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Photodynamic therapy (PDT) refers to light activation of a photosensitizer to generate highly reactive intermediaries, which ultimately cause tissue injury and necrosis. Photosensitizing agents, administered orally or intravenously, have been used in non-dermatologic applications and are being proposed for use with dermatologic conditions such as actinic keratoses and non-melanoma skin cancers.
Two common photosensitizing agents are 5-aminolevulinic acid (5-ALA) and its methyl ester methyl aminolevulinate (MAL). When applied topically, they pass readily through the abnormal keratin overlying the lesion and accumulate preferentially in dysplastic cells. 5-ALA and MAL are metabolized by the underlying cells to photosensitizing concentrations of porphyrins. Subsequent exposure to photoactivation (maximum absorption at 404–420 nm and 635 nm, respectively) generates reactive oxygen species that are cytotoxic, ultimately destroying the lesion. Photodynamic therapy (PDT) can cause erythema, burning, and pain. Healing occurs within 10 to 14 days, with generally acceptable cosmetic results. PDT with topical ALA has been investigated primarily as a treatment of actinic keratoses. It has also been investigated as a treatment of other superficial dermatologic lesions, such as Bowen's disease, acne vulgaris, mycoses, hidradenitis suppurativa, and superficial and nodular basal cell carcinoma (BCC). Potential cosmetic indications include skin rejuvenation and hair removal.
Actinic keratoses are rough, scaly, or warty premalignant growths on sun-exposed skin that are very common in older individuals with fair complexions, with a prevalence of greater than 80% in fair-skinned people older than 60 years of age. In some cases, actinic keratosis may progress to squamous cell carcinoma (SCC). The available treatments for actinic keratoses can generally be divided into surgical and non-surgical methods. Surgical treatments used to treat one or a small number of dispersed individual lesions include excision, curettage (either alone or combined with electrodessication), and laser surgery. Non-surgical treatments include cryotherapy, topical chemotherapy (5-fluorouracil [5-FU] or masoprocol creams), chemexfoliation (also known as chemical peels), and dermabrasion. Topical treatments are generally used in patients with multiple lesions and the involvement of extensive areas of skin. Under some circumstances, combinations of different treatment methods may be used.
Non-melanoma skin cancers are the most common malignancies in the Caucasian population. Basal cell carcinoma (BCC) is most often found in light-skinned individuals and is the most common of the cutaneous malignancies. Although the tumors rarely metastasize, they can be locally invasive if left untreated, leading to significant local destruction and disfigurement. The most prevalent forms of BCC are nodular BCC and superficial BCC. Bowen's disease is a SCC in situ with the potential for significant lateral spread. Metastases are rare, with less than 5% of cases advancing to invasive SCC. Lesions may appear on sun-exposed or covered skin. Excision surgery is the preferred treatment for smaller non-melanoma skin lesions and those not in problematic areas, such as the face and digits. Other established treatments include topical 5-fluorouracil, imiquimod, and cryotherapy. Poor cosmesis resulting from surgical procedures and skin irritation induced by topical agents can be significant problems.
Regulatory Status
In 1999, Levulan® Kerastick™, a topical preparation of ALA, in conjunction with illumination with the BLU-U™ Blue Light Photodynamic Therapy Illuminator, received approval by the U.S. Food and Drug Administration (FDA) for the following indication: "The Levulan Kerastick for topical solution plus blue light illumination using the BLU-U Blue Light Photodynamic Therapy Illuminator is indicated for the treatment of non-hyperkeratotic actinic keratoses of the face and scalp." The product is applied in the physician's office. As of December 2011, the FDA has not approved this product for use in treating actinic keratoses in locations other than the face and neck.
A 5-aminolevulinic acid patch technology (5-ALA Patch) is available outside of the U.S through an agreement between Intendis (part of Bayer HealthCare) and Photonamic GmbH and Co. KG. The 5-ALA patch is not approved by the FDA.
Another variant of PDT for skin lesions is Metvixia® and the Aktilite CL128 lamp, each of which received FDA approval in July 2004. Metvixia® (Galderma, SA, Switzerland; PhotoCure ASA, Norway) consists of the topical application of methyl aminolevulinate (MAL) in contrast to ALA used in the Kerastick procedure, followed by exposure with the Aktilite CL 128 lamp, a red light source (in contrast to the blue light source in the Kerastick procedure). Broadband light sources (containing the appropriate wavelengths), intense pulsed light (IPL), pulsed dye lasers (PDL), and potassium titanyl phosphate (KTP) lasers have also been used. Metvixia is indicated for the treatment of non-hyperkeratotic actinic keratoses of the face and scalp in immunocompetent patients when used in conjunction with lesion preparation (debridement using a sharp dermal curette) in the physician's office when other therapies are unacceptable or considered medically less appropriate.
PhotoCure also sought FDA approval of Metvixia for the treatment of BCCs. However, the indication for BCCs was not approved. In April 2009, HealthCanada approved Metvix (as it is called in Canada) for treatment of BCCs, as well as actinic keratoses. Metvixia is also marketed in Europe.
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 exclusion or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Medically Necessary
Blue Cross and Blue Shield of Montana (BCBSMT) may consider photodynamic therapy (PDT) medically necessary as a treatment of:
Not Medically Necessary
BCBSMT considers photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications not medically necessary.
Actinic Keratoses
Multiple randomized controlled trials (RCTs) evaluating photodynamic therapy (PDT) for actinic keratoses have been published. Piacquadio and colleagues published findings in 2004 of data submitted for U.S. Food and Drug Administration (FDA) approval of Levulan® Kerastick™. Two similarly designed studies randomly assigned 243 patients with 4 to 15 non-hyperkeratotic actinic keratoses on the face or scalp to receive active or placebo PDT. From 63% to 69% of patients in the active treatment group reported complete response at 8 weeks, compared to 13% to 14% in the placebo group. Patients who were not complete responders after 8 weeks had retreatment of the persistent lesions. Among these patients, 43% showed a complete response after a second treatment, compared to only 4% in the placebo group. This clinical trial has since been published in the peer-reviewed literature. (1) In a 2003 trial, Pariser and colleagues conducted a randomized, placebo-controlled trial of 80 patients with actinic keratoses. (2) The authors reported that the complete response rate for the methyl aminolevulinate (MAL) group was 89% compared to 38% in the placebo group.
A 2009 double-blind RCT conducted in Germany by Hauschild and colleagues evaluated PDT with 5-aminolevulinic acid (5-ALA) using a self-adhesive patch. (3) Eligibility criteria included Caucasian patients, age 18 years and older with skin type I-IV and actinic keratoses on the head and of mild or moderate grade, as defined by Cockerell (maximum diameter of 1.8 cm and interlesional distance of at least 1 cm). Women of child-bearing potential were excluded, as were individuals who had used treatments or had other conditions that might interfere with study treatments. Patients were randomly assigned to receive 5-ALA patches containing 8 mg 5-ALA or identical placebo patches. Patches were square, measuring 4 cm2, and patients received 3–8 of them, depending on their number of study lesions. The primary efficacy outcome was the complete clinical clearance rate 12 weeks after PDT. A total of 99 of 103 randomized patients were included in the primary efficacy analysis; 4 patients who withdrew from the study were excluded. The complete clinical clearance rate on a per patient basis (all lesions cleared) was 62% (41 of 66) in the 5-ALA patch group and 6% (2 of 33) in the placebo patch group, a statistically significant difference favoring PDT.
Several trials have compared PDT to cryotherapy for treating actinic keratoses. In 2006, Morton and colleagues published an industry-sponsored, 25-center randomized left-right comparison of single photodynamic treatment and cryotherapy in 119 subjects with actinic keratoses on their faces or scalps. (4) At a 12-week follow-up, PDT resulted in a significantly larger rate of cured lesions compared with cryotherapy (86.9% vs. 76.2%, respectively, cured). Lesions with a non-complete response were retreated after 12 weeks; a total of 108 of 725 lesions (14.9%) received a second PDT session; 191 of 714 lesions (26.8%) required a second cryotherapy treatment. At 24 weeks, the groups showed equivalent clearance (85.8% vs. 82.5%, respectively). Thus, approximately 12% more cryotherapy sessions were required to achieve comparable outcomes to PDT. Skin discomfort was reported to be greater with PDT than with cryotherapy. Investigator-rated cosmetic outcomes showed no difference in the percentage of subjects with poor cosmetic outcomes (0.3% vs. 0.5%, respectively), with more subjects rated as having excellent outcomes at 24 weeks after PDT (77.2% vs. 49.7%, respectively). With PDT, 22.5% had cosmetic ratings of fair or good compared to 49.9% for cryotherapy. Subjects perceived PDT to have better efficacy and cosmetic outcome.
In 2010, Szeimies and colleagues in Germany reported 12-month follow-up data from a study comparing PDT using a self-adhesive patch to cryotherapy. (5) The study had the same eligibility criteria and primary outcome as the Hauschild et al. study, (3) described above. A total of 148 patients were randomly assigned to the 5-ALA patch group, 49 to a placebo group, and 149 to a cryotherapy group. The study used a test of non-inferiority of PDT versus cryosurgery. Fourteen patients who dropped out were excluded from the analysis comparing PDT and cryotherapy, leaving 283 patients. The rate of complete clearance of all lesions was 67% (86 of 129) in the 5-ALA group, 52% (66 of 126) in the cryosurgery group, and 12% (5 of 43) in the placebo group. The clearance rate was significantly higher in the 5-ALA patch group than either the cryosurgery group or placebo patch group. Results were similar in the analysis of clearance rates on a lesion basis. The 360 patients with at least 1 lesion cleared at 12 weeks were followed up for an additional 9 months; 316 completed the final visit 1 year after treatment. The overall clearance rate on a lesion basis was still statistically higher in the 5-ALA patch group compared to placebo (in both studies) and compared to cryosurgery (in the second study). Thirty-two percent of patients in the 5-ALA group from the first study and 50% of patients in the 5-ALA group from the second study were still completely free from lesions. The corresponding figure in the cryosurgery group was 37%. Cosmetic outcome was rated by a blinded investigator at each 3-month visit and categorized as excellent, good, fair, or poor. At 1 year, on a per lesion basis, 210 (53%) in the cryosurgery group, 422 (82%) in the 5-ALA patch group, and 47 (90%) in the placebo patch group were categorized as having an excellent cosmetic appearance by the Investigators (statistically better cosmetic appearance in the cryosurgery versus the 5-ALA groups). In addition, 1 year after treatment, 94% of the lesions in the 5-ALA group and only 68% of the lesions in the cryosurgery group were normally pigmented; this difference was statistically significant. In the safety analysis, there were high rates of local reaction to patch application and cryotherapy at the time of treatment, but no serious adverse effects due to study intervention were documented. The photodynamic therapy patches used in the German studies have not been cleared by the FDA for use in the United States.
Basal Cell Carcinoma (BCC)
A 2007 Cochrane review evaluated surgical, destructive (including PDT), and chemical interventions for BCC. (6) The authors concluded that surgery and radiotherapy appeared to be the most effective treatments, with the best results being obtained with surgery. In addition, they stated that cosmetic outcomes appear to be good with PDT, but additional data with long term follow-up are needed. The Cochrane review did not distinguish between BCC subtypes.
Superficial BCC
A 2008 industry-sponsored multicenter open trial compared MAL-PDT with surgery for small (8–20 mm) superficial BCC in 196 patients. (7) At 3 months after treatment, 92% of lesions treated with MAL-PDT showed clinical response, compared with 99% of lesions treated with surgery (per protocol analysis). At a 12-month follow-up, no lesions had recurred in the surgery group, and 9% of lesions had recurred with MAL-PDT. Approximately 10% of patients discontinued MAL-PDT due to an incomplete response or adverse event, as compared with 5% of patients in the surgery group. Cosmetic outcomes were rated by the investigators as good to excellent in 94% of lesions treated with MAL-PDT in comparison with 60% following surgery.
