text:
The news out of Canada is that authorities have broken up a terrorist cell that had more than 50 electronic circuit boards that could be used in improvised explosive devices (IEDs). The details of the plot are still a bit cloudy, but Canadian authorities were quick to point out that the plotters had ties to other actors in Pakistan, Afghanistan, Iran, and Dubai. One of the cell members taken into custody had reportedly received terrorist training in Afghanistan/Pakistan. And this raises a basic point.
The Canadian plotters are being referred to as a "homegrown" cell, which is true from a certain point of view. They all lived in the West, and it is likely that some if not all of them were radicalized while living in Canada. But when analysts and commentators say "homegrown" they often act as if this is something new – as if we now have to worry about terrorists being indoctrinated in the West, whereas previously we did not. In that sense, the terminology is misleading.
Al Qaeda operatives and like-minded terrorists have long been recruiting in the West. The suicide hijack pilots for the September 11 operation were indoctrinated in Hamburg, Germany. Other al Qaeda terrorists were recruited in the U.S. long before the 9/11 attacks. So, "homegrown" terrorism isn't new.
The scope of the "homegrown" threat has certainly increased since 9/11. In that sense, the phrasing is helpful. The ability of al Qaeda cleric Anwar al Awlaki and other top jihadists to indoctrinate susceptible new recruits via the Internet is just one prominent example of how the homegrown threat has evolved and grown.
There is another aspect to the "homegrown" moniker that is misleading. At least one of the alleged terrorists arrested in Canada traveled to Afghanistan/Pakistan for training. Much of the time this is the case: Even terrorists who are indoctrinated in the West end up traveling abroad to receive training.
This underscores the importance of physical safe havens.
Consider some of the terrorist attacks/plots since January 2009. Najibullah Zazi's plot against New York City commuter trains was broken up in 2009, but only after Zazi was trained by al Qaeda in northern Pakistan. The would-be Christmas Day bomber, Umar Farouq Abdulmutallab, was first indoctrinated in the UK but traveled to Yemen for training before trying to blow up Flight 253. Faisal Shahzad, who tried to detonate a car bomb in the middle of Times Square, lived in the U.S. for years and was first radicalized here, but he traveled to northern Pakistan to receive training from the Pakistani Taliban.
On the other side of the ledger, the Fort Hood Shooter, Maj. Nidal Malik Hasan, was radicalized here in the U.S. but never traveled abroad for training as far as we know. Then again, Hasan didn't need training for the type of operation he pulled off. It is easy to pick up a gun and start shooting. It is much more difficult to blow up trains (Zazi), construct an underwear bomb (Abdulmutallab), or detonate a car bomb (Shahzad). It is so difficult that even after receiving training two of these terrorists failed to achieve their mission despite being able to deploy their weapons of mass terror.
In this admittedly limited sample then, three of four "homegrown" terrorists who have targeted the U.S. since January 2009 all traveled abroad to one of the jihadists' safe havens for training. The Canadian cell is no different. The cell received at least some training abroad.
The bottom line is that "homegrown" terrorism does not mean that the terrorists themselves are unconnected to the global jihadist threat. Quite often they seek out and receive assistance from professional terrorists living in jihadist hotspots abroad. Terrorist safe havens are still an important part of the threat we face.
Thomas Joscelyn is a senior fellow at the Foundation for Defense of Democracies.
The FBI detonated a bomb in Pennsylvania made of the components Faisal Shahzad intended to use before he resorted to cheaper alternatives. In May, Shahzad left his SUV in the middle of Times Square, where it merely smoked instead of exploding:
Read more...
Writing at the Daily Beast a few days ago, Philip Shenon (formerly an investigative reporter at the New York Times) had a scoop that deserves wider attention. According to Shenon, a "senior federal law enforcement official" told him that the Obama administration has sent a "clear, if carefully worded warning" to Pakistani leaders.
Quoting the Koran in a 2006 email, Times Square bomber Faisal Shahzad wrote that "those who believe" should "fight in the Cause of Allah." Shahzad expressed anger over the cartoon drawings of Mohammed, conflicts that pitted Muslims against non-Muslims, and democracy.
In the aftermath of the failed Times Square bombing, the world appears--not for the first time--to be catching on about Pakistan. That country's reality is simple: Radical Islamist movements have a choke-hold over the military and intelligence services, and blackmail Islamabad into subsidizing jihadist activities across South Asia, from Afghanistan to Burma, the latter with a small Muslim community. In addition, the large Pakistani diaspora, mainly in the UK and U.S., shelters numerous active agents of and contributors to terrorist efforts.
On 60 Minutes Sunday night, Secretary of State Hillary Clinton made what CBS News rightly called a "remarkable" allegation. Secretary Clinton was first asked if the would-be Times Square bomber had ties to terrorists operating out of Pakistan. "There are connections," Clinton responded before expressing some ambiguity as to the precise nature of those connections. (Other senior Obama administration, including Attorney General Eric Holder and President Obama's chief counterterrorism advisor John Brennan clarified those connections earlier in the day.)
Clinton was asked what message she would deliver to the Pakistanis in the wake of the Times Square attack. She answered:
Early Sunday morning, May 2, I awoke and followed my usual routine: Grabbed a cup of coffee, logged onto my computer, scanned the news for major developments in the war, and checked my email. It was no ordinary morning, though, as the evening before someone had attempted to set off a car bomb in Times Square in New York City.
Mayor Mike is coming for your guns, but not even this administration -- and this Congress -- is naive enough to play along. Bloomberg appealed to Congress this week to address what is oddly being called the "terror gap," but which supporters of Second Amendment rights better describe as "secret government lists." The question is this: Should U.S. citizens on terror watch lists be allowed to purchase firearms? The answer from Congress is yes (though the Huffington Post and the New York Times would have you believe it's just Republicans obstructing Bloomberg's "common sense" proposal).
Faisal Shahzad on terror list since 1999.
Andy McCarthy wants to know why the criminal complaint was even made public.
Josh Rogin notices that Barack Obama has made the UN more popular in the U.S., while the president's own support wanes.
Byron York notices an alarming paragraph deep inside a New York Times profile of Faisal Shahzad:
George LaMonica, a 35-year-old computer consultant, said he bought his two-bedroom condominium in Norwalk, Conn., from Mr. Shahzad for $261,000 in May 2004. A few weeks after he moved in, Mr. LaMonica said, investigators from the national Joint Terrorism Task Force interviewed him, asking for details of the transaction and for information about Mr. Shahzad. It struck Mr. LaMonica as unusual, but he said detectives told him they were simply "checking everything out.
George LaMonica, a 35-year-old computer consultant, said he bought his two-bedroom condominium in Norwalk, Conn., from Mr. Shahzad for $261,000 in May 2004. A few weeks after he moved in, Mr. LaMonica said, investigators from the national Joint Terrorism Task Force interviewed him, asking for details of the transaction and for information about Mr. Shahzad. It struck Mr. LaMonica as unusual, but he said detectives told him they were simply "checking everything out.
On Sunday morning, Janet Napolitano twice suggested that the attempted attack in Times Square was a "one-off" event during an interview with ABC News. ABC's Jake Tapper had asked Napolitano directly about the possibility of international involvement, given the similarities (superficial, at least) between the crude bomb discovered in the Nissan Pathfinder in New York City and those used in attempted bombings in London and Glasgow in 2007. "Well, right now, we have no evidence that it is anything other than a one-off, but we are alerting state, local officials around the country, letting them know what is going on."
Calling the attempted attack a "one-off" wasn't directly responsive to Tapper's question. But it's clear that Napolitano, who also described the bomb as "amateurish," wanted to downplay the seriousness of the attack.
While in Washington, D.C. today for fundraising events, Marco Rubio was asked whether Faisal Shahzad, a the alleged Times Square bomber, should be Mirandized.
His initial response was ambivalent. "It all depends on how they're going to try him. And that's an important question that we're facing," Rubio said. "That's one of the great challenges of the war on terror."
An FBI official says Faisal Shahzad was put on a no-fly list hours before his arrest, but he was apprehended on a flight he booked on the way to the airport and which he paid for in cash.
New York City Mayor Michael Bloomberg, while refusing to criticize agencies, said the suspect was "clearly on the plane and shouldn't have been." An FBI official said Shahzad was placed on No Fly list hours before his arrest.
New York City Mayor Michael Bloomberg, while refusing to criticize agencies, said the suspect was "clearly on the plane and shouldn't have been." An FBI official said Shahzad was placed on No Fly list hours before his arrest.
Faisal Shahzad, a 30 year-old naturalized American citizen from Pakistan, has been arrested as the chief suspect behind the failed car bomb attack on Times Square this past Saturday. The good news is, of course, that the bomb was fairly unsophisticated (showing a low-level of expertise), it failed to detonate (sparing the lives of New Yorkers and tourists), and the man believed to be responsible for assembling and deploying the car bomb was apprehended in short order. Authorities were able to pinpoint the would-be terrorist in impressively little time.
It is not all good news, however. Law enforcement and intelligence officials failed to stop the perpetrator from placing his bomb in the first place. We were simply lucky that onlookers weren't killed. If this was truly the work of a rogue individual, a "one-off" event as Homeland Security Secretary Janet Napolitano suggested on Sunday, then that failure would be somewhat understandable. As law enforcement and intelligence professionals have repeatedly lamented, it is exceedingly difficult to stop a "lone wolf" terrorist.
Type in your emailaddress to get started:
A Parody.
A Parody
View more [+]
It's not the Democrats, despite their self-flattering claims
Holding the line against the Islamic State.
The crackpot social science of generational analysis
Hosted by Michael Graham.
Edmund Burke's war on terror—and ours.
Become a Fan on Facebook
Follow us on Twitter
© Copyright 2014 The Weekly Standard LLC - A Weekly Conservative Magazine & Blog. All Rights Reserved.
Privacy Policy | Terms of Use


text:
A collection of news and information related to Minnesota Golden Gophers published by this site and its partners.
Top Minnesota Golden Gophers Articles
Displaying items 1-11
Monday's multi-sport college and local roundup: ODU loses top women's basketball player to MinnesotaStory | May 12, 2014 | 11:40 PMColleges: Women's basketball: Old Dominion lost its top player, Shae Kelley, who announced she will transfer to Minnesota for her final collegiate season, the Virginian-Pilot reported. With the Gophers, she will play for former VCU coach Melanie...
Teel Time: Neither Pythagoras nor Bill James could explain ACC baseball's title drought
Expect high seeds for U.Va., VCU in NCAA basketball tournament
Thursday's multi-sport college and local roundup: Ohio State assistant will coach JMU, report says; Newsome reportedly gains E&H job; Hokies, Purdue to square off twiceStory | Dec 19, 2013 | 9:38 PMCOLLEGE FOOTBALL Report: JMU to hire Ohio State co-defensive coordinator Withers Ohio State co-defensive coordinator Everett Withers will be named James Madison's head coach, sources told FootballScoop.com. Withers reportedly was on campus Thursday...
Thursday's local college basketball roundup: Norfolk State wins home opener after unveiling title bannerStory | Nov 29, 2012 | 7:29 PMBefore Thursday's home opener against St. Francis of Brooklyn, N.Y., Norfolk State celebrated last season's landmark year, raising its first Mid-Eastern Athletic Conference championship banner. The current Spartans trailed for much of the...
Teel Time: Virginia-Wisconsin rematch in ACC-Big Ten Challenge
Teel Time: U.Va.-UNC soon will be second-oldest rivalry in Bowl SubdivisionStory | Nov 14, 2012 | 1:19 PMVirginia's most intense football rival is Virginia Tech. North Carolina's is N.C. State. Recruiting repercussions and state bragging rights are paramount. But for longevity and continuity, Virginia's series with North Carolina has no...
Down the Line: Local tennis notes: Kingsmill seniors repeat as sectional champs
Duke offers influential win opportunity for Virginia
Teel Time: Records against final top 25 revealing for Hokies, UVa football
Teel Time: UVa has most productive half in a year versus MichiganStory | Nov 30, 2011 | 6:29 AMDuring the first 17 minutes of Tuesday's game against Michigan, Virginia scored 14 points, shot 20 percent from the field and missed 7-of-8 attempts from beyond the 3-point arc. Only the Cavaliers' defense and foul trouble that benched the...

