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July 23, 2010
PAMELA C. BAIR, PLAINTIFF,v.COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.
Magistrate Judge Susan Paradise Baxter United States Magistrate Judge
Judge Sean J. McLaughlin
I. Recommendation
Plaintiff, Pamela C. Bair, brought this action pursuant to 42 U.S.C. § 405(g) for judicial review of the final determination of the Commissioner of Social Security ("Commissioner") which denied her application for disability insurance benefits ("DIB') under title II of the Social Security Act ("Act"), 42 U.S.C. §§ 401-433. Plaintiff filed a motion for remand based on new evidence on October 2, 2009. (Doc. No. 12). Plaintiff also filed a motion for summary judgment (Doc. No. 16) and brief in support (Doc. No. 17) on November 2, 2009. The Commissioner filed a cross-motion for summary judgment (Doc. No. 18), and brief in support (Doc. No. 19) on December 1, 2009. For the following reasons, it is respectfully recommended that Plaintiff's motion for summary judgment be granted insomuch as it requests a remand for further proceedings not inconsistent with this opinion. It is further recommended that Plaintiff's motion for remand be denied as moot and the Commissioner's motion for summary judgment be denied.
II. Report
Plaintiff protectively filed for DIB on February 21, 2006 alleging disability due to herniated discs in her neck and stenosis with an alleged onset date of November 5, 2004. (R. 99, 102). Her claim was denied at the state agency level on August 3, 2005. (R. 41). Plaintiff filed a request for a hearing before an administrative law judge ("ALJ"). (R. 53). A hearing was held before ALJ William Vest on June 5, 2008. (R. 374-407). Plaintiff, who was represented by counsel, appeared at the hearing and testified on her own behalf. (R. 378-398). An impartial vocational expert also testified. (R. 398-407). The ALJ issued a decision on July 11, 2008, finding that Plaintiff was not disabled within the meaning of the Act. (R. 12-27). The Appeals Council subsequently denied Plaintiff's request for review, thereby making the decision of the Commissioner final in this case. (R. 4-6). Plaintiff now seeks review of that decision by this Court.
A. Facts
Plaintiff was forty-nine years old at the time of the hearing, and therefore was defined as a "younger individual," age 18-49, pursuant to 20 C.F.R. §§ 404.1563. (R. 99). Plaintiff obtained a GED and her prior work includeds employment as inspector at a plastic parts factory, a housekeeper, a janitorial supervisor, and a day care center worker. (R. 25, 103-104).
Plaintiff underwent a cervical MRI on November 2, 2004, which showed disc herniations centrally at C4-5, C5-6, and C6-7. (R. 184). The spinal cord was effaced at C4-5 centrally and to a milder extent at C5-6. Id. Plaintiff was referred to Dr. John Flamini, a neurologist, by her family practitioner, Dr. Jeffrey Start. (R. 196). Plaintiff reported neck pain, and numbness, paresthesia, and dysesthesia in the first few digits of her right hand. (R. 180).
Dr. Flamini performed nerve conduction studies in Plaintiff's right arm, which revealed mild Tinel's sign and mild Phalen's sign. Id. Dr. Flamini concluded that the tests revealed no evidence of radiculopathy and very mild medial neuropathy of the right wrist as evidence of mild carpal tunnel syndrome. Id. He prescribed a two week treatment of anti-inflammatory medications and follow-up with an orthopedist if necessary. Id.
On December 30, 2004, Plaintiff was evaluated by Diane Adiutori, CRNP, and Dr. Richard Mendel, a neurologist. (R. 177). Ms. Adiutori performed a physical examination noting normal strength and grips with positive Phalen's sign on the right. (R. 179). Plaintiff was assessed with disc herniations at C4-5, C5-6, and C6-7 with no nerve root impingement. (R. 177). Plaintiff was prescribed a six week course of physical therapy and prescribed Flexeril, a muscle relaxant. Id. Plaintiff underwent twelve physical therapy treatments in January and February 2005, but experienced no relief from her symptoms. (R. 174, 177-178). Plaintiff returned to Dr. Mendel on February 22, 2005. (R. 176). Dr. Mendel opined that the medical literature did not support surgery for neck pain and recommended an increase of her Motrin and an evaluation by Dr. Thomas for cervical joint facet injections. Id.
Plaintiff was evaluated by Dr. James Kang, a neurological surgeon, on March 14, 2005 at the request of Dr. Start. (R. 21, 321). Plaintiff reported numbness and tingling in her right hand and neck pain. (R. 321). On examination, Dr. Kang noted a normal gait, "very limited" range of cervical motion, dull pinprick on the right C6 dermatome, and slight hyperflexia but negative Babinski sign, Hoffman sign, and clonus sign. (R. 322). Review of Plaintiff's MRI revealed the same findings as noted by her previous physicians. Id. Dr. Kang assessed classic multi-level stenosis caused mostly by a radicular syndrome. He recommended an anterior corpectomy with an allograft fibular strut fusion. Id. Plaintiff's cervical corpectomy at C5 and C6, allo-graft fibular strut fusion at C3 through C7, and posterior cervical fusion at C3 through C7 was performed on April 21, 2005. (R. 246-248). Dr. Kang's post-operative diagnosis was multilevel cervical stenosis, C3 through C7 with spinal cord compression and cervical radiculopathy. (R. 246).
X-rays of Plaintiff's cervical spine in May 2005 showed an uncomplicated fusion and posterior stabilization. (R. 251). Plaintiff returned to Dr. Kang on May 20, 2005 for follow-up. Overall, Dr. Kang noted that she was doing "quite well" with relief of arm pain, but she was having difficulty sleeping. (R. 312). Dr. Kang placed Plaintiff on Elavil for her nervousness and sleep and continued her Vicodin with the instruction to slowly taper the medication. Id. She was also given a cervical collar. Id. Plaintiff was seen again on July 1, 2005 at which time she reported mechanical neck pain and tiredness. (R. 309). He noted that she was experiencing a "little" withdrawal from the narcotics and had some delayed recovery due to her continued smoking. X-rays showed a "beautifully healing" cervical fusion. Id. Physical therapy was ordered. Id. Plaintiff attended physical therapy from July through November of 2005. (R. 273-289).
On August 3, 2005, Plaintiff records were reviewed by a state agency medical evaluator, Tamela Coscoran. (R. 271-277). Ms. Coscoran opined that Plaintiff was capable of occasionally lifting twenty pounds and frequently lifting ten pounds; standing or walking for six hours out of a eight hour work day; sitting for about six hours out of an eight hour work day; was unlimited in her ability to push and pull; and was occasionally able to climb, balance, stoop, kneel, crouch, and crawl. (R. 272-273).
On October 3, 2005, Plaintiff returned to Dr. Kang with complaints of mechanical neck pain. (R. 308). Dr. Kang noted that Plaintiff had not quit smoking and was working full time. On examination, Plaintiff's cervical range of motion was mechanically stiff, but her neurological status was still normal. Id. Dr. Kang opined that the pain was related to Plaintiff's fusion still trying to complete itself and he again warned her of the effects of smoking on fusion healing. Id. Plaintiff returned to Dr. Kang on March 20, 2006. (R. 307). Plaintiff reported an increase in the her neck pain. On examination, her cervical range of motion was mechanically stiff, but her neurological status was normal. Id. Dr. Kang ordered a new MRI to rule out a further disc herniation and prescribed Flexeril and a soft neck collar "to rest her neck at the end of the day." Id.
Plaintiff's records were reviewed on June 1, 2006 by Sonia Clover, a state agency medical evaluator. (R. 323-329). Ms. Clover opined that Plaintiff was capable of occasionally lifting twenty pounds and frequently lifting ten pounds; standing or walking for six hours out of a eight hour work day; sitting for about six hours out of an eight hour work day; and was unlimited in her ability to push and pull. Id. On the same date, Dr. Manella Link, a psychiatrist completed a psychiatric review technique after a review of Plaintiff's records. (R. 330). He opined that Plaintiff was experiencing depressive symptoms secondary to her pain. (R. 333).
Dr. Link suggested that Plaintiff had mild limitations in her activities of daily living and in concentration, persistence, and pace and no difficulties in social functioning. (R. 340).
On July 20, 2006, Plaintiff was evaluated by Dr. Rodney Bingham, a pain management specialist, at the request of Dr. Start. (R. 352-353). Plaintiff reported that her extremity numbness resolved post-surgery but that she was experiencing cervicothoracic bilateral pain that worsened throughout the day. (R. 352). She noted that the pain was constant, sharp, aching, and throbbing. Id. Plaintiff's physical examination was normal except for a limited cervical range of motion in the left and right and limited cervical flexion and extension.
(R. 353). Plaintiff was diagnosed with cervical post-laminectomy syndrome and cervical radiculitis. Id. Dr. Bingham noted that Plaintiff's pain seemed to be mainly "somatic in etiology." Id. He recommended that analgesic management was the most appropriate option with the use of an electrical stimulation device. He noted that he had no other treatment to offer at the time. Id.
Plaintiff was examined by Dr. Thomas Mroz, a spine surgeon, on October 25, 2006.
(R. 345). Plaintiff reported neck pain that was worse with motion. On examination, Dr. Mroz noted paraspinal atrophy, lack of extension, tenderness, and pain. Id. A CT scan was ordered. Id. Plaintiff was again examined by Dr. Bingham on February 12, 2007. (R. 351). Dr. Bingham noted Plaintiff's visit to the Cleveland Clinic to see Dr. Mroz and noted that she had discontinued care with Dr. Kang. Id. Plaintiff reported pain in the lower cervical spine with radiation into the left shoulder and mandibular discomfort. Id. She also reported headaches that were increasing in frequency. Id. Plaintiff's examination was normal except for tenderness elicited on palpitation of the lower cervical and upper thoracic spine area and limited cervical rotation. Id. Dr. Bingham opined that management with conservative treatment was producing moderate improvement. He further opined that treatment with ibuprofen had provided "significant symptom control" but that the pain had become progressive in intensity and frequency. Id. Plaintiff was given a prescription for cervical facet injections. Id.
