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Reasonable Request for Rep System Changes
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Survivor of Remus
Join Date: Jun 2012
Posts: 366
# 1
Reasonable Request for Rep System Changes
Ok, now that im looking at it it seems like ALOT of dilithium, And it just seems like u /copyed the Fleet system.
Now Here are my sugjestions to make it less painful...
1. Turn it into a Fleet branch so fleet members share the same System or maybe each fleet member somewhat shares some of their progression making fleet STFing very effective which will encoruage fleets to work together.
2. Account wide. Or Semi Account Wide Maybe for every char you get up your entire account gets said boost. Like my Main becomes Lvl 2. The rest of my account becomes lvl 1. My 2nd char gets lvl 3 the rest of my chars, lvl 2, then 3rd char lvl 4, rest lvl 3, 4th lvl 5 rest lvl 4. So if i level 5 chars up in rep exponentialy, i will only have to lvl ONE level for all my other chars.

subset: commoncrawl


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CONTEST: Generationals / Lowell @ The Garrison (Friday, Dec. 5th)
Just as two contests finished today on Indie Music Filter, I'm happy to announce a new one for a show next Friday featuring Generationals and Lowell. Read on to get details.
Collective Concerts Presents
with Lowell
Fri, December 5, 2014
The Garrison
Doors: 8:00 pm
Tickets: $12.50
This event is 19 and over
Want a way into the show?
Click in to enter.


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Anyone here watching this? It''s pretty much an X-Men Lite show. Not bad but not particularly good either.%0D\ %0D\ Poor David Strathairn, reduced to this. Guess a paycheck is a paycheck.
DataLounge get your fix of gay gossip, news and pointless bitchery.
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The reason people use a crucifix against vampires is that vampires are allergic to bullshit.
Richard Pryor
You gotta be cool when you're macho man, cuz you can't be sensitive and care about someone having a good time in bed, cuz that's too scary... When you don't use sensitivity when you're having sex, or share some of your soul, nothing gonna happen, because men really get afraid. Men really get scared in bed.
Other quotes by Richard Pryor
I know that if I wasn't scared, something's wrong, because the thrill is what's scary.
Movies are movies, and I don't think any of them are going to hurt the moral fiber of America and all that nonsense.
I believe the ability to think is blessed. If you can think about a situation, you can deal with it. The big struggle is to keep your head clear enough to think.
When you ain't got no money, you gotta get an attitude.
It's easy to love somebody. Shit, sit with them a little bit and talk to them a while.
I bought my parents a home before they died, and they got to see that I was going to be all right. They always thought I would go someplace.
Comedy rules! Don't let anybody tell you otherwise, and there are no rules in stand-up comedy, which I really like. You can do anything you want and you can say anything that comes to mind, just so long as it's funny. If you ain't funny then get the fuck off the stage, it`s that simple.
Motherfucker looked at me like I owed him money. (on Reagan)
There was a time in my life when I thought I had everything - millions of dollars, mansions, cars, nice clothes, beautiful women, and every other materialistic thing you can imagine. Now I struggle for peace.


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GUELPH — While Bill Baier battles stage four renal cancer, his brother Brian is fighting the system on his behalf, trying to get an expensive drug treatment covered through the provincial drug plan.
But while Votrient is being reviewed by the Ontario Drug Review Panel and is expected to be put on the list of drugs covered by the province eventually, it might not get there in time for Bill, a Brighton resident, whose parents reside in Guelph.
"The good news is that after five weeks, the cancer growth has stopped increasing, so the choice of Votrient was medically correct," Brian Baier, said in a phone interview. "The bad news is that Votrient is not covered in Ontario, not by Trillium or the Ontario Drug Benefit."
Brian said the pills cost $50 each and Bill takes four a day. That adds up $6,000 a month, and that adds up to financial difficulty for Bill and his family.
He's re-mortgaged his home and taken out a line of credit and his extended family is offering support. His local Rotary Club has stepped up to help with some of the expenses as well.
"I don't get the logic," Brian said. "It's funded in seven other provinces, but not here. I find that insulting."
Brian said he's written to Canada's health ministry, Ontario' health minister, Premier Dalton McGuinty and other MPPs, but is only getting the runaround.
"They all say 'thank you for your correspondence. We're sorry to hear about your brother,' and then they proceed to tell me why they can't help. It's unconscionable that it's covered in seven other provinces, but not in Ontario," Brian said. "This is an outrageous amount of money."
Since Bill lives in Brighton, so Brian approached Rob Milligan, MPP for Northumberland Quinte West, who agreed to post a petition to expedite the funding of Votrient on his website and keep copies in his offices. Milligan said he'd present the petition to the Legislative Assembly — and then the legislature was prorogued.
"With prorogation, there's no opportunity to ask the government the hard questions," Milligan said in an interview. "I wrote the Minister of Health asking for guidance on how to get the drug on the list when seven other provinces cover it. There's been no response from the minister yet."
GlaxoSmithKline Inc., which manufactures the drug, has offered Bill a compassionate care discount, but that still leaves a considerable outstanding expense.
Although he lives in Brampton now, Brian grew up in Guelph and his parents still live here. He said he was overwhelmed to see so many old friends and neighbours rallying support around the petition.
But Guelph MPP Liz Sandals said petitions don't carry any weight with the drug formulary.
"We should not be making medical decisions for political reasons," she said. "People get hopeful when a petition is tabled at the legislature, but medical decisions should be made for medical reasons and not based on what I think or don't think."
Sandals said it's a two-step process for getting drugs approved and funded in Ontario.
Firs,t Health Canada reviews the drug to determine if it's medically safe. Once approved, physicians can prescribe the drug but it's still not covered by provincial drug plans. Sandals said Votrient has been approved for use by Health Canada, but on a restricted schedule, meaning it is only approved for a narrow group of people under specific circumstances.
Then it goes to the Ontario Drug Review Panel, which is a panel of experts who look at the evidence of drug trials to determine if a drug is effective. Then the panel makes a recommendation to the Ministry of Health.
"It has to be more effective than other drugs used for the same condition," Sandals said. "These decisions are based on medical evidence."
There's also a process called the Pan-Canadian Oncology Drug Review which does the scientific evidence-based review on behalf of all provinces and territories.
"This group made a recommendation that Votrient should be funded in some circumstances," Sandals said. This is why it is funded in some provinces, but Ontario still does its own review, she said.
She said the Ontario Drug Review Panel is expected to make a recommendation regarding Votrient soon, but didn't know if that would be a matter of months or years.
As for the cost of the drug, Sandals said drug companies try to recoup the cost of research and development in the price of the drugs, and research is expensive.
"Then, if the drug can only be used by a narrow patient group, the cost is higher," she said.
She said the executive officer of the drug review panel has taken a hard line with drug companies of late and has been successful in negotiating down the cost of some drugs.
"If we get a more sensible price we can afford to bring more drugs into the formulary. That doesn't solve the problem for this family, however," she said.
Sandals said the review panel is independent of the legislature, "so whether we're prorogued or not prorogued has no influence on this."
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Recently, the Missouri Credit Union Association (MCUA) filled the positions of vice president of Events and vice president of Communications. These new hires will round out MCUA's Member Relations department, which supports the marketing and communication needs of its member credit unions.
Save the date for the 2012 CUNA Marketing Management Schools, to be held April 30-May 3, 2012, at the Paris Hotel in Las Vegas, NV.
Attend and you will leave inspired, enthusiastic and passionate, never to see marketing as a job that you "have to show up for every day" again. Plus, you can earn your designation as a Credit Union Certified Marketing ExecutiveTM (CU-CME)!
Learn more and register early to SAVE $200 at: http://cuna.org/training-education/event/MM1NV12
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text: Computer and electronics 04/11/2007 08:25 AM 04/11/2007 08:25 AM Computer and electronics By Associated Press 04/11/2007 08:25 AM Computers and electronics have changed the way businesses operate. In this almost paperless society, many companies would not be able to operate efficiently without functioning computers and electronics. Bluestreak Media Page: [[$index + 1]]


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Palit Dickinson Apartments240 Langdon St, Madison, WI 53703 View On Map (608) 257-7910
For rates, availability, and other information fill out the availability request form and a representative from Palit Dickinson Apartments will contact you shortly
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Robert Kraft: 'I love the Tuck Rule and forever will'
PHOENIX -- No one thinks the Tuck Rule makes any real sense. That's why the NFL is considering getting rid of the controversial rule, best known for altering the outcome of the Patriots-Raiders playoff game in 2001.