subset: commoncrawl


text:
Online Shopping with Google's Froogle
SearchDay, Dec. 12, 2002
Google has launched a beta version of a new shopping search tool called "Froogle" that the company claims is the most comprehensive product search engine available on the web.
Outsourcing Search Engine Optimization
SearchDay, Dec. 11, 2002
Choosing a firm to do search engine optimization needn't be confusing or frustrating if you start by creating a request for proposal that focuses on your own specific needs.
Using Search Engines to Fill in the Blank
SearchDay, Dec. 10, 2002
Rather than agonizing over formulating the perfect query, take advantage of the power of search engines to easily "fill in the blank" for the answer to many types of questions.
AlltheWeb Alchemist Contest Winners Announced
SearchDay, Dec. 9, 2002
Now there's a quick and easy way to change the look of the AlltheWeb search engine, by downloading one of the wining entries from the company's Alchemist contest.
Elsewhere at Internet.com
Text Link Ads -- With a Dash of Content
Recipe for relevance: Don't just return results, return content with paid search engine listings.
Book Review: Human Factors and Web Development, 2nd ed.
A collection of sixteen chapters from leading experts in the field this book provides a fascinating glimpse into current and future HCI research into man-machine interaction on the web.
Web Writers, Post Thyself
Basic HTML is as essential as the ABCs of marketing communicators. How --and where -- to learn basic code.
Online Fraud Growing in Scale, Sophistication
Fraud will cost online retailers about $500 million during this holiday season, according to a new study out by industry analyst giant Gartner, Inc.
Search Headlines
NOTE: Article links often change. In case of a bad link, use the publication's search facility, which most have, and search for the headline.
The Original Search Marketing Event is Back!
SES Denver (Oct 16) offers an intense day of learning all the critical aspects of search engine optimization (SEO) and paid search advertising (PPC). The mission of SES remains the same as it did from the start - to help you master being found on search engines. Register today!


text:
6 Simple Ingredients That Take Food to the Next Level
These instant flavor-boosters make simple dishes taste amazing.
Back Next
Greg Marino/Studio D
Balsamic glaze
Drizzle this thick, syrupy glaze on everything: steaks or pork chops, roasted root vegetables, even fresh strawberries and ice cream. Set of 2, $15.95; amazon.com


text:
I give Angelina Jolie a lot of credit. She does a lot of work with UNICEF, and for women, and for starving kids, etc. etc., but that lady is one odd bird. Supposedly -- supposedly -- the real reason Brad Pitt's non-wife is extra rail-thin these days is because she actually is starving herself. For the children.
A source "close to Angelina" recently told US Weekly that the actress "puts herself on fasts to make statements for the children she visits." They added, "She says, 'If they can't eat, I can't eat.' She does different cleanses from around the world. It's very dramatic, but that's how she gets."
I don't know about you, but that makes perfect sense to me!
If this is true -- and Lord knows if it is -- it's absurd. Angelina does and has a ton of things children in third world countries don't. Like electricity and working toilets. Does she stop using those also? And while she's at it, she may as well quit wearing all those expensive, fancy dresses on the red carpet. And she definitely shouldn't be indulging in things like private planes and ridiculously overpriced facials and massages and whatnot.
I'm not bagging on Angelina. Like I said, I think all the work she does is great -- it's more than many other celebrities ever do. But this logic is simply ass-backwards. I get that she's deeply moved by the people she meets on her trips, but I don't think going on some hoity-toity Gwyneth Paltrow-esque juice cleanse is going to "make a statement" with the children. I'm sure they're just thrilled to see her and happy somebody cares enough to do what she does. Silly celebrities.
Do you think Angelina starving herself for the kids makes sense?
Image via Splash
I agree with Kelticmom but not the tone in her statement.
If I were one of those starving kids I'd ask her why she doesn't eat in a country with food readily available at every turn. I'd say she takes it for granted.
Does she also sleep outside in a hut? Walk everywhere she goes, with no shoes on? Drink unpurified river water, which she also bathes in, washes her clothing in, and go to the bathroom in?
Or is she just picking and choosing the sacrifices she's making for the children?
Personally, I think it sounds like exactly the kind of thing a person does to GET attention, rather than TURN our attention to the actual issues with the world. It comes across as fake and completely self-serving.
Travel Agent
Travel sites
Do it yourself
Concierge service through your credit card


text:
Sign up for Yardbarker's daily Top 10 newsletter, the Morning Bark! Customize to get news on your favorite sports and teams.
Report: Nick Marshall cited for marijuana possession
Auburn University quarterback Nick Marshall has been cited for 'marijuana possession of less than one ounce' according to Reynolds Police Chief Ronnie Holder. The news comes from a report from WSFA 12 in Georgia. Marshall's vehicle was pulled over due to a possible tint violation, and the officer smelled marijuana on him, but was only […]
Via Full Scale Sports
July 11, 2014 | Discuss
Georgia Bulldogs Recruiting: Bulldogs sign 21 players
The Georgia Bulldogs had an excellent National Signing Day on Wednesday, officially adding twenty-one players to the roster. This batch of recruits, which includes in-state players such as Norcross defensive end Lorenzo Carter and Cedartown running back Nick Chubb, has gained a great deal of praise from the various recruiting websites, earning the #8 spot by Rivals, #8 by 247Sports...
Via isportsweb.com
February 05, 2014 | Discuss
Nightmare at Jordan-Hare: Dawgs lose 43-38 heartbreaker
A come-from-behind victory for the Georgia Bulldogs was in sight in Auburn, Alabama on Saturday afternoon, but a miracle 73-yard touchdown pass from Tigers quarterback Nick Marshall to Ricardo Louis on fourth and eighteen thwarted Georgia's chances with just twenty-five seconds left in the game. Quickly forgotten was the Bulldogs, led by quarterback Aaron Murray, outscoring the...
Via isportsweb.com
November 18, 2013 | Discuss
Auburn Stuns Georgia With 73-Yard Hail Mary in Final Minute, Coaches Collapse on Sidelines in Disbelief (GIFs)
Hail Mary? More like Hail Marshall. After Georgia crawled their way back against Auburn, overcoming a 20-point fourth-quarter deficit courtesy of three straight Aaron Murray touchdown drives, the Tigers staved off their ferocious rally with a miraculous play of their own. With the Bulldogs up 37-36 with less than a minute remaining, Auburn was facing a fourth-and-18 situation from...
WATCH: Auburn beats Georgia on miraculous Hail Mary
The Auburn Tigers kept their visions and hopes of a BCS title game alive after it looked like they had given away a big lead to the Georgia Bulldogs. With the game in the balance on a fourth down late in the fourth quarter, Auburn QB Nick Marshall heaved a bomb down field that was tipped by a couple of Bulldogs defenders. The ball somehow managed to fall into the hands of the intended...
Via The Nosebleeds
Video: Nick Marshall Throws Unbelievable 73-Yard TD On Hail Mary That Bounces Off Of UGA Defense
Auburn is still a legitimate national title contender, and the Tigers just showed why by demonstrating some extreme resiliency against the Georgia Bulldogs. Auburn trailed 38-37 with less than two minutes to save their season following Aaron Murray's third touchdown of the quarter. The offense took the field with confidence, but the comeback drive didn't start off the way they...
Via College Spun
Auburn to rely on Marshall, running game vs. Georgia
Auburn should win. Lets get that out front. The seventh-ranked team Tigers have played very well in big games and established themselves as a ground-control offensive force capable of controlling the clock, just the sort of thing needed at home against Georgia on Saturday. Plus, the Tigers are sitting where no one thought they would be: one win away from the biggest Iron Bowl...
Via Fox Sports South
November 13, 2013 | Discuss
The Georgia Bulldogs bulldoze over Appalachian State 45-6
The Georgia Bulldogs took care of business against the struggling Appalachian State Mountaineers on Saturday, overcoming a slow start that saw the team hold a slim 7-6 advantage through the start of the second quarter to outscore the Mountaineers 38-0 the rest of the way. Games of the Southern Conference variety tend to be forgetful, but Bulldogs' fans may very well remember this...
Via isportsweb.com
November 12, 2013 | Discuss
Marshall work-in-progress as QB for Malzahn's Tigers
AUBURN, Ala. -- The program featured a smiling Gus Malzahn in an orange visor and orange polo shirt with the headline "It's A New Day" stretched across the cover. The slogan, which the new Auburn coach himself has used more than a time or two in his short tenure, has popped up across Alabama, appearing on 50 billboards and it's led to one fan putting Malzahn'...
Via Fox Sports South
August 31, 2013 | Discuss
Three Kicked Off UGA Football Team- Marshall, Sanders, Seay
For alleged theft of money from other players...The HQ is working to confirm that...But two of the names are Georgia heavyweight high schoolers...Special teamer Nick Marshall from Wilcox County High and Chris Sanders from Tucker High, along with Lee County grad Sanford Seay are all gone.CMR sent out his standard release that said in part that "It's a privilege to play college...
Via Online Sports Guys
February 03, 2012 | Discuss
College Football News
Delivered to your inbox
You'll also receive Yardbarker's daily Top 10, featuring the best sports stories from around the web. Customize your newsletter to get articles on your favorite sports and teams. And the best part? It's free!
Follow us on Twitter


