text:
Bertolotti, L., and P. Balci. 2012. Appendix 10-1: St. Lucie River Watershed Protection Plan Update in 2012 South Florida Environmental Report. Available at http://my.sfwmd.gov/portal/page/portal/pg_grp_sfwmd_sfer/portlet_prevreport/2012_sfer/v1/appendices/v1_app10-1.pdf. Accessed June 5, 2012.
Bhomia, R., P. W. Inglett, D. B. Ivanoff, and K. R. Reddy. 2012. Soil accretion rates in the Stormwater Treatment Areas of the Everglades (in preparation).
Blake, N. 1980. Land into Water—Water into Land: A History of Water Management in Florida. Tallahassee, FL: University Presses of Florida.
Borkhataria, R., D. L. Childers, S. E. Davis, III, V. Engel, E. E. Gaiser, J. W. Harvey, T. E. Lodge, F. Miralles-Wilhelm, G. M. Naja, T. Z. Osborne, R. G. Rivero, M. S. Ross, J. Trexler, T. van Lent, and P. R. Wetzel. 2011. Review of Everglades Science, Tools and Needs Related to Key Science Management Questions. Available at http://www.everglades-seres.org/Products_files/SERES_Reviews_Merged%20copy.pdf. Accessed May 29, 2012.
Borsuk, M., R. Clemen, L. Maguire, and K. Reckhow. 2001. Stakeholder values and scientific modeling in the Neuse River watershed. Group Decision and Negotiation 10:355-373.
Bruland, G. L., T. Z. Osborne, K. R. Reddy, S. Grunwald, S. Newman, and W. F. DeBusk. 2007. Recent changes in soil total phosphorus in the Everglades: Water conservation area 3A. Environmental Monitoring and Assessment 129:379-395.
Caffie-Simpson, W., V. Lopez, M. Morrison, J. Outland, and G. Knecht. 2011. Comprehensive Everglades Restoration Plan Annual Report–470 Report, in Appendix 7-1: 2011 South Florida Environmental Report. Available at http://www.sfwmd.gov/portal/page/portal/pg_grp_sfwmd_sfer/portlet_prevreport/2011_sfer/v1/appendices/v1_app7-1.pdf. Accessed March 6, 2012.
Carney, A., S. Feken, S. Jones, B. Lawhon, and R. Linch. 2012. Comprehensive Everglades Restoration Plan Annual Report–470 Report, Appendix 1-4 in 2012 South Florida Environmental Report. Available at http://www.sfwmd.gov/portal/page/portal/pg_grp_sfwmd_sfer/portlet_prevreport/2012_sfer/v1/appendices/v1_app1-4.pdf. Accessed March 29, 2012.
Cattau, C., W. M. Kitchens, B. Reichert, A. Bowling, A. Hotaling, C. Zweig, J. Olbert, K. Pias, and J. Martin. 2008. Snail Kite Demography Annual Report 2009. U. S. Geological Survey Florida Cooperative Fish and Wildlife Research Unit. University of Florida.
Cattau, C., W. M. Kitchens, B. Reichert, J. Olbert, K. Pias, J. Martin, and C. Zweig. 2009. Snail Kite Demography Annual Report 2009. Unpublished report for the U.S. Army Corps of Engineers. Jacksonville, FL: USACE.
Chen, C. Y., and C. L. Folt. 2005. High plankton biomass reduces mercury biomagnification. Environmental Science and Technology 39:115-121.
Clark, M. W., and K. R. Reddy. 2007. Spatial variability and modeling of soil accretion in the Shark River Slough of the Everglades. Final report submitted to the Department of Interior, Everglades National Park.
Craft, C. B., and C. J. Richardson. 1993. Peat accretion and N, P, and organic C accumulation in nutrient-enriched and unenriched Everglades Peatlands. Ecological Applications 3:446-458.
Davis, J. H., Jr. 1946. The peat deposits of Florida: their occurrence, development and uses. Florida Department of Conservation, Geological Bulletin No. 30. Florida Geological Survey. Tallahassee, Florida. Available at http://ufdc.ufl.edu/UF00000489/00001/130j. Accessed May 29, 2012.
Davis, S. M., and J. C. Ogden, eds. 1994. Everglades: The Ecosystem and Its Restoration. Delray Beach, FL: St. Lucie Press.
DeBusk, W. F., and K. R. Reddy. 1998. Turnover of detrital organic carbon in a nutrient-impacted Everglades marsh. Soil Science Society of American Journal 62:1460-1468.
Doering, P. H. 1996. Temporal variability of water quality in the St. Lucie Estuary, South Flordia. Journal of the American Water Resources Association 32:1293-1306.
Doering, P. H., and R. H. Chamberlain. 1999. Water quality and source of freshwater discharge to the Caloosahatchee Estuary, Florida. Journal of the American Water Resource Association 35:793-806.


text: Oscar is two years old and is already neutered and leash trained. He likes other animals and enjoys people. Oscar would do best with lots of room to run and play with his new family. He is the perfect size, almost knee high and only about 38 pounds. He would make a great snuggle buddy. Coming to the shelter as a stray, Oscar's breed is unknown. He is all white except for one black ear. Please come out and visit him, he is ready and waiting for his new home. For more information about adopting Oscar or other area shelter pets, visit www.newberrycounty.net/animal/adoptions.htm.

subset: commoncrawl


text:
Campbell, D.T., and J.C. Stanley 1966 Experimental and Quasi-Experimental Designs for Research. Chicago, IL: Rand McNally.
Cash, D.W. 2001 In order to aid in diffusing useful and practical information: Agricultural extension and boundary organizations. Science, Technology, and Human Values 26(4):431-453.
Cash, D.W., W.C. Clark, F. Alcock, N.M. Dickson, N. Eckley, D.H. Guston, J. Jager, and R.B. Mitchell 2003 Knowledge systems for sustainable development. Proceedings of the National Academy of Sciences 100(14):8086-8091.
Clark, W.C. 2007 Sustainability science: A room of its own. Proceedings of the National Academy of Sciences 104:1737-1738.
Clark, W.C., and G. Majone 1985 The critical appraisal of scientific inquiries with policy implications. Science, Technology, and Human Values 10(3):6-19.
DiMaggio, P.J., and W. Powell 1983 The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields. American Sociological Review 48:147-160.
Federal Emergency Management Agency 2006 HAZUS: FEMA's Software Program for Estimating Potential Losses from Disasters. Available: http://www.fema.gov/plan/prevent/hazus/ [accessed May 2007].
Feldman, M.S., and A.M. Khadamian 2000 Managing for inclusion: Balancing control with participation. International Public Management Journal 3(2):49-68.
2001 Principles for public management practice: From dichotomies to interdependence. Governance 14(3):339-362.
2007 Therole of the public manager in inclusion: Creating communities of participation. Governance 20(2):305-324.
Fischhoff, B. 1989 Risk: A guide to controversy. Pp. 211-319 in National Research Council, Improving Risk Communication. Washington, DC: National Academy Press.
Freudenburg, W.R. 1989 Social scientists' contributions to environmental management. Journal of Social Issues 45(1):133-152.
Funtowicz, S.O., and J.R. Ravetz 1992 Three types of risk assessment and the emergence of post-normal science. Pp. 251-274 in S. Krimsky and D. Golding, Eds., Social theories of risk. Westport, CT: Praeger.
Gardner, G.T., and P.C. Stern 1996 Environmental Problems and Human Behavior. Boston, MA: Allyn and Bacon.
2002 Environmental Problems and Human Behavior, 2nd ed. Boston, MA: Pearson Custom Publishers.
Gieryn, T.F. 1995 Boundaries of science. Pp. 393-443 in Handbook of Science and Technology Studies. S. Jasanoff et al., Eds. Thousand Oaks, CA: Sage Publications.
Guston, D.H. 2001 Boundary organizations in environmental policy and science: An introduction. Science, Technology, and Human Values 26(4): 399-408.


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It's Your Business: Kids eat free at Jason's Deli Aug. 2-11
Paying for children to eat at Jason's Deli will take a holiday for a few days.
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|Product name
|Sunmate snack master Cook's dog's for roasted cock Pan pumpkin and carrot bread 55 g
|For more product information
|Contents: 55 g
* Is a powder containing beta carotene and fiber pumpkin and carrot shortbread cookies, baked bread (for dogs).
|Product description
|See sunmate snack master cock Mr. dog's for roasted cock Pan pumpkin and carrot bread 55 g ', is a powder containing beta carotene and fiber pumpkin and carrot shortbread cookies, baked bread (for dogs). Salt, synthetic preservatives and artificial coloring, no, we care about your dog's health.
|How to give
|-Given as a pet for snacks.
-Ideal for reward for training and disciplining a snack.
-This product is not staple. Always give your pet food and.
-Degree heat in the toaster oven and enjoy the flavor of freshly baked.
-If the long-term retention will be frozen and save natural extract, please give.
