text:
Elect IT: Technology and the Democratic Process
On Election Day 2008, Americans will head en masse to the polls to cast their ballots in an undoubtedly historic election. But what the average voter might not realize is this election is historic in more ways than one.
Not only has information technology enabled voters to have more access to information about the candidates and the electoral process, but it's never been easier for people to participate in the process, as the Internet has helped break down barriers to both transparency and accessibility.
"People expect to get the information they want with a quick Web search, and as more people experience the power of having information at their fingertips, it will be increasingly difficult for the government to keep any of its information behind closed doors," said Daniel Newman, executive director and co-founder of MAPLight.org, a nonprofit, nonpartisan organization that works to show the public the connection between money and politics.
IT has opened those doors, as voters have better access to candidates' views and finances, as well as a clearer understanding of how to register, where to vote and what's on the ballot.
Improving Transparency
In prior years, public government information was held captive, available only to those who could afford to pay a fee.
"Government agencies would often make their data sets available only in bulk on big computer tapes," Newman explained. That meant it was practical only for large database companies to load these tapes onto their computers and sell access by the hour back…
Please log in or subscribe to read this article


text:
Youth Development
"Recognizing the high rate of teenage pregnancy, I formed an after-school girls group where they could openly discuss self-esteem, good communication, and personal values. Topics were combined with crafts, cooking classes, and field trips. With their newly acquired skills and self-respect, these students are now better equipped to stand up to peer pressure and avoid risky behavior."
Kristen CummingsVolunteer in Peru
Volunteers work with at-risk youth ages 10 to 25, helping communities develop programs to assist young people.
Depending on your specific assignment, you might:
- Support the development of life skills through healthy lifestyles training, including HIV/AIDS awareness, reproductive health, and nutrition
- Prepare youth for the world of work through financial literacy, employability skills, and career planning
- Engage youth as active citizens through service learning and civic involvement
- Work with parents, teachers, and community organizations to support youth development
How do I qualify?
Applicants must have an associate degree and one year of full-time counseling experience with at-risk youth;
OR five years of relevant full-time work experience;
OR a bachelor's degree in any discipline with six consecutive months of full-time experience;
OR a master's of social work;
OR be a licensed social worker with youth experience. All experience must be relevant, as described in the next column.
Applicants must have at least six months of full-time work experience teaching or counseling in at-risk youth programs. Other qualifying experience includes full-time work in one or more of the following categories: youth; conflict resolution or mediation skills; HIV/ AIDS counseling or awareness training; coaching or working with physically or mentally disabled youth; or with national and community service programs.
How will this advance my career?
Through serving as a Peace Corps Volunteer, you can gain fluency in a foreign language, international experience, and cross-cultural understanding, attributes that are highly sought-after assets in today's global economy. Experience as a Peace Corps Volunteer working with at-risk youth is valued by numerous organizations, including the U.S. Agency for International Development, the U.S. Department of Health and Human Services, and many private companies and nongovernmental organizations seeking individuals with unique skills. Find out how returned Peace Corps Volunteers receive advantages in federal employment.
Also See: Volunteer Benefits
Last updated Jan 30 2014

subset: commoncrawl


text:
Special Offer
All right gentlemen, listen up.
The list of women in your life who we want to hear about is pretty damn short. Theres your mom, your sister (if you have one), and well, thats about it. So next time you feel tempted to talk about your former flame, do us all a favor and shut it...and for God's sake, never utter any of the phrases below.
1. "She was wild and crazy...if you know what I mean."
The last thing any girl wants to picture is you doing the nasty with a Lady Gaga clone in the bedroom. If you want to encourage us to be bolder, just ask.
2. She used to model" or "She was a butterface."
Your exs hotness (or lack of) is a touchy issue: If we find out she was fugly, we wonder why you couldn't get a hotter chick until now. If you admit she was gorgeous, it makes us insecure about how we stack up. The best possible way to describe how attractive an ex was is to shrug your shoulders and say, "She was all right." The indifference satisfies us (at least until we stalk your old Facebook photos).
3. "She's fluent in four languages and is working on her second book. I don't know how she does it all, what with being a Yale med student too..."
Geez. And here we thought our monthly book club made us interesting. Any time we hear about another woman who can do it all (and is a freakin' genius to boot!), it makes us question our own successes and worldly attributes.
The Hot List
Must Reads
From Our Partners


text:
Army to close wounded warrior unitsPosted on 06.09.09 by R. Lee Wrights
Source: MSNBC
"The Army plans to reduce the size of some of its 36 wounded warrior units by the end of the month and close three by October after tightening standards to stem a flood of patients, a spokesman said Tuesday. The warrior transition units were created in 2007 to address reports of substandard care for wounded, ill and injured soldiers. The number of soldiers in these units has dropped from a high of more than 12,000 last June to about 9,500 currently as the Army screened patients more closely." (06/09/09)
Link: http://www.msnbc.msn.com/id/31189985/
Filed under: RRND News | Report Bad Link
Bookmark this post in Furl or Del.icio.us


text:
YOU MAAAAAAD *Cam'ron voice" …
Comment posted [Video] Evelyn Lozada Appears On Iyanla Vanzant's 'Fix My Life' [Updated Part 1 & 2] by Mimi.
YOU MAAAAAAD *Cam'ron voice"
Mimi also commented
- And I can never understand why people are in their feelings about anonymous post. You must be a part of their bitter biddy club.
- You hoes hated Evelyn just weeks ago now you can relate to her? If that ain't the definition of self-hate. You all need therapy…talk that *** out with a Pastor or something.
- Not ashamed at all. I like to see how worked up you bitter old birds can get.
- Just like you AZZsumed Chad hates himself because he married Evelyn right. Please go die now. And I'm 10 1/2 hoe. YOU MAAAAAAD!
- You hoes are pitiful. Why because a man chooses to date a fair skin women does it have to mean he hates himself. My father is the darkest of dark, my mother is very fair and I'm somewhere in the middle. Does my father hate himself? Did he send a wrong message to me because he married my mother? I sure can't tell. The only people worried about complexion are bitter Black women.
Recent comments by Mimi
- Miguel's Girlfriend Shows Off Engagement Ring [Updated]
Naw at first glance (without reading the commentary) the educated guess could tell that's a infinity symbol. Don't defend stupidity.
WRONG AND STRONG. *In my Trini accent*
- The Game Wants Cheating Legalized, Says 'Every Man Cheats'
Comment of the year goes to @Werd *cues round of applause*
- Fabolous: 'I Don't Think Marriage Is In The Future For Me'
They say a man knows within the first year if he wants to marry you or not. This whole waiting around 1000 years is a red flag is my opinion. I do think men want to get married as much as women. The difference is men have to be 100% sold on a women. Women on the other hand settle a lot more often.
- Ciara Performs On Jimmy Kimmel Live!, Celebrates 27th Birthday With Private Bash
She looks stunning.
- Donald Trump Requests President Obama To Release His College Records And Passport Application
He is soooooooo annoying. Why does his political opinion even hold any clout??? Let's see your school records Donald…or as I like to call him WIG *Nene Leakes voice*.
Just come out and say you hate his black *** and get it over with. I respect it more than this tired old reaching antics!
powered by SEO Super Comments


text:
(Slide 1 of 24)
Start at the beginning |
View recipes as list
« Previous | Next »
Looking for a vegetarian option for your next cookout? This grilled eggplant and portobello sandwich is our answer. For extra flavor, we top it with slices of garden-fresh
tomato and spicy arugula. Serve with a mixed green salad.
Recipe: Grilled Eggplant & Portobello Sandwich
Vote Now! | More Polls | Comments
© 2014 Eating Well, Inc.
6221 Shelburne Road
Suite 100
Shelburne, VT 05482, USA
© Copyright 2014, Meredith Corporation. All Rights Reserved | By using this site, you agree to our Terms of Service.