An RCT that compared PDT with cryotherapy for superficial BCC was published in 2008. (8) This multicenter European study included 120 patients, aged 18 and older, with previously untreated primary superficial BCC. Sixty patients with 114 lesions were randomly assigned to treatment with MAL-PDT (1 treatment), and 58 patients with 105 lesions were randomly assigned to cryotherapy (2 freeze-thaw cycles). Patients who had not responded at 3 months received 2 further MAL-PDT sessions (n=20) or repeat cryotherapy (n=16). The primary outcomes were measured 3 months after the last treatment and included 58 patients with 103 lesions in the MAL-PDT group and 57 patients with 98 lesions in the cryotherapy group. The overall response 3 months after the last treatment on a per lesion basis was 100 of 103 (97%) in the MAL-PDT group and 93 of 98 (94.9%) in the cryotherapy group; the difference was not statistically significant. Results were not reported on a per patient basis. Findings were similar for lesions treated once or repeatedly. Treatment groups did not differ in the recurrence rates at any time during follow-up; at 5 years, the overall lesion recurrence rate was 22% with MAL-PDT and 20% with cryotherapy. There was, however, a better cosmetic outcome with MAL-PDT. The percent of lesions rated by investigators as having an excellent cosmetic appearance at 3 months was 30% in the MAL-PDT group and 4% in the cryotherapy group (p=0.0005), and at 5 years was 60% in the MAL-PDT group and 16% in the cryotherapy group (p=0.00078). There was a high rate of local, transitory adverse events, mainly pain; no patients discontinued the study due to treatment-related adverse events. This study did not compare cryotherapy to standard surgical or radiation therapy.
Nodular BCC
Several trials have compared PDT to surgery for treating nodular BCC. In 2008, Mosterd and colleagues published an RCT evaluating 5-ALA PDT for patients with nodular BCC. (9) The study included 149 patients with 173 primary nodular BCC; 85 tumors were assigned to PDT and 88 to surgical excision. Two patients, each with 1 tumor, dropped out before treatment. At 3 months, 78 of 83 (94%) tumors in the 5-ALA-PDT group and 86 of 88 (98%) tumors in the surgery group had resolved completely; this difference was not statistically different. After a median follow-up of 28 months, there were 21 failures (recurrent tumor) after PDT and 2 after surgical excision. A Kaplan-Meier survival analysis estimated the 3-year cumulative incidence of failure as 30.3% in the PDT group and 2.3% in the surgery group (p<0.001).
In 2007, Rhodes et al. published a 5-year follow-up of an industry-sponsored multicenter randomized study comparing MAL-PDT to surgery for nodular BCC. (10,11) A total of 101 adults with previously untreated nodular BCC were randomized to receive MAL therapy or surgery. At 3 months, complete response (CR) rates did not differ between the 2 groups; however, at 12 months, the CR rate had fallen from 91% to 83%, while in the surgery group the CR rate had fallen from 98% to 96%. Of 97 patients in the per protocol population, 66 (68%) were available for 5-year follow-up; 16 (32%) discontinued in the MAL-PDT group due to treatment failure or adverse events versus 6 (13%) in the surgery group. A time-to-event analysis of lesion response over time estimated a sustained lesion response rate of 76% for MAL-PDT and 96% for excision surgery. Cosmetic outcomes were rated as good to excellent in 87% of the MAL-PDT patients and 54% of the surgery patients. Thus, although cosmetic outcomes may be improved, PDT does not seem to be as effective as surgery in terms of the more important clinical outcomes of treatment completion and lesion recurrence.
In 2010, Foley and colleagues reported on a pair of industry-sponsored single-blind RCTs evaluating MAL-PDT versus placebo for treating primary nodular BCC (5 mm or less in depth). (12) One study was conducted in Australia and the other in the United States, but used the same design and procedures. Patients were randomly assigned to receive treatment with PDT using MAL 160 mg/g or placebo cream. The initial treatment cycle consisted of 2 PDT sessions a week apart. Patients whose lesions showed a partial response at the 3-month follow-up underwent a second treatment cycle. Clinical response was categorized as complete response ([CR] disappearance of lesion), partial response ([PR] at least 50% reduction in the longest diameter of the lesion), no response (less than 50% reduction in the longest diameter) or progression (at least 20% increase in the longest diameter). Combining the 2 studies, 131 patients with 160 lesions were enrolled (there were 66 patients in the Australian study and 65 patients in the U.S. study). Sixty-six patients were assigned to the MAL-PDT group and 65 to the placebo group. After randomization, 10 lesions were excluded because they were found histologically not to be nodular BCCs, leaving 150 lesions (75 per group). A total of 117 of 150 lesions (78%) received 1 complete treatment cycle, and 31 of 150 (21%) received 2 complete treatment cycles. The remaining 2 lesions received only a partial treatment cycle. Data on the primary outcome, rate of CR per lesion 6 months after the last treatment is as follows: (Note that p-values were not reported for any of the outcomes).
Overall response
55/75 (73%)
20/75 (27%)
Response by baseline depth (mm)
14/16 (88%)
5/16 (31%)
0.7 to <1.0
12/15 (80%)
4/15 (27%)
1.0 to <2.0
18/31 (58%)
7/31 (23%)
2.0 to 5.0
9/11 (82%)
4/12 (33%)
Response by baseline diameter (mm)
<10 mm
49/64 (77%)
18/61 (30%)
10-20 mm
6/11 (55%)
2/14 (14%)
There were small numbers of lesions in some of the stratified analyses, so estimates of response rates are less precise. The rate of any local adverse event was 49 of 66 (74%) in the MAL-PDT group and 30 of 65 (46%) in the placebo group. The most common local event was a burning sensation of the skin, which was reported by 19 patients (29%) in the MAL-PDT group and 8 patients (12%) in the treatment group. In addition, 9 serious adverse events were reported by 6 patients, 2 treated with MAL-PDT and 4 treated with placebo. None of the serious adverse effects were determined to be related to the study treatment. The study is limited by a lack of statistical reporting and a comparison only to placebo, not surgery.
In 2011, Lindberg-Larsen et al. published an uncontrolled retrospective study evaluating recurrence of BCC after treatment with PDT. (13) A total of 90 patients with 157 lesions (n=111 superficial BCC, n=40 nodular BCC and n=6 unknown) were initially treated with MAL-PDT. Each lesion was treated twice, with 1 week between treatments. The authors did not report the initial rate of clinical response. Recurrence was defined as reappearance of a histologically-verified BCC in a previously affected area. The estimated recurrence rate was 11% at 6 months, 16% at 12 months, and 19% at 24 months. There was a significantly higher rate of recurrence for nodular BCC than superficial BCC (e.g., at 12 months, the recurrence rates were 28% and 13%, respectively, p=0.008). Study findings suggest the use of PDT with superficial BCC and not with nodular BCC. However, there may be confounding factors. For example, the authors noted that nodular BCCs were more frequently located on patients with fewer tumors and that patients with more tumors had a lower risk of recurrence.
Squamous Cell Carcinoma in situ (Bowen's disease)
In 2003, Salim and colleagues published the results of a trial that randomly assigned 40 patients with Bowen's disease to undergo either topical 5-FU or MAL therapy. (14) A total of 29 of the 33 lesions (88%) in the PDT group cleared completely, as compared with 22 of 33 (67%) in the 5-FU group. In the 5-FU group, severe eczematous reactions developed around 7 lesions, ulceration in 3, and erosions in 2. No such reactions were noted in the PDT group.
A 2006 multicenter randomized trial with 225 patients (from 40 hospital outpatient dermatology clinics in 11 European countries) compared MAL with cryotherapy or 5-FU for the treatment of Bowen's disease (squamous cell carcinoma in situ) with lesions on the face or scalp (23%), neck, or trunk (12%), or extremities (65%). (15) Unblinded assessment of lesion clearance found PDT to be non-inferior to cryotherapy and 5-FU (93%, 86%, 83%, respectively) at 3 months and superior to cryotherapy and 5-FU (80%, 67%, 69%, respectively) at 12 months. Cosmetic outcome at 3 months was rated higher for PDT than the standard non-surgical treatments by both investigators and blinded evaluators, with investigators rating cosmetic outcome as good or excellent in 94% of patients treated with MAL-PDT, 66% of patients treated with cryotherapy, and 76% of those treated with 5-FU.
Literature on the use of PDT for acne consists of several small (n=30 or fewer per group) RCTs from outside of the United States. Results from these initial studies suggest a reduction in lesion count but significant adverse effects of MAL treatment. In one study, 30% of subjects dropped out of the MAL group due to pain. (16)
A 2010 RCT found fewer adverse effects but did not find a clear treatment benefit with a combined intervention of topical 5-ALA and pulsed dye laser treatment. (17) This was a single-blind split-face study and included 44 patients with facial acne. A randomly selected side of the face received the intervention and the other side of the face remained untreated. Patients received up to 3 treatments at intervals of approximately 2 weeks. Twenty-nine patients (66%) completed the 16-week study. For most outcomes, there were no statistically significant differences between the treated and untreated sides of the face. This included change from baseline to 16 weeks in the mean number of inflammatory papules, pustules, cysts, closed comedones or open comedones. There was a significantly greater reduction in erythematous macules on the treated compared to the untreated side of the face (a mean reduction of 5.9 and 2.5, respectively; p=0.04). In addition, the improvement in mean Leed acne severity score was significantly greater on the treated side of the face (-1.07) than the untreated side (-0.52); p=0.001. There were few adverse effects, and they tended to be mild. A limitation of the study was the high drop-out rate.
Other dermatological indications
No controlled studies were identified on PDT therapy for other dermatologic indications. Only case series were identified. Most, such as 2 on hidradenitis suppurativa (18,19) and one on PDT for patients with interdigital mycoses (20) included fewer than 15 patients each. A large retrospective case series was published in 2011 by Xiao and colleagues in China. (21) A total of 642 patients with port-wine stains were treated with PDT; 507 were included in the study, and the remainder were excluded because they had had previous treatment for their lesions or were lost to follow-up. After treatment, 26 (5.1%) of patients were considered to have complete clearing, 48 (9.5%) had significant (<75% to <100%) clearing, and 77 (15.2%) had moderate (<50% to <75%) clearing. This single uncontrolled study is insufficient to draw conclusions about the effect of PDT on health outcomes in patients with port-wine stains.
Photodynamic therapy refers to light activation of a photosensitizing agent light to produce photochemical effects in the target area. The evidence to date suggests that the net health outcome is better with surgery than with PDT for treating BCC and that PDT for superficial BCC has a similar efficacy to cryotherapy and better cosmetic outcomes. In addition, there is evidence from RCTs that PDT is an effective treatment for selected patients with actinic keratoses of the face and scalp compared to placebo or cryotherapy. There is insufficient evidence that PDT improves the net health outcome for nodular BCC and other dermatological conditions compared to accepted treatments. Thus, PDT may be considered medically necessary for treating selected patients with actinic keratoses, superficial BCC, and Bowen's disease and is considered experimental, investigational and unproven for all other dermatologic indications.
Practice Guidelines and Position Statements
The 2012 clinical practice guideline on basal cell skin cancers from the National Comprehensive Cancer Network (NCCN) states: "In patients with low-risk superficial basal cell skin cancer, where surgery or radiation is contraindicated or impractical, topical therapies such as 5-fluorourcil, imiquimod, photodynamic therapy (e.g., methyl aminolevulinate [MAL], amino levulinic acid [ALA]), porfimer sodium), or vigorous cryotherapy may be considered, even though the cure rate may be lower." (22)
In 2008, the British Association of Dermatologists published guidelines containing the following statement on PDT: "Multicentre randomized controlled studies now demonstrate high efficacy of topical photodynamic therapy (PDT) for actinic keratoses, Bowen's disease (BD) and superficial basal cell carcinoma (BCC), and efficacy in thin nodular BCC, while confirming the superiority of cosmetic outcome over standard therapies. (23) Long-term follow-up studies are also now available, indicating that PDT has recurrence rates equivalent to other standard therapies in BD and superficial BCC, but with lower sustained efficacy than surgery in nodular BCC. In contrast, current evidence does not support the use of topical PDT for squamous cell carcinoma...There is an accumulating evidence base for the use of PDT in acne, while detailed study of an optimized protocol is still required."
The International Society for Photodynamic Therapy in Dermatology published consensus-based guidelines on the use of PDT for non-melanoma skin cancer in 2005. (17) Based on both efficacy and cosmetic outcome, they recommended PDT as a first-line therapy for actinic keratosis. The guideline authors considered ALA to not have sufficient tissue penetration for nodular basal cell carcinoma. Based on 2 randomized-controlled and 3 open-label studies, it was concluded that MAL-PDT can be effective for nodular BCC lesions less than 2 mm in depth, if debulked. The guideline recommended PDT for superficial basal cell carcinoma as "a viable alternative when surgery would be inappropriate or the patient or physician wishes to maintain normal skin appearance." The report concluded that PDT is at least as effective as cryotherapy or 5-FU for Bowen's disease but that there is insufficient evidence to support the routine use of topical PDT for squamous cell carcinoma.
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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.
173.0-173.9, 232.0-232.9, 702.0


