here are a few things you can do to show love to yourself and your friends.
The post Single on Valentine's Day? Simple ways to be happy appeared first on Fayette Woman.
Coronary heart disease is the most common cause of death for women in the United States. Take the leap to beat heart disease.
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In strategic planning requires us to define our mission, vision, and values, all critical to "Mission You."
The post Mission You: A Strategic Plan for Your Life appeared first on Fayette Woman.
Don't like beets? No worries! These beet pancakes will put a little love on your breakfast table and may change your mind about this under-appreciated veggie.
The post Valentine Beet Pancakes appeared first on Fayette Woman.


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That was no less frustrating to watch in person.
I have the Braves. And Braves poser fans.
That was no less frustrating to watch in person.
I have the Braves. And Braves poser fans.
It seemed like Gonzales is always on the edge of balking (is that a word?). I guess he gets away with it because he's not moving his hands from the set position.
That would be extremely annoying to hit against, methinks.
"Bring on Rod Stupid!"
Anyone else have a bad feeling that this homestand is going to be a disaster? They lost a winnable game last night, and today they are facing Derek Lowe. Arroyo has pitched well so far, but I don't like our offense against Lowe. Tomorrow we have our fifth starter going against a guy they've never faced before. Monday they face Oswalt and Tuesday Wandy Rodriguez. I was hoping for a 3-3 or 4-2 homestand, but I'm not feeling confident right now...
I miss Adam Dunn.
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Erratum: Vol. 49, No. 45
In the Notice to Readers, "Shortage of Tetanus and Diphtheria Toxoids," an error occurred in the next to last sentence of the second paragraph. The sentence should read, "Arthritis-type reactions may occur among persons who receive multiple doses of tetanus toxoid-containing vaccines (TT or Td), especially within short intervals (<10 years)."
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NeurogesX Reports Fourth Quarter and Year-End 2008 Results
Qutenza(TM) Receives Positive Committee Recommendation in European Union
Corporate Highlights:
- CHMP issued positive opinion recommending approval of Qutenza(TM) (formerly NGX-4010) for treatment of peripheral neuropathic pain in non-diabetic adults either alone or in combination with other medicinal products for pain
- Qutenza NDA accepted for review by U.S. FDA for PHN
Upcoming 2009 Milestones:
- European commercial partnership for Qutenza anticipated first half of 2009
- European Commission decision on MAA for Qutenza for the treatment of peripheral neuropathic pain in non-diabetic adults alone or in combination with other medicinal products for pain anticipated first half of 2009
- FDA PDUFA date of
During 2008, NeurogesX continued to make significant progress on the regulatory front in
Regarding the European regulatory process for Qutenza, on
Fourth Quarter and Year-End 2008 Financial Results
Total operating expenses for the fourth quarter of 2008 were approximately
Net loss for the fourth quarter of 2008 was approximately
For the 12 months ended
Cash, cash equivalents and short-term investments were approximately
Development Update
NeurogesX' near-term focus is to secure regulatory approvals of the NDA and MAA for Qutenza. The CHMP's positive opinion recommending approval in the E.U. of Qutenza for the treatment of peripheral neuropathic pain in non-diabetic adults either alone or in combination with other medicinal products for pain, was made in reliance on NeurogesX' commitment to conduct certain post-marketing studies. These post-marketing commitments, which are often required by the CHMP as a condition of an approval recommendation, may include an open-label safety study of Qutenza in on-label indications, as well as a clinical safety and efficacy study in painful diabetic neuropathy. These studies could potentially be conducted and/or funded by a European commercial partner, and the timing for initiating such studies will be provided following the European Commission's decision regarding final marketing authorization for Qutenza.
NGX-1998, the Company's second-generation, liquid formulation of the same active ingredient found in Qutenza, has completed three Phase 1 studies. The most recent of these studies was in 36 healthy volunteers to evaluate potential control formulations for use in later-stage clinical studies. The liquid formulation may address neuropathic pain conditions in areas of the skin that are difficult to target through a dermal patch application, and potentially offers similar efficacy in a shorter application time versus Qutenza. NeurogesX is currently evaluating the timing to initiate Phase 2 development of NGX-1998.
NeurogesX continues to pursue business development opportunities to advance its opioid and acetaminophen prodrugs.
- NGX-9674 and NGX-5752, novel prodrugs of acetaminophen, have completed in vivo and in vitro preclinical studies, in which they demonstrated approximately 10 times greater solubility in water versus acetaminophen.
- NGX-1576, a novel prodrug coupling acetaminophen to a liver protectant, has been evaluated in vitro and in vivo. Equivalent dose levels of NGX-1576 in mice produced significantly less liver toxicity than acetaminophen, while additional data demonstrated the production of equivalent plasma levels of acetaminophen.
- NGX-6052, the most advanced molecule synthesized in NeurogesX' opioid prodrug platform, has been evaluated in proof of concept in vivo and in vitro preclinical studies for its potential to deliver therapeutic efficacy with an abuse-deterrent profile and improved side effect profile.
Conference Call Details
The Company will hold its quarterly conference call today at
To participate, please dial 1-877-407-0789 (
A replay of the conference call will be available beginning
About NeurogesX, Inc.
NeurogesX (NASDAQ: NGSX) is a biopharmaceutical company focused on developing and commercializing novel pain management therapies. Its initial focus is on chronic peripheral neuropathic pain, including postherpetic neuralgia (PHN), painful HIV-distal sensory polyneuropathy (HIV-DSP) and painful diabetic neuropathy (PDN). NeurogesX' late-stage product portfolio is led by its product candidate Qutenza(TM), a dermal high-concentration capsaicin patch designed to manage pain associated with peripheral neuropathic pain conditions, that the Company believes offers significant advantages over other pain therapies. NeurogesX submitted a new drug application (NDA) for Qutenza with the U.S. Food and Drug Administration (FDA) in
NeurogesX' second most advanced product candidate, NGX-1998, is a topically applied, liquid formulation containing a high concentration of capsaicin designed to treat pain associated with neuropathic pain conditions. NGX-1998 has completed three Phase 1 studies and NeurogesX is currently evaluating the timing of entering Phase 2 development.
NeurogesX' early stage product pipeline includes pre-clinical compounds which are prodrugs of acetaminophen and various opioids. The company has evaluated these compounds in vitro and in vivo and is currently seeking development partners for these programs.
Safe Harbor Statement
This press release contains forward-looking statements for purposes of the Private Securities Litigation Reform Act of 1995 (the "Act"). NeurogesX disclaims any intent or obligation to update these forward-looking statements, and claims the protection of the Safe Harbor for forward-looking statements contained in the Act. Examples of such statements include, but are not limited to, the expected timing and outcome of regulatory decisions and the label approval being sought or that may be obtained with respect to the MAA for Qutenza in the European Union and the NDA for Qutenza with the FDA, including the timing of European Commission approval of the MAA and the PDUFA date for the NDA; NeurogesX' plans, and expected timing, with regard to seeking partnerships for its product candidates, including potential commercial partners for Qutenza in the European Union and
NEUROGESX, INC. (A Development Stage Company) CONDENSED CONSOLIDATED STATEMENTS OF OPERATIONS (in thousands, except share and per share data) (unaudited) Three Months Ended Twelve Months Ended December 31, December 31, 2008 2007 2008 2007 Operating expenses: Research and development (1) $2,497 $5,654 $16,104 $25,321 General and administrative (2) 2,155 2,412 10,182 7,455 Total operating expenses 4,652 8,066 26,286 32,776 Loss from operations (4,652) (8,066) (26,286) (32,776) Interest income 56 443 1,057 1,673 Interest expense (152) (272) (792) (1,219) Other income (expense), net (40) 6 (14) 366 Net loss (4,788) (7,889) (26,035) (31,956) Accretion of redeemable convertible preferred stock - - - (4,626) Net loss attributable to common stockholders $(4,788) $(7,889) $(26,035) $(36,582) Basic and diluted net loss per share attributable to common stockholders $(0.27) $(0.58) $(1.49) $(4.06) Shares used to compute basic and diluted net loss per share attributable to common stockholders 17,553,133 13,570,572 17,519,415 9,017,627 Non-cash stock-based compensation expense included in operating expenses: (1) Research and development $148 $158 $745 $893 (2) General and administrative 185 184 755 869 $333 $342 $1,500 $1,762
NEUROGESX, INC. (A Development Stage Company) CONDENSED CONSOLIDATED BALANCE SHEETS (in thousands) December 31, 2008 2007 (unaudited) (1) Assets Current assets: Cash and cash equivalents $10,435 $31,478 Short-term investments 14,071 21,373 Prepaid expenses and other current assets 412 585 Restricted cash 40 - Total current assets 24,958 53,436 Property and equipment, net 468 453 Restricted cash 160 240 Other assets 4 56 Total assets $25,590 $54,185 Liabilities and Stockholders' Equity Current liabilities: Accounts payable $370 $1,712 Accrued compensation 1,039 680 Accrued research and development 1,067 1,198 Other accrued expenses 540 1,848 Notes payable - current portion 2,833 3,859 Total current liabilities 5,849 9,297 Non-current liabilities: Notes payable - non-current portion 191 3,024 Deferred rent 276 156 Accrued research and development - non-current - 347 Total non-current liabilities 467 3,527 Stockholders' equity: Common stock 18 17 Additional paid-in capital 209,370 205,417 Deferred stock-based compensation (2) (15) Accumulated other comprehensive income 32 51 Deficit accumulated during the development stage (190,144) (164,109) Total stockholders' equity 19,274 41,361 Total liabilities and stockholders' equity $25,590 $54,185 (1) The balance sheet at December 31, 2007, has been derived from the audited consolidated financial statements at that date.