text:
Intermittent fasting is a new thing I just decided imma try maybe next month. I have a goal of 50lbs by December. I will do almost anything to burn as much fat. I want to lose 75lbs by December even though that is highly unlikely.
So i was a day off my weigh in. I weighed in this morning and lost 4.4lbs YAYYYY
Now just a thousand more to go.
So the first week of this weight loss challenge is almost up. We started on Tuesday and have been working hard since. I personally chose my cheat day to be a Saturday because that is a good day to go out with friends to get a bite to eat and not micromanage every little thing. I have been pretty good with my calories and my exercise. I am hopefully soon going to be starting p90x. I am slightly scare to be honest. I am also getting insanity workouts soon. I also will be posting some yummy recipes soon. I will try to get on here more often to post things for you guys. I just have school, I'm in the school play, and I am in a club. Those things alone, take up at least 11 hours a day. My play rehearsals last 2 - 3 hours. I leave my house at 7:15 am and don't get home until 7 pm if I am lucky. Well enough of that, back to the topic. I am hoping for at least a 5lb loss on the scale this Tuesday. As for Cameron, I don't know what he expects for his loss. When I talk to him, he seems like he is doing very well with our challenge. Anyways I have homework, cleaning, and grocery shopping to do.
Tomorrow will be the start of our journey and competition. Im pumped for some motivation and healthy competition.
RULES!!!1. Weigh yourself nude every TUESDAY morning and check it in on myfitnesspal.com2. MUST RECORD EVERYTHING INCLUDING FOOD, EXERCISE, and WATER on myfitnesspal.com EVERY DAY3. There will be punishments for not checking in.4. Only positive encouragement 5. No asking each other of their weight6. You must work out at least 30 minutes a week.7. If we cheat we must be honest8. At least once a week we have a therapy phone session9. At least once a month we try a new healthy food or workout10. No putting ourselves down11. WE ARE ALLOWED ONE CHEAT DAY A WEEK
- Missa
This blog is dedicated to my friend Cameron's and mine weight loss journey. We are going to be posting stuff on here such as recipes, new exercises, sometimes vlogs, and our struggles. We are having a little healthy competition to see who can lose the most weight. I will post our rules that we agreed on and tools that we use. Hope that if anyone is reading this, that you can gain some advice and encouragement.
- Missa


text:
Reader Comments (Page 1 of 1)
For those that want bragging rights, there will still be server firsts. It seems to me there are only 2 choices for a level capped player to stay in the game: raid or dailies. I would be perfectly happy if the game offered more than the same boring dailies for me to do after 85. Why not offer quests with a 'boss strategy' for solo players? And offer competitive rewards? I play 30+ hours a week and I'm 'casual'. I don't want to level new characters. I want to play my main because I *like* playing my main. It's not that I don't want to raid. I can't find a guild who raids on my schedule. And even if I were raiding 4 nights a week, I think it would become just as tiresome as the doing the same dailies repetitively. While the LFR solution has potential, unless you can change the social behavior of 75% of the player base, it's not going to be fun.


text:
Categories > Celebrities > My Chemical Romance > Why do you all hate me?
Back to the arcade0 Reviews
They've gone back to the arcade...
"come on Gee... hurry up" I said jumping up and down
"Yeah Gee, Hurry up!" Mikey protested with me.
"God. you two are like kids"
"Rain check big bro.. we are kids"
"Oh.. yeah I forgot that!"
Gerard smiled at me as we walked in..
God this was hard all I wanted to do was hold his hand... Or walk with his arm around me.. but no!
Mikey walked ahead of us.
"Baby, this is so hard" I said wrapping my arm around his waist.
"what is?" He asked wrapping his arm around my waist.
"This hiding from Mikey stuff, I dont like lying Gee"
"Well he hasn't excatly asked us straight out now has he?"
"Well no-"
"So we're not lying"
"unless.. you just wanna tell him?" he asked with an eyebrow raised
Wow... uhh.
"Baby, he wants to be your friend now so it won't matter.. and If you and Gerard... Well then that would be fine by me.... just as long as you were both
happy' isn't that excatly what he said?"
fucking Gerard Way, making a point all the time.
He pushed his lips against mine...
Just enough to give me a tiny kiss.
"Mikeys waiting" he said tangling our fingers together.
I forgot that the whole of Belleville could have seen that if they were here... And I forgot that I had problems. And I forgot my Boyfriend is fucking the
best thing in the whole of the world.
We walked through the door... Mikey talking to a girl I knew... From school...
"Sasha. This is- Wow." he said looking at our hands.
Gerard gripped tighter smiling at me.
"It'll be fine babe" He smiled at me.
"Sasha, This is m-"
"your that Iero kid right?"
"Thats me" I spoke up
"Oh... Your talking to Mikey?-"
"If you'll let me finish!"
"Sasha, This is my big brother Gerard. And-" He looked at our hands again
"And this is Gerards boyfriend and my great Friend Frankie.. he goes to our school"
"Oh.. i thought you didn't like him... I mean like Alicia, and Jaxon... Kevin... Leighton and Kelly?"
"Well thats not going to happen anymore"
"So if you don't mind me and my Brother and his amazing boyfriend are going to have some fun, Tell Sarah. no I will not take her to prom"
"Are you sure? she really likes you?"
"No, I dont wanna know people who diss Frankie. If I have to I'll go with Frank" he said taking Gerards hand and pulling us towards something.
"M-Mikey.. thanks, You shouldn't have... Thanks"
"Well I'm guessing your gonna be like my brother now too, And you are my friend so.."
"Y-you don't care about me and Gee?"
"Is there something there?"
I looked at Gerard who looked into my eyes.
"Yip.. There is"
"Cool" Mikey said giving us a smile and pulling us to the photobooth.
Mikey kneeled on the seat. Wrapping his arms around Gerards neck.
Gerard stood infront of him and put his arms around my waist. Kissing my cheek.
"keep these as cleen as you can.. I want these on my wall"
"Shut up Mikey" Gerard said as he pushed the button.
One flash.
Next thing I knew Mikey had his right hand to my head like a gun...
Gerard did the same thing to Mikey.
Two flashes.
Gerard pulled me so his forehead was touching mine...
"Good God" I heard Mikey call
Gerard bit my bottom lip... I had to try so hard to keep a moan in.
Three flashes
Then I pulled Gerard and Mikey by the waist. Putting my arm around them both... they soon did the same thing to me.
I turned my eyes in Gerards direction and smiled.
While Gerard looked up and opened his mouth.
I didnt know what Mikey did.
Four flashed.
"well there 'ya go Frankie, you got your damn photos" Mikey smiled playfully pushing me into Gerard while he laughed like a maniac.


text:
There are park alerts in effect.hide Alerts »
Cave Creek Campground Closed
Cave Creek campground located at Mile Marker 16 is currently closed due to hazard trees.
What to Bring for the Tour
Go to Cave Tours page
Did You Know?
The mountains surrounding Oregon Caves are composed of ocean crust including rocks uplifted directly from the mantle. These mantle rocks make up one of the largest serpentine rock outcrops in the nation.


text:
DiagramDraw Download
|Home | Submit | Privacy | Contact Us | Sitemap | Top 100 | New Software | Advertise with us
MP3 & Audio
Free Downloads > Multimedia & Graphics > CAD > DiagramDraw 0.95
DiagramDraw 0.95
Diagram Draw is an easy to use diagram creator. The success of any enterprise depends not only upon the meticulous deduction but also in a great extent, on the way you communicate the information. When intricate text information fails to satisfy your needs, Diagram Draw stretches a helping hand. Using a competently organized set of tools, you can create drawings and diagrams that will ease the process of data communication within your workgroup.
Relate Software Downloads
Rozmic Instant Messenger Chat Software - Users in over 90 percent of all large companies still use public Instant Me...
Word-to-CHM Converter - Convert Word to HTML Help, Create CHM from Word, HTML Help Creator, CHM Creator.
Desktop Christmas Tree - If you have started redecorating your apartment for Christmas and New Year,...
Joyland Casino - Play at Joyland Casino and get an amazing $850 bonus!
Arcade Balls - This nice logic game takes place at the board 12x12 with vivid balls. The p...
AnySplit.exe - *Split and join any kind of files. *Support large files .(>1GB) *E...
Recover File / Recover Data - Critical Information you must know! Did you know that files you have previo...
Netrek XP 2006 - Netrek is a free multiplayer online space battle game.
Netrek Classic - Netrek is a free multiplayer online space battle game.
free 3D Manta Ray Aqua - A Must see screensaver of photorealistic Manta Rays swimming across the scr...
SPOTLIGHT Software
|Copyright 2007 5StarShare.com All rights reserved.


text:
Two days into the new year...and it is that time again.
I had my routine bone scan today. In two weeks I will have my routine CT Scan and Mammogram. We won't have results for a few days...so I am trying to be patient. I don't like surprises, so I hope everything comes back clean.
Friday, January 2, 2009
Beginning The New Year With Scanxiety
Posted by Maxine Middleton
2 comments:
Very shortly this web page will be famous amid all blogging
people, due to it's fastidious posts
Have a look at my web blog ... Air Max Femme
- June 10, 2013 at 5:18 AM
There is definately a lot to learn about this issue.
I really like all of the points you have made.
Review my page ... Sac A Main Louis Vuitton
- June 14, 2013 at 3:20 PM
Subscribe to: Post Comments (Atom)


text:
Examining the Impact of Security Management on the Business
The "Examining the Impact of Security Management on the Business" survey was conducted to determine how security management affects organizations' agility with regards to connectivity of critical business applications in the modern data center.
The current approach to managing security policies and devices is not in alignment with what the business requires. In order to improve both security and agility, information security professionals, network operations and application owners alike need greater visibility of the impact of security changes and cloud migrations on data center applications.


text:
A while ago I visited a friend of mine to shoot some wet plates, which was amazing.. in the spirit of analogue photography I took my box brownie along, which I picked up for £1, to see if it works. Amazingly, it does! So heres a couple of test shots and the camera itself - it even has a little portrait lens attachment which i've yet to try. The caravan is a portable darkroom whichSamused for his previous project.
I will get back out with it again soon, such a fun little camera.
That is a very sweet picture of my caravan and one of my cameras. Thanks Mark!


text:
Reader Comments (Page 1 of 1)
loop_not_defined said...
@Narshe: "If someone wants to play a tank or healer, they use a class that can be a tank or healer."
This isn't opinion: you're wrong. On multiple levels. Here's two.
A) I love to tank. I also love to play multiple classes. I don't tank on my Hunter or Priest...want to take a stab at why?
B) Many people play a class because they love what it's about. Not because of it's role. My wife plays Warlocks because she loves Warlocks...not out of some infatuation with DPSing over Tanking or Healing.
C) Rerolling might seem like a simple decision to you. It is not a simple decision for many. Don't make the mistake of thinking everyone feels the same way you do about something, or makes such decisions in the same context you might.