-[How to guide] below to give me. Amount of grant depends on the breed, weight, momentum, physical condition and seasonal. While such flights should increase or decrease.
-Please note it.
[Feeding directions... dog size (weight): one day salary targets weak]
Small dogs (less than 5 kg): 1-4
Small breeds (5-10 kg): 4-6
Medium-sized dogs (10-20 kg): 6-8 pieces
Large dogs (20-40 kg): 8-12 pieces
Dogs: 1-2
* With small to very small dogs and puppies, please give.
* A few times, please give salary amount of the day.
* After birth in less than 2 months in young dogs do.
|Please note that
|-This product is only pet. The children eat the wrong please do not.
-When giving children pets for the safety always adults observe.
● do not store location within reach of young children.
|How to save
|-And kept in place after your purchase out of direct sunlight and give us as soon as possible after the opening must be tightly closed bag. Also long term storage if you store in the freezer and defrost, please give.
|-In the bag we are in quality agents (alcohol products). We are made of safe materials, but food is please do not accidentally give pet, pet false food not.
* Please give, might have followed such as white flour and Brown burnt, but no problem is quality assured.
* This bag is for the natural filling, slightly higher.
|Allergy view
|This product uses the following raw materials.
Milk, wheat and soy.
|Country of origin
|Sunmate co., Ltd.
|Raw materials
Flour sugar (sugar, glucose syrup, oligosaccharide) shortening bread yeast (yeast) Ginseng powder pumpkin powder skim milk powder starch processing starch fragrances
9.40% crude protein crude fat over 5.90% crude fiber below 2.60% crude ash 1.30% less moisture 16.30% less energy 359 kcal (per 100 g)
Other ingredients.
Vitamin A (retinol equivalent) 48 μ g α-carotene 147 g beta carotene 508 µm μg
|JAN code
|Sales origin
|Sun mate
|JP Post EMS
|Your order will be shipped to you via Japan Post EMS. Japan Post is a speedy delivery service that delivers to more than 120 countries. With an effective tracking system and insurance program, EMS is able to offer a secure delivery worldwide. You can track your package with the tracking code provided and it will be delivered within a week. See estimated shipping fee
[Return and Cancellation Policy]
There is a policy of a no refund, no exchange and cancellation for international shipping services. Please check your items, their size and colors if they are OK before purchasing.
[About shipping trouble and accident insurance]
If international shipping is damaged or partly missing during delivery,
the actual damage cost will be compensate within the limits of following guidance.
● Shipping method [EMS]: usually maximum of \20,000 is paid for the actual loss
● Shipping method [Air mail / SAL / surface] : Not Insurance
When EMS use, no charge up to the article value equivalent to 20,000yen.
Then premium (additional charge) of 50yen will be added per 20,000yen.
If you order more than 20,000yen (exclude shipping cost),
you have undertaken the procedure to enter additional charge for covers all fees.
To unsubscribe from covers all fees, please reply to our shop
with "not joining the insurance system" as main body of e-mail.
An early indication of your disposition to this matter would be very much appreciated.
[When your item is broken]
when the item is damaged and delivered to the receiver,
the latter has to preserve the postal item in the current condition and make a statement
regarding the missing part of the package or damaged item in the local Post Office.
Please follow the procedure below.
1. Hold on to broken items, package and shipping materials. They will be necessary when we apply compensation.
2. Visit the nearest post office with broken items, package, shipping materials and shipment invoice.
3. File a damage report at post office.
4. After the damage report is made, please send an email to our shop.
5. Later, we will shipping you new items.
Start Date: 01/05/2015 00:00 JST
End Date: 30/07/2015 23:59 JST
Start Date: 21/05/2015 00:00 JST
End Date: 31/05/2015 23:59 JST
This product cannot be shipped to United States from the store.
Please contact the store for further information.


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Certified massage therapist and posturist Robert Macaraeg deals with more than just tense muscles. Though his nimble fingers and firm hands are quite capable of kneading out stubborn kinks, he draws upon his understanding of the human form to help clients walk tall and live free of posture-related pains. To accomplish this, he combines manual muscle work with strategic stretches that squeeze out toxins and retrain the muscles, teaching them to keep the body upright during long periods of sitting or marathon planking matches.
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- Iowa State Reversible Tote Bag
Function and style combine in this universal tote. Made of 100% cotton, the tote measures 19" x 14" x 2". It is reversible with logos inside and out. The reverse color combination is the primary school color with a single primary school logo on both sides and the secondary school color with repeating logo design.
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text:
Jobs' commitment to personal computers' graphical interface, mouse and WYSIWYG, or "What You See Is What You Get," changed all our lives forever. Many of you can surely remember the early Internet, when only numbers and letters were transmitted from computer to a remote machine.
These developments changed dissemination of news forever, and those of us in the newspaper industry are acutely aware of Jobs' influence.
Before Jobs and Apple computer, typesetting was accomplished by phototypesetters, hulking machines that cost $50,000 to $125,000 and suffered frequent breakdowns — requiring repairs that were likely to cost more than the purchase-price of a high-end desktop computer.
Reporters used typewriters to compose their articles, often typing them up several times in their entirety for a final draft.
When Denton Publications armed their employees with Apple computers — we were "early adopters" — our reporters and editors gained speed and creativity, as well as pursuing higher standards in our work. Those costly and unreliable phototypesetters were scrapped.
The Apple computers gave us remarkable capability to readily compete with the corporate giants in getting vital news out to the public on a timely basis.
Jobs' innovation of a graphical interface, combined with the Internet a decade or so later, prompted a seismic shift in publishing, as people began obtaining news faster and more conveniently via the Internet.
A new generation has increasingly adopted this digital conduit as more convenient and satisfying.
We at Denton Publications embraced this trend early on — about a decade ago — delivering community news on an array of websites, when many other newspapers were depending solely on newsprint. Since then, we have continued our commitment to digital news delivery by continually enhancing our online offerings.
Also, we have the most advanced digital pre-press composition equipment that can deliver the highest-fidelity printed products — also an indirect result of Jobs' remarkable vision.
We at Denton Publications are thankful for Steve Jobs' incredible talent and imagination. Although he has passed on, his remarkable contributions to society — which are bringing us all closer together — live on through the innovations he left behind.
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Crocs Really Sexi Jelly Sandal
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text: Its easy for fly fishing to be a rich mans sport. I've been fishing in a 50 rain jacket for quite some time. I can honestly say I haven't lost a fish, gotten wet or felt unequipped without a wading jacket. There is an expensive version of everything. Being functional and packable for trips Is all I want.


text:
21st century
22nd century
The Far Future
2000s | 2010s | 2020s | 2030s | 2040s | 2050s | 2060s | 2070s | 2080s | 2090s
2040 | 2041 | 2042 | 2043 | 2044 | 2045 | 2046 | 2047 | 2048 | 2049
2048 timeline contents
The Antarctic Treaty comes
up for review
Antarctic Treaty comes up for review
is the last remaining unspoilt wilderness; untouched by the massive
industrialisation common everywhere else on the planet. It covers an
area of 13.7 million sq km (5.3 million sq miles) and is covered by
an ice sheet 4 km (2.5 miles) deep. It has no human inhabitants, other
than a small number of scientists in research stations.
The vast,
icy continent is governed by the terms of the Antarctic Treaty, which
came into effect in 1961. This was signed by Argentina, Australia, Chile,
France, New Zealand, Norway, the UK, Belgium, Japan, South Africa, the
USA and Russia. The first seven of these countries have historic claims
to the continent (none of which are generally recognised) and the Treaty
preserves the status quo, neither recognising nor repudiating the old
claims, but forbidding their expansion in any way. The terms of the
Treaty also forbid the assertion of new claims.
The discovery
of a hole in the ozone layer, and other concerns, led to the addition
of a new environmental protocol agreed in 1991. This entered force in
1998. It was intended to protect Antarctica's environment and ecosystems,
and included a total ban on the exploitation of mineral and energy resources,
as well as strict regulation of pollution and other damaging activities.
The protocol is open for review in 2048, exactly 50 years after it was implemented.*
Much has
changed in the last half century. Earth's population is over 50% larger, placing a substantial drain on the Earth's resources which
has become alarmingly obvious by now. Metal and mineral supplies continue to be an issue, even with large-scale recycling systems in place.* Despite objections from environmentalists, there is general consensus
among the international community that some limited exploitation of
Antarctica should be permitted, within certain specially controlled areas.
Over the next few years, a new treaty is drawn up with modified clauses, though disputes continue over territorial boundaries.
There are
significant logistical challenges to mining and mineral extraction in
the region – such as the isolation, extreme cold, rough seas and thick
ice sheet. However, new technologies look set to mitigate these problems,
including the use of robots, heavy automation and alternative methods
of drilling. In addition, climate change and the melting of ice is making
it possible to exploit some previously inaccessible areas of the western
ice sheet.
© Staphy | Dreamstime.com
1 Protocol on Environmental Protection to the Antarctic Treaty, Wikipedia:
Accessed 8th August 2010.