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Blue and White Restaurant
1355 Highway 61 North, Tunica, MS 38676Map
+1 662 363 1371
Cuisine: American,Seafood
Many customers are called by name at this local favorite. The breakfast menu offers Southern favorites like Tennessee ham with gravy, eggs, biscuits and choice of grits or hash browns. Lunch offerings include hamburgers, catfish, or oysters on a bun. More substantial meal entrees include chicken and fried quail with gravy. If you are hungry, try the seafood platter, a fried assortment of scallops, shrimp, oysters, stuffed shrimp and frog legs. Rips in the upholstery testify these seats have seen a lot of wear, but the place is clean, the food is good and the waitresses are chatty.
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Barn Door Hardware Re-Imagined
Posted by Bill Esler | Posted: 10/03/2013 9:37PM
Barn door hardware maker Krown Lab, Portland, OR, says it has re-imagined sliding barn door hardware. Its hardware is hand crafted to highly styled, minimalist design. Three models are offered: Baldur, Oden, and Rob Roy, with sealed or exposed bearings, depending on model.
It's newest material option is a fusion of bamboo veneer laminated on precision-machined, stainless steel Baldur and Oden trolleys. The standard stainless steel track was replaced with one made of 100% organic materials. A green-engineered, FSC-certified wood fiber core is laminated on both sides with bamboo veneer, and can hold 150 lbs.
For a modern sliding barn door hardware with a natural, woody feel — Bamboo has a warm caramel tone, and fits modern and minimalist to rustic and down-to-earth styles.
About the Author
Bill EslerBill Esler, Editorial Director, Woodworking Network Bill is responsible for overall content at WoodworkingNetwork.com Woodworking Network magazine, and related newsletters. Bill also manages event programs for Woodworking Network Live conferences at the Woodworking Machinery & Supplies Expo in Toronto and Cabinets & Closets Expo. He developing audience engagement programs using custom digital printing, live lead-generating events, custom websites, and custom digital and print content. Read Bill Esler's woodworking blogs. He can be reached at email@example.com or follow him on Google+.
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Audacious: The Fine Art of Wood from the Montalto Bohlen CollectionSalem , MA
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Tampa Drug Rehab Reviews State Government Report, Announces Program Aimed at Decreasing Drug-Induced Deaths
Individuals seeking relief from cocaine, heroin, marijuana and other drugs can get no-cost consultations. Call (855) 912-7867 for an appointment at Drug Addiction Treatment Centers.
Tampa, FL (PRWEB) November 14, 2013
A Tampa drug rehab center is turning its attention toward cutting back the number of deaths as a result of drug abuse through its programs at Drug Addiction Treatment Centers.
According to a report released by the Florida Department of Law Enforcement, in the first half of 2012, the four most frequently occurring drugs found in dead people were all Benzodiazepines (2,622, including 730 Alprazolam occurrences), Ethyl Alcohol (1,980), Oxycodone (759), and Cocaine (668).
Drug Addiction Treatment Centers is gearing all of its programs toward stopping this incredible sad and horrible turn in a person's life. A new video launched by the center introduces people that are seeking relief from their drug addiction a place to turn to for understanding, support and aid.
Drug rehabilitation allows adults and adolescents a chance to get clean from their drug of choice, whether it is cocaine, heroin, marijuana, or prescription drugs. A part of this process is detoxification, cleansing out the physical body filled with mind-altering substances. Drug detox's main goal is to rid the body of chemical toxins.
Drug rehab centers stand firmly upon the foundation of the Twelve Spiritual Principles of recovery, which include Honesty, Hope, Faith, Courage, Integrity, Willingness, Humility, Love for Others (Brotherly and Sisterly), Justice, Perseverance, Spirituality and Service. These centers exist to support and guide recovering individuals as they learn to seek a different path that does not involve drugs.
For more information on Drug Addiction Treatment Centers in Tampa, visit http://drugdetox.org or call (855) 912-7867.
For the original version on PRWeb visit: http://www.prweb.com/releases/tampa-drug-rehab/opiates-oxycontin-xanax/prweb11323082.htm