Plaintiff returned to Dr. Bingham on March 5, 2007 and reported "appreciated pain" on the right in the shoulder and the arm to the elbow with a pain level of eight out of ten. (R. 350). Dr. Bingham did not change his diagnoses from the prior visit and opined that conservative management and intervention management had not been maximized. In conjunction with this opinion, he prescribed a Medrol dose pack, an electrical stimulation device, a facet branch block, and Lyrica, as a pain management agent. Id. Plaintiff returned for a cervical facet median branch block at C3-C4 and C4-C5 on March 16, 2007. (R. 349). Plaintiff had a follow-up on March 26, 2007 and reported that the pain had decreased to a three out of ten, but was aggravated by standing activities in her home. (R. 348). She also reported a pricking sensation progressing to a severe ache. She noted using Vicodin and Flexeril at night. Id. Dr. Bingham noted a "significant response" to the facet block and suggested Plaintiff might experience more long term relief with radiofrequency thermocoagulation. Id. She was continued on her medications. Id.
Plaintiff was examined by Dr. Start on June 12, 2007 for complaints of chronic low back pain. (R. 360). Dr. Start noted that the pain was having a detrimental effect on her concentration, mentation, motivation, mood, self-esteem, sleep, and family life. Id. Dr. Start also reported anxiety, depression, stress, and mood swings. Id. On examination, Plaintiff's gait was antalgic with a right-sided limp; pain was elicited over the third and fourth spinal process; crepitus was palpitated; and range of motion was limited ten to fifteen degrees and flexion to twenty to thirty degrees in the back and neck. (R. 361-362). Dr. Start opined that Plaintiff was "having some pain in her lower spine from overall deconditioning" and would "benefit from some simple daily exercise." (R. 362). He also discussed the effects of depression on pain, but did not feel it was the right time to have a full discussion on the matter due to Plaintiff's negative reaction. She was continued on Flexeril and her other medications. Id.
On September 4, 2007, Plaintiff returned to Dr. Bingham to discuss the effectiveness of her prior facet block. (R. 347). Plaintiff reported that her pain was moderately relieved for several weeks but that the pain then reoccurred in the same place and of the same quality. Id. She noted pain ranging from a four to five out of ten to a ten out of ten. Upon examination, motor strength, grip, coordination, and range of motion in the shoulders, elbows, and wrists were all normal. Id. Tenderness was present over the right shoulder and over the entire cervical spine with significantly limited cervical rotation and flexion and extension. Id. Dr. Bingham again recommended radiofrequency thermocoagulation. Id.
Plaintiff returned to Dr. Start on December 11, 2007 for left shoulder and neck pain.
(R. 357-359). Plaintiff reported that she was getting some relief from one half to one whole Norco a day. Id. Plaintiff noted that she felt her pain was bad enough that she should apply for disability permanently and brought along a form from her attorney. Dr. Start referred her to Dr. Kolade on the issue of disability. Id. Dr. Start reported that her pain had a detrimental impact on her concentration, mentation, motivation, mood, self-esteem, sleep, family life, and functionally impaired sitting, walking, riding in a vehicle, and mobility. Id. Dr. Start noted that Plaintiff's posture included not raising her upper arm greater than ninety degrees, not rotating in a side bend flex and not extending her neck more than a few degrees in any direction. (R. 358-359). Dr. Start prescribed a small amount of hydrocodone/APAP and Norco and warned Plaintiff of the narcotic qualities of both. Id.
B. Hearing Testimony and ALJ's Opinion
On June 5, 2008, Plaintiff, who was represented by counsel, testified at the hearing before ALJ William Vest.Plaintiff testified that she ceased working due to numbness in her arm and significant pain in the back of her neck. (R. 378). She asserted that the corrective procedure of April 2005 did not cause improvement and that she continued to experience numbness and had developed chronic pain with headaches and pain in the ears and jaw. (R. 378-379, 380). Plaintiff noted that she could walk and would walk around her neighborhood, once in awhile, during the week. (R. 380). Plaintiff further testified that she could do some housework, including dishes and laundry, watched TV, read, played cards, drove, cooked, shopped, and went to church. (R. 381-382, 386). Plaintiff contends that she can lift five pounds and can sit for about twenty minutes before needing to stretch and move. (R. 382).
With regard to medications, Plaintiff testified to taking Flexeril, Hydrocodone, and ibuprofen with a little bit of relief. (R. 383). She noted that the medicines would make her drowsy. (R. 392). She also testified that she needed to lie down during the day to relieve her pain. Id. Plaintiff reported that she could stand still for about twelve to thirteen minutes and could drive for about fifteen to twenty minutes before needing to readjust her position. (R. 393-394). She testified to difficulties concentrating and focusing due to pain and headaches. (R. 397, 398).
On July 11, 2008, the ALJ rendered a decision which was unfavorable to Plaintiff under the five-step sequential analysis used to determine disability. (R. 15-27). At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since November 5, 2004. (R. 17). At step two, the ALJ found that Plaintiff had the following severe impairments: cervical stenosis and degenerative joint disease. (R. 17). At step three, the ALJ concluded that Plaintiff's impairments did not meet or equal one of the listed impairments set forth in 20 C.F.R. 404 Subpart P, App. 1. (R. 19). At step four, the ALJ determined that Plaintiff was unable to return to any past relevant work. (R. 25.) At step five, the ALJ concluded that the government had met its burden to show that Plaintiff had the residual functional capacity to work. (R. 19). He assessed her residual functional capacity as follows:
After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b). Light work involves occasionally lifting no more than 20 pounds at a time with frequent lifting or carrying of ten pounds with pushing and pulling of objects of equivalent stipulated weights. Specifically, the claimant is capable of sitting for up to six (6) hours out of an eight (8) hour workday and she is capable of standing and/or walking for up to six (6) hours out of an eight (8) hour workday. In the performance of work activity, the claimant should be allowed to alternative between sitting and standing as needed. The claimant is capable of occasionally bending, stooping and squatting with no climbing. She is to perform no work at unprotected heights and no work that involves hazardous situations that might cause harm to self or others, such as work with dangerous machinery or work at unprotected heights.
She is capable of understanding, remembering, and carrying out simple instructions and performing simple tasks as consistent with unskilled work activity. She is limited to the performance of low stress jobs. The undersigned notes that occasional is defined to mean occurring from very little up to one-third of an eight-hour workday (cumulatively, not continuously) and is consistent with the meaning in the Dictionary of Occupational Titles. The claimant has no significant communicative, environmental, manipulative, or visual limitations and minimal mental limitations as noted. The claimant is able to perform sustained work activity on a regular and continuous basis for eight hours per day, forty hours per week with normal breaks being sufficient.
(R. 19-20). Consequently, the ALJ found that Plaintiff was not under a disability within the meaning of the Act. (R. 20).
C. Standard of Review
The Act limits judicial review of disability claims to the Commissioner's final decision. 42 U.S.C. § 405(g). If the Commissioner's finding is supported by substantial evidence, it is conclusive and must be affirmed by the Court. 42 U.S.C. § 405(g); Schaudeck v. Comm'n of Soc. Sec. Admin., 181 F.3d 429, 431 (3d Cir. 1999). The Supreme Court has defined "substantial evidence" as "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389 (1971); Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999). It consists of more than a scintilla of evidence, but less than a preponderance. Stunkard v. Secretary of Health & Human Servs., 841 F.2d 57, 59 (3d Cir. 1988).
When resolving the issue of whether an adult claimant is or is not disabled, the Commissioner utilizes a five-step sequential evaluation. 20 C.F.R. §§ 404.1520 and 416.920 (1995). This process requires the Commissioner to consider, in sequence, whether a claimant (1) is working, (2) has a severe impairment, (3) has an impairment that meets or equals the requirements of a listed impairment, (4) can return to his or her past relevant work, and (5) if not, whether he or she can perform other work. See 42 U.S.C . § 404.1520; Burnett v. Commissioner of Social Security, 220 F.3d 112, 118-19 (3d Cir. 2000) (quoting Plummer v. Apfel, 186, F.3d 422, 428 (3d Cir. 1999)).
To qualify for disability benefits under the Act, a claimant must demonstrate that there is some "medically determinable basis for an impairment that prevents him or her from engaging in any substantial gainful activity for a statutory twelve-month period." Kangas v. Bowen, 823 F.2d 775, 777 (3d Cir. 1987); 42 U.S.C. § 423 (d)(1) (1982). This may be done in two ways:
(1) by introducing medical evidence that the claimant is disabled per se because he or she suffers from one or more of a number of serious impairments delineated in 20 C.F.R. Regulations No. 4, Subpt. P, Appendix 1. See Heckler v. Campbell, 461 U.S. 458 (1983); Stunkard, 841 F.2d at 59; Kangas, 823 F.2d at 777; or,
(2) in the event that claimant suffers from a less severe impairment, by demonstrating that he or she is nevertheless unable to engage in "any other kind of substantial gainful work which exists in the national economy . . . ." Campbell, 461 U.S. at 461 (citing 42 U.S.C. § 423 (d)(2)(A)).
In order to prove disability under the second method, a claimant must first demonstrate the existence of a medically determinable disability that precludes plaintiff from returning to his or her former job. Stunkard, 841 F.2d at 59; Kangas, 823 F.2d at 777. Once it is shown that claimant is unable to resume his or her previous employment, the burden shifts to the Commissioner to prove that, given claimant's mental or physical limitations, age, education and work experience, he or she is able to perform substantial gainful activity in jobs available in the national economy. Stunkard, 842 F.2d at 59; Kangas, 823 F.2d at 777; Doak v. Heckler, 790 F.2d 26, 28 (3d Cir. 1986); Rossi v. Califano, 602 F.2d 55, 57 (3d Cir. 1979).
D. Discussion