text:
Small Claims Arbitrator Volunteers
With the consent of the parties, a volunteer Arbitrator hears and decides everyday New Yorkers' Small Claims disputes. Cases are interesting and fun.
Attorneys interested must be admitted to the bar at least five years* and complete training consisting of a two-hour class (in which you earn 2 free CLE credits), plus one or two evenings observing an experienced arbitrator. Once you have completed the training, you will be sworn in and may choose where and how often you would like to sit throughout the year. Join the over 2300 Small Claims Arbitrators in New York City who preside over 95% of the cases heard in the Small Claims court.
In addition, the Association of Small Claims Arbitrators bar offers approximately four additional CLE classes throughout each year to its members who are current with their annual $50.00 membership fee. Past topics have included Bailments and License to Park, Tariffs and the Montreal Protocol, Creative Legal Writing, and Ethics classes.
For more information, contact Joseph A. J. Gebbia, Director of the Association of Small Claims Arbitrators, at: email@example.com
* 2 years admitted for Court Attorneys - Atty General - Corporation Counsel
Upcoming Events
Register for all classes by contacting the Executive Director of the Association of Small Claims Arbitrators, Joseph A. J. Gebbia at: email@example.com
High Tech Legal Ethics 2.0 ;
Understanding How Nano-size Arbitrations Can Lead to Mega-size Attorney Misconduct (2 CLE Credits)
Presented by Pery D. Krinsky, Esq., KRINSKY PLLC
(Free to Association of Arbitrators Members, Non-members $25)
March 6th, 2014, 6 PM - 8 PM
New York City Civil Court
111 Centre Street, Room 325
New York, N.Y. 10013


text:
Photos: Meet the newest member of the Cowboys — Kyle Wilber
With their first pick of the fourth round and the 113th overall choice, the Cowboys drafted outside linebacker Kyle Wilber on Saturday.
Wilber, who played at Wake Forest, is a 6-4, 249-pound defender. He collected 3.5 sacks last season for the Demon Deacons and finished second on the team with a career-high 70 tackles. Wilber will join a rotation of outside linebackers that includes DeMarcus Ware , Anthony Spencer, Victor Butler , and Alex Albright.
Photo: AP


text:
Show items that are
Shop for Global Furniture USA Furniture at Comfy Couch Company in Columbus, OH.
Prices subject to home office audit & correction.
Comfy Couch Co.
4056 Morse RD
Columbus, OH 43230
Phone: 614-416-8872
Comfy Couch Co. Outlet
6845 Commerce Court Drive
Blacklick, OH 43004
Phone: 614-655-5830
Comfy Couch Co. features a large selection of quality living room, bedroom, dining room, home office, and entertainment furniture as well as mattresses, home decor and accessories. Comfy Couch Co. has a store location in Columbus, OH. Comfy Couch Co. serves the surrounding areas of Albany, Alexandria, Amanda, Ashland, Ashville, Baltimore, Bellefontaine, Bellville, Blacklick, Bladenburg, Bloomburg, Brice, Brinkhaven , Broadway, Brownsville, Buckeye Lake, Bucyrus, Butler, Canal Winchester, Cardington, Carroll, Celina, Centerburg, Centerburg, Chillicothe, Cincinnati, Circleville, Clarksburg, Columbus, Commercial Point, Crooksville, Croton, Dayton, Delaware, Dresden, Dublin, East Liberty, Etna, Franklin Furnace, Frazeyburg, Gahanna, Galena, Galloway, Gambier, Granville, Gratiot, Grove City, Groveport, Heath, Hebron, Hilliard, Hopewell, Jackson, Jackstown, Johnstown, Kenton, Kirkersville, Lancaster, Laurelville, Lewis Center, Lithopolis, Logan, London, Mansfield, Marengo, Marion, Marysville, Marysville, Millersport, Mount Gilead, Mount Vernon, New Albany, New Holland, Newark, Orient, Orient, Ostrander, Pataskala, Pickerington, Plain City, Powell, Prospect, Reynoldsburg, Rushsylvania, Shelby, Somerset, Springboro, Springfield, Sunbury, Thornville, Utica, Waldo, Washington Court House, Washington Court House, Waynesville, West Jefferson, West Lafayette, West Liberty, Westerville, and Zanesville. If you're looking for the perfect furniture to suit your needs as well as your lifestyle, stop by Comfy Couch Co. in Columbus, OH today!
Design and Development: MicroD Inc.
Website Powered by ePiphany


text:
Oct 26
Exact Editions
Welcome to the Tumblr of Exact Editions. Here we share with you a little selection from some of the magazines that work with us.
Exact Editions works with the world's most prestigious magazine and newspaper brands, enabling them to mobilise and monetise their products online and via the App Store.
The Exact Editions digital platform offers a range of services to publishers: Universal Subscriptions, apps branded for specific magazines, free apps in iTunes, e-commerce solutions and free open publications, as required.
Since its inception in 2005, Exact Editions has consistently been at the forefront of digital publishing development. Its headquarters are in London, UK.
- nicolas3298 reblogged this from exacteditions
- exacteditions posted this