NeurogesX, Inc. The Ruth Group Stephen Ghiglieri Stephanie Carrington / Sara Ephraim (investors) Chief Financial Officer (646) 536-7017 / 7002 (650) 358-3310 firstname.lastname@example.com firstname.lastname@example.com Jason Rando (media) (646) 536-7025 email@example.com
SOURCE NeurogesX, Inc.


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It's a freaking Tuesday night. What else could possibly be going to where you don't want to park yourself in front of the League Pass or illegal stream on the internet and enjoy six games of basketball joy?
Illusions, Michael… Tricks are what whores do for money
(Magic at Bobcats, 7:00PM EST)
It's pretty simple for the Charlotte Bobcats – all they need to do in order to win basketball games is play their games at home and hope Gerald Wallace grabs at least 15 rebounds in the game. But that's not a realistic thing to expect every time the Bobcats need a win, especially against a team like the Magic. In case you haven't heard, Dwight Howard is a giant eagle in a huge human Halloween costume. GM Otis Smith saw this giant eagle in a huge human Halloween costume and signed him to circle the backboard both ends of the floor and grab whatever bounces off of the orange circle attached to the fiberglass window. So even though the Bobcats are at home, it seems unlikely that the accompanying necessity for this Bobcats team to win is going to happen. Gerald Wallace isn't grabbing 15 rebounds in a game in which he's having to guard the perimeter and out-soar Dwight Howard for the boards. It's about as likely as throwing a letter into the ocean.
Hey! That was supposed to be OUR record… not yours! (Wizards at Heat, 7:30PM EST)
The Washington Wizards have a new coach, a new old star back in the lineup and some new depth. The problem is they have the same old record. The Heat on the other hand have an old center with old knees, their same old superstar and a looming decision for their star that could bring him back to his old hometown to play basketball next year. So why do they have records that don't match these scenarios? This sounds like the great plot to a Kate Hudson movie. Sign up McConaughey, slap a PG-13 rating for three curse words and a shirtless surfer, and you've got yourself the Wizards-Heat game. The Wizards are sorely missing Antawn Jamison to provide that extra scoring, even though Andray Blatche has solicited some improvement in his game this year. At the very worst, you're getting to see Gilbert Arenas and Dwyane Wade duke it out for 48 minutes while JaVale McGee and Michael Beasley have a "Who can be quirkier†contest in the tunnel.
The Latest DJ Hero Mashup: Melo Yellow Vs. Kiss From a Rose (Nuggets at Bulls, 8:00PM EST)
It's the return of J.R. Smith! I really shouldn't have to give you another reason to watch this game. For the first time after seven games of bliss and MVP talk for their star, Smith will return to jack up ill-advised shots whilst throwing gang signs at George Karl and texting Eddy Curry to see if he wants to go to a movie. But more importantly in this game, you'll get to see two small forwards who are playing out of their collective minds go at it. So far this season, Carmelo Anthony has re-written the Better Basketball DVDs with his amazing arrays of ways to score (imagine him in Rock'N'Jock!). Luol Deng on the other hand has proven that he's completely healthy and ready to live up to his insane contract. Oh by the way, he's grabbed 60 rebounds and turned the ball over only six times in six games. Normally, you'd laugh at me and tell me I'm crazy for saying that about Luol but this is no joke.
/poor excuse to post this picture
When playing Oregon Trail, I actually got Dysentery (Blazers at Grizzlies, 8:00PM EST)
I never really figured out what Dysentery is. It's one of those weird diseases like hypoglycemia or lactose intolerance that sounds completely made up. I've also never really figured out what the Grizzlies are doing with their team. The Allen Iverson experiment blew up after three games and the Zach Randolph explosion is advancing at a greater speed than that 1200-mile-in-diameter fire planet that Dallas Corbin and the hooker from He Got Game had to make out to stop in a temple in order to stop from destroying the Earth in The Fifth Element. I actually have no idea where I'm going with this but I watched that scene from that movie the other day and was utterly confused by the entire thing. Oh hey, look! It's Marc Gasol versus Greg Oden. This is actually a really great match-up – two of the better rebounding centers in the league trying to battle it out for board supremacy. Throw in Brandon Roy tossing daggers while Rudy Gay tries to harness his inner brilliance into something worthy of superstardom and wins. This may actually be the game of the night and that's saying something with these final two games coming up.
Hey T-Mac and Josh Howard, take your time coming back. We're actually better than expected (Rockets at Mavericks, 8:30PM EST)
I've started the Houston Rockets for Most Improved Player campaign and I'd like you to join me. I'm not picking Aaron Brooks, Trevor Ariza or Chuck Hayes to be the MIP. I want the entire team to win the award. It's really the only way this award will make sense this season. And none of these players should take away votes from the other. On the flip side, if you're only tuning into one quarter every night, make sure it's the fourth quarter of the Mavericks games. My god, it's down-right arousing what they seem to do with the final 12 minutes of a basketball game. You've got Dirk screaming after every made basket or successful three steps up the floor. JJ Barea is running under player's legs like a kid at an And 1 Mixtape Tour. Shawn Marion is dialing back the clock to five years ago and talking people into thinking this Mavs team can be a contender. Overall, this will just be two good teams winning basketball with completely different styles of jacking up threes.
Because I know something you don't know. I am not left-handed. (Thunder at Kings, 10:00PM EST)
The first time we had this contest this season, it was in OKC and the Kings were heavy with Kevin Martin free throws. Now, they've switched hands with their sword (due to his depressing injury) and are slaying teams (Jazz and Warriors). And it isn't just the inspiring play of Tyreke Evans who is literally having his way with opposing backcourts and not even bothering to leave money on the dresser when he leaves. It's Beno Freaking Udrih playing like he should have gotten more than the mid-level exception. It's Jason Thompson playing like he'll be an All-Star much sooner than your favorite young power forward will be and Omri Casspi become everybody's favorite rookie off the bench (No, it's NOT you, Chase Budinger). And all they have to do now is get revenge against a young team with foolish playoff hopes (more on that later this week – tease!). The fans voted incorrectly when they asked for the Bulls-Nuggets to be on NBATV. This is the game of the night and worth staying up for, East and Central coasts.


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This large grouper is so massive that it actually has a planetary system of small fish while floating in the Caribbean Sea.
Daniel Gabriel Angelo Jean-Baptiste was born on the Caribbean Island of Saint Lucia , in 1963, to parents of Dutch Jewish and African Carib descent. Jean-Baptiste childhood experience was that of a tiny one street Village of Choiseul, under the shadow of the towering Gros Piton. Spare time was spent fishing off the village�s long wooden jetty, which gave Jean-Baptiste first glimpses of the colourful creatures that inhabited the Caribbean Sea. The plants and fish that intrigued the young boy would later dominate his art. Childhood days were sweet, sweet as perfumed breezes of Saint Lucia. In 1978 he moved to Canada where he was introduced to silk painting during his eight years working with a commercial art for Display...
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37 year old woman | Burlington, ON, CAN | Seeking men 35-42 within 50 miles
I love to laugh.
It's tough writing about yourself...so..I'm going to take the easy route and talk about how my friends view me :-)....My friends describe me as kind, giving, outgoing, fun-loving, attractive, and intelligent.... I love getting dressed up for an evening out, but I'm equally as comfortable heading to a local pub to catch the game....or staying in to watch a good movie...(favorite movie...Its a Wonderful Life)....I have a great sense of adventure...love to zip line, water ski, sail, rollerblade....oh and did I mention...shop:-) I have a comfortable life and a great job... I am looking for someone who is in a similar place in life, that shares a similar sense of humour-I love to laugh...its the key to my heart:) My ideal guy must also be kind and fun loving...sound like you???
Coffee and conversation , Dining out , Movies/Videos , Music and concerts , Exploring new areas , Nightclubs/Dancing , Playing cards , Playing sports , Shopping/Antiques , Travel/Sightseeing , Volunteering , Watching sports , Wine tasting
Aerobics, Cycling, Dancing, Golf, Inline skating, Running, Swimming, Walking / Hiking
I exercise 5 or more times per week.
I have Dogs
I have a 3 year old Lab.