Plaintiff makes several related arguments in her motion for summary judgment and motion for remand. Generally, she argues that the ALJ's residual functional capacity evaluation was unsupported by substantial evidence. In support of this argument, Plaintiff contends that the ALJ erred in rejecting Plaintiff's complaints of pain and functional limitations, mistakenly concluding that Dr. Start's most recent report showed a resolution of symptoms, selectively relying on a few objective findings to find that Plaintiff's symptoms had resolved, ignoring the medical evidence of Dr. Mroz, and in giving significant weight to the two state agency evaluators. In her second argument, Plaintiff asserts that the ALJ erred at step two in finding her depression was non-severe. Finally, Plaintiff argues, in her motion for remand, that this case should be remanded due to an omitted medical record from April 25, 2007. The Commissioner argues that Plaintiff has failed to prove that she is disabled and that the decision of the ALJ is, therefore, supported by substantial evidence.
1. Residual Functional Capacity Assessment
Plaintiff argues that the ALJ erred in his determination of her residual functional capacity. Specifically, she contends that the ALJ ignored, misinterpreted, or gave inappropriate weight to a good deal of the evidence of record. The Commissioner responded by arguing that the ALJ properly incorporated all of Plaintiff's functional limitations into his residual functional capacity assessment.
""Residual functional capacity'[RFC] is defined as that which an individual is still able to do despite the limitations caused by his or her impairment(s).'" Burnett, 220 F.3d at 121(quoting Hartranft v. Apfel, 181 F.3d 358, 359 n.1 (3d Cir. 1999)). A claimant's RFC represents the most, not the least, that a person can do despite his or her limitations. See Cooper v. Barnhart, 2008 WL 2433194, at *2 n.4 (E.D.Pa., June 12, 2008) (citing 20 C.F.R. § 416.945(a)). In determining a person's RFC, an administrative law judge must consider all the evidence of record. 20 C.F.R. §§ 404.1520, 416.920. Although an administrative law judge can weigh the credibility of the evidence when making a RFC determination, he or she must give some indication of the evidence which is rejected and the reasons for doing so. Id. As the court stated in Burnett, "'[i]n the absence of such an indication, the reviewing court cannot tell if significant probative evidence was not credited or simply ignored.'" Id. at 121 (quoting Cotter v. Harris, 642 F.2d 700, 705 (3d Cir. 1981)).
The ALJ made two particular errors in his assessment of Plaintiff's residual functional capacity: 1) he gave significant weight to the residual functional capacity assessments of two non-physician evaluators and 2) he failed to discuss Plaintiff's consultation with Dr. Mroz and her final visit with Dr. Start. As to the first issue, the ALJ assigned "significant weight" to the two state agency assessments that Plaintiff could perform light work.*fn1 Individuals whose opinions are considered "acceptable medical sources" and entitled to substantial weight in certain circumstances include licensed physicians or psychologists and are the only sources whose opinions can establish a medically determinable impairment. Social Security Ruling ("SSR") 06-03p, 2006 WL 2329939 at *1-2 (S.S.A. 2006). Neither Ms. Clover nor Ms. Coscoran were acceptable medical sources under the regulations and only qualify as an "other source" under 20 C.F.R. § 404.1513 (d)(1).
As an additional issue, the two evaluators did not even examine Plaintiff, but instead performed a record review. Controlling or "significant" weight is generally relegated to a claimant's treating or consulting physicians who have at least examined that individual. "A cardinal principle guiding disability eligibility determinations is that the ALJ accord treating physicians' reports great weight, especially 'when their opinions reflect expert judgment based on a continuing observation of the patient's condition over a prolonged period of time.'"
Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000) (quoting Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999)); see also Allen v. Bowen, 881 F.2d 37, 41 (3d Cir. 1989); Podedworney v. Harris, 745 F.2d 210, 217-18 (3d Cir. 1984). And reports from consulting physicians who have examined the claimant and rendered assessments on conditions within their respective area of expertise are to be given appropriate evidentiary weight, which will vary based on the circumstance and the other medical evidence presented. Gordils v. Secretary of Health and Human Services, 921 F.3d 327, 328 (1st Cir. 1990) (citing Rodriguez v. Secretary of Health and Human Services, 647 F.2d 218, 223 (1st Cir. 1981) (weight to be afforded a consulting/examining physician's report "will vary with the circumstances, including the nature of the illness and the information provided the expert.").It is therefore evident that the ALJ gave inappropriate weight to these reports.
This assignment of weight is further compounded by the failure of the ALJ to discuss all of the relevant medical evidence including a consultation with Dr. Mroz of the Cleveland Clinic, which led to a notation of paraspinal atrophy and Dr. Start's final examination of Plaintiff in December 2007. (R. 345). In his opinion the ALJ concluded that Plaintiff's chronic neck pain "appear[ed] significantly improved" due to the June 2007 records of Dr. Start. (R. 25). Although the ALJ asserted that Plaintiff had "full range of motion" in her neck, this assertion was not supported in the record. (R. 24, 360-362). The ALJ then stated that "there [was] no further evidence from Dr. Start to consider, which is indicative of no need for continued and frequent follow-up despite the claimant's alleged continued chronic pain complaints." (R. 25). As was noted above, Plaintiff did return to Dr. Start with complaints of chronic pain and he noted her posture, flexing, and extending difficulties in both the back and neck. (R. 358-359). These records are not supportive of the conclusion that Plaintiff's pain had "significantly improved" and this assertion, therefore, was not supported by substantial evidence. Due to these errors, it is recommended that this case be remanded to the ALJ for further proceedings.
2. Plaintiff's Credibility
Plaintiff raises additional issues relating to the assessment of her credibility. In his opinion, the ALJ concluded that Plaintiff's subjective complaints had "some merit." (R. 25). Plaintiff asserts that this assessment fails to adequately take into account her well-documented struggles with pain as evidenced by the medical record.
The ALJ must give serious consideration to the claimant's subjective complaints, even when those assertions are not fully confirmed by objective medical evidence. See Mason v. Shalala, 994 F.2d 1058, 1067-68 (3d Cir.1993); Welch v. Heckler, 808 F.2d 264, 270 (3d Cir.1986). Pain alone, if sufficiently severe, may be a disabling impairment that prevents a claimant from performing any substantial gainful work. E.g., Carter v. Railroad Retirement Board, 834 F.2d 62, 65, relying on Green v. Schweiker, 749 F.2d 1066,1068 (3d Cir. 1984); Smith v. Califano, 637 F.2d 968, 972 (3d Cir. 1981); Dobrowolsky v. Califano, 606 F.2d 403, 409 (3d Cir. 1979). Similarly, an ALJ must give great weight to a claimant's subjective description of his or her inability to perform even light or sedentary work when this testimony is supported by competent evidence. Schaudeck v. Commissioner of Social Security, 181 F.3d 429, 433 (3d Cir. 1999), relying on Dobrowolsky.
Where a medical impairment that could reasonably cause the alleged symptoms exists, the ALJ must evaluate the intensity and persistence of the pain or symptom, and the extent to which it affects the individual's ability to work. This obviously requires the ALJ to determine the extent to which a claimant is accurately stating the degree of pain or the extent to which he or she is disabled by it. See 20 C.F.R. § 404.1529(c). Hartranft v. Apfel, 181 F.3d 358, 362 (3d Cir. 1999). If an ALJ concludes that the claimant's testimony is not credible, the specific basis for such a conclusion must be indicated in his or her decision. See Cotter, 642 F.2d at 705. The Court of Appeals has stated: in all cases in which pain or other symptoms are alleged, the determination or decision rationale must contain a thorough discussion and analysis of the objective medical and the other evidence, including the individual's complaints of pain or other symptoms and the adjudicator's personal observations. The rationale must include a resolution of any inconsistencies in the evidence as a whole and set forth a logical explanation of the individual's ability to work.
Schaudeck, 181 F.3d at 433.
Given, the ALJ's conclusion, based on inadequate evidence, that Plaintiff's pain had "significantly improved," it is evident that his assessment of Plaintiff's testimony and reports regarding pain were similarly flawed. While Plaintiff evidently received short-term relief from the facet block administered by Dr. Bingham and some additional relief from narcotic pain relievers like Vicodin, the ALJ has failed to support his conclusions regarding the improvement of Plaintiff's pain.
3. Plaintiff's Depression
Plaintiff's third argument encompasses the ALJ's step two determination that Plaintiff's "medically determinable mental impairment of depression" as diagnosed by Dr. Start did not cause more than "minimal limitation in the claimant's ability to perform basic mental work." (R. 18). He concluded that Plaintiff's depression was non-severe. Id. Plaintiff argues that her depression met the Third Circuit's standard and was severe and also should have been considered in conjunction with her other ailments.
An impairment is severe if it imposes significant restrictions in the ability to perform basic work activities. Social Security Ruling 85-28. "An impairment or combination of impairments can be found 'not severe' only if the evidence establishes a slight abnormality or a combination of slight abnormalities which have 'no more than a minimal effect on an individual's ability to work.'" Newell v. Commissioner of Social Security, 347 F.3d 541, 546 (3d Cir. 2003) citing SSR 85-28. "The severity step...should only be used to screen out de minimis claims." Roberts v. Massanari, 2001 WL 1580241, *3-4 (E.D.Pa., Dec. 10, 2001)(citing Bailey v. Sullivan, 885 F.2d 52, 56-7 (3d Cir.1989)).