2 Five Valuable Metals That Could Vanish by 2055, Environmental
Accessed 14th August 2010.


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text:
Who's the Boss?
Jakob Lodwick Vimeo
Jakob Lodwick's juicy, controversial exit from Vimeo, the online video company he founded in November 2004, was summed up in the 2007 TechCrunch headline: "Vimeo Founder Fired; Does a Bong Hit." As the story goes, Lodwick disagreed with Barry Diller, the company's main investor, on a variety of business issues. On his departure, Gawker noted "The real reason we think Lodwick got fired? Vimeo's position on ComScore's top 10 U.S. online video properties. Or, rather, its non-position."


text:
News from WTOP
News from the AP
Mike Causey
Shows & Panels
Shows & Panels
- Agency of the Month
- Business of Government Hour
- The CFO Agenda: Delivering value from financial transparency and audit efforts in the public and private sector
- Cloud-Driven Data Insights in Government
- CXO Surveys
- Disaster Resilience for America
- Federal News Countdown
- Government Perspectives on Mobility and the Cloud
- Reducing Risk in the Cloud
- Reimagining the Next Generation of Government
Shows & Panels
- AFCEA Answers
- American Readiness: Renewable Power and Efficiency Technologies
- Ask the CIO
- The Business Case for Cloud Computing in Government
- Cloud-Driven Data Insights in Government
- Connecting the Dots: Digital Authentication in Government
- Data-Centric Approaches to Government in the Cloud
- Delivering the Digital Government Mission
- Federal Executive Forum
- Federal News Radio's National Cyber Security Awareness Month Special Panel Discussion
- Federal Tech Talk
- The Future of Government Data Centers
- Government Perspectives on Mobility and the Cloud
- Industrialized, Interoperable and Insight-driven Federal Health Panel
- Innovation and Tech Superiority through Acquisition Reform
- Mitigating Insider Threats in Virtual & Cloud Environments
- Moving Agency Applications to the Cloud with PaaS
- Reducing Risk in the Cloud
- Security in the Age of Targeted Attacks
- Air Traffic Management Transformation Report
- The Business of Cloud
- Cloud First Report
- Data Driven Cloud Series
- Disaster Resilience for America
- General Dynamics IT Enterprise Center
- Gov Cloud Minute
- Government in Technology Series
- Homeland Security Cybersecurity Market Report
- The Intersection: Where Technology Meets Transformation
- Modern Mission Critical Series
- National Cybersecurity Awareness Month
- The New IP for Federal IT
- The Social Platform Solution for the Department of Veterans Affairs
- Technology Insights
- The Cyber Security Report
- The Next Generation Cyber Security Experts
Shows & Panels
- Cloud-Driven Data Insights in Government
- Disaster Resilience for America
- F-35 Lightning II Program
- Government Perspectives on Mobility and the Cloud
- On DoD
- Pentagon Solutions
- Reducing Risk in the Cloud
- Reimagining the Next Generation of Government
- Transforming Business Operations at the Defense Department
Utah polygamous family says going on TV liberating
Monday - 3/10/2014, 11:22am EDT
BRADY McCOMBS
Associated Press
SALT LAKE CITY (AP) -- The newest Utah polygamous family featured in a reality TV show says sharing their story with a wide audience has been liberating.
Brady Williams and his five wives were a bit apprehensive ahead of the airing of a pilot episode in September, but they said this week an interview with The Associated Press that it felt liberating to be open about who they are and what they believe.
"It really is like coming out of the closet," said Brady Williams, 43. "It's very liberating."
His wives feel the same way, including his second, Robyn Williams, 40, who said: "I feel more free to just be who I am and not be so afraid."
The first of nine episodes of the show, "My Five Wives," airs Sunday on TLC. It chronicles the life of Brady Williams, his five wives and their 24 children who live in a small rural community outside of Salt Lake City dominated by a branch of the fundamentalist Mormon church.
The family once belonged to the group, known as the Apostolic United Brethren, but withdrew during the mid-2000s after re-evaluating their core beliefs. Now, they practice polygamy not because they think they must to get to heaven, and avoid hell, but because they prefer the lifestyle.
Their show begins airing in a social and political climate that has softened significantly toward plural families in recent years.
A federal judge in Utah struck down key parts of the state's polygamy laws in December, marking a victory for the Williams and hundreds of other polygamous families in the state. The ruling decriminalizes polygamy, making only bigamy -- holding marriage licenses with multiple partners --illegal.
The family that brought that lawsuit against the state of Utah, Kody Brown and his four wives from TLC's "Sister Wives," is credited with helping create greater acceptance for plural families. Their show, which debuted in 2010 with footage of the family at their house in northern Utah, was ground-breaking in demonstrating to viewers across the country that not all polygamists are child predators like Warren Jeffs, the imprisoned leader of a polygamous sect on the Utah -Arizona border.
The Williams family members said they don't expect viewers to be surprised by much, other than maybe how similar they are to non-polygamous families. It's normal times five, the family jokes. Viewers will see tears, joy and quarrels, they said.
TLC is banking on viewers being fascinated by the unique dynamics of a plural family: regular family sit-down meetings among the adults where Brady Williams follows an agenda written on a notepad; side-by-side multiplexes where they live; and nightly family dinners where the children line up like kids in a school cafeteria to get their food.
Then there's the always-intriguing dynamic among the wives who share a husband. In the first episode, Brady Williams suggests the women work out their issues directly with one another rather than always coming to him, only to see it lead to hurt feelings and shouting.
Among the topics discussed by the family during the season is a possible move out of Utah, maybe even to Washington state.
The Browns of "Sister Wives" fled Utah for Las Vegas after their show aired under the threat of prosecution from a county official. The Williams aren't terribly worried about that happening to them, as long as the recent court ruling stands. But they say they don't feel welcomed in the tight-knit community where almost everyone but them belongs to the church.
"There haven't been any overt acts of disapproval," Brady Williams said. But he added: "We want to be able to feel comfortable in our own skin."
Aaron Bronson, a principal at the school in the community and member of the Apostolic United Brethren, said he doesn't begrudge the Williams family for doing the show. He said the production crews have been respectful, and he's heard no complaints from the Williams family's neighbors.
"If they want to go public with what they believe, it's their choice," Bronson said. "It's not something I would choose to do with my family. It's a rocky road."
Follow Brady McCombs at https://twitter.com/BradyMcCombs
Copyright 2014 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text:
The Church
The Bride of Christ
Teaching Series by R.C. Sproul
In this series, Dr. R.C. Sproul provides an overview of ecclesiology, the doctrine of the Church. Dr. Sproul explains how the truth of Scripture is the basis for Church unity and discusses the marks of a biblical Church. Learn MoreCD $31.00 $27.90 Add to Cart
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The Best of 2003-2006 Pastors Conferences
Conference Messages by Various Authors
The intense pressure to adopt man-centered approaches to ministry from the world pounds against preachers and congregants alike. We must therefore be exhorted to remain God-centered in our worship and encourage our leaders as they faithfully preach the Word. This … Learn MoreMP3 CD $45.00 $36.00 Add to Cart
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Bought with a Price: 2006 National Conference
Conference Messages by Various Authors
Ligonier Ministries' 2006 National Conference, Bought with a Price , discusses God's plan for the church and the congregant's role in it. Dr. Sproul is joined by other Christian scholars, pastors, and leaders, including J. Ligon Duncan III, Sinclair Ferguson, … Learn MoreDVD $85.00 $76.50 Add to Cart
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Passing Lane Motors, LLC, St. Louis's Premier Classic Car Dealer, is pleased to offer this 1991 Nissan 300ZX Twin Turbo for sale! Highlights Include: 3.0L V6... More
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|Popular | Random | Origins
TierriaRate Tierria: Do you like this name?
Get creative with Tierria | Add to list (0)
Meaning and name origin
Tierria \ti(er)-ria\ as a girl's name is of Spanish origin, and the meaning of Tierria is "earth". Tierria is a variant of Tierra (Spanish): geography name that rhymes with Sierra.
Tierria has 3 variant forms: Tiera, Tierrea, Tiyaira.
Tierria is not a popular first name for females and an equally uncommon surname or last name for all people (2000 U.S. Census).
Displayed below is a comparison of the popularity of the girl name Tierria and its variant forms. Variation forms ranked in the Top 1000/100 are Tiera and Tierra. (2015 statistics).
Similar Names
Tierria is also pronounced similarly to Terra, Terri, Terrie, Terrya and Tiarra. Another suggested similar baby name is Tierre. These names tend to be more commonly used than Tierria.
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SERVICE CREDIT UNION is pleased to announce that Guardian Angel Credit Union became part of Service Credit Union earlier this year. Service Credit Union has served members for over 55 years. As of January 26th your Berlin and Lancaster branches began servicing both Service Credit Union and former Guardian Angel members.
Branch hours will remain the same until June 1st when your former Guardian Angel account will be automatically transferred to Service Credit Union. At that time, branch hours will expand and you can begin accessing Service Credit Union products, services and locations.