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1 Reviews
First reviewed by Lisa
yummy. delightful. suprising (good).
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I am not to hip on creating my own theme to I picked one and simply replaced the jpg banner at the top with my custom jpg, giving it the same name placing it in the same directory. I do not know if it is the same size. It shows up in Safari, but not in IE on Mac. So it probably is not showing up in Windows IE either. It is just showing white nothingness.
The theme I chose also had graphic buttons at the top, and they did not show up either in IE, only in Safari. The text links that appear below the buttons do appear. These where in the header file. The only thing I changed with these is where they link to, and the titles.


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April 26, 2012
Jon Pertwee would be proud of Matt Smith, says former 'Doctor Who' companion
Katy Manning voices her approval of 11th Doctor actorBuy DVD and Blu-ray
from Amazon UK
Former Doctor Who star Katy Manning has suggested that Jon Pertwee would approve of his successor, Matt Smith.
Manning starred as Jo Grant for three years in the 1970s opposite Pertwee's third Doctor. And now she has said that her former co-star would be "very proud" of Smith's portrayal of the 11th Doctor.
She told the Radio Times: "It's an education to watch [Matt's] beautifully realised physicality as the Doctor. I said to him, 'Jon Pertwee would be very proud of what you're doing with this character.'"
Manning appeared alongside Smith when they both guest-starred in spin-off The Sarah-Jane Adventures with the late Elisabeth Sladen. Manning said of the experience: "It was the first time I'd actually worked with Lis, although we'd already become close friends. We had a lot of past with Jon that bonded us.
"When I was a newbie at conventions, she really helped me through. After she died, I said in an interview she was the quintessential Doctor Who girl. And I really meant it."
Manning caused controversy in the 1970s by posing nude for a magazine alongside a Dalek. Doctor Who returns for its seventh revived series in the autumn.
- Previous: 'The Amazing Spider-Man 2' being developed by 'Star Trek' writers
- Next: 'Avengers Assemble': Scarlett Johansson wants solo Black Widow movie


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He didn't explicitly say either, actually, but since he was replying to earlier posts about downloading and running Xcode on Mavericks, it appears that his comment refers to running Xcode on Mavericks. I wasted enough time searching in vain for the Xcode 6.3 system requirements, and then downloading the 6 GB file referenced above, to justify posting a clarification for others who might find this thread.
4/15/15 at 3:11pm


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Mendocino L-Shaped Reception Station
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Yeah screw the young guys!We should be in the spotlight and making money! Who care's about the future!
The WWE has adopted this new philosophy of phasing out the "old" and pushing the "new" which is all connected to their attempt to market themselves to a younger audience. Small children wouldn't be able to relate to the older guys or know/respect their legacy enough to get into the show. The bottom line is, is that the WWE has given all of its long loyal fans the http://serve.mysmiley.net/mad/mad0055.gif in exchange for a younger audience.
I've wondered this myself. Even as a rookie, I would expect them to speak up for themselves because their whole reputation is on the line and that is worth a lot more than a pay cheque in my opinion.
I read a report somewhere that Triple H and Shawn Michaels were among those who spoke out against the camp comedy and soap opera crap. I've also heard that various wrestlers, including Steve Austin and Mick Foley were on the verge of stupid gimmicks and names until they spoke up and told Vince they hated the idea. Maybe the wrestlers themselves have more leeway than they believe, but are too busy kissing ass and hankering for the contract they'll just accept what they're given.
WWF was always about pushing new talent for the old. Bob Backlund was dethrowned for Hulk Hogan. Then the Warrior experiment failed so it went back for Hogan. Then to the Bret/Shawn era. Then to the Stonecold/Rock era. Then Triple H. Now it's Cena and Orton.
You guys missed what Belzova was trying to say. She was saying that the vets should be treated equally with the newbies instead of like how TNA does an puts all of the older talents over the newbies they currently have. IMO I think it would make for better entertainment if everyone was treated fairly. As for Matt Hardy she was just using him as an example because all of the Vets. started freaking out after his release.
Simple. They want a job.
If they paid you a nice paycheck wouldn't you dress as a soaring eagle?


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GOP weighs undoing vets pension cuts as debt price
WASHINGTON (AP) — House Republican leaders Monday unveiled a plan to reverse a recently passed cut to military pensions as the price for increasing the government's borrowing cap, but it received a rocky reception from skeptical conservatives.
GOP leaders briefed rank-and-file GOP lawmakers at a meeting in the Capitol on Monday evening in hopes of passing it on Wednesday before departing Washington for a week-long vacation. It's unclear whether the vote would still go forward after it was rejected by many conservatives.
"Right now we've got a debt ceiling bill that increases spending, which is diametrically 180 degrees opposite of what we were battling over just two years ago — where the question was how much in spending cuts we were going to get," said Rep. Mo Brooks, R-Ala.
The GOP bill would extend Treasury's borrowing authority for at least another year, repeal the curb passed in December on pension inflation adjustments for military retirees under the age of 62, and extend automatic cuts to Medicare and other programs to 2024, another year than presently scheduled.
It's not clear that the plan will fly with Democrats. Their votes would be needed to help pass the measure since some Republicans refuse to vote to raise the debt ceiling under any circumstances. A spokesman for House Minority Leader Nancy Pelosi, D-Calif., said Democrats will continue to insist that any debt limit legislation omit add-ons, even bipartisan proposals like repealing military pension cuts.
But a 94-0 Senate procedural vote on Monday demonstrated the widespread support in both parties to repeal the pension cut, and GOP leaders seem confident they would win Democratic votes. The Senate tally came in relation to a stand-alone bill to repeal the cut. A key consideration for Republican leaders is whether to schedule the vote — with the markets open — if they are uncertain of the outcome.
If Monday's plan falls through, GOP leaders may have little choice but to yield to Democratic demands for a debt ceiling measure that's "clean" of GOP add-ons, which would be a bitter defeat for a party that has sought to use must-pass debt ceiling measures as leverage to force spending cuts on Democrats.
The cuts to cost-of-living pension increases for military retirees under the age of 62 were part of December's budget agreement, backed by House Budget Committee Chairman Paul Ryan, R-Wis. Repealing them would cost $7 billion over the coming decade, the Congressional Budget Office said Monday.
The reduction has sparked an uproar among advocates for veterans, and lawmakers in both parties want to repeal it. The cost of canceling the cut would be borne by extending for an additional year a 2 percentage point cut to Medicare reimbursements to doctors and hospitals, as well as cuts to a handful of other benefit programs. Those cuts, known as sequestration, would now extend through 2024, with savings for that year finally appearing to make up for almost a decade's worth of additional pension spending.
Time is running out for lawmakers to act to lift the debt limit. Treasury Secretary Jacob Lew told lawmakers last week that Treasury will exhaust by Feb. 27 its ability to employ accounting maneuvers to borrow to pay its bills.