In support of his determination that Plaintiff's depression had a minimal impact on her ability to work and thus was non-severe, the ALJ utilized the "paragraph B requirements" of section 12.00C of the Listing of Impairments. The four criteria are activities of daily living; social functioning; concentration, persistence, and pace; and episodes of decompensation. 20 C.F.R., Part 404, Subpart P, Appendix 1. The ALJ concluded that Plaintiff had no limitation to mild limitation in these areas of functioning, in partial reliance on the psychiatric review technique from June 2006. (R. 18). It is evident from the record that Plaintiff reported difficulties with concentration and focus, mostly in relation to her pain.Dr. Start recorded his concerns regarding the relationship between Plaintiff's pain and depression in both his June 2007 and December 2007 records. (R. 357-359, 361-362). He noted that her pain was affecting her concentration, mentation, motivation, mood, self-esteem, sleep, and family life. Id.
Since the psychiatric review technique was performed based on a review of records from prior to June 2006 and serious concerns of depression were not raised until June 2007, the ALJ's rationale is not supported by substantial evidence. The failure of the ALJ to review the December 2007 records of Dr. Start is also significant in this respect since it also included discussion of depression symptoms. Secondarily, the reviewing psychiatrist never examined Plaintiff and based his opinions strictly on a review of Plaintiff's records. Seemingly, the ALJ went on to consider Plaintiff's depression in the residual functional capacity assessment, however, as this case will be remanded, the issue of severity should be revisited.
4. New Evidence
In an unrelated argument, Plaintiff contends that this case should be remanded based on evidence obtained after the opinion of the ALJ was rendered and the case was appealed to the Appeals Council. Attached as Exhibit A to Plaintiff's Brief in support of her motion for remand is a medical record from the office of Dr. Mroz dated April 25, 2007. (Pl. Brief, Doc. No. 3, Exhibit A).
The United States Court of Appeals for the Third Circuit has set forth guidelines for determining when a "new evidence" remand is proper under § 405(g): "[T]he evidence must first be "new" and not merely cumulative of what is already in the record. Second, the evidence must be "material;" it must be relevant and probative.... Beyond that, the materiality standard requires that there be a reasonable possibility that the new evidence would have changed the outcome of the [Commissioner's] determination. Finally the claimant must demonstrate good cause for not having incorporated the new evidence into the administrative record." Szubak v. Secretary of Health and Human Servs., 745 F.2d 831, 833 (3d Cir.1984) (citations omitted); see also Cruse v. Astrue, 2010 WL 1133423, * 4-5 (W.D.Pa. March 23, 2010)(where a physician's report did not set forth opinions relating to physical limitations or inability of the claimant to work, there is no reasonable probability that it would have changed the outcome of the case.) In order to satisfy the "materiality" requirement, "the new evidence [must] relate to the time period for which benefits were denied, and [must] not concern evidence of a later-acquired disability or of the subsequent deterioration of the previously non-disabling condition." Id.
In light of the fact that it is recommended that this case be remanded on other grounds, as noted above, this issue is moot. On remand, this evidence may be submitted and considered by the ALJ, thus allowing for its incorporation into the formal record.
III. Conclusion
For the reasons stated above, it is recommended that the Motion for Summary Judgment filed by Defendant at [Doc. No. 18] be denied. It is further recommended that the Motion for Summary Judgment filed by the Plaintiff at [Doc. No. 16] be granted insomuch as it requests a remand not inconsistent with this opinion. In addition, it is recommended that Plaintiff's Motion for Remand based on New Evidence at [Doc. No. 12] is moot and should be denied.
In accordance with the Magistrate Judge's Act, 28 U.S.C. § 636(b) (1)(B) and (C), and Rule 72.1.4.(B) of the Local Rules for Magistrate Judges, the parties are allowed ten (10) days from the date of service to file objections to this Report and Recommendation. Any party opposing the objections shall have ten (10) days from the date of service of objections to respond thereto. Failure to timely file objections may constitute a waiver of any appellate rights.
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With no cover at V's Main Stage, we thought it only right and in the true spirit of things to send our Main Stage reporter to Staffs - the one with the most rain. Well, it always pisses down for Radiohead anyway...
Main Stage Staffs, Saturday 19 August
It's already damp as bedraggled early punters trudge their way through the effects of last night's downpour, but the clutch of teenage girls gathered down the front seem oblivious. Handsome newcomer Gavin DeGraw bounds onstage with the energy of an e-numbered toddler, but if it weren't for his talented support troupe, his formulaic lilting would sound as exciting as a James Blunt record.
Kubb offer a similarly dull musical experience, although Collier's warm, effeminate vocals are soothing, the attempt at a vast, soaring chorus for 'Somebody Else' falls face down in the mud. By the end we're all half asleep.
Rain now firmly on the cards for the rest of the day, it's up to The Dandy Warhols to breathe some life into the limp crowd. Courtney Taylor-Taylor surveys the assembled with an iron glare, his ego only marginally smaller than drummer Brent DoBoer's hair as they launch into a frenetic performance which sets everyone in motion.
[r-zone1]It's impossible to tell exactly who's in Sugababes these days, but the bitchiest girl group in history do a sterling job of glossing over the turbulent past in this slick, polished performance. In a marked contrast to the muddy gathering, the Topshop-ed trio look especially well-groomed and sass their way through a sultry collection of their best pop anthems.
A surprise appearance from James Morrison on the back of his topping the album charts sees an impromptu couplet featuring bestseller 'You Give Me Something'. It does little to titillate the bemused crowd who give his gentle acoustic meanderings only a smattering of applause.
[l-zone2]Hard Fi make a valiant attempt at "talking to the kids" but ultimately this tired approach fails to engage. Nevertheless, the poor man's Arctic Monkeys try their hardest to win the crowd with the eminently danceable 'Cash Machine', but other than this, they're wholly unmemorable.
[r-zone3]Although his legacy is more apparent in recent times than ever before, Paul Weller's own enthusiasm for music seems to be on the wane in this fairly disappointing appearance. The set itself is mixed – only two appearances from Jam songs, and the crowd are visibly bored throughout.
[l-zone4]Will they? Won't they? Although Faithless' future is uncertain, there's no denying they can still give one of the best performances of the weekend. Their pneumatic stage presence brings the crowd together in a single euphoric mass as they collectively scream 'WE COME ONE!' Even their more laid back trip hop has everyone juddering in this electrifying set.
[r-zone5]And so it comes to The Smiths, sorry, Morrissey, drawing a fairly insubstantial crowd despite the coveted top slot. Launching into 'Panic' it becomes clear that this is going to be yet another mish mash of the not very new and the very old. Morrissey himself looks more ancient than ever, his brown ensemble serving only to highlight the greys and add to the ever-present nostalgia. Even his politics are recycled; new single 'In The Future When All's Well' jumps on the bandwagon with its Bush/Blair-mongering. Still, the public are more than happy to oblige Mr Misery as he bleats his way through a spartan back catalogue. As always it's his ex-band's classics that receive the strongest reception. Makes you wonder – if it weren't for his insistent backwards-vision, would he really be headlining tonight?
Main Stage Staffs. Sunday 20 August
[r-zone1]As the sun makes a welcome appearance, orange-tinted one hit wonder Daniel Powter takes to the stage and slumbers through a long, bland, piano drone. The torture hits a peak during the closing hit as a microphone turned crowd-ward for the chorus receives a deadened silence. 'Bad Day'? Too right.
Just when you thought bands of recent times couldn't rip off the classics any more, out step the Dead 60's, who remarkably haven't been investigated for copyright abuses and proceed to play what could easily be a wealth of unreleased Clash and Specials b-sides. The magic of yesteryear works wonders on the restless horde however, and an extended 'Riot Radio' sees singer Matt McManamon's wail echo Strummer's with uncanny similarity.
It's great to see that in the post-reshuffle of The Divine Comedy, Neil Hannon still retains a dazzling wit. There's an element of fun throughout with their eponymous 'National Express' and the dedication of 'Diva Lady' to "the many and varied characters we saw at Chelmsford". Endearing.
Hurrah! The sun is finally out and it's a good job too, because The Magic Numbers aren't nearly as good under a grey sky. Brimming with joy throughout, the supremely cheerful foursome can't help but bring a smile to all and sundry with the soothing 'Forever Lost' and new single 'Take A Chance'.
[l-zone2]In their final UK show of the year, Bloc Party find themselves in front of their biggest crowd yet. Alongside the glorious 'Banquet' and 'Helicopter' we're treated to new tracks from the forthcoming album, highlight being the thrilling 'Waiting for the 7.18'. Superb.
[r-zone3]An alarming number have congregated to catch Keane, and it's made all the more confusing when their set turns out to be even more soul-destroying than their records. Chaplin might be as charismatic as ever but he can't do anything to save this dismal offering.
[l-zone4]Robotic breakdancing? Food-based percussion? Mass puppet destruction backstage? It can only be Beck who, in easily the most amusing performance of the weekend puts earlier bands of the day to shame with his eclectic live show. Mixing his much-celebrated back catalogue with tracks from the new album and a brief covers medley, the golden-haired pixie and his wooden miniatures bring the set to a close with a deafening 'E-Pro'.
[r-zone5]There simply isn't an adequate way to introduce one of the most important bands in the world, and anyway, Radiohead speak for themselves. It's been three years since their last UK festival appearance and expectations are high; the five-piece are renowned for their incredible festival outings. They are at their most spectacular tonight as they stick to the tried-and-tested approach with a formidable setlist, incorporating the epileptic 'Paranoid Android' and the devastating 'Street Spirit'. We also see the welcome return of 'Creep' to the crowd's utter delight, but it's the true singalongs 'Just' and 'Karma Police' that drown out Yorke in spectacular fashion. The band are in their element here and it shows – they're a truly cataclysmic finale to the weekend.