text:
|Dermatologic Applications of Photodynamic Therapy
|Medical Policy
|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/1:2013
|Return to Medical Policy Index
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
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 photosenitizing 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 accumulates 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) generates reactive oxygen species that are cytotoxic, ultimately destroying the lesion. 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. 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 > 80% in fair-skinned people over the age of 60. In some cases actinic keratosis may progress to squamous cell carcinoma. 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 squamous cell carcinoma (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.
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.
Photodynamic therapy may be considered medically necessary as a treatment of:
Non-hyperkeratotic actinic keratoses of the face and scalp.
Superficial basal cell skin cancer only when surgery and radiation are contraindicated.
Bowen's disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated.
Photodynamic therapy is considered investigational for other dermatologic applications, including, but not limited to, acne vulgaris, non-superficial basal cell carcinomas, hidradenitis suppurativa, or mycoses.
Photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications is considered not medically necessary.
Policy Guidelines
Surgery or radiation is the preferred treatment for superficial basal cell cancer and Bowen's disease (see Rationale). If photodynamic therapy is selected for these indications because of contraindications to surgery or radiation, patients and physicians need to be aware that it may have a lower cure rate in comparison with surgery or radiation.
In 2002, a CPT code was introduced to specifically describe photodynamic therapy for actinic keratoses:
96567: Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.g., lip) by activation of photosensitive drug(s), each phototherapy exposure session.
While ICD-9 code 702.0 specifically describes actinic keratoses, it does not designate their location.
In 2002, a HCPCS J code was introduced to describe the 5-aminolevulinic acid:
J7308: Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (354 mg)
In 2011, a HCPCS J code was introduced for Metvixia®:
J7309: Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 gram
Photodynamic therapy typically involves two office visits: one to apply the topical ALA and a second visit to expose the patient to blue light. The second physician office visit, performed solely to administer blue light, should not warrant a separate Evaluation and Management CPT code. Photodynamic protocols typically involve two treatments spaced a week apart; more than one treatment series may be required.
Benefit Application
BlueCard/National Account Issues
Plans that have contract language regarding medical necessity that includes criteria regarding cost effectiveness may wish to consider the relative cost effectiveness of photodynamic therapy compared to other equally effective nonsurgical treatments. Photodynamic therapy has not been shown to be more effective for the treatment of actinic keratosis or superficial basal cell carcinoma than other non-surgical treatments. Compared with cryotherapy, cosmetic outcomes and patient tolerance may be improved. Photodynamic therapy may result in better clearance and cosmetic outcomes in comparison with cryotherapy or topical 5-fluorouracil for the treatment of Bowen's disease.
The policy was created in 2001 and was updated regularly with searches of the MEDLINE database. The most recent literature search was for the period December 2011 through November 2012. Key literature is described below and focused on studies evaluating FDA-approved photosensitizing agents.
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 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 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.
A 2012 randomized pilot study from Spain compared PDT using methyl aminolevulinate (MAL) alone, imiquimod alone, and the combination of the 2 treatments. (6) Patients with non-hyperkeratonic actinic keratoses were randomly assigned to 1 of 3 groups: 1) 1 session of PDT with MAL (n=40): 2) self-administered imiquimod 5% cream for 4 weeks (n=33); or 3) PDT, as above, followed by 4 weeks of imiquimod cream (n=32). Follow-up occurred 1 month after PDT (group 1) or 1 month after the end of treatment with imiquimod (groups 2 and 3). The primary outcome measure, complete clinical response, was defined as the total absence of actinic keratoses by visual evaluation and palpation. Complete clinical response was achieved by 4 (10%) of patients in group 1, 9 (27%) of patients in group 2, and 12 (37.5%) of patients in group 3. There was a statistically significantly higher rate of complete response in the PDT plus imiquimod group compared to PDT only (p=0.004). A limitation of the study was that the PDT-only group was followed for a shorter amount of time, which could at least partially explain the lower rate of complete response.
Conclusions: Evidence from multiple RCTs has found that PDT improves the net health outcome in patients with hyperkeratotic actinic keratoses on the face or scalp compared to placebo or cryotherapy. One trial reported superior outcomes with a combination of photosensitizing agents compared to a single agent. However, this was a preliminary study and the superiority of combined treatment compared to PDT alone would need to be confirmed in larger numbers of patients followed for similar amounts of time.
Basal Cell Carcinoma (BCC)
A 2007 Cochrane review evaluated surgical, destructive (including PDT), and chemical interventions for basal cell carcinoma. (7) 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 2012 systematic review by Roozeboom and colleagues examined randomized and non-randomized trials evaluating treatments for superficial basal cell carcinoma. (8) A total of 16 studies were identified that evaluated PDT for treating BCC; 6 of the studies were RCTs. There was significant heterogeneity among studies (p<0.0001). A pooled estimate of complete response after treatment with PDT in 13 studies (PDT arms only) was 79% (95% confidence interval [CI]: 71% to 87%). In 3 studies that compared illumination regimens, only 1 arm was included, and in 2 studies that compared PDT agents, both arms were included.
A representative RCT was published in 2008 by Szeimies and colleagues. (9) This was an industry-sponsored multicenter open trial comparing MAL-PDT with surgery for small (8–20 mm) superficial BCC in 196 patients. 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.
Another trial, published in 2008 by Basset-Sequin and colleagues, compared PDT with cryotherapy for superficial BCC. (10) 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.
Conclusions: A Cochrane review of RCTs concluded that surgery and radiotherapy are the most effective treatments for patients with BCC. RCTs have found not found statistically significant differences in the clinical response rate with PDT compared to cryotherapy. This suggests, but does not conclusively demonstrate, similar efficacy. In addition, cosmetic outcomes have been better after PDT compared to cryotherapy.
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. (11) 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. (12, 13) 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). (14) 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. Overall, the clinical response rate at 6 months, the primary outcome, was 55 of 77 (73%) after MAL-PDT and 20 of 75 (27%) after placebo. (P values were not reported for any of the outcomes). Response rates were higher in smaller lesions (<10mm diameter) than larger lesions (10-20 mm) in both groups. 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. (15) 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.
Conclusions: An RCT found a higher response rate after PDT compared to placebo, but also a higher rate of adverse effects, suggesting that PDT may not improve the net health outcome for patients with nodular BCC. Other RCTs have found similar initial clinical benefits with surgery and PDT in patients with nodular BCC, but recurrence rates have been higher after PDT. One observational study found a higher rate of recurrence in patients with nodular BCC treated with PDT than patients with superficial BCC who had been treated with PDT. Overall, the evidence is insufficient for demonstrating that PDT improves the net health outcome for patients with nodular BCC.
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-fluorouracil (5-FU) or MAL therapy. (16) 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%). (17) 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.
Conclusions: RCTs have found that PDT has similar or higher efficacy compared to cryotherapy and 5-FU for patients with Bowen's disease. In addition, adverse effects/cosmetic outcomes appeared to be better after PDT. There is a lack of RCTs comparing PDT to surgery or radiotherapy in patients with Bowen's disease; as a result, conclusions cannot be drawn about PDT compared to these other treatments.
Literature on the use of PDT for acne consists of several small (n=25 or fewer per group) randomized controlled trials (RCTs) from outside of the United States. Studies varied in the comparison intervention used and several evaluated combined treatments. Moreover, some studies reported significant adverse effects associated with PDT treatment. For example, a 2006 study by Wiegell and colleagues in Denmark evaluated patients 12 weeks after MAL-PDT (n=21) or a control group (n=15). (18) There was a 68% reduction from baseline in inflammatory lesions in the treatment group and no change in the control group (p=00.23). However, all patients experienced moderate to severe pain after treatment and 7 of 21 in the treatment group (33% did not receive the second treatment due to pain.
Several split-face studies have been conducted. A 2010 single-blind RCT, for example, included 44 patients with facial acne. (19) A randomly selected side of the face received the intervention (combined treatment with topical 5-ALA and a pulsed dye laser) 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.
In 2012, Shaaban and colleagues in Egypt conducted a split-face study that included 30 patients with inflammatory and nodulocystic acne. (20) In each patient, the right side was treated with a monthly session of ALA-PDT plus intense pulsed-light (IPL) treatment, and the left side was treated with IPL only. From baseline to the 1-month follow-up, the mean count of facial acne lesions decreased from 9.55 (standard deviation [SD]: 1.1) to 2.1 (SD: 1.68) in the combined treatment group and from 9.8 (SD: 4.8) to 5.01 (SD: 1.7) in the IPL-only group. The difference in lesion count between groups was statistically significant. Limitations of the study were that it was not randomized and did not include a group that received PDT as the sole intervention.
Conclusions: There are several small RCTs and non-randomized controlled studies evaluating PDT for treating acne; most have been performed outside of the United States. The studies have varied in the comparison intervention used and several evaluated combined treatments. Moreover, some studies reported significant adverse effects associated with PDT treatment. There remains insufficient evidence to draw conclusions about the effect of PDT on the net health outcome in patients with acne.