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Fast-rising Xolos reach their latest goal: playing for the title in Mexico's top league
TIJUANA The home locker room at Estadio Caliente has a domed ceiling with designs of Aztec warriors juggling soccer balls illuminated by alternating shades of blue and green mood lighting. The dome creates a unique acoustic effect, where the coach can be practically whispering and players can hear him clearly on the other side of the room.
It's strangely appropriate. This soccer team, and this city, no longer has to shout to be heard.
Club Tijuana Xoloitzcuintles de Caliente, or Xolos for short, suddenly finds itself in the finals of Mexico's top league, hosting top-seeded Toluca at sold-out Estadio Caliente tonight in the first leg of the two-game series. The second leg is Sunday at Toluca, and the team with the highest combined score is crowned champion.
Tijuana? A champion?
It's something almost unfathomable for this city of 1.6 million people that has long been regarded as a gritty border outpost considered unworthy of Mexico City's refinements or the country's proud culture — a place where people go to leave.
"I don't think we've even realized the scope of it all because we're concentrated so much on beating Toluca and winning the championship," said Roberto Cornejo, the club's assistant general manager who lives in Point Loma. "But you can notice it. People are just happy. There's definitely a bounce in their step. Civic pride is up. Few things other than sports can create that.
"And it's not just Tijuana. It's Tecate, Mexicali, Ensenada, the South County of San Diego. It's the whole region."
Another sign: There's a booming industry of counterfeit Xolos jerseys.
"It's an issue," Cornejo said. "But what's the cliché? Imitation is the highest form of flattery."
Liga MX, the newly branded first division, has no Super Bowl — no single game with two weeks of media hype that is the culmination of an endless schedule. Instead there are split seasons annually, the Apertura (open) and Clausura (closed), with a championship at the end of each. The Xolos had just four days to prepare for Toluca after dramatically eliminating Leon in the semifinals on Sunday.
But soccer is Mexico's NFL in terms of interest and obsession, and Liga MX is rapidly becoming one of the better (and richer) leagues on the planet, a notch or two above Major League Soccer in the United States and about a half-dozen levels above San Diego's indoor and outdoor teams. Midfielder Joe Corona is a member of the U.S. national team and a part-time starter for the Xolos.
All the more amazing, then, to think that the Xolos didn't exist six years ago.
Jorge Hank Rhon, the owner of the Caliente sports-betting company and Tijuana's former mayor, purchased rights to a second-division team in Tijuana and began building a soccer stadium in the far turn of the Agua Caliente thoroughbred racetrack. Estadio Caliente has since expanded to 20,000 seats, and construction is under way to complete an upper deck with luxury suites along the west sideline.
Within four years, the team gained promotion to the first division alongside legendary Mexican clubs Chivas and America. Last spring, they reached the eight-team playoffs for the first time.


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Release DateOctober 01, 2010
MPAA RatingPG-13
Duration120 min.
Production Budget$50 millions
StudioColumbia Pictures
Official Siteclick here
REVIEWS RATE: Critics Readers [Rate It]
Cast and Crew
DirectorDavid Fincher
ProducerScott Rudin, Michael De Luca, Dana Brunetti, Cean Chaffin
ScreenwriterAaron Sorkin
- Jesse Eisenberg as Mark Zuckerberg
- Justin Timberlake as Sean Parker
- Andrew Garfield as Eduardo Saverin
- Rashida Jones as Marylin Delpy
- Max Minghella
- Rooney Mara as Erica Albright
- Dakota Johnson as Amelia Ritter
- Brenda Song as Christy Lee
- Joseph Mazzello as Dustin Moskovitz
- Malese Jow
- Armie Hammer as Cameron Winklevoss/Tyler Winklevoss
- Josh Pence as Tyler Winklevoss
- Wallace Langham as Peter Thiel
On a fall night in 2003, Harvard undergrad and computer programming genius Mark Zuckerberg sits down at his computer and heatedly begins working on a new idea. In a fury of blogging and programming, what begins in his dorm room soon becomes a global social network and a revolution in communication. A mere six years and 500 million friends later, Mark Zuckerberg is the youngest billionaire in history... but for this entrepreneur, success leads to both personal and legal complications. From director David Fincher and screenwriter Aaron Sorkin comes The Social Network, a film that proves you don't get to 500 million friends without making a few enemies. The film is produced by Scott Rudin, Dana Brunetti, Michael De Luca, and Cean Chaffin and based on the book "The Accidental Billionaires" by Ben Mezrich.