One person who won't likely be voting against it, though, is Patriots owner Robert Kraft. Kraft, while speaking at the NFL owners meetings in Phoenix, professed his love for the Tuck Rule.
"To be honest, prior to the snow game, I never knew what the Tuck Rule was," Kraft said. "I love the Tuck Rule and forever will."
It's a very good bet that the owners vote to eliminate the Tuck Rule. But they might not get a vote from everyone involved.
"I might have to abstain," Kraft said.
The Tuck Rule is utterly ridiculous: It doesn't make much logical sense to have an impossibly difficult to interpret set of circumstances surrounding whether a passing attempt is incomplete or a fumble.
This is precisely why the NFL is willing to dump the rule. Just don't expect Kraft to vote against it.


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By Paul Albano: First, this wasnt a controversial decision. I just looked up the word controversy and the dictionary seems pretty insistent on the notion that a controversy involves some form of disagreement. Well, theres no disagreement here. Pacquiao and Bradley fought. Pacquiao won said fight.
And it wasnt close. Should Manny have pressed harder to get rid of Bradley, and take the fight out of the judges increasingly grossly incompetent hands? Sure, I suppose so. Just as we should all read more classic novels and eat less sugar and stop removing the Do Not Remove tags from our futons and mattresses. And does Bradley deserve some credit? Why yes, yes he does. Bradley got beaten up for twelve rounds and he didnt quit. No sir. He just continued to get beaten up. So a doff of the cap to Mr. Bradleyhes a gentleman amongst men, and he gets beaten up with grace and dignity..
As for the judges, many are writing off Duane Ford and C.J. Rosss scorecards as a bad night. And why not? We all have bad nights. Why, just the other night I watched a lion eat a gazelle on some nature show, and wouldnt you know it, I ended up scoring the fight for the gazelle (it showed heart, and ultimately I thought it won enough of the quiet rounds). So maybe thats what happened to the Pacquiao-Bradley judges. Maybe Duane Ford (who, like C.J. Ross, scored it 115-113 for Bradley), a licensed judge in nearly every state that hosts meaningful fights, a veteran of over one hundred world title bouts, ex-head of the Nevada State Athletic Commission, and current Vice President of the International Professional Ring Officials Associations (an organization that oversees training of U.S. sanctioned boxing judges) had one of those bad nights. The kind of bad night where you find yourself in Vegas, ringside, judging a major PPV fightand scoring it in favor of the guy who got hit twice as often, while landing at a much lower connect percentage, with unmistakably less power.
So yeah, maybe thats what happened, the megastar, big money fighter lost a tough luck decision in a contest he dominated (which would make sense, because its not like boxing has a reputation for favoring megastar, big money fighters or anything). Or maybe something far more sinister happened. That thing that no one likes to talk or think about in boxing, or really, in any sport. Maybe the fight was fixed. Like actually fixed. For real. As fans, we have a strange relation to a rigged event. We make frequent accusations that a referee or a judge, or perhaps even an athlete, arent on the up and up, especially if theyre contributing to an outcome we dont like, but we seem very reluctant to actually believe thats the case. Even if the evidence screams otherwise. Which makes sense, because the base component of sports appeal is that the outcome of the game or match isnt predetermined. And if thats lost, the whole enterprise is lost.
Now far be it from me to accuse anyone in particular of fixing such the Pacquiao-Bradley fight, but well, Bob Arum sure does have a creepy smile. And his hair totally isnt that weird shade of brown naturally. And oh yeah, Arum stands to make millions from a rematch (especially if the rumors that Pacquiao was leaving Top Rank, Arums promotional company, are true). Ill stop here, because I have no more facts beyond the fight and the judging, though I suspect this angle will get more legs in the coming weeks and months.
But in close, crossover stars like Manny Pacquiao and Floyd Mayweather are supposed to be the guys that return boxing to at least a portion of its former glory. Mayweather did his part last month in an entertaining but clear victory over future hall of famer Miguel Cotto, and Pacquiao did his part Saturday night dominating a fringe top 10ish pound for pounder. Yet boxing probably didnt gain many fans in the past two months, and in fact based on the early returns from Twitter, has likely hemorrhaged many that it had. Which is a shame. Its a great sport filled with great athletes, and the most fun of all the sciences. Now all it has to do is fix nearly everything about itself except the in-ring product.
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Olay Regenerist Thermal Mini-Peel Reviews
Nice warm feeling!I enjoyed the heating aspect of this product. It is so relaxing! — 7 years, 3 months agoamymont | 3 reviews
Love this polisherThis product works so very well for me. It is also very nice using in the shower first thing in the morning. The warmth of the polisher along with the heat of the shower just great. The smell is very nice too a fresh scent. My skin just seemed to get better and better every time I used it. The sad thing is I live in Germany now and cannot find it here. I have nothing but raves for this product, Fabulous !!! — 7 years, 4 months agoichliebemeinhaut | 71 reviews
This review is: Helpful | Not helpful | Inappropriate | 3 of 3 people said helpful
Perfect!My skin has never been so clear or so soft. I've been using this product for a year now and don't plan on switching anytime soon. — 7 years, 4 months agoCarolineT | 3 reviews
average cleanserit feel warm and the sensation is nice, is a good cleanser with out being excellent, the thermal effect should do better fro claning because some areas dont llok as clena and others tend to feel too dry.Is that the polish effect?. — 7 years, 4 months agotabathabonita | 12 reviews
This review is: Helpful | Not helpful | Inappropriate | 2 of 4 people said helpful
Skin GenereistI enjoyed using this product. It made mk skin feel smooth. — 7 years, 5 months agoLM | 1 reviews
Soft smooth skin after 1 useMakes my face softer, smoother and feels great while using. I was surprised how well it heats up. No worries on my over sensitive skin. A new must have. — 7 years, 5 months agoJennzalot | 3 reviews
Nice & WarmHave used this for a few months, especially in the morning. Exfoliates well without being too abrasive. The warm lather feels good. Would buy again — 7 years, 4 months agodebbie20 | 3 reviews
love this productthe regenerist skin care is a brillant line i really do feel like my skin is getting the nutrients it deserves — 7 years, 5 months agoposierosie | 3 reviews
Better than overprice FREEZE productsIf you look at the ingredients in this product they are almost exactly the same as overpriced salon and high end department store products that do the same thing. I read ingredients. This product rocks. — 7 years, 5 months agokathie29 | 78 reviews
Love it!I love the way it feels when you are applying it. It makes my face look and feel so soft. — 7 years, 5 months agokitkattanner | 2 reviews
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Print to your heart's content with the Brother HL-2270DW. The integrated wireless 802.11b/g interface of this Brother laser printer has a one-touch AOSS, Wi-Fi Protected Setup wireless configuration that allows easy and safe synchronization. With a print speed of 27 pages per minute, the Brother HL-2270DW printer helps save time, by speeding through your document printing. With a 250-sheet paper tray, the Brother laser printer reduces the hassle of replenishing the paper every now and then. Harboring the automatic duplex printing technology, the Brother printer offers double sided printing. The Brother HL-2270DW supports a resolution of 2400x600 DPI that makes printing clear and detailed.
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Joe Pelham aka HiDefJoe Skater Profile
Hometown: Tampa FL, Stance: Regular, Age: 26, Status: Am
Notes: Joe Pelham joins Skatepark of Tampa in 2012 as our filmer and travel companion. He puts together all the SPoT Life episodes and more. Member of the super group known as the SPoT Media Team and has more frequent flyer miles than you.
Last Update: Tuesday, May 15, 2012 Submit an Update
Joe Pelham aka HiDefJoe on Instagram (@hidefjoe)
Thank you to the #compoundcollective for letting me be apart of the #lovethyneighorhood art project. What a great experience it was from the first day of filming, to the premier at Crowbar. Happy New Years everyone. Link in bio. @sambellipanni @jeremeknibbs @justdylanperry @derick.01 @ericmckenney @the_mole_av_club @sbuggica @tomcat_yc
Joe Pelham aka HiDefJoe Comments
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- Contest Results - over a decade's worth of contest history.


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The lights went out on John Murray's amateur schoolboy final, but the Manchester ace has promised to put Kevin Mitchell's lights out in their Battle of Britain blockbuster showdown next month. Murray's fight against James Richardson was stopped in the second round of their Schools ABA final in 2001 when rioting broke out at the Broadway Theatre, Barking, with the then Sports Minister Kate Hoey in attendance.