Other dermatological indications
No controlled studies using FDA-approved photosensitizing agents were identified on PDT therapy for other dermatologic indications. Only case series were identified. Most, such as 2 on hidradenitis suppurativa (21, 22) and one on PDT for patients with interdigital mycoses (23) included fewer than 15 patients each. A large retrospective case series was published in 2011 by Xiao and colleagues in China. (24) 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.
Conclusions: There is insufficient evidence that PDT improves the net health outcome in patients with dermatological conditions other than those discussed in previous sections of the document.
Photodynamic therapy (PDT) 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 basal cell carcinoma (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 investigational 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: "Since cure rates may be lower, superficial therapies should be reserved for those patients where surgery or radiation is contraindicated or impractical…In patients with low-risk shallow cancers, such as SCC in situ (Bowen's disease) or low-risk superficial BCC, topical therapies such as 5-fluorouracil, imiquimod, PDT (MAL, porfimer sodium or topical amino levulinic acid) or vigorous cryotherapy may be considered even though the cure rate may be lower." (25)
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. 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." (26)
The International Society for Photodynamic Therapy in Dermatology published consensus-based guidelines on the use of PDT for non-melanoma skin cancer in 2005. 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. (27)
Medicare National Coverage
Centers for Medicare and Medicaid Services (CMS) coverage policy on treatment of actinic keratosis dated November 26, 2001, notes: "Various options exist on treating actinic keratosis. Clinicians should select an appropriate treatment based on the patient's history, the lesion's characteristics, and the patient's preference for specific treatment….Less commonly performed treatments for actinic keratosis include dermabrasion, excision, chemical peels, laser therapy, and photodynamic therapy....Medicare covers the destruction of actinic keratosis without restrictions based on lesion or patient characteristics." (28)
- Piacquadio DJ, Chen DM, Farber HF et al. Photodynamic therapy with aminolevulinic acid topical solution and visible blue light in the treatment of multiple actinic keratoses of the face and scalp: investigator-blinded, phase 3, multicenter trials. Arch Dermatol 2004; 140(1):41-6.
- Pariser DM, Lowe NJ, Stewart DM et al. Photodynamic therapy with topical methyl aminolevulinate for actinic keratosis: results of a prospective randomized multicenter trial. J Am Acad Dermatol 2003; 48(2):227-32.
- Hauschild A, Stockfleth E, Popp G et al. Optimization of photodynamic therapy with a novel self-adhesive 5-aminolaevulinic acid patch: results of two randomized controlled phase III studies. Br J Dermatol 2009; 160(5):1066-74.
- Morton C, Campbell S, Gupta G et al. Intraindividual, right-left comparison of topical methyl aminolaevulinate-photodynamic therapy and cryotherapy in subjects with actinic keratoses: a multicentre, randomized controlled study. Br J Dermatol 2006; 155(5):1029-36.
- Szeimies RM, Stockfleth E, Popp G et al. Long-term follow-up of photodynamic therapy with a self-adhesive 5-aminolaevulinic acid patch: 12 months data. Br J Dermatol 2010; 162(2):410-4.
- Serra-Guillen C, Nagore E, Hueso L et al. A randomized pilot comparative study of topical methyl aminolevulinate photodynamic therapy versus imiquimod 5% versus sequential application of both therapies in immunocompetent patients with actinic keratosis: clinical and histologic outcomes. J Am Acad Dermatol 2012; 66(4):e131-7.
- Bath-Hextall F, Leonardi-Bee J, Somchand N et al. Interventions for preventing non-melanoma skin cancers in high-risk groups. Cochrane Database Syst Rev 2007; (4):CD005414.
- Roozeboom MH, Arits AH, Nelemans PJ et al. Overall treatment success after treatment of primary superficial basal cell carcinoma: a systematic review and meta-analysis of randomized and nonrandomized trials. Br J Dermatol 2012; 167(4):733-56.
- Szeimies RM, Ibbotson S, Murrell DF et al. A clinical study comparing methyl aminolevulinate photodynamic therapy and surgery in small superficial basal cell carcinoma (8-20 mm), with a 12-month follow-up. J Eur Acad Dermatol Venereol 2008; 22(11):1302-11.
- Basset-Seguin N, Ibbotson SH, Emtestam L et al. Topical methyl aminolaevulinate photodynamic therapy versus cryotherapy for superficial basal cell carcinoma: a 5 year randomized trial. Eur J Dermatol 2008; 18(5):547-53.
- Mosterd K, Thissen MR, Nelemans P et al. Fractionated 5-aminolaevulinic acid-photodynamic therapy vs. surgical excision in the treatment of nodular basal cell carcinoma: results of a randomized controlled trial. Br J Dermatol 2008; 159(4):864-70.
- Rhodes LE, de Rie M, Enstrom Y et al. Photodynamic therapy using topical methyl aminolevulinate vs surgery for nodular basal cell carcinoma: results of a multicenter randomized prospective trial. Arch Dermatol 2004; 140(1):17-23.
- Rhodes LE, de Rie MA, Leifsdottir R et al. Five-year follow-up of a randomized, prospective trial of topical methyl aminolevulinate photodynamic therapy vs surgery for nodular basal cell carcinoma. Arch Dermatol 2007; 143(9):1131-6.
- Foley P, Freeman M, Menter A et al. Photodynamic therapy with methyl aminolevulinate for primary nodular basal cell carcinoma: results of two randomized studies. Int J Dermatol 2009; 48(11):1236-45.
- Lindberg-Larsen R, Solvsten H, Kragballe K. Evaluation of recurrence after photodynamic therapy with topical methylaminolaevulinate for 157 basal cell carcinomas in 90 patients. Acta Derm Venereol 2012; 92(2):144-7.
- Salim A, Leman JA, McColl JH et al. Randomized comparison of photodynamic therapy with topical 5-fluorouracil in Bowen's disease. Br J Dermatol 2003; 148(3):539-43.
- Morton C, Horn M, Leman J et al. Comparison of topical methyl aminolevulinate photodynamic therapy with cryotherapy or Fluorouracil for treatment of squamous cell carcinoma in situ: Results of a multicenter randomized trial. Arch Dermatol 2006; 142(6):729-35.
- Wiegell SR, Wulf HC. Photodynamic therapy of acne vulgaris using methyl aminolaevulinate: a blinded, randomized, controlled trial. Br J Dermatol 2006; 154(5):969-76.
- Orringer JS, Sachs DL, Bailey E et al. Photodynamic therapy for acne vulgaris: a randomized, controlled, split-face clinical trial of topical aminolevulinic acid and pulsed dye laser therapy. J Cosmet Dermatol 2010; 9(1):28-34.
- Shaaban D, Abdel-Samad Z, El-Khalawany M. Photodynamic therapy with intralesional 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: a comparative study. Dermatol Ther 2012; 25(1):86-91.
- Gold M, Bridges TM, Bradshaw VL et al. ALA-PDT and blue light therapy for hidradenitis suppurativa. J Drugs Dermatol 2004; 3(1 Suppl):S32-5.
- Schweiger ES, Riddle CC, Aires DJ. Treatment of hidradenitis suppurativa by photodynamic therapy with aminolevulinic acid: preliminary results. J Drugs Dermatol 2011; 10(4):381-6.
- Calzavara-Pinton PG, Venturini M, Capezzera R et al. Photodynamic therapy of interdigital mycoses of the feet with topical application of 5-aminolevulinic acid. Photodermatol Photoimmunol Photomed 2004; 20(3):144-7.
- Xiao Q, Li Q, Yuan KH et al. Photodynamic therapy of port-wine stains: long-term efficacy and complication in Chinese patients. J Dermatol 2011; 38(12):1146-52.
- National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Version 2.2012. Basal cell and squamous cell skin cancers. Available online at: http://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf. Last accessed December, 2012.
- Morton CA, McKenna KE, Rhodes LE et al. Guidelines for topical photodynamic therapy: update. Br J Dermatol 2008; 159(6):1245-66.
- Braathen LR, Szeimies RM, Basset-Seguin N et al. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus. International Society for Photodynamic Therapy in Dermatology, 2005. J Am Acad Dermatol 2007; 56(1):125-43.
- Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Treatment of Actinic Keratosis (250.4). Available online at: www.cms.gov. Last accessed December, 2012.
|Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.g., lip) by activation of photosensitive drug(s), each phototherapy exposure session
|ICD-9 Procedure
|ICD-9 Diagnosis
|Actinic keratosis (code does not indicate location)
|Other malignant neoplasm of skin code range
|Carcinoma in situ if skin code range (includes Bowen disease)
|Aminolevulinic hydrochloric acid for topical administration, 20%, single unit dosage form (354 mg)
|Methyl aminolevulinate (MAL) for topical administration, 20%, single unit dosage form (354mg)
|ICD-10-CM (effective 10/1/14)
|Actinic Keratosis
|Other malignant neoplasm of skin code range
|Carcinoma in situ of skin code range
|ICD-10-PCS (effective 10/1/14)
|ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.
|Extracorporeal therapies, physiological systems, phototherapy skin, codes for single and multiple
|Type of Service
|Place of Service
|Physician's office
Actinic Keratoses, Photodynamic Therapy
BLU-U Blue Light Photodynamic Therapy
CureLight Broadband
Levulan KeraStick
Metvix, Photodynamic Therapy
Photodynamic Therapy, Actinic Keratoses
Policy History
|Add to Medicine section
|New policy
|Replace policy
|Policy updated; policy statement unchanged, additional reference added
|Replace policy
|Policy revised with literature review update for the period October 1, 2001, to February 2004; policy statement changed to include Metvix therapy (investigational due to lack of FDA approval), also added a statement regarding cosmetic indications for photodynamic therapy. Description and Rationale sections expanded to include discussion of Metvix
|Replace policy
|Literature review update for the period of 2004 through February 2005; policy statement on Metvix therapy changed to may be considered medically necessary. Additional indications of acne vulgaris, mycoses, and hidradenitis suppurativa added to investigational policy statement for Metvix. Added acne and mycoses as an investigational indication for ALA
|Replace policy
|Literature review update; reference number 13 added. Policy statement unchanged
|Replace policy
|Literature review update and expanded discussion of non-melanoma skin cancers; reference numbers 14-21 added. Policy statements revised; may be medically necessary for superficial basal cell carcinoma or Bowen's disease when surgery or radiation is contraindicated. Drug name of Metvix updated to current Metvixia trade name. Title change - "Treatment of Actinic Keratoses and Other Skin Lesions" replaced by "Dermatologic Applications"
|Replace policy
|Literature review update through June 2008; references reordered; reference numbers 17, 19, 22, 24 added; policy statements unchanged
|Replace policy
|Literature review update through October 2009; reference numbers 24 to 29 added; policy statements unchanged.
|Replace policy
|Literature review update through November 2010;
References 28 to 31 added; policy statements unchanged. New HCPCS code for Metvixia added.
|Replace policy
|Literature review update through December 15, 2011. Rationale extensively re-written. References 13, 19, 21 added; other references renumbered or removed. Policy statements unchanged.
|Replace policy
|Literature update through November 2012. References 6, 8, 20 and 25 added; other references renumbered or removed. Policy statements unchanged