subset: commoncrawl


text:
As we reported in our June 21 post, CMS has published the proposed revisions to the physician work RVU component. The notice, which opens the proposal to formal comments, was published in the June 29, 2006 Federal Register.
Each practice will have to look closely and see how their revenues will be effected, if at all. Overhanging this will be the emphasis on "budget neutrality", i.e. no more money. This year, at least, wholesale cuts were stopped. Physicians continue to lose ground in revenue and take home income. I believe that there will be pressure to cut physician income in the high income specialties, and modest increases in the lower income specialties. Physicians should be planning a 5 years out, and planning to convert to EMR, use nurse practitioners, and use the web for patient educaiton, registration and appointment setting, limited patient communication via email, and limited online "consultation" with active patients.


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Angel-Hair Pasta with Sauteed Oysters and Chorizo
In this easy pasta course, chorizo -- a cured-pork sausage seasoned with chili powder and paprika -- is a lively complement to cooked oysters and a refreshing departure from the smoked bacon commonly paired with them.
- Servings: 4
Source: MSL Cookbook Vol. 2; The New Classics
- 3 tablespoons extra-virgin olive oil
- 4 ounces dried, hot chorizo sausage, thinly sliced into rounds
- 1/4 cup ( 1/2 stick) unsalted butter
- 2 tablespoons all-purpose flour
- 1/2 teaspoon paprika
- 1/4 teaspoon freshly ground white pepper
- Pinch of cayenne pepper
- Coarse salt
- 2 tablespoons sherry
- 1 1/4 cups heavy cream
- 2 dozen shucked fresh oysters
- 8 ounces angel-hair pasta
- 1/4 teaspoon finely grated orange zest
- 2/3 cup strained oyster liquor
Bring a large pot of water to a boil. Meanwhile, heat oil in a large saucepan over medium-high heat. Add chorizo. Cook, stirring, until crisp, about 3 minutes. Transfer to a plate lined with paper towels, and let drain. Wipe out pan.
Melt butter in pan over medium heat. Add flour, spices, and 1 teaspoon salt. Cook, whisking constantly, 3 minutes (do not brown). Add sherry, and cook, whisking, 1 minute. Whisk in cream and oyster liquor. Bring to a simmer, and whisk until thick, about 3 minutes.
Add salt to boiling water; add pasta, and cook until al dente. Drain. Add oysters to sauce; gently poach until just cooked through, 1 to 2 minutes. Add pasta; toss. Divide among plates. Top with chorizo; sprinkle with orange zest.


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text: Let's try a fun little snack cake that's filled with some serious flavors. This recipe is a "healthier" option for a perfect after school snack or even a post workout pick-me-up. The recipe calls for two large apples, so each bite is packed full of Envy Apple love. To give […] Read more


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Folks, @ShaneBlueChief is live streaming an interview on Meerkat at 10pm tonight from @CorkBic Twitter account. RT please?
Absolute TV Gold, folks!!! This will go down with the guy slipping on the ice as epic RTE News coverage!!
Seriously folks. How long does this need to go on? And the world allows these bullies to behave as they want... twitter.com/mintpressnews/…
Really well-done to @QuinoaIreland on their runner-up spot at #SWLimerick today - great idea - I've no doubt it will be a great success!
#corkcoffeeweekend @dukescoffeeco - a "quiet" moment earlier.