Earlier on in the evening, amateur star Mitchell received rave reviews over his superb performance, stopping Colan Foreman in the final, and a fight with Murray was being talked about.
"Although my fight was a joke and got abandoned half-way through the second round, I made sure I watched Mitchell that night because he was the big thing in the amateurs back then. He was the big star and everybody raved about him going to the Athens Olympics." said Murray.
"We were only a weight division apart so I felt that I would either meet him in the amateurs or later down the line in the pros."
"In the end we didn't meet as we both turned pro in 2003 and went our separate ways."
"He was at super-featherweight and winning titles and I was winning titles at lightweight so it was inevitable we were going to meet sometime."
Murray and Mitchell now clash for real on Saturday 9th July at the Excel London, in one of the biggest domestic showdowns in recent years, live on Sky Sports 1HD.
He added, "I can't wait to finally get Mitchell on July 9. It's been a long time in the making and a victory will really propel me into the public consciousness.
"The lights may have gone out on my fight in the school boy finals, but I promise that Mitchell's lights will be put out at the Excel.
"This will be the best John Murray you are going to see, no excuses, I'm going to do a real job on Mitchell.
"The winner is promised a world title fight next and it's been my dream to fight for that so I'm letting Mitchell get in my way."
Tickets for North 'n South are available now, priced at £40, £50, £75, £100, £150 and £200, from 0844 844 0444 or ticketmaster.co.uk
OPENING BELL SET FOR 22nd ANNUAL HALL OF FAME INDUCTION WEEKEND IN CANASTOTA, NEW YORK
CANASTOTA, NY - JUNE 9, 2011 - The opening bell will soon ring for the 22nd Annual Boxing Hall of Fame Induction Weekend, June 9-12th. A huge gathering of boxing legends of yesterday and today has been assembled to participate in festivities in Canastota.
The four-day celebration will officially begin with the opening ceremony at 5 p.m. today (June 9th) on the Hall of Fame grounds. The weekend will also feature over twenty events including ringside lectures, banquet, golf tournament, 5K Race / Fun Run, the Parade of Champions and the Official Induction Ceremony on Sunday, June 12th at 2:30 p.m.
Living inductees to be honored at the Official Induction Ceremony on Sunday, June 12th are three-division champion Julio Cesar Chavez (Mexico), junior welterweight champion Kostya Tszyu (Russia / Australia), heavyweight champion Mike Tyson (USA), trainer Ignacio Nacho Beristain (Mexico), referee Joe Cortez (USA) and screenwriter Sylvester Stallone (USA). Posthumous inductees will also be honored.
The Village of Canastota and the Hall of Fame organization looks forward to welcoming boxing fans and from around the world for the annual celebration of the sweet science, said Hall director Ed Brophy.
An impressive lineup of boxing legends of yesterday and today will participate. Among returning Hall of Famers are Carmen Basilio, Carlos Ortiz, Ruben Olivares, Marvelous Marvin Hagler, Aaron The Hawk Pryor, Ken Norton, Gene Fullmer, Jake LaMotta, Don Chargin, Bert Sugar, Angelo Dundee, Lou Duva, Stanley Christodoulou, Jeff Fenech, Brian Mitchell, Michael Carbajal, Pipino Cuevas, Ricardo Finito Lopez, Carlos Zarate, Chiquita Gonzalez, Barry McGuigan, Azumah Nelson, Jose Sulaiman, Bob Arum and Wilfried Sauerland.
Other boxing celebrities include Livingstone Bramble, Marlon Starling, Leon Spinks, Jesse James Leija, John H. Stracey, Billy Backus, George Chuvalo, Al Bernstein, Riddick Big Daddy Bowe, Erik Morales, Jimmy Lennon Jr. and Sergio Martinez.
Grand marshals of the Parade of Champions, scheduled for Sunday, June 12th, are the real life inspirations behind the Academy Award-winning film The Fighter, brothers Irish Micky Ward and Dicky Eklund.
For more information on the Hall of Fames 22nd Annual Induction Weekend please call (315) 697-7095 or visit www.ibhof.com.
Joseph Crosby Added To July 15 Albany, NY Boxing Card
LAS VEGAS, NEVADA (June 9, 2011) - Welterweight prospect Joseph Crosby (6-1, 1 KOs) get's back in the ring against Stephen Scott (7-2, 1 KOs) in a eight round fight for the vacant New York State light middleweight title promoted by Ares Promotions, on Friday, July 15th at Crowne Plaza in Albany, NY.
Joseph Crosby said "I wanted to be busier in the ring this year by fighting at least every two months but alot of fighters have been reluctant to fight me. "This opportunity came up to fight for the New York State light middleweight title so for this fight I decided to move up in weight."
In his last fight on March 5, 2011 in Newark, New Jersey, Judah won by four round decision victory over Greg Hackett.
Joseph Crosby said "Winning the New York State title is a good step in my boxing career. I'm training harder than every because on July 15th I want all my fans to come to the fight and celebrate with me after I win my first of many pro boxing titles. I want to thank my opponent for taking this fight, my fans, my entire team and Ares Promotions for this opportunity."
In the main event, Markus Williams (7-1, 1 KOs) will face TBA in a 8 round middleweight fight.
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Offer - Frozen Berries essential Waitrose 450g
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Product Description
Waitrose essential Berries
A mix of blackberries, blackcurrants, redcurrants and strawberries.
A mix of blackberries, blackcurrants, redcurrants and strawberries.
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Keep frozen.
To defrost: Remove the berries from all packaging. Place on a serving plate and leave to defrost at room temperature for 2½ hours or overnight in a refrigerator. Once defrosted keep refrigerated and use within 24 hours
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Room Temperature 2 1/2 hours
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Blackberries, Blackcurrants, Redcurrants, Strawberries
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13 May 2015
really nice
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24 April 2015
Becoming more disappointing
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06 March 2015
bad packaging
Although the fruit is great, I'm so frustrated with the packaging. I have bought this item a few times now & every time the bag has been split, causing all the red juice to leak in my fridge, go all over my floor, kitchen units & splash all over my clothes. As a result, I don't think I'll be ordering this item again.
28 February 2015
cheap but excellent quality berries
good in porridge. and to the reviewer who thought these were too tart - there is a high proportion of currants so tartness is to be expected !
Peach & Raspberry Crumble
A delicious twist on a classic dessert. Made with plump raspberries and juicy peaches.
30 mins
Brioche French Toast with Yogurt, Berries and Honey
Brioche and chilled berries give this classic brunch recipe a twist.
15 mins
Granola Berry Mix
The granola provides fibre, and the addition of the natural sweeteness of the honey combined wit the low far cottage cheese makes this a tasty post-dinner snack.
2 mins
Mini Meringue Kisses
This dessert is perfect for a BBQ.
1 hr 20 mins
Breakfast Smoothie
Packed with vitamins to get your day off to a flying start. Try serving with a swirl of yoghurt or a spoonful of berries on top.
5 mins
- Disclaimer
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my little suv
Reviewed By Robert R (Palm Coast, FL) Reviewed for a 2012 Ford Escape —10/30/2014 7:14 AM
pretty classy hitch lock. good fit,looks good,fast shipping! decent price!
Reviewed By John G (Glendale, NY) Reviewed for a 2013 Jeep Patriot —4/23/2015 9:41 AM
Very easy to use and takes all the movement out of your hitch and associated toys. If you have an extender, it must be hollow to use the anti rattle function on this pin. Otherwise you will need a J pin type lock.


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Developer/publisher Wargaming is giving PC gamers an peek at its upcoming online computer game World of Warships through a selection of newly-released in-game images. These screenshots feature the battleship New Mexico, one of the long-serving American combat vessels sailing for the U.S. Navy for several decades. It was a force to reckon with during WWII.
World of Warships is a naval combat MMO action game set a world of devastating sea wars. The game will feature such seafaring warcrafts as battleships, heavy cruisers, destroyers, and aircraft carriers. In tying in with Wargaming's other two militaristic MMO titles, World of Tanks and World of Warplanes, World of Warships will allow for the sharing of player resources (ie: in-game currency) and the company has stated that all three will be featured in a single map where tank commanders, aviators, and seafarers will battle for global domination.
This game is currently in development.