text:
A young man, recently returned from the Army goes to Florida with his wife. His wife has a telephone conversation with her mother during which the mother speaks about the young man as though he were mentally deranged but the girl reassures her that she is not afraid. The husband, on the beach, goes for a dip in the ocean with a small girl, who is a guest at the hotel. He seems to get along perfectly with the child. When he gets back to his hotel room, where his wife is asleep, he calmly pulls out a gun and shoots himself.
A Perfect Day For Bananafish
by J. D. Salinger January 31, 1948
J. D. Salinger, Fiction, "A Perfect Day For Bananafish," The New Yorker, January 31, 1948, p. 21
Subscribers have access to the current issue and the complete archive of The New Yorker, back to 1925. Subscribers also can access the current issue on tablets and phones via our digital edition. If you subscribe to the magazine, register now to get access. If you don't, subscribe now.
To search for New Yorker cartoons and covers, please visit our store.


text:
Tampa >Doctors >
Surgeons >Moffitt Moriah R Md
508 S Habana Ave Ste 180, Tampa, FL | Directions 3360927.938809 -82.489014
Call for an appointment
Neighborhoods: Southwest
Sign in with Facebook Sign in with Facebook to see what your friends are up to!
Do you have a review of Moffitt Moriah R Md on your blog? If you include the Citysearch image link (shown below) in your post, we'll automatically link to your review from the business profile page. Here's how our Linkback system works:
The Linkback system is free and automatic. It's really that easy.
To link to our business profile page, copy the html below to your web page.


text:
Just for starters, if you came to this analysis page looking for a good or even decent Chlorophyll sweeper to use on your new Sunny Day team, then you've come to the wrong place. Although Seedot has just enough viability to earn an honest analysis, it should not be considered for any seriously competitive Little Cup team. One look at its horrible base stats should tell you why. The only thing that is keeping this evil acorn from falling back into the abyss of unusable Pokemon is its niche of utilizing Chlorophyll, Growth, and Explosion, a combination which no other Little Cup Pokemon possesses. If you're looking for a Pokemon that would be hilarious to defeat your friend's mediocre Little Cup team with, then look no further, because Seedot is ready to rumble.
The main objective of this set is to find a way to pull off one Growth, then proceed to quite possibly sweep, or just explode when low on health. Even though Seedot has a Life Orb, don't go trying to pounce on anything without setting up with Growth first, as Seedot would likely fail to do significant damage and get smashed in the face. However, after a Growth, its STAB SolarBeam OHKOes or 2HKOes anything that doesn't resist the attack or has huge special bulk. Hidden Power Fire is used to take out the Grass- and Steel-types who resist SolarBeam. Finally, Explosion not only sets Seedot apart from most other Chlorophyll sweepers, but also allows it to deal massive damage when it has no other options. Explosion also allows Seedot to take out a troublesome Pokemon and give a teammate a free switch in. Keep in mind, however, that Explosion should only be used when Seedot is low on health and has acquired a Growth boost, since it no longer halves the opponent's defenses.Team Options & Additional Comments >>>
Other Options
Seedot doesn't have much in terms of other move options. Bullet Seed and Seed Bomb both provide a physical Grass-type STAB which could work with a more physically oriented set, but it does less damage than SolarBeam in most cases. However, if you do decide to go with a purely physical set, Swords Dance should be used over Growth so you don't get screwed over with a lesser boost if the weather happens to change. Nasty Plot could be used in the same vein for a specially attacking set as well. Giga Drain could be used if you want some relief from Life Orb recoil, but with Seedot's poor Special Attack stat, it will rarely be healing itself significantly. Synthesis might seem good on paper, but Seedot is just too frail to put it to good use.
Checks and Counters
Cloud Nine Lickitung and Swablu can both brush off SolarBeam and Hidden Power Fire, but must be wary of a +2 Explosion, as it will put a large dent in their HP. Bulky Flying-types such as Vullaby can handle Seedot with ease most of the time, but, once again, need to watch out for a boosted Explosion. Weather changers such as Snover and Hippopotas also screw over Seedot completely, forcing it to lock itself into charging up SolarBeam while they take it out or phaze it, respectively. The former does need to watch out Hidden Power, though, which will OHKO.


text:
UNCONDITIONAL black stretch drill back zip drop crotch jeans.
UNCONDITIONAL's cotton stretch drill drop crotch signature jeans feature a back zip, and zip-up pockets to the front and back.
Colour : Black.
Care instructions :Wash separately in warm water, iron medium, tumble dry medium, do not bleach.
Non-EEC customers receive 20% VAT reduction on checkout


text:
Information about everything Girl Scouts is available through Girl Scouts of Eastern Missouri's many publications, all of which are available online. Girl Scouts of Eastern Missouri produces a number of publications, listed below along with whom they serve and when they are distributed.
Intended for
All Girl Scout publications are also available for check-out at the Emerson Resource Center at the Girl Scouts of Eastern Missouri Service Center.
For more information on any Girl Scouts of Eastern Missouri publication, please contact the Marketing and Communications Department:
Shari McCormick, Marketing and Communications Assistant
Email: email@example.com
Phone: 314.592.2348
Girl Scouts of Eastern Missouri is a proud United Way member and is supported by the following United Way Agencies: United Way of Greater St. Louis, United Way of the Mark Twain Area, United Way of Adair County/Northeast Missouri, United Way of St. Francois County, Franklin County Area United Way.