If you wish to enjoy Service Credit Union's products and services earlier, you can become a Service Credit Union member on or after January 26th at the Berlin or Lancaster branch.
At Service Credit Union, we offer exclusive price incentives and programs for moderate income earners, youth, military, seniors and select employer groups.
More information will follow and will be available at servicecu.org/GACU.
Please contact us at 603.752.2750 for any questions you might have.
Thank you again for your loyalty,
Service Credit Union


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22 Free Crochet Patterns: Afghan Patterns, Crochet Hats, and More
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Fun Cap for Kids
By: Bernat
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Create a fun crochet cap with stripes of color in this free crochet hat pattern from Bernat Yarns. The hot colors and lightweight cotton yarn make it perfect any time of year. This croche hat pattern is easily adjusted to fit toddlers to adults. You can also create this hat in one color for something quick and easy.
- Yarn: Bernat Handicrafter Cotton (Solids: 50 g/1.75 oz or Ombres and Prints 42.5 g/1.5 oz)
23743 (Summer Splash) 1 ball
Contrast A (00056 Yellow) 1 ball
Contrast B (13628 Hot Orange) 1 ball
Contrast C (13712 Hot Green) 1 ball
Contrast D (13740 Hot Pink) 1 ball
23741 (Playtime) 2 balls
- Crochet Hook: Size 4.5 mm (U.S. 7) or size needed to obtain gauge.
Measurements: To fit Toddler 1-3 yrs (Child 5-8 yrs-Adult).
Gauge: 14 sc and 15 rows = 4 ins 10 cm.
With A, ch 4. Join with sl st to first ch to form a ring.
1st rnd: Ch 1. 6 sc in ring. Join B with sl st to first sc.
2nd rnd: With B, ch 1. 2 sc in each sc around. Join C with sl st to first sc. 12 sc.
3rd rnd: With C, ch 1. (2 sc in next sc. 1 sc in next sc) 6 times. Join D with sl st to first sc. 18 sc.
4th rnd: With D, ch 1. (2 sc in next sc. 1 sc in each of next 2 sc) 6 times. Join A with sl st to first sc. 24 sc.
5th rnd: With A, ch 1. (2 sc in next sc. 1 sc in each of next 3 sc) 6 times. Join B with sl st to first sc. 30 sc.
Last 4 rnds form Stripe Pat.
Keeping cont of Stripe Pat, inc 6 sts on every row, as before to 48 (54-60) sts, then every following alt row to 60 (66-72) sts.
Cont in Stripe Pat, work 9 (10-12) rows even.
Next rnd: With appropriate color, working from left to right instead of right to left as usual, work 1 reverse sc in each sc around. Join with sl st to first sc. Fasten off.
Work as given for Stripe Version, omitting reference to color changing.
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this wiki
|First Seen
|Fire Emblem: Path of Radiance
|Inflict damage back to the enemy when the user is attacked
Counter (カウンター Kauntā, Counter, Contre in the French version) is a skill from Fire Emblem: Path of Radiance, Fire Emblem: Radiant Dawn, and Fire Emblem: Awakening.
In Path of Radiance and Radiant Dawn, the enemy will receive half the damage he/she inflicted onto his/her opponent. The activation of the skill is also based on the user's Skill stat.
However, in Awakening, it will always activate. The effects of Counter will only go off against a non-fatal attack on the user and will only reflect back when the attacker is next to the user. In Lunatic+ mode, the enemy often suicide rushes users with Counter because of its effectiveness against the player early on. This continues until Chapter 4 when the player can start level grinding units that can attack from a distance to kill them.
Counter, along with Miracle, can be a devastating combo, espically if the user has +5 HP against melee units, as Miracle can leave the enemy in a dangerous state or even kill them if used properly. However, this also leaves your units in a fairly dangerous state. It can also be used with low defense units that can fight back at a distance, as the enemy will either have to risk taking heavy damage from either their own attacks or the user's attacks.
If an enemy is killed by the effects of Counter, experience is given if the user had dealt some damage during that skirmish. Otherwise, the user will not gain any experience.
Fire Emblem: Path of RadianceEdit
|Upon activation, the enemy will sustain half of the damage he/she inflicted upon his/her opponent.
|Base skill of Titania; Can be assigned with the Counter Scroll.
Fire Emblem: Radiant DawnEdit
|Upon activation, the enemy will sustain half of the damage he/she inflicted upon his/her opponent.
|Base skill of Titania; Can be assigned with the Counter Scroll
Fire Emblem: AwakeningEdit
|Receive non-fatal damage from an adjacent enemy.
|The user will deal back all damage received when attacked by an adjacent enemy. Will not activate on a Dual Strike attack or if the attacker defeats the user.
|Class skill of Level 15 Warriors.
Upon reaching Chapter 3 and beyond of Lunatic+ mode, all enemies have a chance of appearing with this skill.
Non-Canon AppearancesEdit
Counter is the B down special move of Marth, Roy, Ike and Lucina in the Super Smash Bros. series. In all of its versions, Marth, Roy, Ike, and Lucina take a defensive stance and will flash white or blue for a few seconds. If any opponents hit them while they are in their defensive stance, they will quickly counterattack and nullify all damage they would have received. The amount of damaged dealt differs between characters and games. They can nullify projectiles with this move, but they will cause explosive items to detonate such as Link's Bombs or an explosive Crate, dealing damage to them anyways.
Super Smash Bros. MeleeEdit
Marth's counter deals a maximum of 7% damage depending on the intensity of the move he is countering. Marth's counter is much quicker to start up and lasts longer, but the damage is low.
Roy reflects 1.5x the amount of damage he would have received. Roy's is much slower to start up and does not last long, but the damage output is much higher.
Super Smash Bros. BrawlEdit
Marth's counter now reflects 1.1x the amount of damage he would have received with a minimum of 8%. Marth's counter starts up quicker than Ike's counter, but is left vulnerable slightly after his Counter ends
Ike's counter reflects 1.2x the amount of damage he would have received with a minimum of 10%. Ike's start up leaves him vulnerable, but lasts longer and has a shorter recovery window compared to Marth.
Super Smash Bros. for Nintendo 3DS and Wii UEdit
In Super Smash Bros. for Nintendo 3DS and Wii U, three of four Fire Emblem characters (the excluded one being Robin) have Counters, and also have two custom versions of their Counter.
Marth and Lucina's first Custom counter is Easy counter which has an expanded hit window but deals less counter damage. Iai Counter starts up faster and has higher knockback but has a smaller counter window(contrary to description, the move has an increased 1.4 multiplier).
Ike's Paralyzing Counter paralyzes the enemy instead of damaging them, allowing Ike to combo them during the stun, but does 1% and has a far smaller window. Smash Counter's hit starts up much slower than his standard Counter but deals much more damage.


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08.01.05 - The newly crowned NABF Featherweight Champion, Robert "The Ghost" Guerrero (14-0-1, 7KOs), and Andre Ward (1-0, 1KO), the only US Olympic Gold Medalist from the 2004 Games in Athens, will be featured on, Youth Outlook TV every Sunday in January on the WB20 (check your local listings)..
After capturing the NABF featherweight title against his stiffest test, Cesar Figueroa (28-5-2 20KOs) last month, Robert "The Ghost" Guerrero's stock has sky rocketed. Look for the Ghost to fight early and often in 2005.
Gold Medalist Andre Ward's, next bout will be against unbeaten Kenny Kost (7-0, 4KOs) at The Palace Indian Gaming Center in Lemoore, CA Feb. 10, 2005. Andre got his fire lit after an impressive knockout victory in his pro debut televised on HBO with his next bout being televised nationally on the highly rated Best Damn Sports Show Period on FSN.
Robert and Andre talk about their faith in God and how it pertains to their lives and boxing careers. Both fighters, who are Goossen Tutor Promotions running mates, proudly carry the weight of the Bay Area on their back and look to have legendary careers. 2005 will be one of many great years to come, in the lives of undefeated boxing phenom, Robert "The Ghost" Guerrero and Olympic Gold Medalist Andre Ward.
The segments can also be viewed at www.YouthOutlook.com
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Photodynamic therapy (PDT), also called phototherapy, photoradiation therapy, photosensitizing therapy, or photochemotherapy, is an ablative treatment consisting of administration of a photosensitizing agent and subsequent exposure of tumor cells to a light source of a specific wavelength to induce cellular damage. After administration of the photosensitizing agent, the target tissue is exposed to light using a variety of laser techniques. For example, a laser fiber may be placed through the channel of the endoscope, or a specialized modified diffuser may be placed via fluoroscopic guidance. Tumor selectivity in treatment occurs through a combination of selective retention of photosensitizing agent and selective delivery of light.
Photodynamic therapy (PDT) has been investigated for use in a wide variety of tumors, including esophageal cancer, cholangiocarcinoma, prostate, bladder, lung, breast, brain (where it is administered intraoperatively), skin, and head and neck cancers. Barrett's esophagus has also been treated with PDT.