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University of Texas at Arlington Department of Theatre Arts
Welcome to the University of Texas Arlington Department of Theatre Arts. To learn more about our program and what we offer, please complete this interest form. Share your achievements by including a sample of your work, and show us why you would be a great fit for this program. Click the drop-downs on the right and get started now – we are waiting to hear from you!
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This issue includes information regarding results from Tuesday's primary runoff races for Republican candidate for Lieutenant Governor, Republican and Democrat candidates for State Superintendent of Education, and Democrat South Carolina House of Representatives District 54 for the general election in November.
McMaster bests Campbell in GOP runoff for lieutenant governor
Former S.C. Attorney General Henry McMaster soundly defeated Mike Campbell, son of the late GOP icon and S.C. governor, in Tuesday's Republican Party runoff for lieutenant governor. Read more here.
Molly Spearman, Tom Thompson to battle for SC superintendent of education
Republican Molly Spearman and Democrat Tom Thompson won landslide victories in their party runoffs Tuesday for S.C. superintendent of education. Read more here.
State Constitutional Officers
1. Lieutenant Governor
Mike Campbell 36% 48,671
Henry McMaster 64% 85,006 (Winner)
2. State Superintendent of Education
Sheila C Gallagher 59% 23,383 (Winner)
Tom Thompson 41% 16,130
Sally Atwater 43% 57,258
Molly Spearman 57% 76,379 (Winner)
South Carolina House of Representatives
1. District 54 – Democrat - Runoff
Pat Henegan 65% 2,377 (Winner)
Greg Ohanesian 34% 1,269
DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.
© Moore & Van Allen PLLC
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33 year old man | San Jose, CA, USA | Seeking women 20-31 within 50 miles of San Francisco, CA
Active within 24 hours
Here I am!
Well, I am a free spirited and easygoing guy. I read quite a bit and indulge in a fare amount of philosophy, culture, history mostly non-fiction. I love to travel and stay active, positive and happy in life. I am looking for someone who is cheerful, optimistic and inspired, someone who can laugh and take life easy. I'm really good at conversations that start somewhere and end up on the most random and unrelated topics. But I always try to make sense of it all in the end...my friends call me a polyhistor for all the trivia that is lodged in the deep recesses of my head. I also spend quite a bit of time contemplating and trying to understand the world and the people around me. I intend to get a little more focus and write a book/philosophical treatise on my ideas which are constantly evolving. Interesting fact: I am totally Indian but when I got my DNA analyzed from National Genographic I came to know that I share my DNA with all native Americans and but less than 1-2% of Indians. I apparently descended from the people who went all the way to Siberia but were too lazy to cross over to the new world and ended up in South India. It took 10,000 years for my people(me) to finally take air transport to come to the New World. Favorite books, movies, shows, music : I enjoy a lot of TV comedy - Office, Daily Show, Seinfeld, Curb, and a bunch of British shows like Monty Python, Yes Minister, Black Adder 4, Peep Show, Mitchell and Webb look, QI etc.... Movies - Hollywood and Foreign(Indian, Iranian, Spanish...) - Dark Knight, Inception, Gravity, Children of Heaven, Life is Beautiful, Shawshank Redemption, Lord of the Rings, Godfather trilogy, Star Wars, Pulp Fiction, Inception, Catch me if you can, Color of Heaven,....honestly far too many to list here... I read non-fiction - books on history, culture, philosophy and popular physics and watch a ton of documentaries. I have a keen interest in all philosophies and the more I read and more I, contemplate, ponder, meditate, introspect within and realize, I can't help but accept the ultimate congruence of all spiritual doctrines for one moment and then I drift away back into the madness of the world. Music - Check my ipod/spotify - I listen to music from all over the world - Pop, Rock, Alternative, Metal, Rap/HipHop, Western Classical, Latin, African, Middle Eastern Classical(maqams), Ottoman Classical Music, Turkish, Sufi, Rai, Indian - Bollywood and Indian Hindustani/Carnatic classical. Anything euphonic really.....I'd be glad if you can introduce me to some new exotic form of music born out of the unlimited creative power of the human mind. You should message me if you are happy, intelligent, fun, thoughtful and laid back, I've realized over the years that I get along best with those who have some intellectual and philosophical curiosity and can laugh easily. Also if you truly have and value empathy and compassion, I am sure we'll go a long way. You want a healthy caring relationship and are open to share some aspects of my culture. It'd be good if you are mostly vegetarian or trying to be one.
Book club , Camping , Coffee and conversation , Cooking , Dining out , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Performing arts , Religion/Spiritual , Travel/Sightseeing , Volunteering
Billiards / Pool, Cycling, Dancing, Other types of exercise, Walking / Hiking, Weights / Machines, Yoga
I exercise 3-4 times per week.
I like Dogs, Horses
Some other viewpoint
I love traveling.I went on a hiking/backpacking trip last year to South America (Gracias and Abrigado!) and loved Rio de Janeiro, BA and Peru. I am planning my next trip....any ideas? I'd like to do a motorcycle diaries kinda thing in India someday.
University of Southern California, Los Angeles, CA
TV - PBS Frontline, Daily Show, Big bang theory, Seinfeld reruns, Curb, Monty Python, Black Adder 4, Peep Show, Mitchel and Webb look, Yes Minister, QI. Foods - Indian, Thai, Chinese, Italian, Middle Eastern - but vegetarian.
like to hang out with friends, check out new places, go to clubs/bars, hike, watch movies, comedy on TV, read non fiction and spend hours musing at the human condition!
The last days of the Incas, Quantum Enigma, Cheating Death, Black Swan, Moonwalking with Einstein, Chaos, Shantaram.
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What he is looking for
|5'11" (180cms)
|5'0" (152cms) to 5'11" (180cms)
|Body type:
|About average
|Slender, About average, Curvy, Athletic and toned
|No preference
|No preference
|No Way
|No Way, Occasionally
|Social Drinker
|Never, Social Drinker
|Technical / Science / Computers / Engineering
|No preference
I am a Product Manager at a tech company.
|I'll tell you later
|No preference
|Never Married
|Never Married
|Have kids:
|Wants kids:
|Definitely, Someday, Not sure
|East Indian
|No preference
I was born in India and moved to California for grad school 10 years ago.
|No preference
I seek truth through the wide spectrum of philosophies from atheism to panentheism. All religions truly converge at the same reality though they may seem antagonistic to the ignorant fanatic. I eschew dogma, something firmly ingrained in traditions.
|English, Hindi, Spanish, Other
|Graduate degree
|Some college, Associates degree, Bachelors degree, Graduate degree, PhD / Post Doctoral


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35 year old woman | Carmel, IN, USA | Seeking men 25-35 within 50 miles
Im currently dating someone on here and am not looking any longer but match of course keeps your profile up. Thanks I don't look my age because I care about myself and my body. I am intelligent, easy going, fun loving, and enjoy a good book. No drama here! I can't stand kid games. Honesty is a preference though. I like to watch movies rather than TV and normally I'm just plain not home to catch anything on the tube. I love socializing and hanging out with loyal and fun loving friends. I'm all about laughter. I am always on the go, but I do enjoy being a homebody on occasion. I'm looking for someone that doesn't mind running around town exploring everything with me, or I with him. I tend to date younger because men my age don't workout and can't keep up with me. At times I do slow down and stay at home cuddling up with my kitties. I have a bachelors in Psychology from University of Tennessee. I grew up here in Indianapolis but moved to Knoxville, Tennessee after HS, then moved back for family. My mom and my aunt are the funniest characters in my life. I'm looking for someone that can make me laugh. Ive been back 2 years and am establishing myself in friends and searching for a job in my career field. I honestly don't think words can describe me. Really I'm a mix of too many characteristics and most the time people can't quite figure me out. Im not about leading anyone on I am looking for a relationship but if we end up as friends that's fine too. If you like substance in a conversation, laughter, and don't mind leaving your ego at the front door than I'll like you. I don't care about your car, your bank account, or your fancy home/condo. I have my own car, my own bank account, and one day if I achieve my dreams my very own home. I am very independent very passionate about my life and dreams. I like romance and depth and if you can't at least bring some of that to the table then we probably wont enjoy each other.
Book club , Coffee and conversation , Hobbies and crafts , Museums and art , Nightclubs/Dancing , Playing cards
Aerobics, Running, Soccer, VolleyBall
I exercise 1-2 times per week.