text:
The Global Research Funding Forum on Feb. 4-5 will provide opportunities for UNT faculty, staff and graduate students to interact with U.S. and international funding agency representatives.
Panels, keynote speeches and a global funding exhibit will provide information to improve student and scholar research proposals and clarify research priorities. There also will be a display of entries in the Graduate Student Global Research Competition.
Registration is open now at the conference site. Fees are:
Departments and faculty are encouraged to sponsor student registrations; instructions are at the registration site. The forum is co-sponsored by UNT-International, Toulouse Graduate School and the Office of Research and Economic Development.
Distinguished speakers will include Donald Dingwell, European Research Council; David Stonner, National Science Foundation, and numerous chief research officers from U.S. universities. 250 attendees are expected from over 30 countries.
- Mary Beth Butler, UNT International
Posted on: Tue 15 January 2013
Tell us how you or your area supports UNT's Four Bold Goals. Want to share a best practice? Launched a student support service? Developed an efficient process? Learn what others are doing or share your ideas.
No current Deadlines


text:
It's Celyn's and Margaux's debut in Ina Kapatid Anak February 15 2013, which is also dubbed as "Ang Gabi ng Pagpapakilala." This is the grandest night of all and it is the night when Celyn and Margaux will be formally presented to society. Celyn will also be formally introduced as a member of the Marasigan family, and the daughter of Julio and Beatrice.
Screengrab: Ina Kapatid Anak 02-15-2013
Ina Kapatid Anak stars Kim Chiu, Maja Salvador, Enchong Dee and Xian Lim. It airs weeknights on Abs-Cbn Primetime Bida at 8:15 PM.
You may watch the full video replay of Ina Kapatid Anak February 15 2013 online at the following sites:
- Iwantv (Philippine residents) - click HERE. (You will have to login or register first at iwantv.com.ph before you will be able to watch the video.)
- TFC.tv (Viewers abroad) - click HERE. (You will have to login or subscribe first at tfc.tv before you will be able to watch the full video, whenever the latest episode is already available.)
|Previous Episode
|Next Episode
For more Pinoy News & Entertainment Updates,
like/follow Tsapsuy on Facebook and Twitter.
TrulyRichClub.com - Do You Want to Gain Financial Wealth and Spiritual Abundance at the Same Time?


text:
Bring me the head of Mr. Danders!
cake by Amy Thompson, photo by Bruce Guthrie. It was delicious.
Bruce Guthrie took a ton of SPX shots and has some online.
At Richard's talk at the Bethesda Writer's Center, Richard's the one in the sports coat, I'm wearing a black sweater and editorial cartoonist Jen Sorenson's in a leather coat, and then a short-sleeve yellow shirt. Be sure to notice the piles of original art Richard's handing around.
Bruce's SPX pics can be seen here and here. Note Richard Thompson introducing himself to Jeff Smith of 'Bone' fame for the sake of his daughters.
ComicsDC is for information and events relating to cartoons and comics (including comic books, comic strips, political cartoons, animation and caricature) in Washington, DC and its environs (including counties such as Arlington, Alexandria, Fairfax, Prince George's, and Montgomery.) Press releases including store events are welcomed - email email@example.com.
Tuesday, October 16, 2007
Bruce Guthrie's pix of Richard Thompson and Small Press Expo
2 comments:
- richardcthompson said...
Nightmarish, but tasty!
- Mike said...
I liked the brains...
Subscribe to: Post Comments (Atom)


text:
11:08 PM Rome
11:08 PM Rome
As of today! This blog is officially the animations of my life.
9:31 PM Rome
Get excited!
This blog will be back, and better than ever with in the next week! I just need to wait for one, important thing.
11:53 PM Rome
11:51 PM Rome
Snuggling while he rubs your arm. Oh yeah, that's why I miss home.
9:37 PM Rome
How to get a boy to tell you: I love you.
- Give him a Girl Scout cookie.
6:45 PM Rome
9:37 PM Rome
So excited!
I get to be with the best people in the world the ENTIRE weekend from: 9 AM to 9 PM Friday, and bright and early the next day to catch the train with them where we will be traveling to the town we will be bunking together for the next few days.
Literally, an entire weekend, no drama. Just me, my boys, and my team mates. These are the people I love.
Like my soccer mates are the best people in the world. We love each other so much. Maybe it is because we don't go to the same school so we don't have cattiness, but never the less it is awesome. We are all really quirky and stupid so it should make to be a fantastic weekend.
11:23 PM Rome
List of stuff I hate
- that teacher
- Italian class
When homework brings you to tears.
3:27 PM Rome
Just got back from serving Christmas lunch to the homeless.
There is this amazing community that does it in the center of Rome. I had a lot of fun and it was nice to do something that wasn't centered around me this holiday. I can't wait for my birthday, but really Christmas is about giving and I just had an awesome one. Now I get to help my mom cook turkey dinner :3 we have cranberry sauce.
3:21 PM Rome
12:45 PM Rome
My first DSLR is in the mail. <3
I can't wait.


text:
As opposed to yurts, these dome homes are super-insulated, steel reinforced concrete structures. They do share a similar shape to yurts but these buildings can be used as homes, schools, gymnasiums, or storage facilities. The home living plans are unique and we'd be curious to hear from someone who has lived in one.
Check out the residential online evaluator to calculate how much your dream dome would cost.
The following two tabs change content below.
Timothy Dahl
Founder/EIC at Charles & Hudson
Timothy's background includes stints at This Old House, ELLE DECOR, Metropolitan Home and Woman's Day. His work has been published on Wired Design, Bob Vila, DIY Network, The Family Handyman and Popular Mechanics and he has been featured on the Martha Stewart radio show and as a speaker at the ALT Design Summit, K/BIS and the National Hardware Show.
Latest posts by Timothy Dahl (see all)
- Build a Sawhorse Table - September 25, 2014
- Let there be Light: Formulating Our Renovation Plan - September 23, 2014
- Magnum Work Boots: Precision Ultra Lite II Review - September 11, 2014


text:
Sitting in his Land Rover under the shade of a tree at the Hilmi Hoti School in Kosovo, Nathan Hoppe was surrounded by the bustle of some 200 children. It was the second of five camps that he and his wife Gabriela led during the summer months of June and July. He watched as the twenty-five youth counselors and volunteers from Albania engaged the children with music, song, and dance. Though they did not know it, Nathan was attuned to the social formation that was taking place in the children's hearts.
With support of a generous grant from the Orthodox Christian Mission Center's (OCMC) Agape Canister Program, the Kosovo Day Camps are teaching citizenship skills and basic human values that children need to be productive members of their society. Every year there is a theme, which the camp staff discusses and teaches through use of the fine arts. At the closing day of the camp, there is a festival in which the children present songs, poems and skits that they have prepared often reflecting the theme of the camp. Agape funds are used to purchase supplies, compensate the staff, and offset the cost of travel between camp sites.
Local government officials have affirmed that the Kosovo Day Camps have a tremendously positive impact on the whole emotional environment of the area. "It was like everyone started off the academic year with fully charged batteries ready to go and ready to learn after the stimulating experience of the camp," said Idriz Hoti, a former Kosovo Liberation Army officer who now directs a village school in the town of Caralluk.
During their time in Kosovo, Nathan and Gabriela are also able to visit many Serbian and Albanian friends. This spring marks ten years since the end of the war in Kosovo and the Hoppe's have seen many positive changes. Perhaps the most visible is the opening of a new road between Tirana and Prishtina, which cuts the travel time in half and dramatically reduces wear and tear on both people and automobiles.
The Agape Canister Program truly allows God's love to shine forth and helps to heal the wounds and brokenness in this part of the world. Currently Agape funds are supporting nine projects in eight countries around the world. If you would like to become an Agape partner, send an email to firstname.lastname@example.com or call 1-877-GO-FORTH


text:
Editor's Note: This story has been updated to include the race results.
Joggers and walkers got the rare chance to hit the pavement of S. Coast Highway 101 Sunday morning during the Cardiff Kook Run, a combined 5K and 10K race through Encinitas.
Named after the famed statue with an ever-changing wardrobe, the event featured around 2,000 entrants that were up bright and early on Super Sunday 2012, many in costume and more than a few pushing baby strollers.
Both races started and finished on Third Street just south of C Street near . The course turned east on D Street and continued southbound on Second Street through J Street, and then southbound on S. Coast Highway 101. The 10K turnaround was about a half mile south of in Cardiff.
This was the first year for the Cardiff Kook Run, and founders Steve Lebherz and Seth Brewer intend to make it an annual tradition on Super Sunday.
Lebherz said the proceeds from the race will benefit physical education programs at and to maintain the area surrounding the Cardiff Kook statue.
The 10K first place went to Nazario Romero, who finished with a 31:21.5. Close behind was Lief Anderson at 31:25.8, and Okwaru Rura at 31:42.9.
Tony Herr placed first in the 5K at 16:02.6. Second place went to David Easa at 16:21.2, and third place went to Sean Fader at 17:16.0.
You can see a complete list of the results for the 10K and 5K here, courtesy of Gemini Timing.
Did you take photos at this event? Add them to our story, or email them to editor Marlena Medford at firstname.lastname@example.com.
Like this article? Like us on Facebook, too. Or follow us on Twitter.


text:
Better than expected very comfortable
2 New Czech Military Surplus Training Suits, Blue
Item # WX2-191655
- Google+
- Details & Specs
2 new Czech Military Surplus Training Suits PRICED RIGHT !
A major military surplus deal on Top and Bottom pairs for working out and hanging out! New, true blue, comfortable and even a little stylish. The Top has 3/ 4 -zip neck, rib-knit cuffs and waist. Bottoms have elastic waist and cuffs and a single side pocket. Both are an easy-care polyester blend. Machine wash / dry. Imported.
Condition: brand new, never issued.
State Size, as available in the Shopping Cart. A full-body, 2-Pk. value! Get yours ONLINE now!
Please Note : Zipper styles may vary. Sorry, no choice.
!!! Limited Quantities !!!
- Reviews
Customer Reviews
You May Also Like
New Swedish Cotton Training Set, Royal BlueBuyer's Club $17.99 Non-Members $17.99
Used Italian Military Surplus Training SetBuyer's Club $24.99 Non-Members $24.99
10 New Czech Tank Tops, WhiteBuyer's Club $17.99 Non-Members $19.99