Middle of the Road
I love hanging out by the beach, or catching the game at a local pub. For me...its more about the company...even the most mundane of tasks can be made fun with the right person (or people):-)
Brock University, St. Catharines, ON
I love different types of music-from hip hop to jazz to bad 80's ballads. I'm a huge fan of indian, asian, italian foods (which means I pretty much like anything). I cannot function without coffee in the morning. I love to laugh:-)
I love to golf and take long walks/run with my dog.
First, Break all the Rules (for work)
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'7" (170cms)
|5'11" (180cms) to 6'5" (195cms)
|Body type:
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|No preference
|Auburn / Red, Black, Light brown, Dark brown, Blonde, Salt and pepper, Silver, Dark blonde
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Social Services
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|Never Married
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|Graduate degree
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Masters of Social Work


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Clarence Leonard Thompson
Position: HB
Height: 5-11 Weight: 172 lbs.
Born: September 28, 1914 in Montevideo, MN
Died: February 5, 2000 in Jacksonville, FL
High School: Montevideo
College: Minnesota (school history)
Weighted Career AV (100-95-...): 0 (14747th overall since 1950)
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|Joy seems to me a step beyond happiness -- happiness is a sort of atmosphere you can live in sometimes, when you're lucky. Joy is a light that fills you with hope and faith and love.
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Radiation therapy is the standard care for patients with breast cancer undergoing breast-conserving surgery (BCS), as it reduces recurrences and lengthens survival. The conventional radiation therapy regimen consists of approximately 25 treatments of 2 Gray (Gy; a measure of absorbed radiation dose) delivered over 5 to 6 weeks. Nonetheless, not all patients undergo radiation therapy following BCS; the duration and logistics of treatment may be barriers for some women. Accelerated radiotherapy approaches have been proposed to make the regimen less burdensome for patients with early-stage breast cancer at low risk of recurrence:
The critical question is whether these three approaches are equivalent in outcomes and adverse events.
Breast Conservation Therapy
Survival after breast-conservation therapy (BCT) is equivalent to survival after mastectomy for patients diagnosed with tumors categorized as stage I or II. BCT is a multimodality treatment that consists of BCS to excise the tumor with adequate margins, followed by whole-breast external-beam radiation therapy administered as 5 daily fractions per week over 5 to 6 weeks. Local boost irradiation to the tumor bed often is added to whole-breast irradiation to provide a higher dose of radiation at the site where recurrence most frequently occurs. For some patients, BCT also includes axillary lymph node dissection, sentinel lymph node biopsy, or irradiation of the axilla. A number of randomized, controlled trials (RCTs) have demonstrated that the addition of radiotherapy after BCS reduces recurrences and mortality. In an individual-level meta-analysis, the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) reported 5-year risk of local recurrence of 7.3% among breast-conserving-surgery patients allocated to radiotherapy versus 25.9% among those not (2p<0.00001; n=51,958 woman-years). (1) Whole-breast irradiation reduced the 15-year breast cancer mortality risk from 35.9% to 30.5% (breast cancer death rate ratio: 0.83; standard error [SE]=0.05; 95% confidence interval [CI]: 0.75, 0.91; 2p=0.0002; n=7,311 women); there was a similar reduction in mortality from all causes (5.3%, SE=1.8, 2p=0.005). Radiotherapy provided benefits for both node-negative and node-positive women.
Consequently, radiation therapy is generally recommended following BCS. A potential exception is for older women at low risk of recurrence. For example, the National Comprehensive Cancer Network (NCCN) guidelines state that women aged 70 or older may omit radiotherapy if they have estrogen-receptor positive, T1 tumors, clinically negative lymph nodes, and plans to take adjuvant endocrine therapy. (2)
Eight to 10 years of follow-up is needed to assess the outcomes from different treatments for early stage breast cancer. The EBCTCG individual-level meta-analysis provides data on the pattern of recurrences among BCS patients with and without radiotherapy for more than 10 years. In web figure 6a (Available online at: http://www.ctsu.ox.ac.uk/~ebctcg/local2000/annex.pdf , data on the percentage of patients per year with isolated local recurrence is 2.7% and 9.0% for those with and without whole-breast irradiation, respectively, in year 0; 1.5% and 4.8% in years 1–2; 1.1% and 3.7% in years 3–4; 0.8% and 1.9% in years 5–9; and 0.2% for both groups in years 10 and higher (trend χ21=4.3, 2p=0.04). While the recurrence rate falls over time, it persists for more than 10 years. In another study, local recurrence was highest between years 3 to 5 of follow-up, and 67% of events took place in the first 5 years. However, that means 33% of events took place after 5 years. (3) For additional information on the length of follow-up needed, see the two TEC Assessments on APBI. (4,5)
Most patients diagnosed with stage I or II breast cancer now are offered a choice of BCT or modified radical mastectomy, but BCT is selected less often than expected. Studies have shown that those living furthest from treatment facilities are least likely to select BCT instead of mastectomy and most likely to forgo radiation therapy after BCS. (6-8) A study using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) tumor registries from 1992 to 2002 examined how many women with early stage (I or II) breast cancer received radiotherapy within 4 months following BCS. (9) After adjusting for age, they found that in 2002, 30.8% of Caucasian women and 44.7% of African-American women had not received radiotherapy. Furthermore, these rates had increased from 24.7% for Caucasians and 34.0% for African Americans in 1992.
Given that duration and logistics appear to be barriers to completion of treatment, there has been interest in developing shorter radiotherapy regimens. Two approaches have been explored.
The first method is to provide the same dose to the whole breast in a shorter time by increasing the dose provided per treatment (hypofractionation). This approach was initially avoided out of concern that increasing doses to target the tumor more effectively might induce more severe adverse events from radiation exposure, thus, tipping the balance between benefits and harms. More recent research, some of which is highlighted below, has allayed some of these concerns. AWBI has been used especially in Canada and Europe.
The second approach to reducing radiotherapy treatment time is APBI. It differs from conventional whole-breast irradiation in several ways. First, the radiation only targets the segment of the breast surrounding the area where the tumor was removed, rather than the entire breast. This approach was based in part on the finding that recurrences are more likely to occur close to the tumor site rather than elsewhere in the breast. Second, the duration of treatment is 4 to 5 days (or 1 day with intraoperative radiotherapy) rather than 5 to 6 weeks, because the radiation is delivered in fewer fractions at larger doses per fraction to the tumor bed. Third, the radiation dose is intrinsically less uniform within the target volume when APBI uses brachytherapy (i.e., the implantation of radioactive material directly in the breast tissue). The major types of radiotherapy used after BCS are outlined in Table 1. They differ in their techniques, instrumentation, dose delivery, and possibly in their outcomes.
Table 1. Major types of radiation therapy following breast-conserving surgery
RT Type
Whole (W) or partial (P) breast
External beam (E) or brachytherapy (B)?
Approx duration of treatment
Published RCTs (length of follow-up in yrs)
* Interstitial brachytherapy entails placement of multiple hollow needles and catheters to guide placement of the radioactive material by a remote afterloading device. It is more difficult to perform than other types of brachytherapy and has a steep learning curve.
To appreciate the differences among radiotherapy techniques, it is useful to understand attributes of radiation delivery. The goals of cancer radiotherapy are usually to provide the tumor or tumor bed with a high dose of homogeneous radiation (e.g., all parts of the tumor cavity receive close to the targeted dose). Areas adjacent to the tumor may be treated with a lower dose of radiation (e.g., with whole-breast irradiation, to treat any unobserved cancerous lesions). Radiation outside the treatment area should be minimal or non-existent. The goal is to target the tumor or adjacent areas at risk of harboring unseen cancer with an optimum dose, while avoiding healthy tissues.
Brachytherapy Boost with Whole Breast Irradiation
Brachytherapy has been used as an alternative to external beam radiation therapy to deliver boost radiation therapy combined with whole-breast external-beam radiation therapy. Most of the studies of local boost brachytherapy use temporarily implanted needles, wires, or seeds after patients recovered from surgery and completed whole-breast radiation therapy. Studies have not shown the superiority of boosting with brachytherapy compared to photon and electron boost, and brachytherapy may yield an inferior cosmetic result. Therefore brachytherapy as a boost is not considered medically necessary.
Regulatory Status
The various radiotherapy modalities presented in this report have been approved or cleared for marketing by the U.S. Food and Drug Administration (FDA) (for more details, see Appendix in TEC 2010 [4]). All brachytherapy devices have been approved through the 510(k) process and are either balloon brachytherapy or hybrid balloon-interstitial brachytherapy devices. The FDA has required a black box warning on each stating that "The safety and effectiveness of the … [brachytherapy device] as a replacement for whole breast irradiation in the treatment of breast cancer has not been established.
Participating Providers are required to Prior authorize radiation oncology/therapy for Blue Cross Blue Shield of Montana (BCBSMT) Members eligible for the CareCore Program. To authorize, Utilize CareCore National's website: http://www.carecorenational.com/ or call 1-866-668-7446, option1. Services that are not prior authorized will be denied. For benefit questions call (BCBSMT) Customer Service at 1-800-447-7828.