I like Cats, Dogs, Exotic Pets, Fish, Horses
Middle of the Road
Broad Ripple for Dancing. I frequent the Panera alot as well to drink coffee and have 'me' days
I enjoy reading and writing and shows like Big Bang Theory and True Blood. I read alot of scifi fantasy adventure.
Im an all around I'll try anything kinda girl. I have two left feet when it comes to sports but dancing is something that comes natural to me.
The Egyptian (no you wont find it on the popular book shelves) It is a diamond in the ruff just like me
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'6" (167cms)
|5'9" (175cms) to 8'11" (271cms)
|Body type:
|About average
|Athletic and toned
|No preference
|Dark brown
|No preference
|No Way
|Social Drinker
|Social Drinker
|Sales / Marketing
|No preference
I work two jobs because well Im hard working and I like to live a decent life. I am searching for a career and I've just not found it yet but I'm well on my way to my dreams and nothing will stop me from achieving them
|Less Than $25,000
|$35,001 to $50,000
|Never Married
|No preference
|Have kids:
|Wants kids:
|White / Caucasian
|White / Caucasian
|Spiritual but not religious
|No preference
If you haven't got an open mind for my religion then I dont think you'll like me. I am not athiest but I dont believe in a god either.
|No preference
|Bachelors degree
|Bachelors degree
I am considering getting my masters in Child Psychology or Counseling but for now I'm looking to see where my Bachelors will take me because I'm not quite ready to hit the school books again.


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Big Country Journal: Rodeo clowns launch flaming watermelon at Texas Cowboy Reunion
STAMFORD, Texas - I saw my first flaming watermelon at the Texas Cowboy Reunion last week. I'm wondering if I'll ever see a second.
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20 Ideas for Bathroom Wall Color
Paint isn't your only option consider wallpaper, fabric, stone and tile. These inspiring designs are packed with great ideas.
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Red Sox fans at Fenway Park sound off on popular players getting traded away and a disappointing season for the local baseball team. (By Steve Silva, Boston.com Staff)
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best way to Colmar
We are traveling and spending time doing ancestral work in the Neuffen / Stuttgart area next week. We would like to make a trip to Colmar also. What or where is the best place to get there from. Is it advisable to spend a night there or just do a day trip.


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The organs of the immune system, called lymphoid organs, work together to clear infection from the body. Lymphoid organs include lymph nodes, lymphatic vessels, and lymphocytes (white blood cells), as well as the spleen, bone marrow, tonsils, adenoids, and thymus gland. There are two major classes of lymphocytes—B cells and T cells. B cells grow to maturity in the bone marrow, and produce antibodies that attach to foreign antigens, marking them for destruction by other immune cells; this is the antibody-mediated response, or humoral immunity. T cells mature in the thymus gland. They attack and destroy diseased cells that they recognize as foreign, as well as regulate and coordinate the overall immune response; this is cell-mediated response, or cellular immunity.
Natural killer (NK) cells are a type of lymphocyte that provide the first line of defense against pathogens by containing infections while the adaptive immune response is generating antigen specific cytotoxic T cells that can clear the infection. NK cells target a wide variety of infectious microbes, tumor cells, and other abnormal cells; they do not need to recognize a specific antigen before they attack and destroy a target cell. Unlike phagocytes, they do not engulf and ingest target cells, but attach to them and inject chemicals that erode the membranes of the target cell and lead to cellular destruction.
The exact mechanism NK cells use to determine which cells to target is not certain; one theory involves recognition of "altered self." Major histocompatibility complex (MHC) molecules are anchored in cell membranes, where they display short polypeptides to T cells, via the T cell receptor (TCRs). The polypeptides may be "self," that is, originating from a protein created by the organism itself, or they may be foreign, originating from bacteria, viruses, pollen, etc. By design of the MHC-TCR interaction, T cells should ignore "self" peptides while reacting appropriately to the foreign peptides. Foreign peptides that provoke an immune response are termed antigens. NK cells have two types of surface receptors, "activating receptors" and "inhibitory receptors." The inhibitory receptors recognize MHC class I alleles, which could explain why NK cells kill cells with low levels of MHC class I molecules; this is known as "missing self" recognition.
Natural killer cell activity can be an important indicator of disease progression and patient prognosis, and may be involved in how the immune system relates to such conditions as infertility, cancer, HIV, leukemia, chronic fatigue syndrome, infections and other diseases.
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 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 or contract, the benefit plan or contract will govern.
Measurement of natural killer (NK) cells is considered experimental, investigational and unproven for any indication.
Natural killer (NK) cell count has been studied in relation to a variety of conditions, including cancer, HIV, leukemia, chronic fatigue syndrome, infections and other diseases. One area of interest, the relationship between NK cells and reproductive failure is a controversial area in reproductive medicine. Vaquero et al. conducted a study to propose a set of tests to clarify the diagnosis of repeated implantation failure in patients undergoing in vitro fertilization (IVF); they concluded that thyroid abnormalities, antiphospholipid antibodies, and increased NK levels are more prevalent in women experiencing IVF failure. However, regarding NK cells and reproductive failure, Rai et al. contend that there is no scientific basis for NK testing in routine practice, and the use of immunosuppressant agents based on the results of such testing may be potentially harmful. Ghazeeri and Kutteh noted that the roles alloimmunity and autoimmunity may play in reproductive failure, including recurrent pregnancy loss and failed IVF, have not been clearly established, and they concluded that large, well-constructed studies examining the benefit of immunological evaluation and treatment are needed before definite recommendations can be made.
Tratkiewicz and Szer studied the loss of NK activity as an indicator of relapse in acute leukemia. They concluded that there was a marked reduction in NK activity in patients with active leukemia when compared with healthy controls, and that NK activity substantially improved in complete remission. All patients who relapsed had significantly reduced NK activity, which in some significantly preceded the time of relapse. Their data suggest that regular assessment of NK activity may be a useful diagnostic tool in patients with acute leukemia.
NK cells are a promising area of immunology and cancer research. Experiments are being done on mice to learn how NK cells cause the immune system to respond to cancer cells. Also, Iwao et al. studied the prognostic value of NK cell infiltration in resected pulmonary adenocarcinoma, and concluded that NK cell infiltration may contribute to regulation of tumor progression, and can serve as a useful prognostic marker in overall and stage I pulmonary adenocarcinoma.
NK cell activity has been evaluated for a variety of other prognostic and diagnostic uses. El-Sameea et al. evaluated NK cells as diagnostic markers of early onset neonatal sepsis; they reported that their data raised the possibility that adding NK cell activity to the standard workup of critically ill patients with suspected sepsis could increase the diagnostic certainty and generate improved patient management. Zeman et al. studied the prognostic value of NK cells in monitoring the course of IFN-alpha (Interferon-alpha) therapy in children with chronic hepatitis and concluded that increased NK cells in these children may be determinant of IFN therapy. Researchers at the University of Miami reported that preliminary evidence suggests that measuring NK activity may support identification of chronic fatigue syndrome in a subgroup of patients with more severe symptoms. Researchers at the Mayo Clinic in Rochester, Minnesota are devising a way to manipulate NK cells to destroy cells containing HIV virus ("latent" or "resting" cells). While their experiments have been successful in laboratory test tubes, they have not been tested on patients in clinical trials.
While measurement of NK cells may support certain diagnoses or conditions, specific studies are scattered, small, and inconclusive. Therefore, measurement of NK cells is not supported by evidence in the peer-reviewed medical literature that permits conclusions on the effect of NK cell measurement on health outcomes, or that demonstrates an improvement in net health outcome through use of NK cell measurement.
2008 Update
A literature search of online and MedLine database was performed through August 2008. No articles were identified that would change the coverage position of this medical policy.
2010 Update
A literature search was performed through August 2010. No articles were identified that would change the coverage position of this medical policy.
2013 Update
A search of peer reviewed literature through September 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy (15-18).
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.
Experimental, investigational and unproven for all diagnoses.


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Current techniques for diagnosing and monitoring asthma and predicting exacerbations are suboptimal. Two new strategies, evaluation of exhaled nitric oxide (NO) and exhaled breath condensate are proposed. These techniques are also potentially useful in the management of other conditions such as chronic obstructive pulmonary disease (COPD) and chronic cough. There are commercially available devices for measuring NO in expired breath and various laboratory techniques for evaluating components of exhaled breath condensate.