Barrett's Esophagus
The esophagus is normally lined by squamous epithelium. Barrett's esophagus is a condition in which the normal squamous epithelium is replaced by specialized columnar-type epithelium known as intestinal metaplasia in response to irritation and injury caused by gastroesophageal reflux disease (GERD). Barrett's esophagus occurs in the distal esophagus, may be of any length, focal or circumferential, and can be visualized by the endoscopist as being a different color than the background squamous mucosa. Confirmation of Barrett's esophagus requires biopsy of the columnar epithelium and microscopic identification of intestinal metaplasia.
Intestinal metaplasia is a precursor to esophageal adenocarcinoma, and patients with Barrett's esophagus are at a 40-fold increased risk for developing this disease compared to the general population. Esophageal adenocarcinoma is thought to result from a stepwise accumulation of genetic abnormalities in the specialized epithelium, which results in the phenotypic expression of histologic features of low-grade dysplasia (LGD) to high-grade dysplasia (HGD) to carcinoma. Most patients with nondysplastic Barrett's esophagus do not progress past nondysplasia. Nondysplastic Barrett's esophagus progresses to HGD at a rate of 0.9% per patient, per year. (1) Progression of low-grade to high-grade dysplasia has been reported as 6–28%. (2) Once HGD is present, the risk of developing adenocarcinoma is 2–10% per patient, per year, and approximately 40% of patients diagnosed with HGD by biopsy are found to have associated carcinoma in the resection specimen.
Several different photosensitizing agents have been used: porfimer sodium (Photofrin®), administered intravenously 48 hours before light exposure, and 5-aminolevulinic acid (5-ALA), administered orally 4 to 6 hours before the procedure. Aminolevulinic acid (ALA) is metabolized to protoporphyrin IX, which is preferentially taken up by the mucosa. Clearance of porfimer occurs in a variety of normal tissues over 40–72 hours, but tumors retain porfimer for a longer period. Treatment of Barrett's esophagus may be enhanced by the use of balloons containing a cylindrical diffusing fiber. The balloon is designed to compress the mucosal folds of the esophagus, thus increasing the likelihood that the entire Barrett's mucosa is exposed to light. All patients who receive porfimer become photosensitive and must avoid exposure of skin and eyes to direct sunlight or bright indoor light for 30 days.
The indications of the U.S. Food and Drug Administration (FDA) label for porfimer sodium as of January 23, 2010 are as follows:
As of February 22, 2012, oral 5-ALA has not yet received FDA approval for any indication.
This medical policy addresses only the non-dermatologic oncology applications of PDT, including Barrett's esophagus. Dermatologic applications for PDT are addressed in a separate medical policy; THE801.027.
In addition, PDT should not be confused with extracorporeal photopheresis, which involves withdrawing blood from the patient, irradiating it with ultraviolet light, and then returning the blood to the patient. Extracorporeal photopheresis is addressed in a separate policy.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions 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, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Medically Necessary
Blue Cross and Blue Shield of Montana may consider one or more courses of photodynamic therapy (PDT) medically necessary for the following oncologic applications:
BCBSMT considers other oncologic applications of photodynamic therapy experimental, investigational and unproven, including, but not limited to:
Federal Mandate
Federal mandate prohibits denial of any drug, device, or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone. Call the BCBSMT FEP Customer Service Department at 1-800-634-3569 for benefit information.
The following combination of codes may be used to describe endoscopic photodynamic therapy: 96570, 96571, 43228, 31641, J9600.
Evidence for photodynamic therapy (PDT) for oncologic applications identified through literature searches are summarized below. Much of the recent literature from outside the U.S. reports experience with photosensitizing agents that have not been cleared for use in the U.S.
Fayter and others produced a systematic review of PDT in the treatment of pre-cancerous skin conditions, Barrett's esophagus, and cancers of the biliary tract, brain, head and neck, lung, esophagus and skin published in 2010 for the Health Technology Assessment (HTA) program of the United Kingdom's National Institute for Health Research (NIHR). (1) The review included literature published through June 2009 and included 88 trials. The authors note a number of limitations in the body of evidence including that there were few well-conducted, adequately powered randomized controlled trials (RCTs), and methodologic limitations and gaps in the evidence base make drawing firm conclusions difficult. The authors' conclusions are summarized as follows: for Barrett's esophagus, PDT in addition to omeprazole appeared to be more effective than omeprazole alone at long-term ablation of high-grade dysplasia and slowing/preventing progression to cancer. No firm conclusions could be drawn for esophageal cancer. Further research into the role of PDT in lung cancer is needed. For cholangiocarcinoma, PDT may improve survival when compared with stenting alone. There was limited evidence on PDT for brain cancer and cancers of the head and neck. A wide variety of photosensitizers were used and, overall, no serious adverse effects were linked to PDT.
Obstructing Esophageal Tumors
When used for palliative treatment, relevant outcomes include short-term resolution of symptoms, such as dysphagia or improvement in swallowing. Long-term outcomes, such as disease-free survival (DFS), may not be relevant in the palliative setting. The product insert for porfimer sodium (Photofrin) describes a multicenter, single-arm study of the use of PDT in 17 patients with obstructing esophageal cancer. (2) Patients received from one to three monthly treatments of PDT. Of the 17 treated patients, 11 (65%) received clinically important benefit from PDT, defined as complete tumor response, normal swallowing, or improvement in dysphagia. Endoscopic debridement of the esophagus may be required after the PDT. At that time, the residual tumor can also be retreated.
McCann and colleagues, in 2011, reported on a systematic review of traditional non-endoscopic and endoscopic treatments for early esophageal cancer, including 26 PDT studies. (3) The reviewers noted the lack of evidence from large, randomized trials and found the quality of evidence available overall was generally low. While the evidence did demonstrate that endoscopic techniques reduced morbidity and mortality compared to esophagectomy, outcomes from endoscopic treatments were similar, and no single endoscopic technique could be identified as a recommended treatment approach. The review focused on tumor response and recurrence and disease-specific and overall survival and did not examine quality-of-life outcomes.
In 2011, Rupinski and colleagues reported on a randomized study of 93 patients with inoperable cancer of the esophagus or esophageal junction to compare argon plasma coagulation (APC) alone to PDT with APC or high-dose rate brachytherapy (HDR) with APC. (4) Both combination therapies were more effective than APC alone in median time to recurrence of dysphagia (85, 59, and 35 days for HDR with APC, PDT with APC, and APC alone, respectively). Overall survival was not significantly different between groups. However, complications occurred more often in the PDT with APC and APC alone groups than the HDR with APC group.
In a retrospective study from China, 90 patients with esophageal cancer underwent photofrin PDT (n=27), PDT combined with chemotherapy (n=33), or chemotherapy alone (n=30) from 2004 to 2007. (5) Rates of symptomatic palliation (85.2%, 93.9%, and 60.0%, respectively) were not significantly different. The differences in median survival rate at 2 years were statistically significant (29.6%, 54.5%, and 16.7%, respectively) (p=0.046).
Obstructing Endobronchial Tumors
Similar to obstructing esophageal tumors, short-term outcomes are also relevant for PDT as a treatment of endobronchial tumors. Laser ablation is commonly used to treat endobronchial lesions, and, thus, the relative efficacy of PDT and laser ablation is also relevant. The product insert cites 2 studies totaling 211 patients with obstructing endobronchial tumors who were randomized to receive PDT or Nd:YAG laser therapy. (2) The response rates (i.e., the sum or complete response (CR) and partial response (PR) rates) for the 2 treatments were similar at 1 week (59% PDT, 58% laser therapy) with a slight increase in response rates for PDT at 6 weeks (60% PDT, 41% laser therapy). Clinical improvement, as evidenced by improvements in dyspnea, cough, and hemoptysis, were similar in the 2 groups at 1 week (25–29%); however, at 1 month or later, 40% of patients treated with PDT reported clinical improvement compared to 27% treated with laser therapy. Due to missing data in the studies, statistical comparisons were not performed.
In another small, published, randomized study comparing PDT and Nd:YAG laser therapy in patients with airway obstruction, Diaz-Jimenez and colleagues reported that the 2 techniques had similar effectiveness over a 24-month period. (6) The authors noted a better immediate response rate associated with laser therapy and suggested that laser therapy may be particularly appropriate for those requiring rapid relief of symptoms. Results of a larger case series of 100 patients with unresectable lesions also report that PDT is associated with successful palliation. (7)
Similar to treatment of obstructing esophageal lesions, repeat endoscopy may be required for tumor debridement, at which time repeat PDT may be performed to treat residual tumor.