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- According to the Star Trek: Star Charts (pp. 72-73) and the Stellar Cartography: The Starfleet Reference Library ("Federation Historical Highlights, 2161-2385"), the Quadros-1 probe is launched.
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Fair Hotel. Close to the beach with easily accessible parking. Excellent rooms with wonderful beds. Delicious food.
Guest Review Highlights
- Great location
- Beach nearby
- Accessible parking
- Rooms could be cleaner
- Could use a good cleaning
- Rooms could be cleaner
- Great room
- Bathroom could be optimized
- Not the best view
- Ordinary amenities


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Schneider, G.; Sebel, P. S.
In clinical practice, indirect and non-specific signs are used for monitoring anaesthetic adequacy. These include haemodynamic, respiratory, muscular and autonomic signs. These measures do not indicate adequacy of anaesthesia in a reliable manner. Many attempts have been made to find a more accurate monitor. Direct monitoring of anaesthetic effect should be possible by EEG measurement. EEG information can be reduced, condensed and simplified, leading to single numbers (spectral edge frequency and median frequency). These methods appear insufficient for assessing anaesthetic adequacy. The bispectral index, derived from bispectral analysis of the EEG, is a very promising tool for measuring adequacy of anaesthesia. An alternative approach is to monitor evoked potentials. Middle latency auditory evoked potentials may be helpful in assessing anaesthetic adequacy. Both techniques need further validation.
© 1997 European Society of Anaesthesiology
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The unadjusted jobless rate in January rose to 4.8% from 4.3% in December, but was below forecasts for 5.1%. The seasonally adjusted rate was flat month-over-month.
The good economic news might be bad news for those hoping for an end to the rate hike cycle. "It's a tough message for the central bank," says economist Carlos Kawall. While the economy doesn't seem to be going onto a very strong path, unemployment is still very low, and wages are still moving up. So it creates a real dilemma for the bank."
Inflation accelerated to 5.91% in 2013 vs. the 4.5% target, and policymakers responded by hiking the benchmark Selic 325 basis points to 10.5%.
EWZ -0.7% premarket
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text:
Electronifying B2B Payments
Giving suppliers access to supply chain finance is helping persuade them to accept payments in electronic formats.
By David McLaughlin, Tom Schoenberg and Gavin Finch, Bloomberg |
May 21, 2015
Fines and penalties to total $5.8 billion.
By Greg Farrell, Bloomberg |
December 11, 2014
State agency looks at algorithms used in forex trading platforms of Deutsche Bank, Barclays.
By Howard Mustoe, Bloomberg |
December 11, 2012
Bank will pay $1.9 bln and enter a deferred prosecution agreement with U.S. Justice Department.
August 16, 2012
Regulators on both sides of the Atlantic irked by the New York Department of Financial Services' conduct.
August 6, 2012
New York investigation looks into financial arrangements between insurance companies and captives.
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text:
Can you say too soon?
Just eleven years ago, the yuppie-tastic adaptation of Bret Easton Ellis' "American Psycho" made its way to the big screen and it seems it's about time for an update.
According to Variety, Lionsgate is eyeing for writer Noble Jones to re-imagine the film.
"American Psycho" was set to the backdrop of the Wall Street boom of the 1980s and follows a wealthy investment banker who moonlights as a homicidal maniac.
It starred...oh, gosh. Who can remember? It's been so long and who knows what that actor is even up to these days.
The project is in its early development but the script is said to explore how the character "would fare in modern day Gotham."
An interesting choice of words...
Who do you think should star in the revamp?
For more, click Variety.
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This beautiful gift tag features a bold poinsettia that is sure to add festive cheer to any gift.
gift tags, poinsettia
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Black Jack Regular
Square Gift Tag
Sep 15 2011
Sep 19 2011
Thanks for the nice comments! Stacey-I took your advice and removed the petal from the back. You're right, that does make the flower on the front the star. Thanks so much!
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text:
Asia's first hydro-electric power station was set up in Karnataka. But that was a century and ten years ago, and that was under the gaze of visionaries like Sir M. Visvesvaraya.
In circa 2011, when politicians and administrators can only see cuts, kickbacks and commissions in every project they undertake (or don't), school children study by candlelight, in Hubli on Tuesday, as the scheduled loadshedding in the State entered the second day.
Meanwhile, the State power minister Shobha Karandlaje has taken the BJP's default position on every issue: blaming her Congress predecessors, blaming the Centre, blaming the Telangana crisis and indeed blaming everybody but herself for the power crisis.
Photographs: Karnataka Photo News
Also read: Nothing romantic about a candlelight newscast
Tags: BJP, Churumuri, Hubli, KPN, Ranganath Bharadwaj, Sans Serif, Shivanasamudra, Shobha Karandlaje, Sir M. Visvesvaraya


text:
We had so much fun making these. The dough was super simple. I don't have a big food processor so I put the hard peppermint candies in a baggie, in another baggie and let my kids smash then to smitherines on the driveway with a hammer!
Then they took turns rolling the dough into the sugar and putting them into the mini muffin pan. Then of course was the fight over who got to put the maraschino cherries in the dough. Serious fun.
I took these to a BBQ and they were a hit. They looked gorgeous and everyone was surprised by the taste of the mint.
The original recipe calls for these with the stems on. I only had enough cherries with stems for about half of them. I don't really think the stems are essential. I got this recipe from Noble Pig and she has amazing photographs. I'm guessing she used a bit more dough for each tassy as she got 48 and I got 60. Plus, if you look at her pictures, her dough goes over the cherry a bit. It depends on the size of the cherrys too. None of this matters. They were delicious and I would totally make them again!!
Cherry Tassies
Adapted from Noble Pig
1 1/4 cups butter, room temperature
2 cups powdered sugar, divided
1 tsp. baking powder
1/2 tsp. salt
1 tsp. peppermint extract
1 tsp. vanilla
1 egg
2 1/2 cups all purpose flour
1/2 cup finely crushed striped peppermint candies (about 18 - 20) You can use a food processor. Or a hammer.
Maraschino cherries with stems, drained
Regular sugar for sprinkling
Generously coat a mini muffin pan with cooking spray. Set aside. In a large bowl, beat butter on medium for about 30 seconds. Gradually, beat in 1 1/2 cups of powdered sugar, baking powder and salt. Beat in peppermint extract, vanilla and egg. Beat in as much of the flour as you can. Using a spoon, stir in any remaining flour and candies.
Place remaining 1/2 cup powdered sugar in a bowl. Shape into 1 in. balls, roll in powdered sugar. Press each ball into bottom and up sides of prepared muffin cups. Place cherry, stem side up, in each cup. Bake about 12 - 14 minutes at 350 or until pastry is browned. Sprinkle lightly with sugar as soon as they are out of the oven. Cool and loosen from pan. The original recipe says it makes 48 but I got 60, apparently I didn't use as much dough.
Total calories = 5060 calories
60 servings = 84 calories per cherry tassy
Other desserts you may enjoy!
Crispy Chocolate Chip Cookies
Peanut Butter Cheesecake Brownies
Calories calculated from calorieking.com. Some numbers are approximate and rounded.


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One of the trademarks of Mike Leach's tenure at Texas Tech has been his willingness to look outside of Texas when recruiting players. With so many talented high school prospects inside the state, c...
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The DK Eyewitness Italy Travel Guide, now available in PDF, is your indispensable guide to this beautiful part of the world. The fully updated guide includes unique cutaways, floorplans and reconstructions of the must-see sites, plus street-by-street maps of all the fascinating cities and towns. The new-look guide is also packed with photographs and illustrations leading you straight to the best attractions on offer. The uniquely visual DK Eyewitness Travel guide will help you to discover everything region-by-region; from local festivals and markets to day trips around the countryside. Detailed listings will guide you to the best hotels, restaurants, bars and shops for all budgets, whilst detailed practical information will help you to get around, whether by train, bus or car. Plus, DK's excellent insider tips and essential local information will help you explore every corner of Italy effortlessly.SAN POLO: Muro an Pizzeria Map 6 E1 Rio TerAn dei Frari 2604, 30125 Tel 041 524 53 10 Closed Thu A branch of the Muro ... CASTELFRANCO: Barbesin anan Regional Italian Via Montebelluna di Salva Rosa 41, 31033 Tel 0423490446 Closedanbsp;...
|DK Eyewitness Travel Guide: Italy
|Dorling Kindersley Ltd - 2014-10-01


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Italian Bagel Sandwich
Total Time
Prep 10 mins
Cook 10 mins
Ingredients Nutrition
- 4 sun-dried tomato bagels
- 1⁄2 lb lean virginia baked ham, thinly sliced
- 4 slices tomatoes
- 4 slices onions
- 4 slices mozzarella cheese
- dried basil
- Slice bagels in half.
- Place 2 to 3 slices of ham on bagel half.
- Top with a slice of tomato and sliced onions.
- Sprinkle with dried basil.
- Top off with a slice of mozzarella cheese.
- Place bagel half open-faced, also places the other half of the bagel alongside it in toaster oven or broiler for about 10 minutes until cheese is melted and sandwich is heated through.
- Sandwiches probably need less time than in toaster oven, so check sandwiches occasionally.
Most Helpful
This was okay but not great. I would definitely use fresh basil leaves next time and even add pizza sauce to give it an added kick.