text:
I just want to say thank you prophet ahmed for all you have done for me.
He is back now. That very powerful spell caster STOP THE DIVORCE – and get my ex boyfriend back.
My name is Joy Philip, from Canada. I never believed in love
spells or magic until i met this spell caster once when i went for a business summit
early this year. I meant a man who's name is PROPHET AHMED
he is really powerful and could help cast spells to bring back one's gone,
lost, misbehaving lover and magic money spell or spell for a good job or
luck spell .I'm now happy & a living testimony cos the man i had wanted to
marry left me 3 weeks before our wedding and my life was upside down because our
relationship has been on for 3years. I really loved him, but his mother was
against us and he had no good paying job. So when i met this spell caster,i
told him what happened and explained the situation of things to him. At
first i was undecided, skeptical and doubtful, but i just gave it a try.And
in 7 days when i returned to Canada, my boyfriend(now husband) called me by
himself and came to me apologizing that everything had been settled with his
mother and family and he got a new job interview so we should get married. I
didn't believe it cos the spell caster only asked for my name and my
boyfriends name and all i wanted him to do. Well we are happily married now
and we are expecting our little kid, and my husband also got the new job and
our lives became much better.in case you are in any situation you can contact
prophet ahmed at his email email@example.com or his personal cell +2347053375151
Thank you for all your help prophet i promise to share this Testimony to every body in the world wide.
Lenny, just watched the film and it's really cool. I think the best part is how U really let us see your life. This shows how U come up with these amazing songs. I love the album but just knowing how U you came about each song makes it even more incredible! It inspires so many artist (like myself). God has truly blessed U.
I have no doubt that one day our paths will cross and I will get 2 play with U but until then pleez keep the rock funky and the heart on the Son!
One Love
When U gonna release your version of EWFs "Shining Star"? That song is amazing and funky.
DEAR LENNY KRAVITZ : PLEASE CONTACT ME SOON , I NEED THE MONEY I EARNED ...PLEASE HELP ME ...MY BOYS ARE POSSIBLY IN DANGER...WE CAN BE HEARD SINGING AT THE END OF MAXWELL'S PRETTY WINGS , (the part at the end that says momy and I say ahh) our vocals can also be heared layered on GOOD TIME- featuring Owl City & Carly Ray Jepsen...I need your help...hopefully you will see this post...Love Ya... firstname.lastname@example.com 813-504-3847 I posted you a song called: REQUIUM below....Love love love / Beautiful /Love / caramel velveteen / surfer girl / poetess / muese Love, Kenya L. C. Hamilton "K.L."
Dear Lenny Kravitz. I posted a song for you bellow tenta tively titles Requium but you may call it whatever you like...I respect and admire you.... If someone is telling you not to write to me don't listen to them ...they may have alterior motives...or want you for themselves....please pray... God told me that someone in your camp ...is hopeing to keep us apart becous they secretly desire you...I am suffering from sexual harressment... please come scoop me up soon... I can't take this any longer... I have been trying to find you every since we last spoke....but you were busy on tour....I miss you more than words can say...I feel like crying....I have worked so hard and have nothing in my possesion to show for it...even my children are in danger...and I am helpless to help them...please be our hero...please rescue us...I have written so many praises to God and I know God will touch your heart and you will come for me soon...email@example.com 7343 bonita vista way #101 Temple Terrace/Tampa fla, 813-504 3847. Love / beautiful /musewell / shepheard girl/ poetess/KLC Crew love always, Kenya L.C. Hamilon
To Lenny Kravitz, i just thought about something really cool. Do you realise how important you are... I wrote 1000's of songs some as love letters to you others as letters letting you know what type of things I was going through and getting out angst. That means that almost every song you here on the radio ( even christian radio) is either partially a letter to you, letting you know how I'm doing or a love song written to you... that just hit me. I must realy love you more than I have had the time to sit back and realise. Love ya, oh by the way I posted a song here for you, I hate my avatar but it's the best I can do for now with this virus filled computer. Sometimes I want to cry becous I wanted to put up one of my pretty pictures so you would now who this is. Well its me symphony/ love / beautiful / kay/ caramael velveteen/ muezwell ... I hope you read these posts couse thats a top 10 or number 1 song... remember you used to always write to me " Thats a hit ! " . I miss you!! email@example.com Kenya L.C. Hamilton "K.L."
HI LENNY !!! SONG FROM YOUR PROTEGE : I'M PUTTING THIS ONE ON MY VOICE NOTES ON MY PHONE FOR YOU REFERENCE 2-5-13_2156 THIS ONE HAS A ROMANTIC GROOVE LIKE "SUFFOCATE" A SONG I WROTE AS A LOVE LETTER TO YOU...IT STARTS OUT WITH PIANO KEYBOARD AND DRUM, WITH ALSO HUMMING OF THE NOTES. IT ALSO HAS A LAID BACK GROVE LIKE PENNY WITH A WHOLE IN IT.ITS REALY FUNKY !!!!! I WISH YOU COULD HERE WHAT I'M HEARING. YOU MAY WANT TO ADD THIS AS A BONUS TO THE ALBUM YOU ARE WORKING ON. I'M NO LONGER USEING PEN NAMES, SO JUST PUT MY REAL NAME.( BY THE WAY PLEASE COME GET ME SOON. LOVE YA ! :) ) NOTES:IN 4 /4 TIME. B,A,G,E, A-2-3 . B,A,G,E G -2-3 . B,A,G, E, A-2-3 . B,A,G, E G-2-3 (REPEAT) DRUMS THEN ON BEAT OFF BEAT DRUM BEAT ... I KNOW YOU ARE ARE THE ONE FOR ME, YOUR LOVES JUST LIKE POETRY , A REQUIUM THAT GOES, B,YOND SPACE AND TIME. LINE 2: THE BEAT THE RYTHEM AND THE MEASURE. I'VE SEARCHED FOR YOU IN EVERY WHEATHER SNOW, SLEET, HAIL AND THE HOTEST SUNSHINE.LINE 3 : I'VE CAMPED OUT AND WROTE YOU POETRY ,SAT UNDER THE MOON ON THE BEACH. MIAMI IS SO HOT IN JUNE...I EVEN WENT TO PUERTORICO TRYNA MAKE MY WAY TO ELETHURIA ...NO I NEVER EVER FORGOT MY LOVE FOR YOU. CHORUS:YOU ARE THE INSPIRATION ,THE TIME THE BEAT...YOU ARE THE REQUIUM, THE SYMPHONEY. I WANT TO LOVE YOU FOR ETERNITY..I'M THINKIN BOUT OUR ETERNAL LIVES. I WANT TO WAKE UP AND WRITE SYMPHONIES (FOR GOD) THEN POETRY BEFORE WE FALL ASLEEP.YOU ARE MY WORLD ...AND INSPIRE SOLILAQU'ES , EPIC ROMANCES, YOU NAME IT , I THANK GOD FOR YOU. VERSE 2 : YOU ARE THE TAMETER THE LOVE HAIKU. YOU ARE THE INSPIRATION FOR ALL I DO. I'VE BEEN TRYNA BUILD AN EMPIRE FOR YOU. SO WE CAN SHARE THE MELODY OF LOVE, SO COOL. LINE 2 : I'VE LONGED FOR YOU THROUGH NOTES AND DREAMS. EPITAPHS AND