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Number: 0369
Aetna considers the following as medically necessary exclusionary tests to be used for the evaluation of members suspected of having chronic fatigue syndrome (CFS) as recommended by the National Institutes of Health. The selection of studies depends on the specific characteristics of a given case:
* Optional tests to be used when clinically indicated.
Aetna considers the following laboratory tests and procedures experimental and investigational for the diagnosis or treatment of members with CFS. The peer-reviewed medical literature does not support their value in the diagnosis or treatment of individuals with CFS:
Note: Based on the position of the Centers for Disease Control and Prevention (CDC), the following guidelines should be used for the evaluation and study of CFS.
A thorough medical history, physical examination, mental status examination, and laboratory tests must be conducted to identify underlying or contributing conditions that require treatment. Diagnosis or classification can not be made without such an evaluation. Clinically evaluated, unexplained chronic fatigue cases can be classified as CFS if the member meets both of the following criteria:
Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social, or personal activities; and
The concurrent occurrence of 4 or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain, multi-joint pain without swelling or redness; headaches of a new type, pattern, or severity; non-refreshing sleep; and post-exertional malaise lasting more than 24 hours. These symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.
Conditions that exclude a diagnosis of CFS:
Alcohol or other substance abuse, occurring within 2 years of the onset of chronic fatigue and any time afterwards. Severe obesity as defined by a body mass index [BMI = weight in kilograms divided by (height in meters)2] equal to or greater than 45. [Note: BMI values vary considerably among different age groups and populations. No "normal" or "average" range of values can be suggested in a fashion that is meaningful. The range of 45 or greater was selected because it clearly falls within the range of severe obesity]. Any active medical condition that may explain the presence of chronic fatigue, such as untreated hypothyroidism, sleep apnea and narcolepsy, and iatrogenic conditions such as side effects of medication.
Any active medical condition that may explain the presence of chronic fatigue, such as untreated hypothyroidism, sleep apnea and narcolepsy, and iatrogenic conditions such as side effects of medication.
Any past or current diagnosis of a major depressive disorder with psychotic or melancholic features; bipolar affective disorders; schizophrenia of any subtype; delusional disorders of any subtype; dementia of any subtype; anorexia nervosa; or bulimia nervosa.
Some diagnosable illnesses may relapse or may not have completely resolved during treatment. If the persistence of such a condition could explain the presence of chronic fatigue, and if it can not be clearly established that the original condition has completely resolved with treatment, then such members should not be classified as having CFS. Examples of illnesses that can present such a picture include some types of malignancies and chronic cases of hepatitis B or C virus infection.
Any unexplained abnormality detected on examination or other testing that strongly suggests an exclusionary condition must be resolved before attempting further classification.
Conditions that do not exclude a diagnosis of CFS:
Any condition defined primarily by symptoms that can not be confirmed by diagnostic laboratory tests, including fibromyalgia, anxiety disorders, somatoform disorders, non-psychotic or melancholic depression, neurasthenia, and multiple chemical sensitivity disorder.
Any condition under specific treatment sufficient to alleviate all symptoms related to that condition and for which the adequacy of treatment has been documented. Such conditions include hypothyroidism for which the adequacy of replacement hormone has been verified by normal thyroid-stimulating hormone levels, or asthma in which the adequacy of treatment as been determined by pulmonary function and other testing.
Any condition, such as Lyme disease or syphilis that was treated with definitive therapy before development of chronic symptoms.
Any isolated and unexplained physical examination finding, or laboratory or imaging test abnormality that is insufficient to strongly suggest the existence of an exclusionary condition. Such conditions include an elevated anti-nuclear antibody titer that is inadequate, without additional laboratory or clinical evidence, to strongly support a diagnosis of a discrete connective tissue disorder.
A note on the use of laboratory tests in the diagnosis of CFS:
According to the CDC, a minimum battery of laboratory screening tests should be performed. Routinely performing other screening tests for all individuals has no known value. However, further tests may be indicated on an individual basis to confirm or exclude another diagnosis, such as multiple sclerosis. In these cases, additional tests should be done according to accepted clinical standards.
The use of test to diagnose CFS (as opposed to excluding other diagnostic possibilities) should be done only in the setting of protocol-based research. The fact that such tests are investigational and do not aid in diagnosis or management should be explained to the individual.
In clinical practice, no tests can be recommended for the specific purpose of diagnosing CFS. Tests should be directed toward confirming or excluding other possible clinical conditions. Examples of specific tests that do not confirm or exclude the diagnosis of CFS include serologic tests for Epstein-Barr virus, enteroviruses, retroviruses, human herpes virus 6, and Candida albicans; tests of immunologic function, including cell population and function studies; and imaging studies, including magnetic resonance imaging scans and radionuclide (such as single-photon emission computed tomography and positron emission tomography).Background
Chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis, is a clinically defined condition characterized by severe, persistent, disabling fatigue and a combination of symptoms that prominently feature self-reported impairments in concentration and short-term memory, sleep disturbances, and musculoskeletal pain. Diagnosis of CFS can be made only after alternative medical and psychiatric causes of chronic fatiguing illnesses have been excluded. No definitive diagnostic tests for this condition have been validated in scientific studies. Because CFS is clinically non-specific and lacks an identifiable cause or diagnostic test, it remains a diagnosis of exclusion.