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A Good Deal: No Evil 022
Round up4.30 / 5.00 2,143 Views
Park Bench
A short film about a park bench4.17 / 5.00 1,662 Views
frog thing
frogggsgsgs3.79 / 5.00 1,918 Views
aaaannnnnnd.. Dismount!
nice, short but right there made it completely worth it
Pretty good.
Im a big fan of the game so i perfectly under stood what you where trying to get at. The only thing i could really say is that the sound wasnt all the best but other then that i was pleased with the result. Keep it up.
Well, I get all my sfx off of Youtube videos, and I just use editing software to remove the background music, so the quality isnt the best
Not bad.
As you said, ended quickly.
But the bonus was beautiful.
I should've had Salvador holding up a "10"
Simple, straightforward... Animation good, but voice over sounded like it was done into a cheap microphone.
PRECISELY! Im completely broke, so I got my mic for like 9 bucks


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Playing Cards: History of the Pack and Explanations of its Many Secrets.
BENHAM, W. Gurney.
• Terms • Ask a Question
Place Published: London
Publisher: Ward, Lock
Date Published: 1931
Description: Profusely illustrated with many in color. 195 pages. Short 4to, pictorial red cloth (rubbed and neatly repaired at spine ends). London: Ward, Lock & Co., (1931). First Edition. Overall a very good copy.Edition: First
Binding: hardcover
Condition: very good
Language: English
Type: Books
Book ID: 214026
By This Author: BENHAM, W. Gurney.
By This Publisher: Ward, Lock


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Gender: Boy
Meaning: Short form of the biblical Shadrach
Origin: Hebrew
Shadd is a Boy name, meaning of the name is Short form of the biblical Shadrach and origin of the name is Hebrew. This name is mostly used in
If you select the name Shadd for your baby, Congratulations! But if you don't like Shadd then please continue searching our site.
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text: I have been on a mission lately: find a good, reliable sushi place on Commercial Drive. Ginger Sushi offers an intimate little space that is welcoming and interestingly decorated. The textured rice paper walls are attractive, imparting a sense of the casual, genuine exotic, rather than the in-your-face "cutesy" kitch that assails the customers at many sushi restaurants. But how... More


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A versatile thread available in a variety of shimmering colours. Anchor Artiste Metallic is soft and easy to work with, perfect for children to handle and for adding a touch of 'sparkle' to any textile project. This high quality, glistening thread is 80% viscose and 20% metallic polyester. It will add a striking touch of colour to any project. Supplied in 25g balls, 100m in length and suitable for a 2mm needle. Pack of 8.


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The World's Greatest Music
Email the show or Text 61812
As Birmingham's iconic venue celebrates a landmark birthday, we take a look at some of the hall's finest moments, from its opening to the many world-class musicians that graced its stage.
Picture 15 of 15
In May 2012 audiences were treated to a very special screening at Symphony Hall Birmingham of the magical 1939 movie The Wizard of OZ, with live accompaniment from the BBC Symphony Orchestra, conducted by John Wilson.
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Frequency conversion by means of Kerr nonlinearity is one of the most common and exploited nonlinear optical processes in the UV, visible, IR, and mid-IR spectral regions. Here we show that wave mixing of an optical field and a terahertz wave can be achieved in diamond, resulting in the frequency conversion of the terahertz radiation either by sum- or difference-frequency generation. In the latter case, we show that this process is phase matched and most efficient in a counterpropagating geometry.
© 2013 Optical Society of AmericaFull Article | PDF Article
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Yummy asian girl tastes his big tool
Duration: 21min 53sec Views: 3 152 Submitted: 4 months ago Submitted by:
Description: We do everything you could have a rest with such HD vids! A yummy asian girl tastes his big solid tool with her sweet silky lips and a playful tongue. The hottie teases and rubs her clit while sucking the dick, and it makes her slit really hot and horny! A minute later we can see how the dude pierces her hot vaginal flesh with his cock and fucks it properly!
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Leadership and Learning
Going to college is more than taking classes. It is about connecting with people and opportunities in and out of the classroom to learn to lead in the world. Northeastern supports student engagement through these areas as well as many others:
- Student Leadership Development
- Civic and Community Engagement
- Career Development Center
- Learning Support Center
The Arts and Cultural Diversity at Northeastern
Enjoy a rich array of social, cultural, educational, and recreational offerings across Northeastern's multiple campuses in Chicago.
Student Union
Located in the heart of our main campus, the Student Union is the center of student involvement. The Union houses food, lounges, meeting rooms, and events. Get your university ID, rent lockers, buy postage stamps, and get discounted tickets for events as well as find lost items at the Information Center. The Union is the scene of lectures, discussions, concerts, dances, meetings, and other activities.
Recreation, Child Care and Wellness Services
A fit body supports a strong mind. Northeastern offers aquatics, fitness classes, sports clubs, intramural sports, and outdoor adventure. Student membership is paid through a tuition fee. Faculty, staff, and community members are invited to become members.
Northeastern ensures you and your family have the resources you need to succeed.
News & Announcements
Social Work programs receive CSWE reaccreditation, candidacy
1 day agoNortheastern Illinois University's Bachelor of Arts in Social Work (BASW) program has received reaccreditation by the Council on Social Work Education's (CSWE) Commission on Accreditation…
Distinguished Alumnus Award winner Thomas White focuses on the journey
4 days agoThomas White doesn't like to talk about plans. He prefers to talk about journeys. Perhaps that should be a surprise coming from a man who recently…
Noteworthy at Northeastern: The Midwest's most diverse
7 days agoIt doesn't matter who crunches the numbers. They all come up with the same result: Northeastern Illinois University is the most diverse institution in the…


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Fernando's Auto Care
Review for Fernando's Auto Care
JILL D. on 06/18/2012
"Tune up - overall safety check"
Fernando's Auto Care is just what I've been searching for! Being a woman, it's hard to find a mechanic who will respect my concerns. Fernando discussed every detail of the services he recommended and showed me evidence of the parts needing replacement in the shop as he worked on my car. I will definitely return for continued maintenance and repairs!
Vehicle: Honda Odyssey
Service Date: 06/16/2012
Review Created: 06/18/2012 09:54 AM


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Xbox 360 Games
Game Questions & Answers (Q&A) service lets you ask questions about video games for game consoles or PC games. So ask your Kinect: Disneyland Adventures question for Xbox 360 and get answers from real gamers or answer questions and share your insights and experience with the rest of the gaming community.
Boxshot & Details
- Developer: Frontier Developments
- Publisher: Microsoft Game Studios
- Genre: Action Adventure
- Release: Nov 15, 2011
- ESRB: Everyone 10+
Question & Answers
Can't collect all of ariel's doddlehopper's (forks)
I am stuck on finding nemo level 2 - everytime I plat it, I only get 3-4 forks. Is there a way to get them, without doing the attraction?
Answer from: nevie
Can you skip the arials attraction dinglehoppers
Answer this QuestionAsk / All Questions »
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Is Cheniere Energy, Inc. (:LNG) ready to lock in early pre-market gains? The stock is gapping higher before market open, indicating low risk for the upcoming session. Will the stock hold onto the upward movement today? Investors will be taking close notice. The shares are currently gapping 4.90% pricing at $40.85.
A gap is a change in price levels of a stock between the close of one session and the opening of the next one. Gaps happen for both fundamental and technical factors. If a company's earnings, for example, are much greater than previously expected, their stock might gap up the next trading session, opening higher than it closed the day before, leaving a gap.
Investors who partake in gap trading use a simple, disciplined approach to buying and selling stocks. Gap traders find stocks that have a price gap from the previous close and then watch the first hour or so of trading in order to identify what the trading range is. If the stock rises above the range then a buy is signaled, and a sell if it falls below.
Cheniere Energy, Inc. (:LNG) stands 1.46% away from its 50-day simple moving average and also 6.87% away from the 200-day average. Recently, the commodity stands -15.48% away from the 52-week high and 79.17% from the 52-week low. The RSI (Relative Strength Index), an indicator that shows price strength by comparing upward and downward close-to-close movements is 59.41.
Cheniere Energy, Inc. (:LNG)'s performance this year to date is 4.62%. The stock has performed -2.16% over the last seven days, 0.57% over the last thirty, and -10.39% over the last three months. Over the last six months, Cheniere Energy, Inc.'s stock has been 20.87% and -18.04% for the year.