POETRY. ALLEGRO, DOWN BEATS ,AND STACATTO, I'LL BE THERE ...YES, I'M YOUR HERO...I'M LONGING TO FUFILL THIS SYMPHONY( OR YOU COULD SAY I'M LONGING TO CREATE THIS SYMPHONY) BRIDGE : I'M YOUR KING AND YOUR MY QUEEN. YOUR MY HEART, MY SYMPHONEY. I'M YOUR REQUIUM ,YOUR MY POETRY.THROUGH SPACE AND TIME, WE'LL LOVE EACH OTHER FOR ALL ETERNITY... THEN CHORUS AGAIN AND THEN A FADE OUT OR GUITAR SOLO ( may b acoustic depending on the mix) p.s. I' m going to go sing this on my voice notes...please come and rescue me from this nightmare I could write for artists on your label "again" if you like. My plan is to write at least one movie and one symphony for God per week. I LOVE YOU... LOVE/ BEAUTIFUL/ SYMPHONY/ SURFER GIRL/ KENYA / CARAMEL VELVETEEN firstname.lastname@example.com 813-504- 3847 7343 bonita vista way apt. 101 temple terrace/ tampa fl. Love ya, LENNY KRAVITZ, YOU ARE THE MOST PROLIFIC, TALENTED AND HANDSOME EVER !!!! GOD BLESS YOU, SINCERLY...KENYA L. C. HAMILTON p.s. Im thinking you maywant to call this one "Requium" or "lovepoetrysymphony" ( by the way I somtimes write under the name muezwell for some...love you always...Kenya
TO LENNY KRAVITZ: I WROTE A MOVIE AND SONG EXCERT FROM THE MOVIE, HOPEING YOU WOULD RECOGNIZE MY WRITTING STYLE AND KNOW THAT IT IS ME ,YOUR PROTEGE THAT HAS WRITTEN INUMEROUS SONGS, ALBUMS. MOVIES , SPEACHES ETC. I TRIED TO SIGN UP FOR INSTA GRAM SO THAT I COULD SEND A PIC ,SO THAT YOU COULD VERIFY MY IDENTITY BUT WHEN I WENT TO SIGN UP THE WEBSITE SAID THAT ONE CAN NOT SIGN UP ON LINE AND THAT I HAVE TO GET SOME SORT OF DOWN LOAD. I AM NOT COMPUTER SAVY AND I HAVE A VERY OLD COMPUTER AND PHONE. I AM DEALING WITH A LOT RIGHT NOW AND HAVE BEEN , AND I REALY NEED YOUR HELP. I THOUGHT IF I WOTE YOU A MOVIE THAT YOU WOULD RECOGNISE THAT IT IS ME. I DON'T WANT TO GET INTO THE DETAILS OF WHAT IS GOING ON IN MY LIFE RIGHT NOW, BUT JUST KNOW THAT AFTER MY DIVORCE MY EX NEVER PAID CHILD SUPPORT, I HAD KNOW ONE WILLING TO HELP ME .HE HAD BEEN PLOTTING AGAINST ME THE WHOLE TIME. (his mother that also actualy hit me is a legal assistant) I KNOW THAT IN OUR CONVERSATIONS I DID TELL YOU THAT HE WAS VERRY ABUSIVE (.He comes from a very violent and racist family. His father actualy kicked him and me. they are very crazy they think they can do whatever they want becouse they are athiest and ,according to them them they know maffia people. These are probably lies to scare me.but is one of he reasons I was afraid to come to you before. ) ANY WAY, TO MAKE A LONG STORY SHORT . HE WENT AFTER CUSTODY AND WON BECOUSE I HAD NO MONEY , NO LAWYER AND HIS LAWYER SENT ME SHIESTY PAPERS DIRECTING ME TO A NON EXSISTANT COURT HOUSE. I LEAVE MESSAGES AND HE REFUSES TO ANSWER OR ALLOW ME TO TALK TO MY 2 SONS. I REALY NEED YOUR HELP. I NEED YOU TO PLEASE BE MY HERO. I BESEECH THEE HUMBLY TO PLEASE PRAY AND SEARCH YOUR HEART AND TRY TO REMEMBER OUR CONVERSATIONS. I HOPE YOU HAVE NOT FORGOTTEN ME. AFTER OUR LAST CONVERSATION WAY BACK IN 2008 I DROVE TO NY WITHOUT A GOOD PLAN .UNFORTUNATLY THE WEEKEND I WENT UP THERE TO LOOK FOR YOU, YOU WERE AT THE GRAMMYS IN CALIFORNIA. I WROTE TO YOU FROM THE MARRIOTE THAT I WAS IN TOWN BUT YOU PROBABLY NEVER SAW THE POST. AND I DIDN'T PUT A SONG SO YOU PROBABLY DIDN'T KNOW IT WAS ME. (by the way I posted a song and partial movie script ,under ask the staff where there are better editing features) IF YOU DID SEE IT. AFTER THAT I WENT BACK TO FLORIDA AND WAS SUFFERING FROM FLU AND EXHAUSTION AT THE SAME TIME THAT YOU WERE SICK IN MIAMI. A YEAR LATER I TRIED TO CONTACT YOU AT THE SETEI HOTEL HOPEING YOU WERE THERE BECOUSE I MISSED YOU. ALSO WITHOUT CHILD SUPPORT PAYMENTS I WAS HOPEING THAT AS MY MANANGER YOU WOULD HELP ME BECOUSE, I THOUGHT YOU HAD SET UP AN ACCOUNT FOR ME IN PRIVATE. ANYWAYS THEY WERE LESS THAN HELPFUL AT THE SETEI, A HOTEL THAT I DO REMEMBER COMING UP WITH A LOT OF IDEAS FOR, BUT THEY HAD KNOW WAY OF KNOWING THIS. THEN I TRIED LEAVING YOU SOME MESSAGES AT YOUR WEBSITE, BUT I GUESS SINCE I DIDN'T PUT A SONG YOU HAD KNOW WAY OF KNOWING IT WAS ME. THEN I WENT THROUGH A LOT OF OTHER STUFF, LIKE I WAS LIVING AT MY MOTHER AND STEP FATHERS RENTAL PROPERTY AND MY COMPUTER CRASHED AND I HAVE PRETTY MUCH BEEN WITHOUT A COMPUTER FOR 3 YEARS. , I THEN WENT TO LIVE WITH MY GRAND MOTHER. AND THAT IS WHEN THINGS GOT REALY UGLY WHILE I WAS AT THE BIBLIOTECH WITH MY 2 SONS, "someone" PUT ALL OF OUR THINGS OUT ON THE CARPORT LIKE TRASH. SO I WAS LEFT WITH NO CHOICE BUT TO CALL MY EX TO COME GET THE KIDS UNTILL I COULD GET ON MY FEET. I TOLD YOU MY FATHER IS NOT LIVING NOR HAS HE BEEN SINCE HE WAS SHOT A FEW DAYS AFTER I WAS BORN. SO I HAD NO WHERE TO TURN AND NO COMPUTER TO TRY TO CONTACT YOU. MY STEP FATHER DID GIVE ME HIS OLD COMPUTER FOR CHRISTMASS SO I AM GLAD ABOUT THAT. BUT NOW FOR SOME REASON I CAN'T SEEM TO GET IN TOUCH WITH YOU , MY MOM IS DOING HER BEST TO HELP ME, BUT THIS APARTMENT COMPLEX ACTUALY TOWED MY CAR AWAY A YEAR AGO AND I HAVE NO TRANSPERTATION. I HAVE BEEN THROUGH SO MUCH, AND I REGRET NOT COMING TO YOU A LONG TIME AGO WHEN YOU ASKED. I AM VERY CHRISTIAN AND I JUST THOUGHT IT BEST TO GET A DIVORCE FIRST. ALSO I WANTED MY EX TO SIGN THAT HE WOULD NEVER ASK FOR ALLOMONY AS PART OF THE DIVORCE AND I KNEW HE WOULD NEVER SIGN, IF HE KNEW I WAS WITH YOU OR THAT I AM A WRITER. WITH ALL THIS STRESS AND TURMOIL I HAVE NOT BEEN ABLE TO SLEEP. YOU ARE MY ONLY FRIEND, SO ONCE" AGAIN" I AM TRYING TO TURN TO YOU. PLEASE DON'T HOLD IT AGAINST ME THAT I CAN'T FIGURE A WAY TO POST My PICTURE ,TRUST ME I HAVE TRIED SO HARD, BECOUSE I KNEW IF YOU SAW MY PICTURE THAT YOU WOULD KNOW THAT IT IS ME. PLEASE DON'T HOLD IT AGAINST ME THAT I DON'T HAVE THE BEST TECHNOLOGY . IT IS REALY ME !!!!! I HAVE BEEN THROUGH MUCH MORE THAN WHAT I HAVE WRITTEN THIS IS THE SHORTENED VERSION. BUT I GUESS THAT IS ONE OF THE RESONS THAT I AM SUCH A GOOD WRITTER, BECOUSE I HAVE HAD UNIQE EXPERIENCES FROM A CHRISTIAN PERSPECTIVE. I POURED MY HEART OUT INTO SO MANY SONGS LIKE PARADISE (COLDPLAY) ECT.AND MOVIES AND SPEACHES.9so many of the songs and movies were realy love letters to you and also to let you know what i was going through.) THIS REALY IS ME AND I REALY NEED YOUR HELP. I HOPE YOU HAVEN'T FORGOTTEN ME. I NEED YOU MORE THAN YOU KNOW... I STILL LOVE YOU ,BUT IT IS OK IF YOU HAVE MOVED ON...