text:
|Magnetic Resonance Spectroscopy
|Medical Policy
|Original Policy Date
|Last Review Status/Date
Reviewed literature search/12:2012
|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.
Magnetic resonance spectroscopy (MRS) is a noninvasive technique that can be used to measure the concentrations of different chemical components within tissues. The technique is based on the same physical principles as magnetic resonance imaging (MRI) and the detection of energy exchange between external magnetic fields and specific nuclei within atoms.
Magnetic resonance spectroscopy (MRS) is a noninvasive technique that can be used to measure the concentrations of different chemical components within tissues. The technique is based on the same physical principles as magnetic resonance imaging (MRI) and the detection of energy exchange between external magnetic fields and specific nuclei within atoms. With MRI, this energy exchange, measured as a radiofrequency signal, is then translated into the familiar anatomic image by assigning different gray values according to the strength of the emitted signal. The principal difference between MRI and MRS is that in MRI, the emitted radiofrequency is based on the spatial position of nuclei, while MRS detects the chemical composition of the scanned tissue. The information produced by MRS is displayed graphically as a spectrum with peaks consistent with the various chemicals detected. MRS may be performed as an adjunct to MRI. An MRI image is first generated, and then MRS spectra are developed at the site of interest, termed the voxel. While an MRI provides an anatomic image of the brain, MRS provides a functional image related to underlying dynamic physiology. MRS can be performed with existing MRI equipment, modified with additional software and hardware.
MRS has been studied most extensively in a variety of brain pathologies. In the brain, both 1-H (i.e., proton) and 31-P are present in concentrations high enough to detect and thus have been used extensively to study brain chemistry. For example, proton MRS of the healthy brain reveals 5 principal spectra:
- Arising from N-acetyl groups, especially N-acetylaspartate (NAA)
NAA intensity is thought to be a marker of neuronal integrity and is the most important proton signal in studying central nervous system (CNS) pathology. Decreases in the NAA signal are associated with neuronal loss.
- Arising from choline-containing compounds (Cho), such as membrane phospholipids (e.g., phosphocholine and glycerophosphocholine). Choline levels increase in acute demyelinating disease. Brain tumors may also have high signals from Cho.
- Arising from creatine and phosphocreatine
In the brain, creatine is a relatively constant element of cellular energetic metabolism and thus is sometimes used as an internal standard.
- Arising from lipid
- Arising from lactate
Normally this spectrum is barely visible, but lactate may increase to detectable levels when anaerobic metabolism is present. Lactate may accumulate in necrotic areas, in inflammatory infiltrates, and in brain tumors.
Different patterns of the above spectra and others, such as myoinositol and glutamate/glutamine, in the healthy and diseased brain are the basis of clinical applications of MRS. The MRS findings characteristically associated with non-necrotic brain tumors include elevated Cho levels and reduced NAA levels. The International Network for Pattern Recognition using Magnetic Resonance (Available online at: http://azizu.uab.es/INTERPRET/index.html) has developed a user-friendly computer program for spectral classification and a database of 300 tumor spectra with histologically validated diagnoses to aid radiologists in MRS diagnosis. (1)
All the findings reported in this policy refer to proton MRS, unless otherwise indicated.
One of the limitations of MRS is that it provides the metabolic composition of a given voxel, which may include more than one type of tissue. For some applications, the voxels are relatively large (e.g., greater than 1 cm3), although they may be somewhat smaller using a (3 Tesla) 3T MRI machine versus a 1.5T magnet. The 3T technique creates greater inhomogeneities, however, which require better shimming techniques. (2) There are 2 types of MRS data acquisition: single voxel or simultaneous multivoxel, also called chemical shift imaging. Reliable results are more difficult to obtain from some areas, e.g., close to the brain surface or in children with smaller brains because of the lipid signal from the skull. Some techniques are used to deal with these issues; various MRS techniques continue to be explored as well. A combination of MRS is often used with other MRI techniques, including diffusion-tensor imaging, susceptibility-weighted imaging, etc., and possibly other types of imaging such as positron emission tomography (PET).
Peripheral applications of MRS include the study of myocardial ischemia, peripheral vascular disease, and skeletal muscle. Applications in non-CNS (central nervous system) oncologic evaluation have also been explored. Nomograms for prostate cancer are being developed that incorporate MRI and MRS results. (3)
Multiple software packages for performing proton MRS have received clearance by the U.S. Food and Drug Administration (FDA) through the 510(k) process since 1993.
Magnetic resonance spectroscopy is considered investigational.
Policy Guidelines
CPT code 76390 describes magnetic resonance spectroscopy.
Benefit Application
BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational, and thus these devices may be assessed only on the basis of their medical necessity.
The policy was created in 2000 and has been updated on a regular basis with literature searches of the MEDLINE database. The most recent search was conducted for the period of October 2011 through October 2012. The findings of the literature searches are summarized below.
Validation of a new imaging technique involves the following steps:
- Demonstration of its technical feasibility, including assessment of its reproducibility and precision.
- An understanding of normal and abnormal values as studied in different clinical situations. For accurate interpretation of study results, sensitivities, specificities, and positive and negative predictive values compared to a reference standard must be known.
- The clinical utility of an imaging study is related to how the results of that study can be used to benefit patient management. The clinical utility of both true-positive and true-negative tests must be assessed. Relevant outcomes of a negative test (i.e., suspected pathology is not present) may be avoidance of more invasive diagnostic tests or avoidance of ineffective therapy. Relevant outcomes of a positive test (i.e., suspected pathology is present) may also include avoidance of a more invasive test plus the institution of specific, effective therapy. Use of the imaging study should result in net health benefit.
The published data indicate that the second and third criteria have not been met for magnetic resonance spectroscopy (MRS). MRS has been investigated in a wide variety of clinical situations; key potential applications are discussed below.
Literature Review
There are a variety of potential indications for MRS, both for cancer and non-cancer conditions. The clinical utility of MRS will be evaluated separately for each of these indications.
Brain Tumors
A TEC Assessment was completed in 2003 evaluating MRS for evaluation of suspected brain tumors. The 2003 TEC Assessment (4) used the following study selection criteria to identify studies for inclusion in the MRS assessment:
- Sample sizes of 10 or more subjects;
- A method to confirm the MRS diagnosis;
- Specified criteria for a positive test; and
- Available data to calculate diagnostic performance.
The Assessment identified 7 studies including a total of 271 subjects. MRS would be judged to produce a beneficial effect on a health outcome if MRS correctly determined the presence or absence of a tumor and avoided the need for a brain biopsy. The Assessment concluded that MRS did not meet TEC criteria for evaluation of suspected brain tumors. (4)
One study of 12 children treated with radiation for a brain tumor had a magnetic resonance imaging (MRI) scan suggestive of either progressive/recurrent tumor or delayed cerebral necrosis. (5) MRS identified 5 of 7 recurrent tumors, for a sensitivity of 71%. MRS identified 4 of 5 cases (80%) of delayed necrosis, and a fifth case was considered inconclusive.
Five studies that evaluated a heterogeneous group of patients, some with known prior tumor, some with unknown new masses, showed variable diagnostic test characteristics for MRS with sensitivities ranging from 79% to 100% and specificity ranging from 74% to 100%. (6-11) The positive predictive value ranged from 92% to 100%, while the negative predictive value ranged from 60% to 100%. The wide range reported for diagnostic performance in these studies may reflect heterogeneous groups of patients, differences in MRS protocols, or both.
One study evaluated 51 patients with intracranial cystic lesions. (11) MRS properly assigned the correct diagnosis in 47 of 51 patients (92%). However, MRS interpretation was based on investigator judgment, rather than on formal criteria.
The 2003 TEC Assessment concluded that the overall body of evidence did not provide strong and consistent evidence regarding the diagnostic test characteristics or clinical utility of MRS for any condition. Studies of diagnostic performance often included a heterogeneous mix of patients who had clinically important differences and did not clearly delineate how MRS information would be used to guide patient management. Furthermore, differences in MRS technique and methods of analysis across studies made it difficult to synthesize findings from different studies.
A systematic literature review on MRS for the characterization of brain tumors was performed in 2006. This review evaluated whether MRS could differentiate malignant from non-malignant lesions; high-grade tumors from low-grade tumors; and metastatic from primary brain tumors. The review concluded that the evidence on MRS for characterizing brain tumors is promising but that additional high-quality studies are needed. (12) Many of the articles reviewed were flawed, in some cases because of research design and in other cases because key information needed to evaluate the study was not reported (e.g., how many days elapsed between the imaging test and the biopsy, which served as the reference standard).
Other research has attempted to determine whether MRS can differentiate the type of brain tumor. In 2012, Vicente and colleagues reported on a multi-center study to evaluate the ability of single voxel, proton MRS to differentiate 78 histologically confirmed pediatric brain tumors (29 medulloblastomas, 11 ependymomas, and 38 pilocytic astrocytomas). (13) Significant metabolic differences in tumor types were identified by MRS when results from short and long echo times were combined, suggesting that MRS may provide non-invasive diagnostic information.
In 2012, Wilson et al. evaluated MRS as a prognostic tool. This study reported on single voxel, proton MRS using short echo times to predict survival of patients with pediatric brain tumors in 115 patients followed for a median of 35 months. (14) Metabolic changes were identified that predicted survival. Poor survival was associated with lipids and scyllo-inositol while glutamine and N-acetyl aspartate were associated with improved survival (p<0.05).
Studies on the use of MRS to categorize newly diagnosed brain tumors (15); to distinguish between tumors and abscesses or other infectious processes (16); or to diagnose mitochondrial diseases (17) identify the MRS patterns associated with each type of lesion but, once again, do not include the necessary validation study or they report MRS findings that overlap across the categories of interest. Many are also retrospective. (16, 18) Preliminary studies done in Asia with a 3T MRI machine for detecting tumor versus radiation injury reported diagnostic quality MRS studies in 26/28 (93%) cases, and the sensitivity and specificity for those 26 patients based on cutoffs identified in the study were 94.1% and 100%, respectively. (15); see also (19). Validation studies using the same cutoffs in larger samples are needed. (15)
A 2009 review on MRS in radiation injury concludes the following:
MR spectroscopy is presently one of the noninvasive radiologic methods used to distinguish recurrent tumor and radiation injury in patients previously treated with radiation for neoplasm. Still, despite a considerable volume of research in the field, no consensus exists in the community regarding ratio calculations, the accuracy of MR spectroscopy to identify radiation necrosis, and the accuracy of MR spectroscopy in differentiating radiation necrosis from tumor recurrence or the true value of the method in clinical decision making. (20); for another review, see (21).
In a 2011 study, Amin and colleagues compared MRS to single-photon emission computed tomography (SPECT) in the identification of residual or recurrent glioma versus radiation necrosis in 24 patients treated with surgery and radiotherapy. (22) MRS and SPECT results differed in 9 cases of recurrence and were more accurate with SPECT. Specificity and positive predictive value were 100% in both MRS and SPECT; however, sensitivity was 61.1% versus 88.8% and negative predictive value was 46.2% versus 75%, respectively. The use of a single voxel rather than multiple voxels is noted as a limitation in interpreting the MRS results in this study.
Conclusions. Although a number of studies have examined the use of MRS to differentiate between brain tumor recurrence and radiation necrosis, the cumulative evidence remains weak. The studies tend to have small sample sizes (23, 24); they provide incomplete histopathologic data to serve as the reference standard (25); they find that combined imaging modalities, such as MRS and perfusion MRI or diffusion-weighted MRI, outperform MRS by itself (19, 26); or they identify the patterns of interest and the cutoff values for making a diagnosis without providing validation studies. (18, 27) In some cases, a mixed reference standard is used, with histopathologic findings for lesions that are excised, undergo biopsy, or are reviewed at autopsy and longer follow-up for patients not undergoing surgery. (18, 19) Although having a mixed reference standard is not optimal, it may be the only feasible option in patients with brain tumors, some of which are located in parts of the brain not amenable to surgery. Some studies report mostly on primary brain tumors, (15, 19) while others focus mostly on metastases of cancers located in other parts of the body. (23, 25)
Research continues on using MRS to identify dementia, especially in its early stages. A community-based study was conducted to evaluate whether MRS could distinguish between patients with normal cognition (Group 1), dementia (Group 2), or mild cognitive impairment (MCI; Group 3) in a population with a low Mini-Mental State Examination (MMSE) score. (28) From an initial population of 215 with low MMSE scores, MRS results were obtained for 56 patients. Comparing MRS to clinical diagnoses, the results were mixed for MRS, with statistically significant differences in metabolic patterns between patients with dementia (Group 2) and patients without dementia (Group 1 and Group 3) but not between patients with MCI and those with normal cognition (Group 1 vs. Group 3). In a 2012 study, Shiino and colleagues compared proton MRS in 99 patients with Alzheimer's disease (AD), 31 patients with subcortical ischemic vascular dementia (SIVD) and 45 elderly controls. (29) Differences in metabolic patterns were seen in both AD and SVID patients. Especially notable were increases in myoinositol concentration in the hippocampus identified in AD but not in SIVD (0.95 area under the receiver operating characteristic (ROC) curve).
Breast Cancer
MRS is being investigated to improve the specificity of MRI of the breast, which has a high false-positive rate. Bartella et al. conducted a preliminary study using MRS to evaluate suspicious lesions 1 cm or larger identified on MRI. (30) They found that the addition of MRS increased the specificity of MRI in the specific population examined to 88% (23/26) and could have prevented unnecessary biopsies; the sensitivity was 100% (31/31). As the authors note, these findings need to be confirmed in larger studies and with a more diverse set of lesions. In particular, their sample only included one ductal carcinoma in situ (DCIS), and other studies have suggested that the choline peak they used to indicate a positive MRS result may be less likely to occur with DCIS.
Liver Disease
MRS has been evaluated as a noninvasive alternative to liver biopsy in the diagnosis of hepatic steatosis. It has been compared to other noninvasive imaging procedures such as computed tomography (CT), dual-gradient echo magnetic resonance imaging (DGE-MRI), and ultrasonography (US); liver biopsy was the reference standard and a 3T MRI machine was used. In a prospective study of 161 consecutive potential living liver donors, DGE-MRI was reported to be the most accurate test for diagnosing hepatic steatosis. While DGE-MRI and MRS were similar for hepatic steatosis 5% or greater, DGE-MRI outperformed MRS for hepatic steatosis 30% or greater (especially regarding specificity) and on quantitative estimates. (31); see also (32).
Prostate Cancer
The utility of MRS has also been investigated for identifying whether prostate cancer is confined to the organ, which has implications for prognosis and treatment. Wang et al. found that the addition of MRI findings, both endorectal MRI and MRS, improved the accuracy of the staging nomograms traditionally used to predict the likelihood of organ-confined prostate cancer. (33) Although the study was not ideally designed to assess the incremental value of MRS over MRI alone, it found that the area under the ROC curve was larger when MRS was included, but the difference was not statistically significant.
The results of the American College of Radiology Imaging Network (ACRIN) study 6659 were published in April 2009. (34) This prospective, multicenter study compared the use of MRI with and without MRS to identify the extent of prostate cancer by sextant prior to prostatectomy in 134 patients. The results from centralized histopathologic evaluation of prostate specimens served as the reference standard; MRI and MRS images were independently reviewed by 8 readers. With complete data on 110 patients, no difference was found in the area under the ROC curve for MRI alone versus MRI and MRS combined. That is, the use of MRS provided no incremental value in identifying the extent of prostate cancer.
In a meta-analysis of 7 studies (of 140 screened) on using MRS to diagnose prostate cancer, the pooled weighted sensitivity was 0.82 (95% confidence interval [CI]: 0.73–0.89); specificity, 0.68 (95% CI: 0.58–0.76); and the area under the curve, 83.40. (35) All of these results are based on a cutoff for identifying "definitive" tumor of 0.85 for the ratio of (choline plus creatine) to citrate.
A single-institution randomized, controlled trial (RCT) published in 2010 compared conducting a second randomly selected biopsy (group A) to a biopsy selected partly based on MRS and dynamic contrast-enhanced (DCE) MRI results (group B). (36) The participants were selected from 215 consecutive men with an elevated prostate-specific-antigen (PSA) (between 4 and 10 ng/mL), an initial negative biopsy result, and a negative digital rectal examination; 180 patients participated in the study. Cancer was detected in 24.4% of group A patients and 45.5% of group B participants. Fifty patients from group A with 2 negative biopsy results agreed to undergo biopsy a third time using MRS and DCE MRI results; 26 more cancers were found. Overall, 61.6% of the cancers detected had Gleason scores 7 (4+3) or more. The cancers detected after using MRS and dynamic contrast-enhanced MRI imaging also lined up with the suspicious areas detected on imaging. The sensitivity and specificity of MRS were 92.3% and 88.2%, respectively; adding dynamic, contrast-enhanced MRI increased the sensitivity to 92.6%, and the specificity to 88.8%. Limitations of the study include that it was conducted at a single center, analysis was confined to the peripheral zone of the prostate gland, and more samples were drawn from group B patients than from group A patients (12.17 vs. 10 cores, respectively). Furthermore, given the concerns about potential overtreatment among patients with early stage prostate cancer, the benefits of detecting these additional cancers need to be evaluated by examining clinical outcomes for these patients. Similar issues arise in Policy 7.01.121 on saturation biopsy of the prostate.
In a similar report from this institution by these authors, 150 patients with a negative prostate biopsy, despite PSA elevations, were randomized to MRS or MRS plus DCE-MRI to locate prostate cancer foci for a second targeted biopsy. (37); see also (38). The addition of DCE-MRI to MRS yielded increased sensitivity and specificity over MRS alone (93.7% and 90.7% versus 82.8% and 91.8%, respectively). Pedrona and colleagues also reported on the combined use of MRS and DCE-MRI for prostate cancer in 106 patients in a prospective cohort study. (39) The authors reported combined MRS and DCE-MRI results yielded unacceptably low positive predictive value of 19%. Negative predictive value was 91%. Sensitivity was 71% and specificity was 48%. The authors indicated the combined MRS and DCE-MRI may be useful in avoiding biopsy since the negative predictive value was 91%; however, further study is needed.
Gauging Treatment Response
The possibility of using MRS to track treatment response and failure has been explored. A small (n=16), preliminary study of tamoxifen treatment for recurrent gliomas found MRS patterns differed between responders and nonresponders. (40) Serial MRS demonstrated that metabolic spectra stabilized after initiation of therapy among responders and then changed in advance of clinical or radiologic treatment failure. In other words, MRS might help predict imminent treatment failure. However, there are relatively few studies with small sample sizes assessing this possible use of MRS. In addition, a number of other types of imaging are being evaluated for the same use, including dynamic, contrast-enhanced MRI, diffusion-weighted MRI, and 18-fluorodeoxyglucose position emission tomography (FDG-PET). Additional studies are needed, including studies comparing modalities or evaluating multimodalities. (41, 42)
Other Indications
MRS has also been evaluated for other uses, such as tracking disease changes among patients with multiple sclerosis (MS), (43) assessing carotid plaque morphology, (44) as biomarkers of traumatic brain injury (45) predicting long-term neurodevelopmental outcome after neonatal encephalopathy, (46); but see also (47) and other applications in children. (48, 49) Additional evidence on these applications is needed.
Ongoing Clinical Trials
A search of online site ClinicalTrials.gov in November 2012 identified many studies using MRS as a research tool. Two active studies on the utility of MRS include the use of MRS to detect cervical cancer (NCT01060033) and for guidance on glioma treatment choice (NCT01263821).
Physician Specialty Society and Academic Medical Center Input
In 2008, in response to requests, input was received from 3 physician specialty societies and 1 academic medical center while this policy was under review. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. The input received from these reviewers disagreed with the conclusions in the policy statement. In particular, information provided was in support of MRS in differentiating radiation necrosis from recurrent tumor and in the differential diagnosis of certain CNS tumors from non-tumors.
Magnetic resonance spectroscopy (MRS) is a noninvasive technique that can be used to measure the concentrations of different chemical components within tissues. The available studies do not provide strong and consistent evidence regarding the diagnostic test characteristics of MRS. Studies do not clearly delineate how MRS information would be used to guide patient management. Thus, it is not possible to determine whether MRS provides relevant clinical information that will safely influence diagnostic thinking and therapeutic choice. The scientific evidence at this time does not permit conclusions concerning the net effect of this technology on health outcomes. Therefore, the use of MRS is considered investigational.
Practice Guidelines and Position Statements
The National Comprehensive Cancer Network's clinical practice guidelines on central nervous system tumors identifies MRS, along with MR perfusion or brain PET, as a modality that can be considered to rule out radiation necrosis, as compared to recurrence of brain tumors. (50) The authors also state that MRS may be helpful in grading tumors or assessing response and that the most abnormal area on MRS would be the best target for biopsy. The limitations include tumors near vessels, air spaces, or bone; the extra time required in an MRI machine; and the limitations occurring with any MRI, such as the exclusion of patients with implantable devices. The guidelines on prostate cancer mention MRS as a possible element of "more aggressive workup for local recurrence (e.g., repeat biopsy, MR spectroscopy, endorectal MRI)," which is one possible element of salvage therapy for patients after radical prostatectomy with rising PSA or positive digital rectal examination after radical prostatectomy with a negative biopsy and studies negative for metastases. (51) The guideline on breast cancer does not mention MRS.
The American College of Radiology updated its practice guideline on MRS of the CNS in 2008. (52) Most of the guideline is devoted to the actual performance of MRS, but it also lists 22 possible indications for MRS when MRI or CT are inadequate for answering specific clinical questions.
Medicare National Coverage
In January 2004, Medicare issued a decision memorandum for MRS for brain tumors that reaffirmed its national noncoverage determination. (53) After reviewing updated literature, a technology assessment it commissioned from the Agency for Healthcare Research and Quality, and the BCBSA TEC Assessment, Medicare found that there was not adequate evidence to conclude that MRS is reasonable and necessary for the diagnosis of brain tumors.
- Sibtain NA, Howe FA, Saunders DE. The clinical value of proton magnetic resonance spectroscopy in adult brain tumours. Clin Radiol 2007; 62(2):109-19.
- Sood S, Gupta A, Tsiouris AJ. Advanced magnetic resonance techniques in neuroimaging: diffusion, spectroscopy, and perfusion. Semin Roentgenol 2010; 45(2):137-46.
- Hricak H, Choyke PL, Eberhardt SC et al. Imaging prostate cancer: a multidisciplinary perspective. Radiology 2007; 243(1):28-53.
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Magnetic resonance spectroscopy for evaluation of suspected brain tumor. TEC Assessments 2003; Volume 18, Tab 1.
- Taylor JS, Langston JW, Reddick WE et al. Clinical value of proton magnetic resonance spectroscopy for differentiating recurrent or residual brain tumor from delayed cerebral necrosis. Int J Radiat Oncol Biol Phys 1996; 36(5):1251-61.
- Rand SD, Prost R, Haughton V et al. Accuracy of single-voxel proton MR spectroscopy in distinguishing neoplastic from nonneoplastic brain lesions. AJNR Am J Neuroradiol 1997; 18(9):1695-704.
- Adamson AJ, Rand SD, Prost RW et al. Focal brain lesions: effect of single-voxel proton MR spectroscopic findings on treatment decisions. Radiology 1998; 209(1):73-8.
- Kimura T, Sako K, Gotoh T et al. In vivo single-voxel proton MR spectroscopy in brain lesions with ring-like enhancement. NMR Biomed 2001; 14(6):339-49.
- Lin A, Bluml S, Mamelak AN. Efficacy of proton magnetic resonance spectroscopy in clinical decision making for patients with suspected malignant brain tumors. J Neurooncol 1999; 45(1):69-81.
- Wilken B, Dechent P, Herms J et al. Quantitative proton magnetic resonance spectroscopy of focal brain lesions. Pediatr Neurol 2000; 23(1):22-31.
- Shukla-Dave A, Gupta RK, Roy R et al. Prospective evaluation of in vivo proton MR spectroscopy in differentiation of similar appearing intracranial cystic lesions. Magn Reson Imaging 2001; 19(1):103-10.
- Hollingworth W, Medina LS, Lenkinski RE et al. A systematic literature review of magnetic resonance spectroscopy for the characterization of brain tumors. AJNR Am J Neuroradiol 2006; 27(7):1404-11.
- Vicente J, Fuster-Garcia E, Tortajada S et al. Accurate classification of childhood brain tumours by in vivo(1)H MRS - A multi-centre study. Eur J Cancer 2012 [Epub ahead of print].
- Wilson M, Cummins CL, Macpherson L et al. Magnetic resonance spectroscopy metabolite profiles predict survival in paediatric brain tumours. Eur J Cancer 2012 [Epub ahead of print].
- Zeng QS, Li CF, Zhang K et al. Multivoxel 3D proton MR spectroscopy in the distinction of recurrent glioma from radiation injury. J Neurooncol 2007; 84(1):63-9.
- Garg M, Gupta RK, Husain M et al. Brain abscesses: etiologic categorization with in vivo proton MR spectroscopy. Radiology 2004; 230(2):519-27.
- Bianchi MC, Tosetti M, Battini R et al. Proton MR spectroscopy of mitochondrial diseases: analysis of brain metabolic abnormalities and their possible diagnostic relevance. AJNR Am J Neuroradiol 2003; 24(10):1958-66.
- Weybright P, Sundgren PC, Maly P et al. Differentiation between brain tumor recurrence and radiation injury using MR spectroscopy. AJR Am J Roentgenol 2005; 185(6):1471-6.
- Zeng QS, Li CF, Liu H et al. Distinction between recurrent glioma and radiation injury using magnetic resonance spectroscopy in combination with diffusion-weighted imaging. Int J Radiat Oncol Biol Phys 2007; 68(1):151-8.
- Sundgren PC. MR spectroscopy in radiation injury. AJNR Am J Neuroradiol 2009; 30(8):1469-76.
- Martinez-Bisbal MC, Celda B. Proton magnetic resonance spectroscopy imaging in the study of human brain cancer. Q J Nucl Med Mol Imaging 2009; 53(6):618-30.
- Amin A, Moustafa H, Ahmed E et al. Glioma residual or recurrence versus radiation necrosis: accuracy of pentavalent technetium-99m-dimercaptosuccinic acid [Tc-99m (V) DMSA] brain SPECT compared to proton magnetic resonance spectroscopy ((1)H-MRS): initial results. J Neurooncol 2012; 106(3):579-87.
- Kimura T, Sako K, Tohyama Y et al. Diagnosis and treatment of progressive space-occupying radiation necrosis following stereotactic radiosurgery for brain metastasis: value of proton magnetic resonance spectroscopy. Acta Neurochir (Wien) 2003; 145(7):557-64; discussion 64.
- Schlemmer HP, Bachert P, Henze M et al. Differentiation of radiation necrosis from tumor progression using proton magnetic resonance spectroscopy. Neuroradiology 2002; 44(3):216-22.
- Chernov MF, Hayashi M, Izawa M et al. Multivoxel proton MRS for differentiation of radiation-induced necrosis and tumor recurrence after gamma knife radiosurgery for brain metastases. Brain Tumor Pathol 2006; 23(1):19-27.
- Truong MT, St Clair EG, Donahue BR et al. Results of surgical resection for progression of brain metastases previously treated by gamma knife radiosurgery. Neurosurgery 2006; 59(1):86-97; discussion 86-97.
- Rock JP, Hearshen D, Scarpace L et al. Correlations between magnetic resonance spectroscopy and image-guided histopathology, with special attention to radiation necrosis. Neurosurgery 2002; 51(4):912-9; discussion 19-20.
- Garcia Santos JM, Gavrila D, Antunez C et al. Magnetic resonance spectroscopy performance for detection of dementia, Alzheimer's disease and mild cognitive impairment in a community-based survey. Dement Geriatr Cogn Disord 2008; 26(1):15-25.
- Shiino A, Watanabe T, Shirakashi Y et al. The profile of hippocampal metabolites differs between Alzheimer's disease and subcortical ischemic vascular dementia, as measured by proton magnetic resonance spectroscopy. J Cereb Blood Flow Metab 2012; 32(5):805-15.
- Bartella L, Morris EA, Dershaw DD et al. Proton MR spectroscopy with choline peak as malignancy marker improves positive predictive value for breast cancer diagnosis: preliminary study. Radiology 2006; 239(3):686-92.
- Lee SS, Park SH, Kim HJ et al. Non-invasive assessment of hepatic steatosis: prospective comparison of the accuracy of imaging examinations. J Hepatol 2010; 52(4):579-85.
- Taouli B, Ehman RL, Reeder SB. Advanced MRI methods for assessment of chronic liver disease. AJR Am J Roentgenol 2009; 193(1):14-27.
- Wang L, Hricak H, Kattan MW et al. Prediction of organ-confined prostate cancer: incremental value of MR imaging and MR spectroscopic imaging to staging nomograms. Radiology 2006; 238(2):597-603.
- Weinreb JC, Blume JD, Coakley FV et al. Prostate cancer: sextant localization at MR imaging and MR spectroscopic imaging before prostatectomy--results of ACRIN prospective multi-institutional clinicopathologic study. Radiology 2009; 251(1):122-33.
- Wang P, Guo YM, Liu M et al. A meta-analysis of the accuracy of prostate cancer studies which use magnetic resonance spectroscopy as a diagnostic tool. Korean J Radiol 2008; 9(5):432-8.
- Sciarra A, Panebianco V, Ciccariello M et al. Value of magnetic resonance spectroscopy imaging and dynamic contrast-enhanced imaging for detecting prostate cancer foci in men with prior negative biopsy. Clin Cancer Res 2010; 16(6):1875-83.
- Panebianco V, Sciarra A, Ciccariello M et al. Role of magnetic resonance spectroscopic imaging ([(1)H]MRSI) and dynamic contrast-enhanced MRI (DCE-MRI) in identifying prostate cancer foci in patients with negative biopsy and high levels of prostate-specific antigen (PSA). Radiol Med 2010; 115(8):1314-29.
- Panebianco V, Sciarra A, Lisi D et al. Prostate cancer: 1HMRS-DCEMR at 3T versus [(18)F]choline PET/CT in the detection of local prostate cancer recurrence in men with biochemical progression after radical retropubic prostatectomy (RRP). Eur J Radiol 2012; 81(4):700-8.
- Perdona S, Di Lorenzo G, Autorino R et al. Combined magnetic resonance spectroscopy and dynamic contrast-enhanced imaging for prostate cancer detection. Urol Oncol 2011 [Epub ahead of print].
- Sankar T, Caramanos Z, Assina R et al. Prospective serial proton MR spectroscopic assessment of response to tamoxifen for recurrent malignant glioma. J Neurooncol 2008; 90(1):63-76.
- Dhermain FG, Hau P, Lanfermann H et al. Advanced MRI and PET imaging for assessment of treatment response in patients with gliomas. Lancet Neurol 2010; 9(9):906-20.
- Harry VN, Semple SI, Parkin DE et al. Use of new imaging techniques to predict tumour response to therapy. Lancet Oncol 2010; 11(1):92-102.
- Bellmann-Strobl J, Stiepani H, Wuerfel J et al. MR spectroscopy (MRS) and magnetisation transfer imaging (MTI), lesion load and clinical scores in early relapsing remitting multiple sclerosis: a combined cross-sectional and longitudinal study. Eur Radiol 2009; 19(8):2066-74.
- Hermus L, Tielliu IF, Wallis de Vries BM et al. Imaging the vulnerable carotid artery plaque. Acta Chir Belg 2010; 110(2):159-64.
- Kou Z, Wu Z, Tong KA et al. The role of advanced MR imaging findings as biomarkers of traumatic brain injury. J Head Trauma Rehabil 2010; 25(4):267-82.
- Thayyil S, Chandrasekaran M, Taylor A et al. Cerebral magnetic resonance biomarkers in neonatal encephalopathy: a meta-analysis. Pediatrics 2010; 125(2):e382-95.
- Wilkinson D. MRI and withdrawal of life support from newborn infants with hypoxic-ischemic encephalopathy. Pediatrics 2010; 126(2):e451-8.
- Rossi A, Gandolfo C, Morana G et al. New MR sequences (diffusion, perfusion, spectroscopy) in brain tumours. Pediatr Radiol 2010; 40(6):999-1009.
- Yuh EL, Barkovich AJ, Gupta N. Imaging of ependymomas: MRI and CT. Childs Nerv Syst 2009; 25(10):1203-13.
- National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Central Nervous System Cancers; v2:2012. Available online at: http://www.nccn.org/professionals/physician_gls/pdf/cns.pdf. Last accessed November 2012.
- National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Prostate Cancer. V.3.2012. Available online at: http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Last accessed November 2012.
- American College of Radiology (ACR) and American Society of Neuroradiology (ASNR). ACR-ASNR practice guideline for the performance and interpretation of magnetic resonance spectroscopy of the central nervous system. Available online at: http://www.acr.org/~/media/B0AF516E53234DA399EF305525504249.pdf. Last accessed November 2012.
- National Coverage Determination for Magnetic Resonance Spectroscopy. Decision Memo for Magnetic Resonance Spectroscopy for Brain Tumors (CAG-00141N). Centers for Medicare and Medicaid Services. 2004. Available online at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=52&fromdb=true. Last accessed November 2012.
|Magnetic resonance spectroscopy
|ICD-9 Procedure
|ICD-9 Diagnosis
|Investigational for relevant diagnoses
|ICD-10-CM (effective 10/1/14)
|Investigational for all diagnoses
|Malignant neoplasm of breast code range
|Malignant neoplasm of prostate
|Malignant neoplasm of brain code range
|Dementia code range
|Multiple sclerosis
|Diseases of liver 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 this imaging but the codes for MRI might be used.
|Imaging, central nervous system, magnetic resonance imaging, brain, codes specific to whether or not contrast is used
|Imaging, hepatobiliary system and pancreas, magnetic resonance imaging, liver, codes specific to whether or not contrast is used
|Imaging, skin, subcutaneous tissue and breast, magnetic resonance imaging, codes specific to bilateral or right or left breast, and whether or not contrast is used
|Imaging, male reproductive system, magnetic resonance imaging, prostate, codes specific to whether or not contrast is used
|Type of Service
|Place of Service
Magnetic Resonance Spectroscopy
Spectroscopy, Magnetic Resonance
Policy History
|Add to Radiology section
|New policy
|Replace policy
|Information updated with TEC Assessment; policy statement unchanged
|Replace policy
|Medicare policy added; policy statement unchanged
|Replace policy
|Literature review update for the period of May 2003 through June 2004; references added; policy statement unchanged
|Replace policy
|Literature update through October 2005; policy statement unchanged
|Replace policy
|Policy updated with literature review through October 2006; policy statement unchanged. Reference numbers 18-23 added
|Replace policy
|Policy updated with literature review through April 2008; reference numbers 1, 2, and 25-35 added; clinical input reviewed. Policy statement unchanged
|Replace policy
|Policy updated with literature search; references 22 and 25 deleted; references 34-39 added; references renumbered. No change to policy statements
|Replace policy
|Policy updated with literature search; Rationale extensively revised. References 2, 23, 24, 28, 31, 32, 34-42, 44 added; reference 43 updated. No change to policy statement
|Replace policy
|Policy updated with literature search. References 25, 30-31 added; references 46-48 updated. No change to policy statement
|Replace Policy
|Policy updated with literature search. References 13-14, 29 and 38 added. No change to policy statement