For Non-Eligible Members, Out of State Providers, and Non-participating providers Prior authorization is recommended. To authorize, call Blue Cross and Blue Shield of Montana (BCBSMT) Customer Service at 1-800-447-7828 or fax your request to the Medical Review Department at 406-441-4624. A retrospective review is performed if services are not prior authorized.
Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.
Medically Necessary
BCBSMT considers accelerated whole breast irradiation and partial breast irradiation medically necessary for clinically appropriate patients.
Not Medically Necessary
BCBSMT considers the use of interstitial or intracavitary brachytherapy boost to be not medically necessary.
BCBSMT considers the use of single-fraction adjuvant intraoperative radiotherapy and the AccuBoost technique to be experimental, investigational, and unproved.
Policy Guidelines
There are several techniques of APBI:
The ASTRO and NCCN practice guidelines state that appropriate schemes for APBI are 34 Gy in 10 fractions delivered twice per day with brachytherapy or 38.5 Gy in 10 fractions delivered twice per day. It is therefore appropriate at present to reimburse for up to 10 fractions (whether external-beam or brachytherapy) for APBI.
Interstitial brachytherapy was commonly used for performing the boost during the development of breast-conserving therapy. While the use of brachytherapy in giving the boost is recognized in the current NCCN guidelines, it does not improve tumor control compared to external-beam boost and results in worse cosmesis. Other brachytherapy techniques (such as Mammosite balloon brachytherapy system) and intraoperative radiotherapy have also been used to perform the boost, but again they have not been shown to be superior to external-beam boosts. Therefore, the use of interstitial or intracavitary brachytherapy or intraoperative radiotherapy in this role is considered not medically necessary. Rare exception to this guideline will be considered for patients who underwent intracavitary brachytherapy or intraoperative radiotherapy under the assumption that these modalities would be used for definitive treatment with APBI, but in whom additional information during or after the completion of the procedure was felt to warrant the use of WBI (e.g., finding positive excision margins).
This policy regarding accelerated breast irradiation following breast-conserving surgery (BCS) for early stage breast cancer is based on a TEC Assessment released in July 2010. (4) This policy substantially revises and replaces, Breast Brachytherapy after Breast-Conserving Surgery, as Boost with Whole Breast Irradiation, or Alone as Accelerated Partial-Breast Irradiation. The use of brachytherapy as boost with whole breast irradiation continues to be considered medically necessary and is not discussed further in this policy. A new radiotherapy regimen, accelerated whole-breast irradiation (AWBI) therapy, has been added to this policy. Intraoperative radiation therapy is also added to this policy.
Accelerated Whole-Breast Irradiation
Four randomized, controlled trials (RCTs) compared accelerated whole-breast radiotherapy to 5-week whole-breast radiotherapy, as well as a fifth, older, nonrandomized study. (3,10-14) Two of the studies are particularly useful, as they directly compare a 5-week to a 3-week regimen. They are both prospectively designed noninferiority trials. Both trials accepted a maximum loss of efficacy of 5 percentage points in local or local-regional recurrence in the accelerated group at 5 or 10 years (one-sided α=0.025 or 0.05). Although the studies differ in the specific fractionation schedules and patient characteristics, they report no difference in local recurrence rates (i.e., recurrence of the cancer in the same breast) across treatment arms.
One study from the United Kingdom includes women with grade 1–3 tumors. (10) Approximately 75% of the women have negative lymph nodes, and approximately 42% had a radiation boost to the tumor bed. Randomization was stratified for hospital, type of surgery (about 15% had a mastectomy), and plans for tumor bed boost. Systemic therapy, primarily tamoxifen, was used by some patients and appears to be fairly evenly distributed across treatment groups. The treatment arms compared a total dose of 40 Gy in 15 fractions over 3 weeks to 50 Gy in 25 fractions over 5 weeks. The hazard ratios for 40 Gy accelerated whole breast radiotherapy versus conventional whole breast radiotherapy were not statistically significant (using the log-rank test) for local or local-regional relapse. The absolute difference in local-regional relapse rates after 5 years was −0.7% (95% CI: −1.7%, 0.9%). There were statistically significant differences in the two treatment regimens for distant relapse and overall survival (OS), with relapse more frequent and survival longer for the 40 Gy accelerated whole breast irradiation (AWBI). This unexpected difference between treatment arms began to appear at about 1 year. The authors speculate that it could be due to chance and might change with longer follow-up. An article on patient-reported breast, arm, and shoulder symptoms, as well as body image, over 5 years of follow-up for both Standardisation of Breast Radiotherapy (START) trials was published in March 2010. (15) At 5 years' follow-up, there is no evidence that providing radiotherapy in fewer, larger fractions increases these adverse events. The 6-year follow-up period on this trial is too short to reach firm conclusions; follow-up continues.
The second RCT from Canadian researchers compared AWBI versus whole-breast irradiation. (11,12) Of 2,429 eligible patients, 51% agreed to participate in the trial. Intention-to-treat (ITT) analysis was used. The 10-year local recurrence was 6.2% for the 42.5 Gy arm AWBI arm and 6.7% for the conventional 50 Gy whole-breast irradiation (absolute difference: −0.5%, 95% CI: −2.5%, 3.5%). Local recurrence rates with accelerated whole breast radiotherapy were not worse than conventional whole breast irradiation, when applying a noninferiority margin of 5%. In "exploratory" subgroup analyses, treatment effects were similar by age, tumor size, estrogen-receptor status, and chemotherapy use (48% had no systemic therapy). However, local recurrence at 10 years for patients with high-grade tumors was 4.7% for the conventional whole breast irradiation arm and 15.6% for the 42.5 Gy AWBI arm. The absolute difference equals −10.9 percentage points (95% CI: −19.1, −2.8, test for interaction, p=0.01).
The overall body of evidence on AWBI compared to conventional whole-breast irradiation suggests local recurrence rates with accelerated whole breast radiotherapy were not worse than conventional whole breast irradiation in patients meeting the criteria of the Canadian trial, when applying a noninferiority margin of 5%. Longer follow-up is needed for the United Kingdom trial.
Patient selection is key, and at this point, only patients similar to those in the Canadian trial should be considered for this therapy. Outcomes could vary in women with other disease characteristics. The patients in this trial all had invasive carcinoma of the breast with negative lymph nodes and surgical margins, and they did not have a radiotherapy boost to the tumor site. Exclusion criteria for the trial included "invasive disease or ductal carcinoma in situ involving the margins of excision, tumors that were larger than 5 cm in diameter, and a breast width of more than 25 cm at the posterior border of the medial and lateral tangential beams, which could increase the heterogeneity of the radiation dose to the breast." In the trial, lymph node status was determined by axillary dissection, but recent reports suggest that sentinel lymph node biopsy is likely to be as effective. (e.g., see 16) Forty-one percent of the women took tamoxifen, despite the fact that 71% were estrogen-receptor positive.
Patients selecting this accelerated whole breast radiotherapy should be told that while the current evidence on this radiotherapy regimen is strong, it is not as strong as that for conventional whole-breast irradiation. Additional RCTs or longer follow-up of the existing trials could uncover additional concerns. Some potential adverse events, such as cardiac ischemia, may take longer to become evident. This regimen has been widely used outside the U.S. without substantial reports of major adverse events. Potential patients should be carefully selected and given full information, while the results of longer follow-up for the START B trial are awaited.
Accelerated Partial-Breast Irradiation
There are three RCTs on interstitial, external-beam, or intraoperative accelerated partial-breast irradiation (APBI) compared to conventional whole-breast irradiation, as well as 7 nonrandomized comparative studies. (17-28) These studies evaluated interstitial, external, or intraoperative brachytherapy; no published comparative studies were found that assessed balloon brachytherapy. For the first, accrual was stopped before reaching the goal specified to evaluate differences in local recurrence, to allow patients to participate in another trial. (17-19) The randomization process was unclear, patients deemed "technically unsuitable" for interstitial brachytherapy were given external-beam APBI; and the patient characteristics and outcomes for each type of APBI were not reported separately. Finally, the sample size of 126 was relatively small, and longest follow-up reported was 66 months. Similar local and regional failure rates were found in the treatment arms.
The second RCT on APBI was reported in 1990 and 1993, and many changes in the care of breast cancer have occurred since. (20,21) The study was weakened by the fact that the initial groups were potentially unbalanced, and nodal status was based on clinical exam, among other factors. Recurrence was higher for the "limited field" treatment arm (analogous to partial-breast irradiation) than for the "wide field" arm (analogous to whole breast irradiation), but some of the "excess" recurrences in the limited field arm were axillary. This may be accounted for by the fact that the axillary area was included in the wide field radiotherapy but not in the limited field; and the initial work-up for nodal involvement was limited. The follow-up was 65 months; and the sample size, 708.