Early-Stage Lung Cancer
It is anticipated that only a minimal number of patients with non-obstructing lung cancer will be appropriate candidates for PDT. Of the 178,000 new cases of lung cancer annually, only 15% are detected with early-stage lung cancer. Of these, approximately 60% are treated with surgery, and another 25% are treated with radiation therapy. Candidates for PDT are limited to those patients who cannot tolerate surgery or radiation therapy, most commonly due to underlying emphysema, other respiratory disease, or prior radiation therapy. In this primary treatment setting, long-term outcomes such as response rates and disease-free survival are important. The product insert for porfimer sodium (Photofrin) also refers to 3 case series totaling 62 patients with microinvasive lung cancer. (2) The complete tumor response rate, biopsy-proved, at least 3 months after treatment was 50%, median time to tumor recurrence was more than 2.7 years, median survival was 2.9 years, and disease-specific survival was 4.1 years. (1) In another case series of 95 early-stage lung cancers, the complete response (CR) was 83.2%. (8)
The labeled indication suggests that PDT for early-stage lung cancer should be limited to those who are not candidates for either surgery or radiation therapy. However, Cortese and colleagues reported on a case series of 21 patients with early-stage squamous cell cancer of the lung who were offered PDT as an alternative to surgery. (9) Patients were followed up closely with repeat endoscopy and surgical resection if cancer persisted after no more than 2 courses of PDT. A total of 9 patients (43%) had a CR at a mean follow-up of 68 months (range 24–116 months) and thus were spared surgical treatment.
It should be noted that Nd:YAG laser therapy, electrocautery, and endobronchial brachytherapy are also considered treatment options for early-stage lung cancer. However, unlike obstructing endobronchial lesions, no controlled studies have compared the safety and efficacy of these techniques.
Barrett's Esophagus with High-Grade Dysplasia
The U.S. Food and Drug Administration (FDA)-labeled indication for treatment of high-grade dysplasia (HGD) is based on a multicenter, partially blinded, study that randomized 199 patients to receive porfimer sodium (Photofrin) plus omeprazole or omeprazole alone. (2) Initially, 485 patients with HGD were screened for the trial; 49% were subsequently excluded because HGD was not confirmed on further evaluation. As noted in the package insert, the high patient exclusion rate re-enforces the recommendation by the American College of Gastroenterology that the diagnosis of dysplasia in Barrett's esophagus be confirmed by an expert gastrointestinal pathologist. (10) Patients randomized to the treatment group received up to 3 courses of PDT separated by 90 days. The primary efficacy endpoint was the CR rate at any one of the endoscopic assessment time points. Complete response was defined, at a minimum, as ablation of all areas of HGD but with some areas of low-grade dysplasia (LGD). A total of 76.8% of patients in the treatment group achieved a CR compared to 38.6% in the control group. At the end of 24 months of follow-up, patients in the treatment group had an 83% chance of being cancer-free compared to a 54% chance in the control group.
Five-year follow-up of subjects in the RCT of PDT with porfimer sodium (Photofrin) in Barrett's high-grade dysplasia conducted for the FDA approval process was reported by Overholt et al. in 2007. (11) Patients with Barrett's esophagus and HGD were randomized to PDT plus omeprazole or omeprazole only. Sixty-one patients were enrolled in the long-term phase of the trial, 48 PDT plus omeprazole group and 13 in the omeprazole only group. Endoscopy with mucosal assessment and biopsies was performed at the first visit and every 3 months until 4 consecutive quarterly biopsy results were negative for HGD and then biannually until 60 months after randomization or until treatment failure. At 5 years, PDT plus omeprazole was significantly more effective than omeprazole alone in eliminating HGD (77% [106/138] vs. 39% [27/70], respectively; p<0.0001). Patients in the PDT group were about half as likely to progress to cancer as those in the omeprazole alone group (21/138 [15%] vs. 20/70 [29%], respectively; p=0.027), with a significantly longer time to progression to cancer favoring PDT. The small number of subjects available for long-term follow-up is a limitation of this study.
Badreddine and colleagues performed a retrospective analysis of a cohort of Barrett's esophagus patients seen at a specialized Barrett's esophagus clinic in the U.S. to identify risk factors for recurrence of dysplasia after ablative treatment including PDT. (12) Three-hundred sixty-three patients underwent PDT with or without endoscopic mucosal resection. Forty patients were lost to follow-up, 46 had residual dysplasia, and 12 had no dysplasia at baseline. Indications for ablation were LGD in 53 patients, HGD in 152 patients, and intramucosal cancer in 56 patients. Median follow-up was 36 months. Recurrence occurred in 45 patients, and median time to recurrence was 17 months. Significant predictors of recurrence on the multivariate model were older age, presence of residual nondysplastic Barrett's, and a history of smoking. The authors note that the possibility of missing prevalent dysplasia despite aggressive surveillance is a limitation in the study.
Pech and colleagues, in a study from Germany, report long-term (i.e., 5-year) outcomes of endoscopic treatment of high-grade intraepithelial neoplasia and mucosal adenocarcinoma in patients with Barrett's esophagus. (13) Patients were excluded if staging examinations did not confirm the suspected diagnosis of Barrett's carcinoma or high-grade intraepithelial neoplasia or if they showed more advanced tumor stage (greater than T1), lymph-node involvement, or metastasis. Patients with localized neoplasia were offered endoscopic resection; those with lesions that were not clearly localized, those with superficial subtle multifocal neoplasia, and patients with no neoplasia found in esophageal biopsies were treated with 5-aminolevulinic acid (5-ALA) PDT. (Note: Oral ALA does not have FDA approval.) Fifty-five patients received only PDT, and 13 had endoscopic resection and PDT. A complete response was achieved in 98.5% of the patients, and CR was achieved in 17% during median follow-up of 37 months.
Prasad et al. report similar outcomes between 2 groups (nonrandomized) of patients who received either PDT (n=129) or surgery (n=70) for high-grade dysplasia in Barrett's esophagus. (14)
There has been ongoing research interest in PDT as an adjunct to endoscopic management of cholangiocarcinoma, primarily as a palliative strategy. In addition, percutaneous biliary drainage is a frequent management strategy for cholangiocarcinoma, and PDT can thus be administered percutaneously. Several case series have reported positive results, as measured by quality-of-life studies. (15-17) Two small randomized studies have reported both palliative effects and an increase in median survival. For example, Ortner and colleagues conducted a trial of 39 patients with nonresectable cholangiocarcinoma who were randomized to receive either endoscopic stenting alone or in conjunction with PDT. (18) The median survival of the 20 patients in the PDT group was 493 days compared to 98 days in the 19 patients who underwent stenting alone. The trial was terminated prematurely due to the favorable results. Zoepf and colleagues randomized 32 patients with cholangiocarcinoma to stenting with and without PDT. (19) The median survival for the PDT group was 21 months compared to 7 months in the control group.
Gao and colleagues performed a systematic review of the literature on PDT for unresectable cholangiocarcinoma. (20) The authors reviewed 2 RCTs, 2 comparative trials with concurrent controls, 1 comparative trial with historical controls, and 15 case series. The 2 randomized trials were rated of moderate quality, and the other available studies were of low to moderate quality. The mean number of subjects was 27 (range: 1–184 subjects). Porfimer sodium (Photofrin) was the photosensitizer used in all but 2 of the included studies.
In a retrospective study by Kahaleh et al., 19 patients were treated with endoscopic retrograde cholangiopancreatography (ERCP) with PDT and stents, and 29 patients treated with ERCP and stents alone at a U.S. center. (21) Most of the patients had Bismuth III and IV lesions; however, some had Bismuth I and II lesions. Some patients in each group received chemoradiation therapy. Mortality in the PDT/stent group at 3, 6, and 12 months was 0%, 16%, and 56% respectively, and 28%, 52%, and 82% in the stent-alone group. The difference was statistically significant at 3 and 6 months. The authors note "it remains to be proved whether this effect is attributable to PDT or the number of ERCP sessions and a randomized multicenter study is required to confirm these data."
In a comparative review with concurrent controls, Witzigmann et al. analyzed records of 184 patients treated over a 10-year period in Germany for hilar cholangiocarcinoma. (22) Sixty patients underwent resection (8 after neoadjuvant PDT), 68 had PDT and stenting, and 56 had stenting alone. Median survival was 12 months in the PDT and stenting patients versus 6.4 months in the stent-alone group (p<0.01). Patients who received PDT and stenting had lower serum bilirubin levels (p<0.05) and higher Karnofsky performance status (p<0.01).
In a 2008 editorial, Baron reviews the pros and cons of PDT for palliation of cholangiocarcinoma and the questions remaining about its role given the available options of chemoradiation, brachytherapy, and plastic and metal stents. (23) On the negative side, he notes that PDT is not available at all centers and requires expertise in endoscopy and PDT, and the fibers available in the U.S. are suboptimal for ERCP use; because of their stiffness, treatment is limited to the main hepatic ducts. The procedure is time-consuming. Post-treatment photosensitivity lasts for 4-6 weeks and may limit quality of life. In favor of PDT, it is reasonably well-tolerated, seems to be effective, and can be repeated without a ceiling dosage effect. It is the only treatment to date in which data suggest improved survival over plastic stent placement alone for advanced cholangiocarcinoma. Baron concludes that the answer to whether PDT should be used for palliation of cholangiocarcinoma is a "qualified yes" but that "further comparative trials are needed to determine the optimal regimen of palliation of obstructive jaundice in these patients."