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The best source for objective equipment information and reviews
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Cub Cadet 5254 Specifications
Strengths BIzLrO Thanks so much for the blog post.Really thank you! Want more.
Weaknesses BIzLrO Thanks so much for the blog post.Really thank you! Want more.
Overall BIzLrO Thanks so much for the blog post.Really thank you! Want more.
Strengths ROo1C3 This is one awesome blog article.Really thank you! Awesome.
Weaknesses ROo1C3 This is one awesome blog article.Really thank you! Awesome.
Overall ROo1C3 This is one awesome blog article.Really thank you! Awesome.
Strengths In fifth year and still does it all. Have had several snow and ice storms last two winters and this thing keeps our drive and a neighbors cleared easily along with about a quarter mile county road.
Weaknesses I have two prior postings. This one is a little more urgent. Had the fuel tank leak in my first posting. Just had the second tank fail and now I know what happened. CHECK THE CAP. There is a small plastic plunger with a stem in the cap that seals off splashes, but last week the stem hung on the disk on the inside of the cap and it closed the tank venting port. The heat of the daya and this stoppage put pressure in the tank, bloating the bottom of the tank which then comes in contact with the rear wheel. The wheel wore two holes in the tank and with the pressure, we had raw gas going all over the rear of the unit. PLEASE CHECK/REPLACE THE CAP
Overall Cub does not make compact tractors like this unit anymore.
Strengths Tough unit. Have had for three years this fall and have used it for snow removal, pulling 6-inch diameter trees, spraying, mowing and pulling 600 lb trailer over 4.5 acre property, aerator, dethatch, seeding, dragging. Love 3-pt hitch.
Weaknesses My posting Oct 2005 with gas tank - no other problems since. Deck removal is more than I like, but deck has withstood a beating over our rough terrain.
Overall Have 300 hours on the unit and I follow mtce procedures. Put it up on jack stands twice a year and do thorough lub and cleaning.
Strengths Tractor has lots of power for the jobs i am putting it through. Plows snow like you would not believe. the thing also cuts grass like you would not beleive. Doesnt matter if it is wet or dry, handles whatever you put her into.
Weaknesses I know from experience from other owners that all the problems that these other reviews are talking about are all operator errors. If the owners would use some common sense they wouldn't have these problems. so many freakin idiots think that the tractor is always to blame, how about using your brain around the tractor and see how that goes.
Overall Tractor is an absolutely awesome piece of equipment. Recomend to anyone who is smarter than a doorknob. As for the rest of you try this, next time your mommy puts you on her lap to tell you that you are special have her read you the owners manual.
Strengths Good power only when it's working.
Weaknesses spends way more hours in the shop than in use. Only have 140 hours on it because nearly every single time I use it I have to take it back to the shop. Oh and taking off and on the mower deck is way more work than it should be.
Overall It's a piece of crap. My Murray mower that I bought for $300 used has ended up mowing the yard more then the cub. If you do buy one and it breaks down right away and more than one or two times. Make the dealer take it back, use a lawyer, cheaper than keeping it.
Strengths motor runs fine/cuts well/lots of power
Weaknesses i could sit here all day and talk about the problems here are just a few.transmission keeps slipping almost to the point being dangerous on hills.it sliped into neutral more than once.am filling complait with cpsc 800-638-2772 dealer sounds fed up too.the tractor has never proformed well for me.cub cadet needs to step up to the plate fix promlems or give me a tractor that works.muffler melting the plastic hood never align to specs/mower deck adjusters come apart and bend
Overall my tractor was in the shop more hours than are on it.
Strengths mows well when deck is holding together, fel is strong enough for most tasks around hobby farm. Engine is stong running and quiet.
Weaknesses deck needs to be set up with heavier pins to hold casters, adjustment linkage keeps loosening and falling off, second time to dealer for transmission, keeps slipping out of gear evan after recall work, flashers quit working after only 3-5 minutes of use, dealer slow at work and part slow to get.
Overall MTD junk product should have paid 1500 more for John Deere or Kubota
Strengths My version is gasoline Kawasaki engine. Runs great and has lots of power. The wife mows over 4 acres and puts it through its paces over fairly uneven terrain. Bought this unit after having a 3200 series with a 60 inch deck. Was just a little too light and I wanted the 3-point hitch for other attachments.
Weaknesses I just got it back from the dealer today after the recall for the shift lever washer. We had not experienced the problem, but what we did run into was a gas tank leak. Cub put the replacement on back order and it has taken three weeks to get it fixed. My dealer is great - offered a loaner, etc, so we could get our chores done. Ended up putting an epoxy patch on 3 leaks on the underside of the tank. This held for most of one mowing, but the tank is definitely too light gauge and the flexxing finally gave out in the leading edge of the ribs that run across the bottom of the tank. The new tank seems to be the same, but if anyone else is having this problem, my dealer said that the Cub dis
Overall We both love the unit.
Strengths It is a great tractor when it runs.
Weaknesses It is currently at the shop again.this is the 6th time since I bought it new in june 2004. The shop has also been to my house to work on it several times.Cub Cadet support does not seem to care about your problem when you call them.I had 3 hoods put on from cracking. 3 choke cables, hydralic lines replaced, throttle cables replaced,switches replaced,fuel pump, water pump,fenders,and alot of deck pins replaced.The hydralic couplers leak.and more small things that i wont even list.
Overall This is my 2nd one. I had a 1648 prior to purchasing this 5254. It was a great little mower But I will never buy a Cub Cadet product again. The service that I get now is absoultly horrible.Cub Cadet makes me feel like they got my money and they dont want to be bothered by me.
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Don Nelson has no use for your little Hall of Fame
Apr 6, 2010, 1:57 PM EDT
Yesterday our own Ira Winderman said shame on the Hall of Fame for not having Don Nelson in it.
Today, Nelson said pretty much the same thing to ESPN's Marc Stein (in a fantastic and wide-ranging interview). Particularly if they vote him in next year just for getting the all-time coaching wins record after skipping him for a number of years.
"If I don't get it at whatever the number was when the season started [1,309], but then I did get in because I got to 1,333, shame on them. A few games shouldn't make a difference. If that's the thing that gets you to the Hall of Fame, shame on them."
Not that Nelson cares that much.
"When I first had the chance to go in, I was kind of excited, but now that I've been skipped a few times, it's not that important to me anymore. My life is going to go on. The way I look at the Hall of Fame, it's for greatness and that ain't me."
It's for innovators, and that is him. It's for winners, and that is him. Nobody, not Nelson himself, is saying he is the best coach ever. But by any reasonable measure, the man is a Hall of Famer. Without a doubt. Not sure how he got skipped over that much.
Shame on them.
- Vanessa - Apr 12, 2010 at 4:41 AM
I think Nelson should be added to the Basketball Hall of Fame for his amazing achievements. I know not everyone likes him, but the guy has won more games as coach than anyone else. You can't get a better argument than that, right? After all, that is the whole point of being a coach – to win games. Some sports bloggers listed on http://www.dozensports.com say Nelson doesn't deserve the praise. But I say, get him in the Hall of Fame where he belongs. It is surely a travesty that this great coach is not given his rightful honor and place in basketball history.
- lisa - Apr 30, 2010 at 6:51 AM
I think that Obama has done a great job in bringing the US population public health insurance. I think that it is an integral part of the UK and other nations' public life. In many ways, access to healthcare is a basic human right. I have been following developments at the online insurance index that lists health insurance sites at http://www.dozeninsurance.com recently. I feel that Obama is doing a good job for the USA overall, it has only been a year. So let's stop giving him a hard time and let him get on with his job. After all, he is a doing a lot better than the previous President ever did.
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Fight Aficionado
"@Fight Affiionado – Whatdya expect? The guy is a novice pro ffs!" – Someone they didn't pick off the arena's bar.Posted October 28, 2013 7:57 pm
i thought AUDREY worked in tesco"s.Posted October 28, 2013 12:00 pm
Breaking news … Audley Harrison's biggest fan and regular employer Eddie Hearn is about to announce Harrison's return to the ring in the US versus UK Heavyweight Pirzefighter tournament next month. We all know Audley is boxing's biggest joke, but Eddie can't get enough of him. You heard it here first. Will Audley ever just go away? Not with Eddie around he won't.Posted October 28, 2013 8:23 am
awful, awful articlePosted October 28, 2013 6:56 am
If you notice Joshua might not look super fast, but he lands on what he is punching at, and he does so in a way behind a jab that is strong enough to move the guard.
Someone like Wilder is fairly fast, but more often than not he is closer to the cornerpost than his opponents head since he is just swinging like a loon.
The home run loon-swinging might get you KO's but it gets YOU KO'ed when you meet someone who can counter.
Give me Joshua's measured work any day.Posted October 27, 2013 8:17 pm
Lol at Collins,
Being Sorby…Posted October 27, 2013 7:00 pm
For a second I thought I was in boxingnews24 reading one of Scott's articles LOLPosted October 27, 2013 12:15 pm
Anonymous suits you better BRUCE!!! you arsh@lePosted October 27, 2013 10:49 am
i,m from nantyglo you thick TW@T!!!BRUCEPosted October 27, 2013 10:45 am
billy muslim boy. i know your from bradford,but can you keep your sandles on after you leave the mosque.Posted October 27, 2013 9:42 am
then he would never be an Anonymous prick!!!like you BRUCE THE CHICKEN CHOKER!!!he would be famous!!!Posted October 27, 2013 9:34 am
well said @Fight AficionadoPosted October 27, 2013 8:57 am
joshua could be another frank bruno.Posted October 27, 2013 8:39 am
no it was that prik Anonymous BUMS name!!aka BRUCE the W@NKERS name!!!Posted October 27, 2013 8:04 am
did someone mention that prick audrey"s name.Posted October 27, 2013 7:47 am
Mick the Marmalizer
Surely the BBBofC have to order British & Commonwealth 115Lb champion Paul Butler to defend against Khalid Yafai now!Posted October 27, 2013 6:06 am
I'm guessing Jeff sorby is an American reporter is he ? He's more or less just written off Kell Brook and Anthony Joshua's hopes in two pro fights!Posted October 27, 2013 5:36 am
seanie M
I will break down Sorbets analysis.
1) Joshua was to slow. Well here we go from what i saw his foot movement was ok (he is 6ft6 and in the land of the giants there isn't a heavy out there with terrific foot movement and grace you could argue about Haye i suppose but then the list goes thin).
2)Sorbet thinks Joshua might be to slow. Really? The jab was snappy and powerful. He connected well with both left and right, showed a little variety and the job set for him.
3) Finally he beat a guy who frankly was not a threat but we are talking a novice fighter (all be it an Oympic champ) who rose through the amateurs quickly to win major honours. He needs to tighten his defence (drops his left) and work on his ring craft but he is a work in progress.
To sum up if Sorbet wishes to comment on a fight why not be objective and call it how it is. However i would not hold my breath if i were you.Posted October 27, 2013 5:25 am
Mick the Marmalizer
Actually with young talent such as Anthony Joshua, Joseph Parker & Hughie Fury we could be in for some good fights @ H/W in a couple of years time.Posted October 27, 2013 4:25 am
boxing barlow
People say the heavy weight division is dead but a wilder vrs joshua fight in a few years has gotta wet your appetite!Posted October 27, 2013 3:44 am
Fight Aficionado
Anthony Joshua (2-0, 2 KO's) dispatched a badly over-matched Paul Butlin (14-20, 3 KO's)." That's not a sporting event. That's a sacrifice.Posted October 27, 2013 2:14 am
I didnt even read the article. I never read the articles here. I get the gist from the headlines and opening paragraph. At the end of the day, Im repeating what eddie was sayingPosted October 26, 2013 11:42 pm
So what you saying then.
I always do. You know he doesnt need feeding the usual bums and so does eddie.Posted October 26, 2013 9:51 pm
Nameless…. I think you are missing the point my friend.
I agree the experts here who leave comments really know their boxing, they've all been in the ring, and fought at a high level as amateurs and pro's!! Who the heck do Joshua and his manager and his coaches and his professional sparring partners and his promoters think they are?? Why don't they listen to the know-it-all experts here?? It baffles me the ignorance Joshua and his people display when there so many keyboard experts here, who know more about the fight game than anyone alive today.Posted October 26, 2013 8:44 pm
Yeah….what are the matchmakers doing putting him in with guys like this, it's unbelievable really.
Just like reading Collins, Anonymous? Well fancy that. Anyone would think they were the same writer, using different pseudonyms…Posted October 26, 2013 8:17 pm
Joshua and Hugie Fury…2 young hvwts. to keep a eye on…could be a huge championship fight between these two someday in the UK. Ofcourse its to early by a long shot…but maybe…Posted October 26, 2013 7:22 pm
Only thing I have to say is that Jeff Sorbet knows absolutely nothing about boxing. To come up with this drivel after a guy has fought only 3 professional rounds is laughable.
Joshua will go on to win a world title down the line, not next week, there are so many flying around and once the Klit Bros are out of the way the pickings are slim.
He put a guy away in 2 rounds that another British Heavyweight title contender couldn't put away in 2 fights.
He has everything you need to be a world champion, the only thing he's lacking is experience… I don't want to big him up and create another Audley Harrison, but I find it hard to understand how anyone can criticise based on what we've seen so far.Posted October 26, 2013 6:49 pm
Brazilian Boxing Fan
In my opinion, Joshua clearly deserved the Gold Medal. I had him beating the Italian by one point.Posted October 26, 2013 6:34 pm
Piss off sorby it's like reading Collins every thing negativePosted October 26, 2013 6:24 pm
yes, he was very lucky in the olympic first round, but he was at least very competitive against camarelle in the final (i had him losing, but not actually the point at that level). stop holding that luck against him, he is clearly very, very good indeed. his accuracy is verysimilar to an early lennox if nothing else. and he really isn't slow at all.Posted October 26, 2013 6:13 pm
Mr Gav
The first 4 or 5 fights will be opoenents like this but he did well butlin is normal fairly durable at this level and should of gone a few more rounds so it was a good KO for someone with josuhas limited experience. So far so good expect to see him fight Harrison in the not so distant futurePosted October 26, 2013 5:41 pm
Brazilian Boxing Fan
Congratulations to Anthony Joshua. I hope he becomes Champion in a few years.Posted October 26, 2013 5:35 pm