(song I wrote "its been awhile...since I can hold my head up high"... a letter to you. ..also other songs like "had a bad day", "hey now your a rock star"..."know these things should'nt you"... "bubly" was written for my 2 sons.. I wrote bleeding love" to let you know I was being abused and also that I will never stop loving you... I wrote "tatoo"and inumerous other love songs all about my love for you. ) I WILL UNDERSTAND IF YOU JUST WANT TO BE FRIENDSAND OR REFER ME TO ANOTHER MANAGER ONCE YOU HAVE GIVEN ME THE MONEY YOU ARE MANAGING FOR ME.I AM THINKING OF REWRITTING THE MOVIE AND TAKING MYSELF/ MY CHARACTER OUT OF ITBUT IT WILL STILL BE WONDERFULL. IT HAS BEEN A LONG TIME SINCE WE LAST SPOKE. HOPEFULLY YOU WILL SEE THIS POST, AND UNDERSTAND THAT MY COMPUTER IS NOT THE BEST, BUT I COULD SEND YOU A PIC THROUGH EMAIL. THAT IS WHERE MY PICTURES ARE, I REALY CAN'T THINK OF ANOTHER WAY. PLEASE RESCUE ME SOON, I AM DEALING WITH MORE THAN I HAVE LET ON... AND I HAVE TOLD YOU IS A LOT. WHAT I AM TRYING TO SAY IS I DON'T KNOW IF I CAN GO ON LIKE THIS MUCH LONGER. MY EX IS ABUSSIVE AND WHAT IF HE WON'T LET ME TALK TO MY 2 SONS, IS BECOUSE HE IS ABUSING THEM AND DOES'NT WANT THEM TO BE ABLE TO TELL ME. HE HASN'T LET ME TALK TO THEM SINCE OUR LAST CONVERSATION ALMOST 2 YEARS AGO IN WICH THE BOYS TOLD ME THEY WERE UNHAPPY, AT THERE OWN PERRIL, BECOUS HE WAS LISTENING TO OUR CONVERSATIONS ! PLEASE HELP US, I WORKED SO HARD WRITING, AND NOW BECOUSE MY PICTURE WONT POST I FEAR YOU DON'T BELIEVE IT IS REALY ME PLEASE "BELIEVE IN ME". MY SONS AND I ARE IN DANGER PLEASE HELP US. I NEED THE MONEY I EARNED, AND YOUR HELP AND HOPEFULLY YOUR FRIENDSHIP ETC.. I HAVE TO GET A LAWYER AND GET MY 2 SONS OUT OF DANGER. YOU DON'T KNOW ALL THE THINGS MY EX IS CAPABLE OF. IF I DON'T HERE FROM YOU SOON I DO'NT KNOW WHAT WILL BECOME OF US. MY TWO SONS AND I NEED YOU AS AN ADVOCATE AND HERO. I KNOW YOU ARE VERY BUSY AND I APPOLOGISE BUT PLEASE CONTACT ME AT firstname.lastname@example.com or you could put a number/privacy block on your phone and call 813-504-3847 I know it is not a good idea to put my phone number on the interrnet but i don't have time to be coy my son's are in danger and we need your help immediatly. My mother is very ill right now she has been in and out of the hospital and has impaired eyesight etc. I have so many awfull things going on right now please help me and my son's this is not a prank. it is really me the writter of innumerouse albums, songs, speaches, movie scripts etc. Kenya L. C. Hamilton Love / beautiful / believe in me / caramel velveteen/ poetess ps. I sent you pictures of me and videos,in the mail a long time ago. I hope you got them and enjoyed them ! Love, yours always, Love Love Love
TO LENNY KRAVITZ: THE MOST TALENTED EVER !!! ICONIC MOVIE SCRIPT WRITTEN FOR YOU IN L.K. FORUM: ASK THE STAFF ( where there are editing features.) Loved your sunday morning picture. All the features on this new to me yet old computer, don't seem to work correctly or I would upload a picture from my phone. I hate the icon I have but I won't complain at least I finanly got a computer.( like for instance I can't send links or pages to friends). Anyways, it realy is me, the writer of inumerous movie scripts , albums , tv shows , speaches etc. I can send a pick email email@example.com then you can verify my identity. I know when we chatted online some would try to pretend to be me, but this realy is me. I am frustrated becous 3 people have tried to help me upload a pic to face book to no avail. I don't have a webcam and this computer won't let me upload piuctures from my phone or emails for icons for some reason. Anyways I realy miss you a lot. I am exstatic about the Black and White america album and your new album that you are working on. You
deliver like non other and sound realy strong and powerful !!!Your music has always been there for me through it all, and I wan't to thank you. Please contact me soon, It realy is me, the writer !!!!! Love /Kenya /Beautiful / Kay / Surfer girl
To Lenny Kravitz : This is Love /Kenya / Beautiful. I have been trying to get in contact with you for 5 yrs now. I would like to contact you privately bu I don't see a button for that. I have written enoumorous songs, albums , tv shows, "speaches" etc, including "Something Beautiful" wth You and Trombone shorty ( I listen to the song every day). I hope you are still my manager and that we are still friends. I have been going throiugh a lot and I need the money that was promissed to me. I have a lot of personal things I would like to discuss. Like how I posted songs and a movie script for you under ,"ask the staff" where there are better editing features and was hopeing your staff would bring this to yopur attention. I don't want to get into the details but my son's and I are being abused by my ex (He will not allow me to speak to my children)and I need help fast. firstname.lastname@example.com 813-504-3847 Its realy me I hope you read this post. I have worked so hard writting Albums and movies ect. under pen names and I am divorced and broke. If I don't hear from you soon I will be frced to hire another mnager and go that route. I can't go on like this forever. I have worked very hard as a writer, do you even have a staff. I have been posting since I got this computer on christmass day.*I have helped so many other artist and now I can't get in touch with anyonein my time of need. I have tried to contact you at Kravitz design priately since 2008 ! I feel as though I am in the movie "The Net" !!! I can't seem to get my picture to post or you would know this is me !!! Well hope to hear from you soon I have a lot of excting ideas to share with you. Love/ Beatiful/ Kenya/ Kay/ surfer girl 813 -504 -3847 Kenya L Hamilton


text:
"I have friends all over the world and although we live in the "Internet Era," I treasure sending and receiving cards from my friends. With that said, I like to be creative too. I ordered this card to say "hello" to my friends and WOW! What an amazing product I did I get!! Nice weight, beautiful colors, perfect size. Whimsical and lovely! It's the type of card and you see and sigh "ahhhh." I received many compliments for it and I'm certainly ordering extras!"
"I absolutely love these cards. They are pretty with just the right touch of femininity. The quality of the paper is amazing for the price! Can't wait to send my first one out!"
"These cards are wonderful! I love the design and TinyPrints even changed the colour to match the business cards I ordered at the same time. The high quality of the paper is exactly what I have come to expect of TinyPrints (and WeddingPaperDivas). The cards are a lovely weight and easy to write on. I can't wait to send one of these cards!"
"Just what i was looking for, personalized cards that i could tweek to make my own. Easy to customize, lots of options, variety of styles to choose from. Quality is top notch."
"i actually ordered this in the black, white & grey tones. i love it. i always want a little something to send after i visit someone to thank them. this is a trendy little postcard that expresses me perfectly. its really high quality like everything ive ordered from tiny prints"