The third randomized trial compared intraoperative to external-beam accelerated partial-breast irradiation and was published online after the completion of the TEC Assessment. (22) It is a noninferiority trial with 28 centers in 9 countries and a sample size of 2,232. An ITT approach was used; 89% of the intraoperative group and 92% of the external radiotherapy group completed treatment. Patients were not blinded to treatment choice. As anticipated in advance, 14% of those in the intraoperative arm received external beam radiotherapy as well, because of unfavorable pathologic features determined after surgery, e.g., lobular carcinoma. The pre-defined noninferiority margin was an absolute difference of 2.5% between groups for pathologically confirmed, ipsilateral local recurrence. After 4 years, wound seroma needing more than three aspirations was significantly more common in the intraoperative group than in the external radiotherapy group (2.1% vs. 0.8%,respectively; p=0.012). Conversely, Radiation Therapy Oncology Group (RTOG) toxicity grade of 3 or 4 was more common in the external radiotherapy group than in the intraoperative group (2.1% vs. 0.5%, respectively; p=0.002). The 4-year local recurrence rates in the ipsilateral breast were 1.20% (95% CI: 0.53%, 2.71%) in the intraoperative radiotherapy arm vs. 0.95% (95% CI: 0.39%, 2.31%) in the external radiotherapy arm (difference between groups=0.25%, 95% CI: -1.04%, 1.54%; log-rank test, p=0.41). Local recurrence rates after 4 years with intraoperative radiotherapy were not worse than with external irradiation, when applying a noninferiority margin of 2.5%. Fortunately for the patients, the recurrence rates are low: 6 in the intraoperative group versus 5 in the external radiotherapy group. But these small numbers make it more difficult to detect real differences between arms, if they exist. Also, while the results are interesting, the follow-up of 4 years is insufficient to reach a conclusion on the comparative benefits and adverse events of these two treatments.
The other 7 nonrandomized, comparative studies were all flawed, due to potential baseline differences in treatment groups, lack of multivariable analyses to account for them, inclusion of patients who did not meet eligibility criteria, variations in treatment within arms, and generally small sample sizes and insufficient follow-up. (23-31)
Overall, the body of evidence on interstitial APBI compared to conventional whole-breast irradiation is weak; and it is extremely weak (i.e., no comparative studies) for balloon brachytherapy and external-beam APBI. The strongest published evidence is on intraoperative radiotherapy, but the follow-up is insufficient at this time. Furthermore, it is becoming increasingly clear that each type of APBI should be judged on its own merits, and studies comparing different APBI techniques to each other, as well as to whole-breast irradiation, are needed. Fortunately, a number of large RCTs are underway.
Given the current level of evidence, it is important for patients to be aware of the uncertainty regarding the outcomes of this approach. This information should include failure rates for the specific devices (e.g., explantation for Mammosite, incomplete expansion of the catheters for some of the hybrid devices), as well as the uncertainty regarding their comparative effectiveness. The intermediate alternative provided by AWBI should also be presented to women who meet the criteria for the Canadian trial, as well as the critical importance of completing radiotherapy for the majority of patients undergoing BCS.
A large, multicenter RCT of APBI versus whole-breast irradiation was initiated in 2005 to compare APBI to whole-breast irradiation. It is led by the National Surgical Adjuvant Breast and Bowel Project and the Radiation Therapy Oncology Group and referred to as NSABP B-39/RTOG 0413 (available online at: www.rtog.org). Patients are randomized to whole-breast irradiation (total dose: 60-66.6 Gy) or APBI (total dose: 34-38.5 Gy). Within the APBI group, the participant's physician may choose whether to use interstitial brachytherapy, Mammosite balloon brachytherapy, or external beam radiotherapy using 3-dimensional, conformal radiation therapy (3D-CRT). The initial target sample size of 3,000 was increased to 4,300 in 2007. The accrual targets for the women with a lower risk of recurrence were met by the end of 2006; only women in the higher risk groups are still being recruited. As of Sept 2008, 3,236 patients had been accrued, of whom 2,948 were White, 204 Black/African American, and 110 Latino/Hispanic. Final data collection for the primary outcome measure is scheduled for June 2015. There are another 6 RCTs on the use of APBI versus whole breast irradiation underway, as well as two trials comparing two forms of APBI (available online at: www.clinicaltrials.gov; see Appendix I). There is also a study on using ABI as a boost with whole breast irradiation and 3 randomized trials comparing standard whole breast irradiation and AWBI. It appears that the first randomized trial that compares recurrence for APBI and whole breast irradiation will be completed in November 2014. The study is being conducted by the University of Erlangen-Nurnberg Medical School and has 1,300 participants.
In a review of the APBI trials currently underway, Mannino and Yarnold (note Yarnold is a lead author on the START A and B trials) raise several concerns regarding variations across the trials. (32) The extent of the initial BCS can vary substantially across studies, as well as the definition of the targeted tumor cavity. A larger margin is usually drawn around the tumor cavity for 3D-CRT, for example, because of the need to allow for variations in set-up and respiration motion. Studies of APBI usually distinguish between "same site relapse," i.e., close to the irradiated area and "elsewhere relapse," yet it is unclear whether what constitutes the same site varies across studies. The percentage of relapses occurring "elsewhere" in the ipsilateral breast in studies of whole-breast radiotherapy following BCS range from 18% to 42% (these studies may include some patients at higher risk of recurrence). Proponents of APBI have sometimes asserted that "elsewhere" tumors are rare, that they are mostly new primary tumors (rather than a recurrence), or that earlier studies have shown that radiotherapy is not effective on these tumors in any case. Mannino and Yarnold challenge each of these points in turn, although they also conclude that the results of the trials currently underway will provide level-1 evidence for or against APBI.
Use as Local Boost Radiotherapy
This section is based on a 1996 TEC Assessment that concluded net health outcomes after brachytherapy for local boost were equivalent to outcomes after external beam radiation therapy for local boost in women given BCS plus whole-breast radiation therapy as initial treatment for stage I or stage II breast cancer. In 7 nonrandomized comparisons (total N=2,022), the rate of local control at 5 years after treatment was 88–98% for those given brachytherapy for local boost, compared to 91–99% for those given external-beam radiation therapy.
Clinical Input Received through Physician Specialty Societies and Academic Medical Centers
In response to requests, input was received from 1 physician specialty society and 4 academic medical centers while this policy was under review in 2011. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. There was near-unanimous support for the policy statement regarding accelerated whole-breast irradiation (AWBI). The input was mixed regarding accelerated partial-breast irradiation (APBI); those agreeing with the conclusion noted the need to define the risks and benefits of this approach in patient subgroups and noted that current data are inconclusive concerning the effectiveness of APBI compared to whole-breast irradiation.
The overall body of evidence on accelerated whole-breast irradiation (AWBI) compared to conventional whole-breast irradiation suggests local recurrence rates with accelerated whole breast radiotherapy were not worse than conventional whole breast irradiation in patients meeting the criteria of the Canadian trial, when applying a noninferiority margin of 5%. Patient selection is important, and at this point, only patients similar to those in the Canadian trial should be considered for this therapy. Thus, accelerated whole-breast irradiation may be considered medically necessary for these patients with clinical characteristics noted in the medically necessary policy statement. Outcomes could vary in women with other disease characteristics.
Overall, the body of evidence on interstitial APBI compared to conventional whole-breast irradiation is weak; and it is extremely weak (i.e., no comparative studies) for balloon brachytherapy and external-beam APBI. The strongest published evidence is on intraoperative radiotherapy, but the follow-up is insufficient at this time. Furthermore, it is becoming increasingly clear that each type of APBI should be judged on its own merits, and studies comparing different APBI techniques to each other, as well as to whole-breast irradiation are needed. Thus, these techniques are considered investigational. Fortunately, a number of large randomized, controlled trials are underway to provide additional data.
Practice Guidelines and Position Statements
According to the National Comprehensive Cancer Network (NCCN) guidelines, (2) "Preliminary studies of APBI suggest rates of local control in selected patients with early stage breast cancer may be comparable to those treated with standard whole breast RT. Follow-up, however, is limited and studies are on-going. Patients are encouraged to participate in clinical trials. If not trial eligible, per the consensus statement from the American Society for Radiation Oncology (ASTRO), patients who may be suitable …." (see below). Intraoperative radiotherapy with a single dose can be performed at those institutions with the expertise and experience. For whole-breast radiotherapy, NCCN recommends either a conventional whole-breast irradiation regimen or a total dose of 42.5 Gy with 2.66 Gy per fraction, which equals 16 fractions. Although the NCCN guidelines do not specify the duration of treatment, the latter is presumably an accelerated whole-breast irradiation regimen. A boost to the tumor bed is recommended for higher risk whole breast radiotherapy patients, i.e., those who are younger than 50 years-old and have positive axillary nodes, lymphovascular invasion, or close margins.
The American Society of Breast Surgeons and the American Society for Radiation Oncology (ASTRO) have issued guidelines for the selection of patients for APBI, which are summarized in Table 2. (33) According to the authors, the impetus for this guideline was the increased use of APBI outside of clinical trials, even as the results of those trials are awaited. The authors cite estimates that more than 32,000 women have already been treated with the MammoSite,® a mechanism for delivering APBI. The statement says that the guidelines are based on the results of a systematic review, which is not described in much detail, and expert opinion.