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Having undesirable fat in various areas of your body can have a significant impact on your health and self-esteem. While conventional weight reduction through workout and diet plan is a great method to reduce weight in general, even the very best workouts can't target problem areas like the tummy, inner thighs, arms, and buttocks. Liposuction is a time tested treatment that is utilized to get rid of excess fat from specific locations of the body, permitting a specific to shape and contour their body to their preference. Is liposuction right for you? Learn now.
Pros of Liposuction
There are lots of advantages to this cosmetic treatment, consisting of:
• Immediately noticeable modifications. Unlike standard weight reduction, liposuction creates modifications that are immediately noticeable in the body. Some distinction is noticeable right away, and the desired outcomes are normally achieved in just a few days.
• Proven and safe. This cosmetic procedure has actually been carried out by seasoned surgeons all over the world for several years and the technique has actually been improved over and once again to be safe and reliable.
• Healing time is usually quickly. The downtime required after having this kind of procedure is typically much less than what is needed for other kinds of cosmetic treatments, including tummy tucks, breast reduction, and more. People who have had the treatment can typically go back to work much more quickly than they expected and can get back to living a healthy, active way of life.
• Weight-loss can be long-term. With the right maintenance techniques, the fat that was eliminated throughout the liposuction procedure will not return.
• Complete control over your physique. With liposuction, a person can have complete control over how they want to look, beyond exactly what traditional diet and workout can provide. Giving individuals this power over their bodies increases self-esteem and assistance people feel their very best.
While there many benefits to liposuction, there are naturally a couple of caveats that should be taken into consideration prior to making the decision to move forward with the treatment.
Cons of Liposuction
Prior to having actually liposuction done, it is necessary to examine the possible disadvantages of the procedure and figure out if the benefits outweigh the dangers in your particular case. Your specialist can help you find out more about the risks associated with the treatment and can assist you decide if progressing is the right thing for you.
• Complications with basic anesthesia. Since liposuction is carried out under general anesthesia, the procedure brings the exact same threats as any other type of surgical treatment where general anesthesia is utilized. Hidden medical conditions may increase these risks.
• Adverse responses. Bruising, bleeding, and pain are all to be anticipated, nevertheless, in unusual cases can cause more considerable problems.
• The possible to gain the weight back. After having liposuction done, it is vital to keep a healthy diet and workout appropriately as advised by your physician. Failure to do so could result in acquiring back the weight that was lost or possibly a lot more.
Although there are risks associated with liposuction, for many individuals, the advantages far outweigh them. Educate yourself about the procedure by having in-depth conversations with your cosmetic surgeon and consider how liposuction has the prospective to affect you as a special individual. Only you and your specialist can figure out if liposuction will supply you with the results you are searching for within your expectations.
Laser Liposuction procedure is a new non invasive procedure to loose unwanted bodyfat in San Martin California
Laser liposuction is a newer, minimally intrusive procedure that involves heating the fat cells to melting point and getting rid of the melted fat through a small cannula. The procedure is typically done right in your doctor's workplace and is an exceptional option for people who have less than 500 ml of fat to eliminate from any one location. Laser liposuction can be a safe, complementary procedure to weight-loss in order to shape the body you've always wanted.
Contact a Surgeon in your San Martin California today.
If you're considering liposuction as a weight-loss solution, it is necessary that you discuss your desires with a qualified plastic surgeon in your area. Your specialist will perform a complete exam and health history survey to identify if liposuction can benefit you and help you reach your physical and psychological goals. Call today for an examination and find out more about how liposuction can help you attain the body of your dreams.


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Northbrook Gardens Apartments in Kansas City, MO
Located at 1917 NE 49th St, Kansas City, MO 64118
1917 NE 49th St, Kansas City, MO 64118
Northbrook Gardens offers 1 bedroom apartments and 2 and 3 bedroom townhomes for rent in Kansas City - making it and easy choice for your living needs. Apartments have big floor plans. Washer and d... More
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Is a car required to access this attraction?
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Is this attraction exciting, unusual, or risky to visit?
Does this attraction require above average amounts of physical activity (long walks, climbs, stairs or hikes)?
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We were picked up by Beno from our cruise ship. Beno was fantastic, very knowledgeable about his country, the area & the wonderful natural surroundings.
We really couldn't...
read more
We were picked up by Beno from our cruise ship. Beno was fantastic, very knowledgeable about his country, the area & the wonderful natural surroundings.
We really couldn't recommend Beno highly enough, he was fantastic & made our trip to Dominica very special.
We met Beno outside the cruise terminal and he took us and other passengers on a 2 hour tour through the town and botanical gardens and up to the water falls. He drove safely and was very informative. At the waterfall we went on a short hike to see the hot and cold waterfalls. We could have taken a plunge...
We found Beno through Trip advisor. We had a great day with him. He knows a lot about the island and is a very friendly guy. If you go to Dominica, book a tour with Beno!
We came across Beno through Cruise Critic and then read great reviews about him on Trip Advisor. We were so happy he was still available, as we contacted him a week before our day of arrival. We originally booked a private tour for my husband, my son and I to visit Titou Gorge, Trifalgar Falls and Champagne Beach. A couple...
Beno took us on a private tour of the island during our honeymoon. The island was beautiful through his eyes. There is a lot of damage from a recent hurricane so out original tour changed - but Beno had great alternatives and we didn't feel shortchanged at all.
We saw Emerald Pool, fruit stand with so many choices of fruit...
My wife and I spent the most enjoyable day of our cruise via a private tour of Dominica with Beno. Beno is very friendly, (he seems to know everyone on the island), knowledgeable and delivers what he promises.
Beno showed us that Dominica is an unspoiled gem of the Caribbean with breathtaking scenery. If you are prepared to take a...
Our group of four booked a private tour with Beno for our first visit to Dominica. He promptly picked us up at the port. Beno was polite, friendly and knowledgeable about the island. He took us everywhere we wanted to go including: the rainforest, Emerald Falls/Pool, Mr. Nice's fruit stand (lot's of fun), and Trafalgar Falls. We ate lunch at...
I recently visited Dominica as one of the Islands on a Thomson Celebration Cruise. When we got off the ship we found Beno. We could not have found anyone better to show us the Island. Beno has vast knowledge of the Island and it was very interesting learning about the Island. The van is air conditioned and Beno takes a...
I do believe Beno was very nice, and he knew so much about his beautiful island. DOMINICA is gorgeous. He drove my husband and I all over the island but it was a bit pricey... but it was a private tour for 2. We absolutely LOVED Champagne Reef, and this is a must see!! We have snorkeled in lots of...
Beno is a fantastic tour guide. Friendly,great driver,very knowledgeable and always on time. Keep up the good work. I definitely recommend him.
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THIS IS A DIRECTORY PAGE. Britannica does not currently have an article on this topic.
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discussed in biography
...himself kept from figures, he welcomed the opportunity offered by Prospero." Two pictures by Caravaggio survive with a provenance that links them to the Cesari workshop: Boy with a Basket of Fruit and Self-Portrait as Bacchus (also called Sick Bacchus). Both were expropriated from Cesari by Scipione...


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PechaKucha was devised in Tokyo in February 2003. Drawing its name from the Japanese term for the sound of "chit chat", it rests on a presentation format that is based on a simple idea: 20 images x 20 seconds. It's a format that makes presentations concise, and keeps things moving at a rapid pace.
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Burlington's Sami Harb remained unbeaten after third-day play on Wednesday (April 24) at the 2013 Canadian Junior Racquetball Championships.
Playing at Cedar Springs Health and Racquet Club in Burlington, Harb defeated Connor Culhane of Coquitlam, B.C., 15-13, 15-6 in the Boys 18 and Under Singles.
Annie Fisher of Burlington remained in contention in the Girls Singles 14 and Under, defeating Jessica Leduc of Valleyfield, Que., 15-4, 15-0. But in the Girls Singles 16 and Under, she lost to Danielle Drury of Saskatoon, 15-6, 17-15. In the same division, Burlington's Callie Hunter lost to Michele Morissette of Baie Comeau, Que., 15-1, 15-1.
Hunter also fell to McKenzie Brayley of Calgary, 15-12, 15-6, in the Girls Singles 18 and Under.
In other play, both Coby Iwaasa of Lethbridge, Alta. and Morissette remain on track to defend their Canadian Junior titles. Iwaasa and Morissette won the U16 and U18 titles last and are trying to repeat in those divisions this year.
In U16, Iwaasa defeated Tanner Prentice of Macrorie, Sask., 15-6, 15-3. He didn't play in U18 on Wednesday. Similarly, Morissette defeated Callie Hunter of Burlington, Ont., 15-1, 15-1, in Girl's U16, and didn't play in U18 on Wednesday.
Players are competing for national junior championships as well as spots on the Canadian Junior National Team that will compete at the 2013 World Junior Racquetball Championships in Sucre, Bolivia in October.
Players in the boys and girls 14 & under, 16 & under and 18 & under divisions can qualify for the team by being one of the two finalists in their division.