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The Empty Family: StoriesPaperback
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- Publisher: Penguin Books Ltd
- Format: Paperback | 224 pages
- Dimensions: 129mm x 198mm x 14mm | 161g
- Publication date: 30 June 2011
- Publication City/Country: London
- Sales rank: 54,494
Product description
In the captivating stories that make up "The Empty Family" Colm Toibin delineates with a tender and unique sensibility lives of unspoken or unconscious longing, of individuals, often willingly, cast adrift from their history. 'I imagined lamplight, shadows, soft voices, clothes put away, the low sound of late news on the radio. And I thought as I crossed the bridge at Baggot Street to face the last stretch of my own journey home that no matter what I had done, I had not done that.' From the young Pakistani immigrant who seeks some kind of permanence in a strange town to the Irish woman reluctantly returning to Dublin and discovering a city that refuses to acknowledge her long absence each of Toibin's stories manage to contain whole worlds: stories of fleeing the past and returning home, of family threads lost and ultimately regained. "Exquisite...The chief reason to read these stories is the peculiar power of Colm Toibin's prose". ("Telegraph"). "Astonishingly precise, depicting complex and conflicted states of mind with rare clarity". ("Observer"). "Beautifully observed". ("Sunday Times"). Colm Toibin was born in Ireland in 1955. He is the author of five other novels, including "Brooklyn", "The Blackwater Lightship" and "The Master", both of which were shortlisted for the Booker Prize, and a collection of stories, "Mothers and Sons".
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Author information
Colm Toibin was born in Ireland in 1955. He is the author of five other novels, including The Blackwater Lightship and The Master, both of which were shortlisted for the Booker Prize, and a collection of stories, Mothers and Sons.
Review quote
Colm Toibin's new collection is the work of an author at the peak of his writing powers The Times Always deeply moving, the stories here - like the surf-washed pebbles on that Wexford beach - will be read for meaning and enjoyed for their shape and sound for ages to come Tribune It's a collection that will only further fuel Toibin's ascent through English fiction Independent on Sunday Exquisite ... The chief reason to read these stories is the peculiar power of Colm Toibin's prose Telegraph Astonishingly precise, depicting complex and conflicted states of mind with rare clarity Observer Beautifully observed Sunday Times Toibin's deceptively straightforward style continues to manage somehow to encompass both lucidity and ambiguity, precision and poetry Irish Times Exquisite Metro, Fiction of the Week These stories are always intensely interesting and sometimes profoundly provocative Irish Independent Perfect; and as good as the best of William Trevor, than which there can be no higher praise Scotsman


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Geraldine Ann Williams died on Thursday, October 6, 2011 after a courageous seven-year battle with cancer.
She was born to the late Silvio Frank and Celesta Ann Trentini Fenice on December 10, 1944 in Weedville.
She graduated as Salutatorian from Bennetts Valley High School in 1962.
She married J.C. "Buck" Williams III on January 14, 1967. They lived in Wilcox before relocating to Lewisburg, W.V. in 1994.
She worked at Airco Speer until starting a family and subsequently owned and operated Jayfor timber companies with her husband until their retirement.
James A. Neubert Jr., 66, of Erie, formerly of St. Marys, died at his home on Tuesday, October 25, 2011.
Born in St. Marys on November 5, 1944, he was the son of the late James A. and Victoria Kornacki Neubert Sr.
He married Josephine "Josie" Martin Neubert, who preceded him in death in 2003.
He was a graduate of Tech High and served 33 years in the U.S. Army and the U.S. Marine Corps with tours in Vietnam, Operation Enduring Freedom and the War on Terror until 2005.
He had worked at G.E. and as a cook at the Sisters of Mercy Motherhouse and Independence Court.
Helen R. Adams, 90, of Mt. Pleasant Rd., Penfield, died Tuesday, October 25, 2011 at the DuBois Nursing Home after a short illness.
She was born July 15, 1921 in Port Vue, Pa., daughter of the late John Francis and Helen (McKenna) Moore.
She married Louis Adams on October 9, 1940. He preceded her in death on November 16, 2006.


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Kumeu River Chardonnay Coddington 2010
Kumeu River - Auckland - New Zealand - Kumeu
Professional Wine Reviews for Kumeu River Chardonnay Coddington 2010
Rated 92 by Robert Parker
The 2010 Coddington Chardonnay opens with delicate notes of warm lemons, white peaches and fresh ginger with hints of apple tart and crushed stones. This medium-bodied, vibrant and silky Chardonnay has great concentration and a long, citrusy finish. Drink it now to 2017+.
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Additional Information on Kumeu River Chardonnay Coddington 2010
Kumeu River
Vintage: 2010
2010 saw extremely high quality viticulture in many parts of the world, with an exceptionally long and hot summer providing huge benefits for wineries across many countries, especially in the southern hemisphere. The northern hemisphere and Europe saw something of a cooler summer and flowering period, but this was by no means as disastrous as it could have been. France, especially, had a fantastic year in 2010, with the world renowned Burgundy region proclaiming that their white wines of this year are ones to look out for, and despite yields being relatively small across much of the country, the quality was exceptionally high. Spain, too, received some cooler weather, but Rioja and the rest of central Spain are hailing 2010 as a very good year indeed, again as a result of smaller, finer yields. California also received similar climatic conditions, but again, wineries are highly positive about the overall effect this had on their produce, as the slightly challenging conditions resulted in smaller yields of much elegance and distinction. 2010 was really Australia's year, and in South Australia and across the Mornington Peninsula, Chardonnay vines produced good yields with a lower sugar level than in previous years. As such, the majority of South Australian white wines from 2010 are superb, and packed full of character. Shiraz also had a great year, and most Australian wineries have been proclaiming 2010 one of the great vintages. Both the Argentinian and Chilean wine industries benefited from some ideal climatic conditions this year, and are reportedly ecstatically pleased with the fact that their 2010 wines ended up with lower alcohol levels, and were beautifully balanced wines packed full of flavor.
Varietal: Chardonnay
In the past couple of decades, the sales of wines made with Chardonnay grapes has risen and fallen more than once. For many people, this green skinned grape was marred by a poor reputation for bland and uninteresting wines, a great shame considering the fact that Chardonnay grapes have proven time and time again to be interesting, versatile and full of surprises. Most commonly, fine Chardonnay wines are buttery, smooth and creamy as a result of malolactic fermentation, yet with hints of tropical fruits and orchard fruits such as apples and pears. What is most remarkable about Chardonnay grapes, however, is the fact that unlike many other 'white' grapes, they are exceptionally good at holding the characteristics of their terroir in the bottle. As such, despite their fluctuating reputation, this is one grape varietal which produces constantly surprising, impressive and varied wines.
Country: New Zealand
New Zealand is widely regarded as one of the most beautiful and ecologically diverse countries in the world, and the wines which are produced there are a fine representation of this diversity and overall quality. With beautifully long and warm summers, a brisk oceanic climate and mile upon mile of gently sloping mountainsides, the vineyards which have sprung up there over the past century have brought about truly fantastic results, with wine now contributing a considerable amount to the economy of the country. In recent years, New Zealand wines have won some of the most prestigious awards available in the wine world, with most of the lauded wineries coming from the Auckland region, where there has been considerable effort to replicate the finest wines of the Bordeaux region of France. The Bordeaux grape varietals (Cabernet Sauvignon, Merlot, Cabernet Franc, Petit Verdot and Malbec) all flourish in the mineral rich soil of the region, and the results have been outstanding, marking New Zealand a strong contender for finest New World wine country.