Table 2. Professional medical society criteria for performing APBI
ASTRO Criteria: "Suitable"
ASTRO Criteria: "Cautionary"
ASTRO Criteria: "Unsuitable"
Criteria for APBI from American Society of Breast Surgeons
Patient factors
Pathologic factors
Nodal factors
Treatment factors
♦ = not reported
*Strongly encouraged to enroll in NSABP B-39/RTOG 04-13 trial.
Key: DCIS, ductal carcinoma in situ; EIC, extensive intraductal component; ER status, estrogen receptor status; LCIS, lobular carcinoma in situ; LVSI, lymphovascular space invasion; N stage, nodal stage; T stage, tumor stage.
Sources: 33-35
Several studies have tried to assess the validity of these recommendations, by comparing recurrence rates retrospectively for patients that meet the criteria for one or more of these categories. Beitsch et al. used data from the American Society of Breast Surgeons MammoSite® Registry. (36) The database does not contain data on all of the elements in the recommendations (multifocality, multicentrality, presence of lymph-vascular space invasion, histology of invasive cancer, BRCA 1 or 2 mutation, and type of nodal surgery performed). Of the total of 1,449 patients in the Registry study, 1,025 (70.7%) could be grouped into the Consensus Statement categories. Of these, 176 fell in the unsuitable category (73.9% were under 50 years-old; 21.6% had positive nodes; 10.2% had more than 2 characteristics that put them in this category; 7.4% had positive margins; 5.1% had extensive intraductal component greater than 3 cm; and 3.4% had tumors greater than 3 cm). The 5-year actuarial rate of ipsilateral breast tumor recurrence was 5.25% in this group (7 patients; 2 at lumpectomy site and 5 elsewhere); 4.04% in the suitable or cautionary categories (24 of 849 patients; 8 recurrences at the lumpectomy site and 16 elsewhere). This difference was not statistically significant (p=0.3223). There were no other statistically significant differences between these two groups for any of the other outcomes reported either: regional nodal failure, distant metastases, disease-free survival, cause-specific survival, and overall survival. Another study that appears to be using the data on the same patients but was able to assign them to all three consensus statement categories (suitable, cautionary, and unsuitable) reached the similar conclusions. (37) A third study compared 199 patients at a single institution who underwent APBI with 199 matched controls who received whole breast irradiation. (38) When each group was stratified into the three categories in the ASTRO consensus statement, there was no statistically significant difference in the 10-year, ipsilateral breast recurrence rates across categories. There did appear to be a statistically significant difference across the categories for the patients treated with APBI, with no patients in the suitable group having distant metastases at 10 years versus 7.1% of the cautionary group and 11.2% of the unsuitable group (p=0.018); this statistically significant trend was not repeated in the patients receiving whole breast irradiation. Similarly, a statistically significant difference in regional nodal failure at 10 years was evident among all patients (0% for the suitable group; 0.7% for the cautionary group; and 4.0% for the unsuitable group); but not for either the APBI or whole breast irradiation group. The authors state that little evidence was available for the consensus panel in deciding which patients were not suitable and called for further research. The generalizability of the findings is open to question, however, because of the small number of events upon which these calculations are based, as well as missing data elements in the MammoSite® registry that are included in the consensus statement categorization. One researcher was an author on all three articles.
ASTRO released guidelines on fractionation for whole breast irradiation in 2010. (39) They rely on the Canadian trial (11,12), START A (14) and START B, (10) and the Owen/Yarnold trial (3,13). They conclude that "Data are sufficient to support the use of HF-WBI [hypofractionated or accelerated, whole breast irradiation] for patients with early breast cancer who meet all of the aforementioned criteria," including aged 50 years or older, disease Stage pT1-2 pN0, no chemotherapy, and treatment with radiation dose homogeneity within + 7% in the central axis plane. The task force did not agree on whether it is recommended to use HF-WBI when receiving a tumor boost.
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2 May 2012 - At Long Last - 38 Comments
NVIDIA Publishes New PTX Back-End For LLVM
NVIDIA this week announced their release of the "NVPTX" back-end for LLVM with the hope to replace the existing PTX (Parallel Thread Execution) back-end inside this compiler infrastructure. This open-source code coming out of NVIDIA is based upon their internal sources.
28 April 2012 - NVPTX - 3 Comments
NVIDIA Confirms Linux Driver Problems
Yesterday I reported on it appearing the 295.40 NVIDIA Linux driver effectively fell off a cliff with a range of performance regressions, stability issues, and other problems. This issue has been confirmed by NVIDIA and they're working to address the situation.
17 April 2012 - NVIDIA 295.40 - 5 Comments
Did The NVIDIA 295.40 Linux Driver Fall Off A Cliff?
While the NVIDIA 295.40 Linux graphics driver closes a high-risk security vulnerability, there's many reports coming in that the proprietary driver's performance has effectively fallen off a cliff and also caused stability issues.
16 April 2012 - Dropping Hard - 19 Comments
A NVIDIA Tegra 2 DRM/KMS Driver Tips Up
Besides a binary driver update from the GeForce/Quadro camp coming out today, a basic DRM/KMS driver for NVIDIA's ARM-based Tegra 2 SOC has appeared this morning.
11 April 2012 - TEGRA-DRM - 6 Comments
NVIDIA 295.40 Closes High-Risk Security Flaw
NVIDIA's Linux team this morning announced the immediate release of the 295.40 Linux driver. There aren't many changes for this release compared to the recent 295.33 driver release, but it does address a high-risk security vulnerability.
11 April 2012 - NVIDIA Linux Driver - 16 Comments
Gdev: A Competitive Open-Source CUDA Implementation
Shinpei Kato, the developer that last year at XDC2011 Chicago presented TimeGraph as an open-source GPU Linux command scheduler and PathScale's GPGPU run-time, has something new to share. Shinpei's latest project is Gdev, which comes down to being an open-source CUDA implementation that's competitive to NVIDIA's proprietary stack.
29 March 2012 - Gdev - 6 Comments
NVIDIA Releases 295.33; Kepler Gallium3D Soon
On the same-day as releasing the NVIDIA GeForce GTX 680 as the first GeForce graphics card based upon the new Kepler architecture, there's a binary driver update from NVIDIA that ushers in the official Kepler Linux support. There's also more surprising news out of the reverse-engineering Nouveau camp, on top of their surprises earlier today.
22 March 2012 - NVIDIA GeForce 600 - 10 Comments
NVIDIA GeForce GTX 680 "Kepler" On Linux?
NVIDIA has finally introduced their first Kepler-based graphics card: the GeForce GTX 680. The new Kepler graphics architecture is an exciting successor to Fermi, but how well does this new graphics processor work under Linux? Here's a glimpse in what to expect for the NVIDIA GeForce GTX 600 series on Linux.
22 March 2012 - GeForce GTX 680 - 33 Comments
NVIDIA Tegra 3 Makes For Fast Ubuntu On ARM
Here are the first set of Phoronix.com benchmarks of the quad-core NVIDIA Tegra 3. Needless to say, four Cortex-A9s combined with NVIDIA graphics leads to a fairly fast ARMv7 experience when running Ubuntu Linux.
17 March 2012 - cardhu - 12 Comments
NVIDIA Is Joining The Linux Foundation
NVIDIA will be joining the Linux Foundation, per an announcement coming out in the morning. But for open-source Linux fans, will this be a reason to rejoice about NVIDIA potentially moving forward with open-source drivers? Don't break out the champagne quite yet.
7 March 2012 - Rejoice? - 18 Comments
State Of NVIDIA's VDPAU, A New Community List
Now that NVIDIA's Video Decode and Presentation API for Unix (VDPAU) has a public list, will NVIDIA be engaging more with the open-source driver community?
25 February 2012 - VDPAU - 1 Comment
There's Hope For DMA-BUF With Non-GPL Drivers
There's some resurrected hope for the kernel symbols of the DMA-BUF buffer sharing mechanism to be not restricted to only GPL drivers, which started off as a request by NVIDIA. This could lead to better NVIDIA Optimus support under Linux, among other benefits.
20 February 2012 - DMA-BUF - 43 Comments
NVIDIA Releases 295.20 Linux Drivers
NVIDIA this morning formally released the 295.20 display drivers for Linux x86/x86_64.
13 February 2012 - New Release - 39 Comments
NVIDIA Releases New Driver For X.Org Server 1.12
Last week NVIDIA released a new beta Linux driver that is supportive of X.Org Server 1.12.
6 February 2012 - It's Here - 4 Comments
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Just a quick one. Tommy Wonders Wild card routine "tamed card" is among my favourites - what a great routine and act. So I'm getting all my acting skills in to it.
Currently I'm using a bit of double scotch tape to stick the two cards together. Tommy wonder uses wax, but what sort? There are so many different waxes out there - which one is best used to stick two cards together without smearing, getting black or otherwise ruining the cards? Hope you can help me.