text:
In May, Missouri lawmakers approved a compromise to keep the Common Core in place for at least two more years but require more oversight and public input. And as Joe Robertson of the Kansas City Star reported, a total of eight committees comprised of lawmakers and parents were supposed to convene at the statehouse this week to begin the work of revising the standards.
There's a section in the new Phi Delta Kappa/Gallup Poll out this week that hasn't gotten much attention: what parents think about schools and student health. (You can read my overview of the full poll, which focuses heavily on questions about teacher quality and preparation, here.)
Some of our favorite stories from EWA members for the past week:
We've all heard the phrase, "Don't believe everything you read." Or see. Or hear.
But this sage counsel often falls on deaf ears. Research shows it takes more effort to question the plausibility and source of a message than simply to accept it as true.
Who are English language learners?
Some would argue there's no consistent answer.
Robert Linquanti, the bilingual project director for English Learner Evaluation and Accountability Support at WestEd, presented on the topic at the EWA Spanish-Language Media Convening in Dallas earlier this month.
After spending more than $3.5 billion on a program to improve chronically low-performing schools — only to see mixed results — the Obama administration is proposing major revisions to the menu of turnaround efforts that low-performing schools can undertake to qualify for funding under the program.
Stephanie Dupaul of Southern Methodist University put the theme of EWA's 2014 Higher Education seminar, "The Good, the Bad and the Ugly: Covering the College Student Experience," to effective use during a session exploring the use of data by colleges:
In a new poll out today, Americans say they want teacher preparation programs to raise the bar for entrance, provide longer training periods for practice teaching, and require new teachers to pass a rigorous certification exam akin to the ones required of lawyers and doctors.
A collection of the latest education journalism, curated by EWA staff.
Apply now for this journalists-only event, Oct. 20-21 in Detroit.
Scott Jaschik of Inside Higher Ed talks to reporters at EWA's 2014 Higher Education Seminar.
Recorded Sept. 6, 2014, at Southern Methodist University in Dallas.
Prompted by the controversy over the type of equipment the Ferguson police department used during protests over the death of Michael Brown, news organizations across the country started requesting information about a U.S. Department of Defense program that provided police departments with defense equipment.
Why should education reporters care?
Some of those police departments happen to belong to school districts, colleges and universities.
The cover story of the New York Times Magazine's Education Issue is a coveted position, and this week it goes to the Big History Project, an online curriculum backed by Bill Gates that's expanding into public school classrooms across the country.
The field of early childhood education—spanning infancy to 3rd grade—has seen tremendous change in recent years, particularly in the years before kindergarten.
If you're new to journalism, or if you're a veteran reporter covering education for the first time, here are a few quick resources to get you up to speed.
Among school reformers, "college readiness" has become a rallying cry. But what does it mean, and how does career readiness factor in?
Philadelphia, PA — Choice Media released the second set of ads in the 4 week PhillySchoolChoice.com campaign to promote education choices to Philadelphia families. This ad campaign features local parents sharing their personal stories about educational options such as charter schools and tax credit scholarships for private schools.
Applications are now being accepted for the 2015-16 John S. Knight Journalism Fellowships program at Stanford University.
The application deadline is Dec. 1, 2014.
Registration and scholarship information now available.
Sign up for the National Seminar