In the revised definition, a consensus viewpoint from many of the leading CFS researchers and clinicians (including input from patient group representatives), CFS is treated as a subset of chronic fatigue, a broader category defined as unexplained fatigue of greater than or equal to 6-month's duration. Chronic fatigue in turn, is treated as a subset of prolonged fatigue, which is defined as fatigue lasting 1 or more months. The expectation is that scientists will devise epidemiologic studies of populations with prolonged fatigue and chronic fatigue, and search within those populations for illness patterns consistent with CFS.
In addition to a thorough history and physical examination, recommended procedures for evaluating patients suspected of having CFS include a mental status examination to identify abnormalities in mood, intellectual function, memory and personality. Evidence of psychiatric, neurologic or cognitive disorder requires that an appropriate psychiatric, psychological, or neurological evaluation be done.
Laboratory tests include a complete blood count with differential cell count, an erythrocyte sedimentation rate, a chemistry profile including liver function tests, thyroid function test (either a thyroid panel or thyroid stimulating hormone), anti-nuclear antibodies, and urinalysis. Additional tests, if indicated, include rheumatoid factor, immune globulin levels, tuberculin skin test, Lyme disease serology (if patient lives in an endemic area), HIV serology, MRI of the head (if indicated to rule out multiple sclerosis), and polysomnography (if indicated to rule out a sleep disorder).
The following tests do not confirm or exclude the diagnosis of CFS: serologic tests for Epstein-Barr virus, retroviruses (except HIV), human herpes virus 6, enteroviruses and Candida albicans; and tests of immunologic function, including cell population and function studies.
Immunologic abnormalities in patients with suspected CFS is an active area of research into the pathogenesis of CFS. However, the published literature is inadequate to determine the sensitivity, specificity, and positive and negative predictive values of these tests. Most of the research has compared the immunologic function of patients with CFS with healthy normal controls, so that it is impossible to know whether the subtle immunologic abnormalities seen are specific to CFS or could be seen in other patients with a wide variety of illnesses with overlapping symptoms.
Although it was originally thought that CFS was related to a viral etiology, more recent studies have failed to find any predictable association between CFS and any particular virus.
A National Institutes of Health consensus conference recommended a list of exclusionary laboratory tests that were considered appropriate for the work-up of a patient with suspected CFS. Since that time, there have been investigations into the immune function of patients with CFS, such as quantitative studies of natural killer cells, B and T cell subsets, and the production of cytokines, such as interferons and interleukin-2. Assessments of these immunologic parameters have produced conflicting results, in part related to varying methodologies used, the heterogeneity of patients who are tested at different points in their disease, and the dynamic nature of the immune system that makes assessment of single tests difficult. While assessments of levels of IgG subsets have shown a decrease in IgG1 and IgG3, the studies were performed on small numbers of patients with undefined control groups or only healthy controls. Therefore, it is not unexpected that the published data fail to indicate the sensitivity, specificity, positive and negative predictive value of the above immunologic tests. While immune function may provide a fertile path for research, its use in the clinical diagnosis and management of CFS is still investigational.
McCully et al (2004) examined if CFS is associated with reduced blood flow and muscle oxidative metabolism. Muscle blood flow was measured in the femoral artery with Doppler ultrasound after exercise. Muscle metabolism was measured in the medial gastrocnemius muscle with (31)P-magnetic resonance spectroscopy. Muscle oxygen saturation and blood volume were measured using near-infrared spectroscopy. The authors concluded that CFS patients showed evidence of reduced hyperemic flow and reduced oxygen delivery but no evidence that this impaired muscle metabolism. Thus, CFS patients might have altered control of blood flow, but this is unlikely to influence muscle metabolism. In addition, abnormalities in muscle metabolism do not appear to be responsible for the CFS symptoms.
Ribonuclease L (RNase L) is a protein induced by interferon that may affect certain anti-viral and anti-tumor effects observed when interferon is induced. Once activated, RNase L is thought to cleave viral DNA and triggering removal of the infected cell by inducing apoptosis. It has been posited that, in the immune cells of CFS patients, RNase L is cleaved by proteases; the resultant RNase L fragments have been posited to increase RNase L enzymatic activity and cleave cellular RNA at an accelerated rate, and also bind to and disrupt normal cellular ion flow. In this way, the RNase L fragments are thought to account for some of the physiological symptoms of CFS. Tests have been developed to quantify RNase L protein fragments (RNase L protein assay (RNAP), R.E.D. Laboratories, Reno, NV)) and to measure abnormal RNase L activity (RNase L activity assay (RNAA)). Although there is evidence that RNase L fragments are increased in a subset of patients with CFS, it has not been demonstrated that measurement of RNase L fragments or enzymatic activity is useful for either the diagnosis or management of persons with CFS.