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All present as Bruins prepare for Penguins
|05.28.13 at 11:15 am ET
WILMINGTON — For the first time in four days, the Bruins practiced on Tuesday. For the first time in weeks, all players were on the ice.
Andrew Ference and Wade Redden joined the rest of Boston's defensemen in the practice as the B's practiced for the first time in anticipation of the start of the Eastern Conference finals against the Penguins this weekend.
The lines, color-coded by jerseys, are the same for the B's as they were against the Rangers, meaning Jaromir Jagr is skating with Patrice Bergeron and Brad Marchand while Tyler Seguin is on the third line.
For more on the Bruins, visit weei.com/bruins.
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Chargers' Freeney has torn quadriceps
San Diego Chargers outside linebacker Dwight Freeney has a torn quadriceps muscle that could sideline him for several weeks or even the rest of the season.
Coach Mike McCoy and general manager Tom Telesco both said Monday that the team doesn't know the severity of the injury or the time frame for recovery for the 33-year-old pass rusher.
Looking for the latest news from around the NFL? Our Insiders got you covered.
Freeney was hurt in the second quarter of San Diego's 30-21 victory against Dallas on Sunday. After being tended to for several minutes, he walked off the field without help.
McCoy said the team and Freeney are exploring their options. Freeney could be placed on injured reserve designated, which would allow him to return later in the season.
"He's talking to some people, we're talking to people and just really kind of figuring out what is the best way to go," McCoy said. "That is a possibility. We'll just wait and see in the next couple of days, the severity of it exactly, what our plan is going forward."
If Freeney was placed on injured reserve designated, he'd be eligible to return to practice in six weeks. He'd be eligible to return to the active list after eight weeks.
If the injury is more significant, he could be lost for the season.
After starring for Indianapolis for 11 seasons, Freeney was released in the offseason after his production dropped for the third straight season.
He sat on the free agent market for more than two months before the Chargers signed him in late May, days after Melvin Ingram tore up his left knee in an offseason workout.
Freeney was Indianapolis' career sacks leader with 107 . He had one-half sack with the Chargers and provided a strong presence off the edge.
"Anytime you lose a great player like Dwight Freeney, it's a blow to your team," McCoy said. "That's offense, defense, special teams, in your league. When you lose one of the greatest players of all time on your team, with an injury like that, in a game, that's tough. I give a lot of guys credit for stepping up."
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The Staples Information Thread: If you have any questions, please check this thread first as it answers many common questions.
The Staples App Thread: For info on app coupons (5 off 25, 10 off 50, etc.) and how to obtain app coupons, go here.
Ink/toner Recycling Primer/FAQ: Information relevant to ink recycling and rewards at Staples and elsewhere.
Sebsa: "This coupon stacking art form is becoming less like the Mona Lisa and more like a Picasso."
Thanks. I purchased the wipes, earbuds, and 5 ream papers together and used the earbud and $5 off paper coupon last Sunday. It looks like the earbud coupon got prorated across all items but it wasn't proportional. Most of the discount came off the wipes. So if I return the wipes, will I get full price back since the other coupons applied (3.99 for earbuds, $5 for paper) were item specific?
Last edited by Elementary_Watson; 02-23-2013 at 02:22 PM..
I waited far too late to really get a good money maker deal but when anyway today and didn't want to leave empty handed. I just want to confirm with the regulars that this will still be a money maker for me when all is said and done. Thanks
I had a $10 off $30 homemailer and while I know that messes up rewards offers my store was out of photo paper and the pencils so this is what I did
the free ream of paper (after SER) $6.99
2.59 of the $10 coupon applied to this
box of paper $20 after coupon
$7.41 of the $10 coupon applied to this
Free earbuds (was not sure if the $10 off $30 would work without them)
I paid $18.39 oop after coupons and tax and suspect I will get back
$6.99 for the ream + .70 for the 10%?
$12.59 for the box of paper + $1.26 for the 10%?
So if I did it correct I get back $21.54 on an $18.39 expense, correct?
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Nevermind -- the email said $20 -- but there is $40 in my account. Must've been referring to just one of the rewards.
Got my Staples Rewards today from this deal and they only gave me $20 when I bought two cases of the paper. Was the coupon good on two, but the rewards good for only one?
Free after Rewards + coupon -Staples® 8.5" x 11" copy paper, 5-ream case. Limit 2 (Item #990176)
$24.99- $4.99 w/coupon -$20 back in rewards = FREE
This coupon has a weird description:
Item no. 990176. Limit 2 cases per customer. While
supplies last. Reg. $24.99 - $20 back in Rewards -
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Augustus Legge
The Right Reverend The Honourable Augustus Legge DD (28 November 1839[1] – 15 March 1913),[2] was Bishop of Lichfield from 1891[3] until 1913.
Legge was the third son of William Legge, 4th Earl of Dartmouth, by his second wife the Honourable Frances, daughter of Reverend George Barrington, 5th Viscount Barrington. William Legge, 5th Earl of Dartmouth, was his half-brother and Colonel Heneage Legge his full brother.[4] He was educated at Eton and Christ Church, Oxford. Ordained in 1864, he was Domestic Chaplain to the Bishop of Rochester then Vicar of St Bartholomew's, Sydenham [5] and after that Rural Dean of Lewisham[6] before his elevation to the Episcopate in 1891. From 1873 to 1876 he was a member of the London School Board, representing the Greenwich Division.[7]
Legge married Fanny Louisa, daughter of William Bruce Stopford Sackville, in 1877. They had several children. Fanny died in December 1911. Legge survived her by two years and died in March 1913, aged 73.[4]
- ^ "Who was Who" 1897-1990 London, A & C Black, 1991 ISBN 0-7136-3457-X
- ^ The Times, Friday, 21 March 1913; p. 7; Issue 40165; col B Deaths
- ^ Two New Bishops Nominated Birmingham And Lichfield The Times Friday, Jun 19, 1953; pg. 8; Issue 52652; col D
- ^ a b thepeerage.com Rt. Rev. Hon. Augustus Legge
- ^ Sydenham Society
- ^ "The Clergy List, Clerical Guide and Ecclesiastical Directory" London, Hamilton & Co 1889
- ^ "The London School Board Elections". Daily News. 29 November 1873.
|Church of England titles
|Preceded by
William Dalrymple Maclagan
|Bishop of Lichfield
|Succeeded by
John Augustine Kempthorne


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See definition in Oxford Advanced Learner's DictionarySaltos de línea: ir|re¦spon|sible
Pronunciación: /ɪrɪˈspɒnsɪb(ə)l/
Definición de irresponsible en inglés:
(Of a person, attitude, or action) not showing a proper sense of responsibility: [with infinitive]: it would have been irresponsible just to drive on
Más ejemplos en oraciones
- We are appalled at the irresponsible attitude you have displayed in condoning such anti-social behaviour.
- I think they are evading their responsibility in a grossly irresponsible way.
- And additional spending of that nature is seen to be fiscally irresponsible.
reckless, rash, careless, thoughtless, incautious, unwise, imprudent, ill-advised, ill-considered, injudicious, misguided, heedless, unheeding, inattentive, hasty, overhasty, precipitate, precipitous, wild, foolhardy, impetuous, impulsive, daredevil, devil-may-care, hot-headed, negligent, delinquent, neglectful, remiss, careless of one's duty, lax, slack, uncaring, casual, insouciant;
North American derelict
rare disregardful, inadvertent, oscitant
immature, naive, foolish, hare-brained, feather-brained;
carefree, blasé;
unreliable, undependable, untrustworthy, flighty, giddy, scatterbrained, erratic;
British tearaway
informal harum-scarum, slap-happy
- 1
- Oraciones de ejemplo
- Without them, Bradford would disappear under an ocean of litter thanks to the thoughtlessness and irresponsibility of others.
- But we're not here to talk about reckless paranoia and fiscal irresponsibility.
- So I have vowed to become less tolerant of stupidity and irresponsibility than I have been.
- 2
- Oraciones de ejemplo
- But what if the people, collectively, behave as irresponsibly as their elected officials are sometimes wont to do?
- Unlike the greedy profiteers and corporate chieftains who actually made money on those stocks, we were not acting irresponsibly.
- He acted irresponsibly, and way over the top for that sort of situation.
Pronunciación: /ɪrɪspɒnsɪˈbɪlɪti/sustantivo
Pronunciación: /ɪrɪˈspɒnsɪbli/adverbio
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Outback Steakhouse
3230 North Roosevelt Blvd., Key West, FL 33040Map
+1 305 292 0667
Cuisine: Steak & Barbecue
Take in the atmosphere of the Australian Outback while enjoying mouth-watering entrees and high-quality service. Serving dinner only, Outback Steakhouse offers an extensive menu featuring appetizers, chicken, ribs, steak, seafood, pasta, salads and desserts for moderate prices. Family-friendly, the casual restaurant has something for everyone at its numerous locations in North and South America, Europe, Asia and Australia. Outback Steakhouse also offers call-ahead seating and curbside take-away. Check website for locations and menu selections.
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Ibis Bay Waterfront Resort
0.2 mi
Inn at Key West
0.3 mi
Parrot Key Resort
0.5 mi
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Coconuts Dolphin Tournament
1.0 mi
Taste Of Key West
1.0 mi
St. Patrick's Day Bar Stroll
1.0 mi
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Capt. Bob's Grill
1.1 mi
Chef Correa's Cafe Sole
2.0 mi
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Cinema Key West 6
0.2 mi
Capt. Bob's Grill
1.1 mi
Tennessee Williams Theatre
1.6 mi
See All Key West Nightlife »


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Following a 19th place finish at the UALR Invite in Hot Springs Village, Ark. the Panthers will head to Peoria, Ill. to compete in the Bradley Invitational. Brittany Atterbury took home a 12th place finish at the UALR Invite and is looking to continue her strong play for the Panthers.
- The Panthers finished in19th at the UALR Invite.
- Brittany Atterbury tied for 12th individually at the UALR Invite.
- Following this meet UNI will play in the Creighton Invite.
- This will be UNI's first time at the Bradley Invite since 2009.
- Senior Brittany Atterbury looks to continue to improve upon her season average of 76.1.
- Sarah Boss and Blair Bonner look to best their season low rounds of 71.