text:
from the editors of:
Camaro Performers
GM High Tech Performance
Super Chevy
Chevy High-Performance
Super Chevy
Chevy High-Performance
All Chevys
55-57 Chevys
Other Vehicles
tech & how to
engines & drivetrain
Chassis & Suspension
paint & body
project cars
additional tech
Best of the Best
Super Chevy
Chevy High-Performance
GM High Tech Performance
How To
Custom Paint Removal - Just Take It Off And Strip
A Disassembly And Paint Removal How-To
Steve Dulcich
May 1, 2008
Planet Color
Santa Ana, CA
« Prev
Next »
View Full Article »
Custom Paint Removal - Just Take It Off And Strip
Wiping compound into body.
We began disassembly of some components while the bumper caps were off. the complete front headlamp assemblies were removed while the front caps were off. there is no way to completely detail paint these without removal, particularly in a color change.
Likewise, the side marker lights were removed from their recesses. We couldn't live with ourselves knowing there is the old white paint in behind there if we simply taped them off. Save all the stock hardware, and catalog it for reassembly.
Our '76 corvette has a key-lock for the factory alarm system mounted in the left front fender, retained by a clip like a door lock. We debated whether it will go back in or not in our custom corvette, and still have not decided. the "Stingray" emblems were in their last year for 1976 and are retained by adhesive. We pried carefully to remove.
There is no way to get a clean finish inside the gas cap area without removing it. four screws and it's out, so it should be removed for any detailed paint job.
The radio antenna mast unscrews from the base, and the base is retained by a large nut that is sometimes stubborn. We worked the nut back and forth with penetrating oil. Once it was loose, the mast was unscrewed, and the base was dropped through the fender.
Our intention is to fully detail all the jambs, which means removing all the hardware, such as these guides for the t-tops; otherwise there will be a visible tape line and white paint hidden underneath.
Detail work necessitates removing all the weatherstripping for a high-quality job. the rear window seal channel was removed by drilling the rivets.
More jamb hardware includes the sill plates, moldings, and the rear finish strip that requires drilling more rivets for removal. All the adjacent interior trim panels will be removed or pulled back before painting.
The lower rocker trim is held on by machine screws along the length. unfortunately, a couple of ours were frozen and required drilling for removal. Once again, for a typical production paint job, many shops will leave these in place, but we wanted the new color to have complete coverage, even where hidden from sight.
Removing the side rearview mirror is done from the exterior of the door, first removing the mounting pin screw to free the mirror, and then two screws to remove the mounting bracket.
This kind of a job necessitates getting inside the doors, which begins with removal of the door panel. the window fuzzy is held on by screws at both ends and snaps out with a stern thumb push. failing to remove these will leave a tape line all across the top of the door.
Getting at the door handle fastener is tight, but with the linkage disconnected and two 7/16-inch nuts removed, the handle is out. the door lock is freed by removing a clip from inside the door.
Here is the reason many corvettes of this vintage need to be stripped of all paint. looking close, the paint is covered in fine cracks, and these go right down to the bottom layer of primer. Painting over a surface like this will inevitably lead to the cracks reappearing.
Our choice for paint removal was a commercial paint stripper. Although sometimes paints can be tough, ours literally melted as the stripper was applied. Work a panel or smaller area at a time, putting a thick, even layer of stripper on the surface with a brush.
Once the stripper has had time to work, use a plastic bondo spreader to scrape the bulk of the goo from the surface and into a container. Our topcoat came off with a single application.
After scraping, the stripped panels were wiped with a clean rag wet with acetone. this removed the remaining paint and most of the stripper residue. the remaining primer is soft compared to the paint and easily sands off.
related articles
Chevrolet Corvette C3 Upgrade - Tech Articles - Corvette Fever Magazine
Read the tech article on upgrading the disc brakes on a 1968 to 1982 c3 corvette using stainless steel brakes force 10 extreme kit.
Read More
Chevrolet Corvette C3 Replacement Bumper - Rubber Bumper Quick Fix - Corvette Fever Magazine
Replace your damaged Chevrolet Corvette C3 Bumper with this Replacement Bumper article, Check out this 1976 Chevrolet Corvette featured in the 2008 May issue of Corvette Fever Magazine or at corvettefever.com.
Read More
1980 Chevrolet Corvette C3 - Vette Magazine
Check out the common problem with 1980 Chevrolet Corvette C3; more spicifically their windshield frame. This problem is known to cause leaks. Check out how to repair it now! - Vette Magazine
Read More
2005 Best Chevrolet Corvette Shops - Tech Articles - Corvette Fever Magazine
Read what the 2005 Best Chevrolet Corvette Shops are, brought to you by the experts at Corvette Fever Magazine.
Read More
most popular
recent how to articles
Chevy Performance Tech Q&A - November 2014
Chevy Performance Parts Bin - October 2014
1971 Chevrolet Camaro Project Orange Krate - Full Frontal
Techin' In With Fletch - October 2014
Inside the New 507-cfm Brodix SR20 Chevy Cylinder Head
sponsored links
subscribe to the magazine
Subscribe and Save 74% off the Cover Price!
get digital
get print