Guidelines for the management of persistent asthma stress the importance of long-term suppression of inflammation using steroids, leukotriene inhibitors, or other anti-inflammatory drugs. Existing techniques for monitoring the status of underlying inflammation have focused on bronchoscopy, with lavage and biopsy, or analysis by induced sputum. Given the cumbersome nature of these techniques, the ongoing assessment of asthma focuses not on the status of the underlying chronic inflammation, but rather on regular assessments of respiratory parameters such as forced expiratory volume in one second (FEV1) and peak flow. Therefore, there has been interest in noninvasive techniques to assess the underlying pathogenic chronic inflammation as reflected by measurements of inflammatory mediators.
Two proposed strategies are the measurement of exhaled nitric oxide (NO) and the evaluation of exhaled breath condensate. Nitric oxide is an important endogenous messenger and inflammatory mediator that is widespread in the human body, functioning, for example, to regulate peripheral blood flow, platelet function, immune reactions, and neurotransmission and to mediate inflammation. In biologic tissues, NO is unstable, limiting measurement. However, in the gas phase, NO is stable, permitting its measurement in exhaled air. Exhaled NO is typically measured during single breath exhalations. First, the subject inspires nitric oxide-free air via a mouthpiece until total lung capacity is achieved, followed immediately by exhalation through the mouthpiece into the measuring device. Several devices measuring exhaled NO are commercially available in the United States. According to a 2009 joint statement by the American Thoracic Society (ATS) and European Respiratory Society (ERS), there is a consensus that the fractional concentration of exhaled nitric oxide (FeNO) is best measured at an exhaled rate of 50 mL per second (FeNO 50 mL/s) maintained within 10% for more than 6 seconds at an oral pressure between 5 and 20 cm H2O. (1) Results are expressed as the NO concentration in parts per billion (ppb), based on the mean of 2 or 3 values.
Exhaled breath condensate (EBC) consists of exhaled air passed through a condensing or cooling apparatus, resulting in an accumulation of fluid. Although EBC is primarily derived from water vapor, it also contains aerosol particles or respiratory fluid droplets, which in turn contain various nonvolatile inflammatory mediators, such as cytokines, leukotrienes, oxidants, antioxidants, and various other markers of oxidative stress. There are a variety of laboratory techniques to measure the components of EBC, including such simple techniques as pH measurement, to the more sophisticated gas chromatography/mass spectrometry or high performance liquid chromatography, depending on the component of interest.
Measurement of NO and EBC has been investigated in the diagnosis and management of asthma. Potential uses in management of asthma include assessing response to anti-inflammatory treatment, monitoring compliance with treatment, and predicting exacerbations. Aside from asthma, they have also been proposed in the management of patients with chronic obstructive pulmonary disease (COPD), cystic fibrosis, allergic rhinitis, and primary ciliary dyskinesia.
Regulatory Status
In 2003, the U.S. Food and Drug Administration (FDA) cleared for marketing the Nitric Oxide Monitoring System (NIOX) (Aerocrine; Sweden) with the following indication: "[Measurements of the fractional nitric oxide (NO) concentration in expired breath (FE-NO)] provide the physician with means of evaluating an asthma patient's response to anti-inflammatory therapy, as an adjunct to established clinical and laboratory assessments in asthma. NIOX should only be used by trained physicians, nurses and laboratory technicians. NIOX cannot be used with infants or by children approximately under the age of 4, as measurement requires patient cooperation. NIOX should not be used in critical care, emergency care or in anesthesiology." In March 2008, the NIOX MINO was cleared for marketing. The main differences between this new device and the NIOX are that the NIOX MINO is hand-held and portable and is not suitable for children under age 7 years.
The Breathmeter (Ekipstech) is another device used to measure exhaled nitric oxide using laser spectroscopy. As of June 2012, the Breathmeter is available for research only; it has not yet received FDA approval or clearance.
The RTube Exhaled Breath Condensate collection system (Respiratory Research, Inc) is registered with the FDA as a Class I device that collects expired gas. Respiratory Research has a proprietary gas-standardized pH assay, which, when performed by the company, is considered a laboratory-developed test.
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Blue Cross and Blue Shield of Montana (BCBSMT) considers measurement of exhaled nasal nitric oxide and/or the collection and analysis of exhaled breath condensate in the diagnosis and management of asthma and other respiratory disorders experimental, investigational and unproven.
This policy was originally created in 2013 with searches of the MEDLINE database through May 2012. Following is a summary of the key literature to date.
Evaluation of the tests for diagnosis requires that the test findings are reproducible on test-retest and that the test is reasonably accurate compared to a validated reference standard. Assessment of the clinical role of exhaled nitric oxide (NO) and exhaled breath condensate (EBC) tests requires controlled studies of those managed conventionally compared to those whose management was additionally directed by test measurements.
Exhaled Nitric Oxide
Reproducibility of FeNO measurements
In 2010, Selby and colleagues published a study from the UK that evaluated the reproducibility of exhaled NO measurements in young people. (2) The study included 494 teenagers, aged 16-18 years, from an unselected birth cohort and 65 asthma patients between the ages of 6 and 17 years. Paired readings were obtained from each participant. The mean within-participant difference in FeNO (second reading minus the first reading) was 1.37 ppb (95% confidence interval [CI]: -7.61 to 10.34 ppb); this difference was statistically significant, p less than 0.001. When participants with high FeNO values (above 75 ppb) were excluded, there was a lower mean within-participant difference, 0.90 ppb (95% CI:-4.89 to 6.70 ppb). Among the 71 participants with asthma, the mean within-participant difference in FeNO in the 2 measurements was 2.37 ppb (95% CI: -11.38 to 16.12 ppb). When FeNO values were categorized as low, normal, intermediate, or high (using different values for participants younger than age 12 years and 12 years or older), the findings were reproducible. That is, there were no statistically significant differences in the categorization using the first and second measurement.
Using FeNO in the diagnosis of asthma in individuals with signs or symptoms of asthma
Several prospective studies have evaluated FeNO devices for diagnosing asthma; studies have generally focused on identifying the optimal FeNO cutpoint. Two studies were identified that used the NIOX MINO device (Aerocrine). In 2009, Schneider and colleagues in Germany published data on 160 patients with symptoms suspicious of obstructive airway disease. (3) All patients underwent measurement of exhaled NO. The reference standard was a stepwise series of tests, beginning with spirometry. Those with forced expiratory volume in one second (FEV1) less than 80% of predicted or FEV1/vital capacity (VC) ratio of 0.70 or less were referred to bronchodilator reversibility testing. Otherwise, patients received bronchial provocation with methacholine. Patients were classified as having asthma when: 1) bronchodilation testing found a change in FEV1 was at least 12% compared to baseline, and at least 200 mL, and lung volumes returned to predicted normal range; 2) bronchial provocation found a 20% decrease in FEV1 from the baseline value after inhaling methacholine stepwise until the maximum concentration. Exhaled NO test findings were compared to the final diagnosis status. According to standard testing, 75 (46.9%) of the patients had asthma. Receiver operating characteristic (ROC) analysis found the highest sum of sensitivity and specificity of exhaled NO at a cut-off of 46 ppb. Among patients with unsuspicious spirometry findings (n=101), 49 had asthma. The optimal cut-off of exhaled NO in this subgroup was also 46 ppb; the sensitivity of exhaled NO was 35%, and the specificity was 90%.
The second study using the NIOX MINO was published in 2010 by Pedrosa and colleagues in Spain. (4) The study included 114 individuals at least 14 years-old who had symptoms consistent with asthma, with or without rhinitis symptoms, and had normal parameters on spirometry and a negative bronchodilator test. Definitive diagnosis was based on symptom assessment and a positive methacholine bronchial challenge test. Individuals underwent FeNO assessment (flow rate of 50 mL/s) just before the methacholine inhalation challenge test. According to challenge test findings, 35 patients (31%) were diagnosed with asthma. FeNO levels were significantly higher in individuals diagnosed with asthma (mean 58 ppb) than in non-asthmatics (mean ppb 30 ppb); p<0.001. Using ROC analysis, the cut-off point with maximum sensitivity (74.3%) and specificity (72.5%) for diagnosing asthma was a FeNO value of 40 ppb.