Gynecological Malignancies
A Phase II European trial with 20 patients of imiquimod and PDT for vulval intraepithelial neoplasia reported by Winters et al. demonstrated an overall response rate of 55% by intention-to-treat analysis. (24) Symptom response at 52 weeks was 65% asymptomatic versus 5% at baseline. The potential benefit of the treatment is its ability to treat multifocal disease. Results from this small trial need to be replicated in additional larger studies before changes are made to the policy statement.
Istomin and colleagues reported on 112 patients with morphologically proven cervical intraepithelial neoplasia grades II and III with at least 1-year follow-up after treatment with Photolon PDT. (25) Complete regression of neoplastic lesions was seen in 104 of the treated women. Of 88 patients infected with human papillomavirus (HPV) of highly oncogenic strains, 47 had complete eradication of the HPV infection 3 months after treatment.
Head and Neck Cancers
In a 2008 review, Biel reported his own experience with 276 patients treated with Photofrin PDT for early oral and laryngeal cancers over a period of nearly 16 years and summarized previously published small case series. (26) Of 115 patients in the author's series with recurrent or primary carcinoma-in-situ (CIS), T1N0 and T2N0, there were 10 recurrences (5-year cure rate 100%) at mean follow-up of 91 months. Five-year cure rate for 113 patients with recurrent or primary CIS and T1N0 squamous cell carcinomas of the oral cavity was 100%, with 6 recurrences within 8 months of initial treatment salvaged with either repeat PDT or surgical resection. Two patients with T1 tongue tumors developed positive regional lymph nodes within 3 months of PDT, had conventional neck dissection, and had been free of disease for at least 5 years. In the 48 patients treated for superficial T2N0 and T3N0 squamous cell carcinomas of the oral cavity, there were 5 recurrences, all salvaged with repeat PDT or surgical resection. Three-year cure rate was 100% (mean follow-up 56 months). Again, these data need to be replicated in larger, multicenter studies that include a comparison group.
In 2009, Wildeman and colleagues reviewed all of the available literature to determine the efficacy of PDT therapy for patients with recurrent nasopharyngeal carcinoma. (27) Of 5 studies, one was a series of 135 patients with reported CR in 76 cases and marked response in 47 cases after hematoporphyrin-derivative-mediated PDT; however, it was not clear if the patients had recurrent nasopharyngeal carcinoma or that PDT was primary treatment. The other 4 studies had 12 or fewer subjects.
A U.S. cancer center enrolled 30 patients in a trial to determine efficacy and safety of Photofrin PDT for primary or recurrent moderate to severe oral or laryngeal dysplasia, CIS, or T1NO carcinoma. (28) Twenty patients had a CR, one had a PR, and one had no response. Three patients with oral dysplasia with an initial CR experienced recurrence. All patients with no response or PR or recurrence after initial response underwent salvage treatment. No patient required airway intervention, and all complications resolved without permanent sequelae.
A retrospective review of Photofrin PDT of 30 patients with early-stage (TisT2N0M0) squamous cell carcinoma of oral cavity and oropharynx found that 24 patients demonstrated CR (follow-up 3-144 months). (29) Six patients who had PR with recurrence were subsequently treated with conventional therapy. Eleven of 24 patients were cancer disease-free at 2 years after PDT.
PDT for treatment of mesothelioma has also been discussed in recent reviews; however, studies identified in the search consisted of Phase one studies and animal studies. A study from Austria with 14 subjects involved intraoperative PDT under hyperbaric oxygenation. (30) No other studies using FDA-approved photosensitizers were identified.
Brain Cancer
Aziz and others describe using intraoperative Photofrin PDT in 14 metastatic brain cancers (7 originating in the lung and 7 from a variety of sources). (31) Of the patients with lung cancer metastases, 1 died of unrelated cause, and 6 were free of brain disease until their deaths. Two of the remaining patients (1 with metastatic bowel cancer and 1 with unknown primary) died of local brain recurrence. A review of the literature on PDT applications in brain tumors relied largely on unpublished data and was not reviewed for this policy. (32)
Ongoing Clinical Trials
A search of online site ClinicalTrials.gov in February 2012 identified 2 Phase III trials. A Phase II/III trial will evaluate whether the presence or absence of biomarkers in Barrett's esophagus influences the outcomes of PDT or radiofrequency ablation treatment. (NCT00587600) A Phase III, randomized controlled study of PDT for inoperable cholangiocarcinoma palliation is scheduled for completion in December 2012. (NCT00907413).
Photodynamic therapy is an ablative treatment consisting of administration of a photosensitizing agent and subsequent exposure of tumor cells to a light source of a specific wavelength to induce cellular damage. After administration of the photosensitizing agent, the target tissue is exposed to light using a variety of laser techniques.
In general, the evidence to assess the role of PDT in the treatment of malignancies and Barrett's esophagus is of limited quality but suggests that PDT may be useful for palliative treatment of obstructing esophageal cancer and endobronchial lesions. PDT for treatment of early-stage non-small cell lung cancer has shown benefit and may be used to improve quality of life for patients who are ineligible for surgery and radiation therapy. PDT may also be considered for treatment of HGD in Barrett's esophagus, as controlled and uncontrolled studies have demonstrated favorable complete response rates with the use of PDT.
Data on use of PDT for other malignancies and Barrett's esophagus without high-grade dysplasia are limited. The published literature consists of generally small case series without comparator groups. Thus, the use of PDT for other malignancies and Barrett's esophagus without high-grade dysplasia is considered experimental, investigational and unproven because the impact on health outcomes is not known.
The policy statements have not been changed due to a lack of any new comparative studies. Radiofrequency ablation and endoscopic mucosal resection appear to be replacing PDT as the preferred methods of ablation for high-grade dysplasia in Barrett's esophagus. Evidence for efficacy of photodynamic therapy for palliative treatment of unresectable cholangiocarcinoma is accumulating; however, randomized controlled trials are needed to confirm its utility compared to alternative treatments such as chemoradiation.
Practice Guidelines and Position Statements
The Society of Thoracic Surgeons published practice guidelines for the management of Barrett's esophagus with high-grade dysplasia in June 2009. (33) The guideline states that, based on grade B evidence, "photodynamic therapy (PDT) should be considered for eradication of (HGD) in patients at high risk for undergoing esophagectomy and for those refusing esophagectomy" and that "it is reasonable to use photodynamic therapy (PDT) to ablate residual intestinal metaplasia after endoscopic mucosal resection (EMR) of a small intramucosal carcinoma in high-risk patients."
The 2011 American Gastroenterological Association's position statement on Barrett's esophagus management recommends photodynamic therapy as an option for treatment of confirmed high-grade dysplasia with Barrett's esophagus. (10)
The National Comprehensive Cancer Network (NCCN) guideline on esophageal cancer lists photodynamic therapy as an ablative method for patients with Barrett's esophagus with HGD, and for palliation of dysphagia in patients with esophageal cancer. (34) Endoscopic mucosal resection and ablation for T1a tumors and EMR or ablation for tumor in situ are listed as treatment options for Barrett's esophagus and high-grade dysplasia.
The 2007 American College of Chest Physicians (ACCP) practice guidelines on bronchial intraepithelial neoplasia and early central airways lung cancer recommend PDT as a treatment option for superficial squamous cell carcinoma in patients who are not surgical candidates. (35) The ACCP guidelines also note there is limited experience in the use of PDT in patients who are candidates for surgery.
The NCCN guideline on non-small cell lung cancer states that PDT is a treatment option in patients with locoregional recurrence of non-small cell lung cancer with endobronchial obstruction or severe hemoptysis. (36)
NCCN lists ablation (PDT is an ablative technique) as a treatment option in patients with microscopic margins (R1) or residual local disease (R2) post-resection of intrahepatic cholangiocarcinoma. (37) NCCN describes PDT as a relatively new therapy for the local treatment of unresectable cholangiocarcinoma saying that the combination of PDT and biliary stenting "has been shown to significantly improve the overall survival of patients with unresectable cholangiocarcinoma based in 2 small randomized clinical trials."
The National Institute for Health and Clinical Excellence (NICE) has published guidance on a number of applications of PDT. Guidelines on PDT for palliative treatment of advanced esophageal cancer, (38) treatment of localized inoperable endobronchial cancer, (39) and treatment of advanced bronchial carcinoma (40) state that current evidence on safety and efficacy is sufficient to support the use of PDT for these indications. NICE states that PDT should be used only with special arrangements for clinical governance, consent, and audit for the following 4 indications: interstitial photodynamic therapy for malignant parotid tumors, (41) early stage esophageal cancer, (42) bile duct cancer, (43) and high-grade dysplasia in Barrett's esophagus. (44) NICE guidance on PDT for brain tumors states that current evidence is limited in quality and quantity, and the procedure should only be used in context of randomized controlled trials with well-defined inclusion criteria and treatment protocols, and collection of both survival and quality-of-life outcomes. (45)
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member's benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.