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A sign on the door of the house reportedly read "Premises is perilous to life," and it was not a joke or an exaggeration. When the ASPCA and the NYPD entered the Queens home on Thursday, July 31, what we found was horrific—and heartbreaking.
Multiple dogs, many of whom were emaciated, scarred, and wearing heavy chains, were found without access to food or water. A bloody treadmill—a tool used to train dogs for fighting—weighted harnesses, steroids, syringes and other dog fighting paraphernalia were found in the home. At least one dog had deep scratch marks raked across its face.
Uniformed NYPD patrol officers from the 113th Precinct responded immediately to a complaint of dog fighting, called the ASPCA helpline, and less than 24 hours later both the NYPD and ASPCA—with the assistance of NYPD's newly appointed Animal Cruelty Investigation Squad—were able to mobilize resources. Siblings Addison Holder, 44, and Keisha Hall, 33, are currently facing charges of animal fighting, unauthorized practice of veterinary medicine and felony drug possession, and are each being held on $100,000 bail. A third defendant was arrested on Wednesday, August 6.
The ASPCA has taken custody of the 20 canine victims found in the home. They are now receiving food, water, enrichment and love—many for the first time in their lives.
"Organized dog fighting is a brutal form of animal abuse where dogs are exploited and forced to fight as their owners profit from their torture," says Matthew Bershadker, President and CEO of the ASPCA. "Through our partnership, the ASPCA and the NYPD are determined to protect New York City's animals from this form of cruelty and bring their abusers to justice."
We are committed to helping these dogs heal, both physically and emotionally, but we need your support now more than ever. When you make a gift today, you will help provide these dogs with the urgent care they so desperately need, and you'll help us continue to rescue victims of animal cruelty across the country.
These dogs and so many other animals deserve a chance at a better life. Please make a donation today.
Michael Vick's case deserves a special place in hell. Not even his own family dogs were sacred...and all this went on while his children watched...nobody should ever support anything he has anything to do with...and to think they allowed him to get another dog...the world is watching Michael...u wont get another chance u POS...
I agree! I hope these lowbrow individuals are lucky enough to discover just how bitchy Karma can be!
You got it, Dana!! Let's hope it comes around soon.
You got it, Dana!! Let's hope it comes around soon.
Can someone find their photos and post to facebook their jobs their neighborhoods so everyone knows!!!!!!!!!!!!!!!!
Throw the book at them give them jsil time and heavy fines hit them hard they deserve it
I absolutely hate animal abuse. I agree, throw the book at them, make them fight for their food & rights in the worst prisons we have. Fine them heavily and pray they can change the loser psychopathic ways


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Duvet thief.
Evie was a little cold in bed last night, Arnie, however, was awake for about 2 hours yesterday.
What a life.
Posted on March 27, 2014, in Uncategorized and tagged cats, Children, Doodlemum, Drawing, Family, Humour, Illustration, Life, Pen and Ink, Sketchbook. Bookmark the permalink. 4 Comments.
Bonnie would have cuddled up to Evie, breathed hot, smelly dog breath and licked her, to keep her warm! Arnie however, is doing what cats do best- look after Number One… and no, that's never, ever going to be a human! What's Evie doing in bed without a dozen fluffies, anyway?


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MRT, LRT fare project hit by S. Korea-backed firm
DOTC's P1.72B automated fare collection system criticized
popular .
A South Korean-backed firm is crying foul over the government's alleged refusal to recognize the company's unsolicited proposal for an automated fare system for Metro Manila's train lines, submitted months before plans for any such project.
The contract for a P1.72-billion automated fare collection system (AFCS) is currently being bid out by the Department of Transportation and Communications (DOTC), with completion expected by January 2015.
However, Kystek Corp., a locally registered company backed by South Korean money, said it originally proposed an AFCS project to the DOTC in 2011.
This offer was accepted and the firm was named its "original proponent" by the DOTC, then under Secretary Mar Roxas.
Under local procurement laws, a company that is declared an "original proponent" for a major project is entitled to a "Swiss challenge." This means that to win the project, the original proponent need only match any offer by other companies that is deemed better than the one Kystek submitted.
"We were already declared the original proponent, but we were surprised when the government suddenly announced that they would bid out the project through an open bidding," Kystek president Kim Young-sung said in an interview.
Kystek, which is backed by South Korea's leading financial services group Mirae Asset, first expressed its intention to take on the project in a letter to Roxas in September 2011.
In a letter on Oct. 3, 2011, DOTC's director of procurement, supply and property management Venancio Santidad said Kystek was the "first proponent" to have expressed interest in the said project.
If the firm submits an unsolicited offer on Oct. 23 of that year—exactly one month after the company's original letter to Roxas—Kystek would be "considered as the preferred bidder of the said project by unsolicited proposal scheme of the BOT (build-operate-transfer) law of the Philippines," the DOTC's letter read.
Under its offer, the company said it would spend $20 million to install an automated fare system at the Light Rail Transit and Metro Rail Transit lines. The technology to be employed would allow passengers to have a single ticket that would work on all three lines.
In a letter on Nov. 21, 2011, DOTC's Santidad confirmed that Kystek was declared the preferred bidder for the project.
According to Kim, the company never received any further letters from the DOTC. The company sent three follow-up letters in April, July, and August of 2012, but never received any reply.
Companies that have expressed interest in the AFCS project include Metro Pacific Investment Corp., SM Prime Holdings Inc., Ayala Corp., DM Consunji, First Metro Investments Corp. and NNT Communications Philippines.
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PINUPS: Science Fiction & Science Fantasy. A Portfolio by Mark Bloodworth
Color and Black and White pin up artwork of females from various extraterrastrial races.
science fiction INUP a & science fantasy p o r t f o l i o b y M ARK B LOODWORTH science fiction a p o r t f o l i o & Andorian Borg Klingon Orion Romulan Vulcan science fantasy b y M ARK B LOODWORTH star trek lost in space Green Dimension Girl barsoom Dejah Thoris marvel comics Rigellan Skrull science fiction a p o r t f o l i o M ARK B LOODWORTH All artwork is © 2008 by Mark Bloodworth. All character names and alien races are © 2008 their respective copyright holders. PINUPS: science fiction & science fantasy, a portfolio by Mark Bloodworth is a Bloodworth Studios Production and is © 2008 Bloodworth Studios. Online Version: December 2008 www.bloodworthstudios.com & science fantasy b y STAR TREK Klingon (Mudflap Girl Pose) Gouache on Watercolor Paper Klingon Marker, Colored Pencil & Gouache on Canson Paper Andorian Marker, Colored Pencil & Gouache on Canson Paper Andorian (Mudflap Girl Pose) Gouache on Watercolor Paper Borg (Mudflap Girl Pose) Gouache on Watercolor Paper following two pages: Orion Romulan Marker, Colored Pencil & Gouache on Canson Paper Marker, Colored Pencil & Gouache on Canson Paper Vulcan (Mudflap Girl Pose) opposite page: Gouache on Watercolor Paper Vulcan Marker, Colored Pencil & Gouache on Canson Paper following page: Orion Marker, Colored Pencil & Gouache on Canson Paper Lost in Space Girl from the Green Dimension Marker, Colored Pencil & Gouache on Canson Paper Barsoom Dejah Thoris Ebony Pencil & Sumi Ink on Drawing Paper opposite page: Marker, Colored Pencil & Gouache on Canson Paper Dejah Thoris following pages: Ebony Pencil & Sumi Ink on 3 ply Britstol Marker, Colored Pencil & Gouache on Canson Paper Dejah Thoris Dejah Thoris Marvel Comics Tana Nile from Rigel 3 Gouache & Sumi Ink on Watercolor Paper opposite page: Skrull Gouache & Sumi Ink on Watercolor Paper t h e a r t i s t M ARK B LOODWORTH urban crime comic book: NIGHTSTREETS for Arrow Comics during "The Black and White Independent Explosion of the Eighties" from 1985-89. In early 1990 he took over art chores on another Arrow title called DEADWORLD (now being published by Desperado). After a few issues Mark had taken over both art and writing chores on the book. In 1991 he was contracted by Marvel Comics to create character design, spot illos, and story art for CLIVE BARKER'S: HELLRAISER. Throughout the rest of that decade and into the new millennium he illustrated many titles, such as: CHEERLEADERS FROM HELL, JACK THE RIPPER, RAVEN CHRONICLES, THE RIPPER LEGACY (from Caliber Comics); the critically hailed ABEL, written by William Harms (from AiT/ Planet Lar); and three plates for ZORRO: THE MASTERS EDITION, VOL 1 (from Pulp Adventures). services, concept art, presentation graphics, rendered images, logos, and a mountain of storyboards for many advertising, apparel and marketing agencies from coast to coast. Since 2004, Mark has been working with film director and instructor, Douglas Schulze (co-founder of the Motion Picture Institute of Michigan) on his latest movie endeavor providing storyboards, concept and production art. A storyteller and artist who created the critically favored, For over a decade as a commercial artist providing Most recently, Mark's artwork can be seen in his MIDNIGHT MORTUARY, an homage to all those great black & white comic monster magazines of the 1970's; and THE RIPPER LEGACY Trade Paperback, the collected 3 issue mini-series written by Jim Alexander (both released through Transfuzion Publishing). More art in print can be found in the Girls of Deadworld Portfolio, the centerpiece of the anthology, DEADWORLD CHRONICLES (from Desperado); as well as working with talents Shannon Denton, Christopher Long, and Rob Worley on a series of children's books called SHORT TALES (released through the Magic Wagon wing of ABDO Publishing). t h e m o d e l K AT H L E E N D E L L Kathleen Dell and I have been friends for close to 17 years now. In that time I don't recall ever seeing her sit still. Then I remembered, she's one of those active people. You see, artists are relatively sedentary. We are quite comfortable with sitting patiently in front of a canvas or pad of paper with only our eyes and hands showing any signs of life. Kathleen is far from that, she exudes life; constantly on the move, seemingly always doing or learning something, a quintessential "Jill Of All Trades". Employed as an administrative assistant, she is also an experienced equestrian; an avid mountain biker; owns and operates a small hobby farm; an entrepreneur, a community volunteer, a charitable funds raiser, and that is just what I'm aware of. Through all this, Kathleen still finds time for her husband, her family, and her friends. One day, apparently, she must have been going down a list of vocations and realized she hadn't been an "artist's model" yet. Lucky for me. I often complain to colleagues and friends about the lack of life drawing I get to do these days, mostly due to finding a model I know I can count on. So, thankfully, my dear friend volunteered. I'm still not sure if it was to fill the missing vocation mentioned above or just because she was getting tired of hearing me whine and complain. Regardless, Kathleen has helped me out on countless occasions and I have noticed something during our sessions...it's the only time I ever see her sit still. Motor City Comic Convention May 2005 (as patrons view the portfolio, Mini-Me picks their pockets) science fiction & science fantasy a p o r t f o l i o b y M ARK B LOODWORTH


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Cinnamon oil
Cinnamon oil
The volatile oil distilled with steam from the leaves and twigs of Cinnamomum cassia; it contains not less than 80% by volume of the total aldehydes of cinnamon oil.