text:
Next, you'll be asked to connect with Twitter. Rest assured, we will never send a tweet from your account
without your permission.
We will send you an email with an invite soon.
How To Get Your Business Listed Online with Citations http://t.co/FeNypluAip via @courtneyengle
How to Build a Better Mailing List via @mike_allton
How to Choose a Topic for Your Next Blog Post via @dukeo
Study: 73% of companies don't tell employees how to use social media via @leaderswest
Why businesses object to workplace social media and why they shouldn't by @DrACorbett via @leaderswest
Tell your business story, one blog at a time via @mike_allton
What Jimmy Fallon could teach businesses about social media via @leaderswest
See what's Trending Now for @matt_hodkinson
Follow @matt_hodkinson on Twitter


text:
Achievements Rockstar Trophies
- August 17, 2012 3:50 p.m.
- July 24, 2013 8:02 a.m.
- March 8, 2014 2:17 p.m.
43 comments
GamesRadar is the premiere source for everything that matters in the world of video games. Casual or core, console or handheld - whatever systems you own or whatever genres you love, GamesRadar is there to filter out what's worth your time and to help you get even more from your games. We deliver the best advice, the most in-depth features, expert reviews, and the essential guides for all the top games.
© Future US, Inc. 4000 Shoreline Court, Suite 400, South San Francisco, California, 94080. All Rights Reserved.
Log in using Facebook to share comments, games, status update and other activity easily with your Facebook feed.