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The Hub Hotel
Situated in the heart of Business Congress & Exhibitions Area, right in front of EXPO2015 and close to Rho Fiera Milano & Fiera Milano City this 4 star Urban Hotel is characterized by a contemporary design. The Hotel offers 162 rooms, eclectic open spaces ideal to set any kind of event, a cozy garden Lounge and an impressive congress center with 9 rooms. Not to be missed the panoramic wellness area with Swimming Pool, Gym & Spa.
"Excellent shuttle service to all important locations" (Booking)
"For visitors to the new Fiera grounds in Milan The Hub is a good choice for a business hotel" (Booking)
"Shuttle service on demand convenient to train station or Uruguay metro station. To come back to hotel just phone and they come pick you up. Less than 30 min from Hotel to city center (shuttle + train/metro). Metro/train ticket sold at receiption for 1 Euro." (Booking)
"The shuttle service was great. When you made a request the shuttle was there in a minute. Perfect price-quality relation and the best choice if you would like a city trip to milan combined with comfort and luxury." (Booking)
"have been to Milan for exhibitions and stayed at some of the best hotels in the area but this hotel was soooo surprisingly good that I look forward to going to Milan again!" (Tripadvisor)
"The Hotel location is very good to be reached from the highway and seems very close to the exhibition" (Tripadvisor)
"Modern Hotel. Best service. Shuttle bus on demand! Perfect rooms" (Tripadvisor)


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Content Pager
Content Pager is a jQuery Joomla content module which can fetch article contents from the selected categories and create pagers. The module has options to show the complete article inside the popup upon clicking the read more text.
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Role of inflammatory mediators in the suppression of insulin receptor phosphorylation in circulating mononuclear cells of obese subjects
- H. Ghanim,
- A. Aljada,
- N. Daoud,
- R. Deopurkar,
- A. Chaudhuri,
- P. Dandona
- … show all 6 hide
Obesity is associated with insulin resistance and inflammation. The circulating human mononuclear cell (MNC) has been shown to respond to low-dose insulin infusion. We have now investigated whether in obesity: (1) phosphorylated insulin receptor beta subunit (p-INSR-β) is reduced in the MNC; (2) pro-inflammatory mediators including inhibitor of kappa light polypeptide gene enhancer in B cells-kinase beta (IKBKB), suppressor of cytokine signalling-3 (SOCS) and protein kinase C-beta 2 (PRKCB2) are increased and related to p-INSR-β; and (3) the reduction in MNC p-INSR-β is related to the reduction in insulin sensitivity.
Materials and methods
MNCs were prepared from fasting blood samples of 16 normal weight and 16 obese female subjects.
Our data show that p-INSR-β is reduced significantly in MNCs from obese subjects compared with that of normal controls. MNCs from obese subjects have higher IKBKB expression, increased nuclear factor kappa B (NFκB) binding and higher mRNA expression of TNFAIP1 and IL6 genes. NFκB binding, TNFAIP1 mRNA and plasma C-reactive protein are inversely related to p-INSR-β. PRKCB2 mRNA and protein expression were significantly higher in the obese subjects and were related significantly to pro-inflammatory mediators but not to p-INSR-β. SOCS3 mRNA expression was markedly elevated and positively related to pro-inflammatory mediators including IKBKB and PRKCB2 on the one hand and inversely related to p-INSR-β on the other.
We conclude that in obesity the MNC is characterised by reduced p-INSR-β and increased inflammatory mediators including IKBKB, PRKCB2 and SOCS3. The increase in SOCS3 but not IKBKB or PRKCB2 is related inversely to p-INSR-β and might mediate the inhibition of p-INSR-β. These data elucidate the relationship between inflammation and insulin resistance using the MNC as a model.
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- Title
- Role of inflammatory mediators in the suppression of insulin receptor phosphorylation in circulating mononuclear cells of obese subjects
- Journal
Volume 50, Issue 2 , pp 278-285
- Cover Date
- 2007-02-01
- 10.1007/s00125-006-0508-9
- Print ISSN
- Online ISSN
- 1432-0428
- Publisher
- Springer-Verlag
- Additional Links
- Topics
- Keywords
- Inflammation
- Insulin receptor
- Insulin resistance
- Mononuclear cells
- Obesity
- Industry Sectors
- Authors
- H. Ghanim (1)
- A. Aljada (1)
- N. Daoud (1)
- R. Deopurkar (1)
- A. Chaudhuri (1)
- P. Dandona (1) (2)
- Author Affiliations
- 1. Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo and Kaleida Health, Buffalo, NY, USA
- 2. Diabetes-Endocrinology Center of Western New York, 3 Gates Circle, Buffalo, NY, 14209, USA


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Couple facing heroin chargesFebruary 25,2013
IRASBURG The Vermont State Police say a couple from Irasburg is facing heron and variety of other charges after their home was searched by investigators.
Police say the home of Robert Cote and Sonya Perkins, both 24, was searched Thursday after an investigation by the Vermont Drug Task Force that lasted for several weeks.
Cote was charged with of sale and trafficking of heroin, possession of depressant, stimulant or narcotic drug, possession of marijuana as well as child endangerment and using a weapon in the commission of a felony. Perkins was charged with trafficking heroin, child endangerment, possession of marijuana, and possession of depressant, stimulant, or narcotic drug.
Police say the couple has two children.
Cote is being held on $100,000 bail. Perkins was released.MORE IN This Just InStephen Goldberg is back with a vengeance. Full StoryDUBLIN Irelands citizens have voted in a landslide to legalize gay marriage, electoral... Full StoryMONTPELIER Nearing 50 years of age, Jeff Weaver, the man tapped to spearhead Sen. Full Story
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Electronics to the RescueBy Capt. Richard Thiel | June 10th, 2011
I mark my time as editor of PMY with a number of technological milestones. One was when we got our first fax machine. (Until then we relied on the U.S. Mail and something called a telex, whose mysteries I could never fathom.)
When the bell on our machine sounded, the staff would all gather 'round to watch a fuzzy, streaky document spool out. We were as enraptured as relatives of the deceased at a séance. Actually reading the thing was another matter.
Looks like Weird Uncle Al Is at It AgainBy Kevin Koenig | June 8th, 2011
Luna EclipseBy Alyssa Haak | June 8th, 2011
A dramatic reenactment.*
The Venice art biennale is in full swing right now. Since 1895, the festival has brought together artists of every discipline ...as well as those who can afford to purchase their art.
A Prosthetic tail saves the life of a dolphinBy Jamie Sheirer | June 7th, 2011
Since leaving home for college, visiting the local aquarium in Clearwater, Florida hadn't made my priority list. That is, however, until someone told me about a resident Atlantic bottlenose dolphin at the aquarium who would be the star of an upcoming motion picture.
If You Want Blood (You Got It)By Kevin Koenig | June 3rd, 2011
Cakewalk for SaleBy Alyssa Haak | June 2nd, 2011
The 281-foot Cakewalk, which debuted at No. 38 on last year's Top 100, is now for sale through Burgess and Merle Wood.
Preparing your boat for hurricane seasonBy Jamie Sheirer | May 31st, 2011
Take My Wife, Please.By Kevin Koenig | May 27th, 2011
Top 100 PreviewBy Alyssa Haak | May 27th, 2011
The Top 100 list is not a static beast. It is like a sort of mythical shape shifter. How do you use the August issue?
Anyways, I'm elbow-deep in Top 100 and here's a bit of a taste of what's to come:
Nobiskrug's 74-meter (242-foot) Sapphire was just delivered to her owners. Any guesses as to what number she'll be on this year's list?
Get Back in the GameBy PMY Broker Insight | May 25th, 2011
By Jason Y. Wood
The market for buying and selling boats is still there. It hasn't gone away, it's just been going through some changes. There are deals to be had, if you know where to look. The good news is that brokers have stayed in the game, watching the fluky market. The right broker can help you find what you need. It may be time to get off the bench.


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Deborah Squires and her team at Northwest Harvest look forward to the season of giving. But this year they've learned for some it's more about taking.
I'm angry, says Squires. I'm just frankly angry because people here are passionate about our mission and we take it personally.
What's got her so worked up? Some group is robo-calling people asking for donations for Northwest Harvest.
There's just one problem, We never do that. The need is real. The cause is good but Northwest Harvest would never use that method to solicit donations, Squires said.
Fake charity scams are common this time of year. And in this case, the bad guys are calling well outside the state looking for cash.
We have a special connection to this group. KING 5 partners with Northwest Harvest for Home Team Harvest. Together we raise enough food and cash to provide millions of meals. This year alone we reached 4 million.
Tis the season for scammers, so don't donate over the phone. Ask for the charity's information and check them out through websites like Guidestar or Charity Navigator.
Give from your heart, but please use your head first.