A 2009 study by Sivan and colleagues in Israel used a different device (CLD88 FeNO analyzer; EcoMedics; Switzerland) that is not FDA-approved. (5) The study included 150 children aged 18 years or younger who were referred for evaluation of possible asthma. It evaluated the diagnostic yield of exhaled NO test findings compared to sputum eosinophil count, the 'gold standard" for assessment of eosinophilic inflammation of the airways. Final assessment of asthma status was done by a pediatric pulmonologist after at least 18 months of follow-up. Receiver operating curves (ROCs) were used to determine the optimal cut-off points for the exhaled NO test in diagnosing asthma. The area under the ROC for exhaled nitric oxide versus eosinophil percent was 0.886. The best cut-off was 18 ppb, which provided 82% sensitivity and 84% specificity. This was similar to the best cut-off for eosinophil count, 2.7%, which had 85% sensitivity and 89% specificity. A 2010 study conducted in Italy included 280 children with asthma, allergic rhinitis or both. (6) The authors used ROC analysis and found that the optimal cut-off for discriminating between patients with bronchial hyperactivity from those with absent or borderline bronchial hyperactivity was 32 ppb of NO.
The cut-off level of exhaled NO also varied in earlier studies. A 2005 study by Berkman and colleagues studied 95 asthmatic and non-asthmatic patients without age limitation and found that a cut-off of FeNO over 7 ppb best differentiated between the 2 groups. (7) In 2003, Dupont and colleagues evaluated 240 non-smoking corticosteroid-naïve patients without age limitations and found the optimal cut-off was 16 ppb exhaled NO. (8)
Using FeNO in the diagnosis of respiratory disorders other than asthma
Rouhos and colleagues in Finland published a study in 2011 on repeatability of FeNO measurements in 20 patients with stable chronic obstructive pulmonary disease (COPD) and 20 healthy controls. (9) FeNO was measured 3 times in each individual; a baseline measurement and measurements 10 minutes and 24 hours after baseline. In COPD patients, median FeNO values were 15.2 ppb at baseline, 17.4 ppb 10 minutes later, and 14.5 ppb 24 hours later. In healthy controls, corresponding median FeNO values were 15.6 ppb, 19.6 ppb, and 15.7 ppb. Differences between the baseline and 24-hour measurements in both groups were not statistically significant. FeNO values 10 minutes after baseline were significantly higher than the 24 hour measurement in both groups; the authors attributed this difference to the fact that patients did not rinse their mouths with sodium bicarbonate between the baseline and 10-minute measurements.
Patient management
Using FeNO to guide treatment decisions in patients with asthma:
In 2005, a TEC Assessment was published on exhaled NO monitoring for guiding treatment decisions in patients with chronic asthma. (10) The assessment identified 2 randomized controlled trials (RCTs); both were published in 2005. Smith and colleagues reported that equivalent outcomes (e.g. exacerbations, pulmonary function) were achieved in the group managed using exhaled NO measurements compared to the group managed using conventional guidelines (11) The FeNO group, however, used lower doses of inhaled corticosteroids at the end of the study. Pijnenburg and colleagues found similar changes in steroid dose and FEV1 in groups managed with and without FeNO measurements. (12) Bronchial hyperreactivity, an intermediate outcome, improved more in the FeNO group. The TEC Assessment concluded that the available evidence did not permit the conclusion that use of NO monitoring to guide treatment decisions in asthma leads to improved outcomes.
A 2009 Cochrane review identified studies comparing outcomes in asthma patients whose medication adjustments were managed based on FeNO levels versus managed based on clinical symptoms (with or without spirometry/peak flow). (13) Six RCTs were identified, including the 2 that had been discussed in the TEC Assessment, as well as 4 additional studies, Shaw et al. 2007, (14) Fritsch et al. 2006, (15) Szefler et al. 2008, (16) and de Jongste et al. 2009. (17) Four studies included children or adolescents, 1 included only adults and the sixth included both adolescents and adults. Two studies were double-blind and the other 4 were single-blind. Five studies used hospital-based FeNO measurements, and one used a portable at-home NO analyzer. Four studies measured FeNO at a flow rate of 50 mL/s.
When findings for the 2 studies that included adults and/or adolescents were pooled (Shaw et al. 2007 and Smith et al. 2005), total n=197, there was not a significant difference in the number of patients experiencing an exacerbation (odds ratio [OR]: 0.85, 95% CI: 0.30 to 2.43) or the occurrence of any exacerbation (mean difference: -0.14, 95% CI: -0.41 to 0.12). There was also no significant difference in symptom scores (mean difference of -0.14 [95% CI: -0.42 to 0.14]). Findings from 3 of the 4 pediatric trials were pooled, total n=782 (Pijnenburg et al. 2005, [12] Szefler et al. 2008, [16] and de Jongste et al. 2009 [17]). As with the adult studies, there was not a significant difference in the number of patients experiencing an exacerbation (OR=0.75, 95% CI: 0.55 to 1.01). Another pooled analysis of these 3 studies found a statistically significantly higher dose of inhaled corticosteroid at the final study visit in patients managed using exhaled NO levels (mean difference: 140.2, 95% CI: 28.9-251.4). A pooled analysis of 2 of the studies (Szefler et al. 2008 and de Jongste et al. 2009, total n=631) did not find a significant difference in symptom scores when patients were managed with and without measurement of exhaled NO (mean difference: 0.04, 95% CI: -0.11 to 0.20). Findings on the number of patients experiencing an exacerbation were not pooled for the pediatric studies. The authors of the Cochrane review concluded, "Tailoring the dose of inhaled corticosteroids based on exhaled nitric oxide in comparison to clinical symptoms was carried out in different ways in the six studies and found only modest benefit at best and potentially higher doses of inhaled corticosteroids in children. The role of utilizing exhaled nitric oxide to tailor the dose of inhaled corticosteroids cannot be routinely recommended for clinical practice at this stage and remains uncertain."
A 2010 review by Barnes and colleagues stated that the published trials comparing exhaled NO measurement as an add-on to clinical guideline management have had substantial design issues that may limit their validity. (18) For example, the authors questioned the adequacy of the cutpoints used for determining a positive test. They pointed out that, due to inter-individual variability in exhaled NO levels, use of individual cutpoints, as determined by baseline assessment, or measuring change from baseline may be more valid than use of a fixed cutpoint. In addition, the authors stated that the choice of outcome variables is important. They asserted that asthma exacerbations may be the most relevant primary outcome, but that was not consistently the case in the published studies. The authors concluded, "The true value of FeNO in improving asthma control and reducing exacerbations has yet to be tested rigorously."
In 2011, Powell and colleagues in Australia published a double-blind RCT evaluating FeNO for guiding treatment decisions in pregnant non-smoking women with asthma. (19) Eligibility included being between 12 and 20 weeks' of gestation and using inhaled therapy for asthma within the past year. Women were randomized to a FeNO algorithm to adjust therapy (n=111) or a clinical guideline algorithm that did not include FeNO measurement (n=109). The FeNO algorithm appeared to be devised by the study investigators. According to the algorithm, the cut-off for reducing the dose of inhaled corticosteroids was less than 16 ppb, and the cut-off for dose increase was at least 30 ppb. Both treatment groups also had their symptoms assessed by the Asthma Control Questionnaire (ACQ), and ACQ scores were utilized in both medication adjustment algorithms. A total of 203 of 220 women (92%) completed the study; analysis was intention to treat. The primary study outcome was the total number of asthma exacerbations during pregnancy (and after study enrollment) for which the patient sought medical attention. The mean total exacerbation rate was significantly lower in the FeNO group (0.29 per pregnancy) compared to the control group (0.62 per pregnancy), p=0.01. Overall, 28 (25%) of women in the FeNO group and 45 (41%) in the control group had at least one exacerbation; the difference between groups was statistically significant, p=0.01. Among the secondary outcomes, there were significantly fewer unplanned doctors visits in the FeNO group (mean of 0.26 per patient) than the control group (mean of 0.56 per patient), p=0.002.