Synonym: cassia oil.
Please contribute to this project, if you have more information about this term feel free to edit this page
This page was last modified on 3 October 2005, at 21:16. This page has been accessed 1,302 times.
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|Showing 1-20
England v New Zealand, 2nd Investec Test, Headingley
Cook hails hero Gooch as prepares to break record
May 28, 2015: England turned to Mark Ramprakash after the Ashes whitewash but Alastair Cook kept his long-term mentor Graham Gooch close. Now surpassing Gooch would be the perfect way, individually, to prepare to win back those Ashes
Cook's clarity breeds resilience
May 25, 2015: With his immaculate concentration at Lord's on Sunday, England's captain revealed his mental toughness. Whatever the sphere, the latter flows from the former
England v New Zealand, 1st Investec Test, Lord's, 4th day
Cook the leader outweighs Cook the captain
May 24, 2015: Alastair Cook will never be a great orator or tactician. He will never rouse with a speech and rarely surprise with a tactic. Instead he must lead by example. This was the innings of a leader. But it wasn't necessarily the innings of a captain
England v New Zealand, 1st Investec Test, Lord's, 4th day
Cook hundred leads England revival
May 24, 2015: Ben Stokes hit the fastest Test hundred at Lord's, off 85 balls, and Alastair Cook ended the fourth day unbeaten on 153 as England build a lead of 295
England v New Zealand, 1st Investec Test, Lord's
Cook and Farbrace face a high-stakes series
May 20, 2015: A captain under immense pressure, a coach potentially pushing a claim for the full-time job. There is much at stake for England at the beginning of their Test summer, but at least the cricket is about to start
England v New Zealand, 1st Investec Test, Lord's
'No ultimatum' on Pietersen - Cook
May 20, 2015: Alastair Cook has denied making any ultimatum over the possible England recall of Kevin Pietersen, but admitted he agreed to the decision not to include him in the team's plans for the summer
Is Cook next in line to bite the dust?
May 17, 2015: England are now in a situation where a change of captaincy in the middle of the Ashes series seems probable
Natural leaders are made in retrospect
May 11, 2015: There is no template for the perfect captain. Some of the game's greatest were not identified as such straightaway
England in West Indies 2015
Anderson leads yet again but woe for Mo
May 4, 2015: The series against West Indies showed England what they already knew: trouble with a second opener, a paucity of spin options and the importance of James Anderson
West Indies v England, 3rd Test, Barbados, 2nd day
Cook relief at ending hundred debate
May 2, 2015: Alastair Cook admitted he had to overcome the "denial" about struggling for runs over the last two years after scoring his first Test hundred in 23 months on the opening day in Barbados
West Indies v England, 3rd Test, Bridgetown, 1st day
Cook ends hundred drought but WI take honours
May 1, 2015: A popular number during this series has been the days since Alastair Cook scored a hundred. The counter can be reset to zero now after he batted into the final over of the opening day
West Indies v England, 2nd Test, St George's, 3rd day
Root hundred puts England in charge
Apr 23, 2015: A sixth Test hundred from Joe Root helped England to a position of increasing dominance in Grenada, as they wore down West Indies during an extended day in the field
West Indies v England, 2nd Test, St George's, 2nd day
Cook, Trott put seal on improved display
Apr 22, 2015: Alastair Cook and Jonathan Trott put on England's highest opening stand since Perth in December 2013 as they strove to provide a sound platform in response to West Indies' 299
West Indies v England, 2nd Test, St George's
Pressure on Cook to end rough run
Apr 20, 2015: Alastair Cook's form is not as bad as has been made out but England need him to start scoring hundreds again
Wisden 2015
English cricket 'losing touch'
Apr 8, 2015: If it was not already abundantly clear that cricket in England has endured a difficult 18 months, then the publication of the 2015 Wisden Almanack this week hammers the point home with a resounding thud
St. Kitts and Nevis Invitation XI v England XI, Basseterre
Under-trial England seek red-ball relief
Apr 6, 2015: A two-day tour match in St. Kitts is England's first stop in a five-month stretch of cricket that could decide the futures of Alastair Cook and Peter Moores
England in West Indies 2015
Winter of despair raises stakes for Cook and Moores
Apr 2, 2015: Some key figures could be shaken out of England cricket if England do not deliver in the West Indies and Alastair Cook and Peter Moores were acutely aware of the pressure as the tour party left for the Caribbean
MCC v Yorkshire, Abu Dhabi, 3rd day
Cook fails again as Rashid leads Yorkshire romp
Mar 24, 2015: There were contrasting fortunes for two of England's party for the Test tour of West Indies next month as Yorkshire, the county champions, thumped MCC by nine wickets inside three days in Abu Dhabi.
MCC v Yorkshire, Abu Dhabi, 1st day
Cook disappoints, Lyth impresses
Mar 22, 2015: Alastair Cook lasted just six balls on his return to action, three months after his last innings on England's tour of Sri Lanka
England news
England were wrong to sack me - Cook
Mar 18, 2015: Alastair Cook has claimed that the ECB's decision to relieve him of the England captaincy a matter of weeks before the World Cup has been proved wrong in hindsight and described the players as looking "shellshocked" during a disastrous campaign that ended
|Showing 1-20
'I made it clear that I was here to win the IPL'
Ricky Ponting talks about Mumbai Indians' amazing turnaround, his relationship with Harbhajan Singh, and being part of perhaps the most star studded coaching line-up in cricket
ESPNcricinfo picks its team of the 2015 season, with a limit of only four overseas players in the XI
MI thrill with typical bouncebackability
In the second half of the tournament, at every training huddle, players were told treat each match as a final. That resonated with Mumbai's talismans who lifted their games admirably
'Started from the bottom now we here' - Pollard
Mumbai Indians won their second IPL title by beating Chennai Super Kings at Eden Gardens, the culmination of a campaign that had begun with four consecutive defeats. Here's what the Mumbai players and coaching staff told iplt20.com after the victory
Most consecutive Tests, and vowel-less surnames
Plus: the shortest turnaround times between Test series, and the nervous and not-so-nervous 90s
An England performance to turn the disenfranchised (66)
Instead of determination, we had destruction. Instead of patience, we had passion. And instead of percentage cricket we had bull's-eyes and jackpots
Freshening up the festival (55)
Perhaps after eight seasons of the IPL there is sameness, flatness, a sense of fatigue? Maybe the template can be revisited
The IPL 2015 tournament XI (43)
ESPNcricinfo picks its team of the 2015 season, with a limit of only four overseas players in the XI
'I made it clear that I was here to win the IPL' (34)
Ricky Ponting talks about Mumbai Indians' amazing turnaround, his relationship with Harbhajan Singh, and being part of perhaps the most star studded coaching line-up in cricket
Australia will test West Indies' resilience (33)
Having begun reasonably well under a new head coach, West Indies' challenge will be to sustain the progress they made in the England Tests