The Powell study demonstrates a potential benefit to using a treatment algorithm that incorporates FeNO levels. However, this trial is prone to many of the same limitations as previous trials of FeNO management algorithms. Most importantly, patients in each group end up on differing regimens of medications according to the algorithm followed. It is then difficult to isolate the effect of the algorithm from the efficacy of the medications themselves. For example, if a FeNO algorithm uses a lenient cut-off point for increasing inhaled corticosteroids, then the FeNO group will likely end up on higher doses of inhaled steroids. Improved outcomes are then more likely to be due to the efficacious effect of inhaled steroids, rather than the inclusion of FeNO in the algorithm. In the Powell study, (19) the cut-off point for increasing inhaled steroids was lowered compared to previous algorithms, thus resulting in more patients being started on inhaled steroids. Together with this, the control group was treated by an algorithm that differed from current treatment guidelines in at least 2 important ways, both which resulted in less intensive treatment compared to treatment guidelines. The net effect of these algorithms was that more patients in the FeNO group received both long-acting beta-agonists and inhaled corticosteroids, although patients treated with inhaled steroids in the control group were treated at higher doses. Therefore, the differences in outcomes may be due to differences in treatment regimens that could have been achieved with or without the use of FeNO in the guidelines.
Using FeNO to guide treatment decisions in patients with respiratory disorders other than asthma
One RCT, a double-blind cross-over study by Dummer and colleagues, evaluated the ability of exhaled NO test results to predict corticosteroid response in COPD. (20) The study included 65 patients with COPD who were 45 years or older, were previous smokers with at least a 10-pack a year history, had persistent symptoms of chronic airflow obstruction, had a post-bronchodilator forced expiratory volume in one second/forced vital capacity ratio (FEV1/FVC) of less than 70% and a FEV1 of 30–80% predicted. Patients with asthma or other co-morbidities and those taking regular corticosteroids or had used oral corticosteroids for exacerbations more than twice during the past 6 months were excluded. Treatments, given in random order, were 30 mg/d of prednisone or placebo for 3 weeks; there was a 4-week washout period before each treatment. Patients who withdrew during the first treatment period were excluded from the analysis. Those who withdrew between treatments or during the second treatment were assigned a net change of zero for the second treatment period. Fifty-five patients completed the study. Two of the 3 primary outcomes, 6-minute walk distance (6MWD and FEV1) increased significantly from baseline with prednisone compared to placebo. There was a non-significant decrease in the third primary outcome, score on the St. George's Respiratory Questionnaire (SGRQ). The correlation between baseline fraction of exhaled NO was not significantly correlated with change in 6MWD (r=0.10, p=0.45) or SGRQ (r=0.12, p=0.36) but was significantly related to change in FEV1 (r=0.32, p=0.01). At the optimal fraction of exhaled NO cut-off of 50 ppb, as determined by ROC analysis, there was a 29% sensitivity and 96% specificity for predicting a 0.2-liter increase in FEV1. (A 0.2-liter change was considered to be the minimal clinically important difference.) The authors concluded that exhaled NO is a weak predictor of short-term response to oral corticosteroid treatment in patients with stable, moderately severe COPD and that a normal test result could help clinicians decide to avoid prescriptions that may be unnecessary; only about 20% of patients respond to corticosteroid treatments. Limitations of the study include that the response to treatment measured was short term, and this was not a trial of management decisions based on exhaled NO test results.
No controlled studies were identified that evaluated the role of exhaled NO tests in the management of respiratory conditions other than asthma and COPD. A prospective uncontrolled study by Prieto and colleagues assessed the utility of exhaled oxide measurement for predicting response to inhaled corticosteroids in patients with chronic cough. (21) The study included 43 patients with cough of at least 8 weeks' duration who were non-smokers and did not have a history of other lung disease. Patients were evaluated at baseline and after 4 weeks of treatment with inhaled fluticasone propionate 100 µg twice daily. Nineteen patients (44%) had a positive response to the treatment, defined as at least a 50% reduction in mean daily cough symptom scores. ROC analysis showed that, using 20 ppb as the FeNO cut-off, the sensitivity was 53% and the specificity was 63%. The authors concluded that exhaled NO is not an adequate predictor of treatment response.
Exhaled Breath Condensate
It appears from the published literature that exhaled breath condensate (EBC) is at an earlier stage of development compared to exhaled NO. For example, several review articles note that before routine clinical use in the diagnosis and management of respiratory disorders can be considered, the following issues must be resolved (22-25):
No controlled studies were identified that evaluated the role of EBC tests in the management of asthma or other respiratory disorders. Representative published studies include a 2009 case series investigating whether components of EBC could predict response to steroid treatment in patients with asthma. (26) Eighteen steroid-naive asthma patients were included; EBC collection, spirometry, and methacholine challenge were performed before and 12 weeks after inhaled steroid therapy (equivalent dose of 400 µg fluticasone propionate/d). Among the molecules in EBC examined, higher IL-4 and RANTES levels and lower IP-10 levels at baseline were correlated with an improvement in FEV1. The study had a small sample size, was uncontrolled, and did not address the clinical utility of EBC testing.
In addition, a 2010 study by Antus and colleagues evaluated EBC in 58 hospitalized patients (20 with asthma and 38 with COPD) and 36 healthy controls (18 smokers and 18 non-smokers). (27) The EBC pH was significantly lower in patients with asthma exacerbations (all non-smokers) at hospital admission compared to non-smoking controls (6.2 vs. 6.4, respectively, p<0.001). The pH of EBC in asthma patients increased during the hospital stay and was similar to that of non-smoking controls at discharge. Contrary to investigators' expectations, EBC pH values in ex-smoking COPD patients (n=17) did not differ significantly from non-smoking controls, either at hospital admission or discharge. Similarly, pH values in EBC samples from smoking COPD patients (n=21) at admission and discharge did not differ significantly from smoking controls.
Practice Guidelines and Position Statements
American Thoracic Society (ATS): In 2011, the ATS published a clinical practice guideline on interpretation of FeNO levels. (28) The guideline was critically appraised using criteria developed by the Institute of Medicine (IOM), which includes 8 standards. (29) The guideline was judged to not adequately meet the following standards: Standard 3: guideline development group composition; Standard 4: clinical practice guideline-systematic review intersection; Standard 5: Establishing evidence foundation for and rating strength of recommendations; and Standard 7: external review.
The ATS guideline included the following strong recommendations (if not otherwise stated, the recommendations apply to asthma patients):
American Thoracic Society/European Respiratory Society: A 2009 statement includes the following key points on exhaled nitric oxide:
"The clinical utility of FeNO-based management strategies has not been explored extensively. Currently available evidence suggests a role in identifying the phenotype in airways disease, particularly in the identification of corticosteroid responsiveness. Due to logistic and cost issues, FeNO is the only biomarker likely to have a role in primary care-based asthma studies, although it is possible that with technological improvements, other techniques including sputum induction could have a role in the medium term." (1)
National Heart Lung and Blood Institute (NHLBI): Their 2007 expert panel guidelines for the diagnosis and management of asthma state:
"Use of minimally invasive markers ("biomarkers") to monitor asthma control and guide treatment decisions for therapy is of increasing interest. Some markers, such as spirometry measures, are currently and widely used in clinical care; others, such as sputum eosinophils and FeNO, may also be useful, but they require further evaluation in both children and adults before they can be recommended as clinical tools for routine asthma management (Evidence D)."
"The Expert Panel recommends some minimally invasive markers for monitoring asthma control, such as spirometry and airway hyper-responsiveness, that are appropriately used, currently and widely, in asthma care (Evidence B). Other markers, such as sputum eosinophils and FeNO, are increasingly used in clinical research and will require further evaluation in adults and children before they can be recommended as a clinical tool for routine asthma management (Evidence D)." (30)
Evaluation of exhaled nitric oxide and exhaled breath condensate are proposed as techniques to diagnose and monitor asthma and other respiratory conditions. Several prospective studies have addressed FeNO measurement; however, there is still no standardized and validated cut-off to use for diagnosing asthma. Multiple randomized controlled studies have evaluated the use of FeNO tests for the management of patients and have not consistently found improvement in health outcomes. Moreover, a 2009 Cochrane review pooling results of studies evaluating FeNO in the management of patients with asthma found a high degree of variability among studies and did not recommend routine use of FeNO in clinical practice. A 2011 RCT of pregnant women with asthma found better outcomes in the group managed using a FeNO algorithm than standard care .. In this study, as in many others, there are concerns that differences in treatment regimens that arise as a result of different algorithms may confound the outcomes, particularly in cases where the control algorithm may lead to undertreatment.
There is less evidence on the utility of FeNO for the diagnosis and management of other respiratory disorders. There are also few studies on exhaled breath condensate evaluation for the diagnosis and treatment of asthma and other conditions. Thus, the evidence is insufficient to determine the effect of exhaled nitric oxide and exhaled breath condensate tests on health outcomes.
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Experimental, investigational and unproven for all diagnosis codes.


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