Kawai and Rokutan (2007) noted that CFS is a complex disease and has no laboratory biomarkers, which makes diagnosis of CFS difficult. Several research groups challenged to identify genes specific for CFS; however, there are no overlaps between studies. The U.S. Centers for Disease Control and Prevention reported remarkable gene expression profiles of a large scale cohort study (n = 227). Reported genes were mostly different from the previously reported genes, again featuring the complexity of CFS. Separately, these investigators identified 9 genes that were significantly and differentially expressed between CFS patients and healthy subjects using an original microarray.
Fostel and colleagues (2006) stated that CFS is a complex syndrome that can not simply be associated with changes in individual laboratory tests or expression levels of individual genes. No clear association with gene expression and individual symptom domains was found. However, analysis of such multi-faceted datasets is likely to be an important means to elucidate the pathogenesis of CFS.
Wang et al (2008) reviewed studies on the treatment of CFS with acupuncture and moxibustion in China. All studies concluded the treatments were effective, with response rates ranging from 79 % to 100 %. However, the qualities of the studies were generally poor, and none of them used a randomized controlled trial design. The common acupoints/sites used in the treatment of CFS, which may reflect the collective experience of acupuncturists in China based on Traditional Chinese Medicine theories can be used to evaluate the effectiveness of acupuncture for the treatment of CFS in future studies using more scientifically rigorous study designs.
In a pilot study, Nijs et al (2008) examined (i) the point prevalence of asynchronous breathing in patients with CFS; (ii) if CFS patients with an asynchronous breathing pattern present with diminished lung function in comparison with CFS patients with a synchronous breathing pattern; and (iii) if 1 session of breathing re-training in CFS patients with an asynchronous breathing pattern is able to improve lung function. A total of 20 patients fulfilling the diagnostic criteria for CFS were recruited for participation in a pilot controlled clinical trial with repeated measures. Patients presenting with an asynchronous breathing pattern were given 20 to 30 mins of breathing re-training. Patients presenting with a synchronous breathing pattern entered the control group and received no intervention. Of the 20 enrolled patients with CFS, 15 presented with a synchronous breathing pattern and the remaining 5 patients (25 %) exhibited an asynchronous breathing pattern. Baseline comparison revealed no group differences in demographic features, symptom severity, respiratory muscle strength, or pulmonary function testing data (spirometry). In comparison to no treatment, the session of breathing re-training resulted in an acute (immediately post-intervention) decrease in respiratory rate (p < 0.001) and an increase in tidal volume (p < 0.001). No other respiratory variables responded to the session of breathing re-training. The authors concluded that these findings provided preliminary evidence supportive of an asynchronous breathing pattern in a subgroup of CFS patients, and breathing re-training might be useful for improving tidal volume and respiratory rate in CFS patients presenting with an asynchronous breathing motion.
In a randomized controlled partially blinded study, Walach and colleagues (2008) examined the effectiveness of distant healing (a form of spiritual healing) for patients with CFS. These researchers randomized 409 patients from 14 private practices for environmental medicine in Germany and Austria in a 2 x 2 factorial design to immediate versus deferred (waiting for 6 months) distant healing. Half the patients were blinded and half knew their treatment allocation. Patients were treated for 6 months and allocated to groups of 3 healers from a pool of 462 healers in 21 European countries with different healing traditions. Change in Mental Health Component Summary (MHCS) score (SF-36) was the primary outcome and Physical Health Component Summary score (PHCS) the secondary outcome. This trial population had very low quality of life and symptom scores at entry. There were no differences over 6 months in post-treatment MHCS scores between the treated and untreated groups. There was a non-significant outcome (p = 0.11) for healing with PHCS (1.11; 95 % confidence interval [CI]: -0.255 to 2.473 at 6 months) and a significant effect (p = 0.027) for blinding; patients who were unblinded became worse during the trial (-1.544; 95 % CI: -2.913 to -0.176). These investigators found no relevant interaction for blinding among treated patients in MHCS and PHCS. Expectation of treatment and duration of CFS added significantly to the model. The authors concluded that in patients with CFS, distant healing appears to have no statistically significant effect on mental and physical health, but the expectation of improvement did improve outcome.
VanNess et al (2010) examined the effects of an exercise challenge on CFS symptoms from a patient perspective. This study included 25 female CFS patients and 23 age-matched sedentary controls. All participants underwent a maximal cardio-pulmonary exercise test. Subjects completed a health and well-being survey (SF-36) 7 days post-exercise. Subjects also provided, approximately 7 days after testing, written answers to open-ended questions pertaining to physical and cognitive responses to the test and length of recovery. Data on SF-36 were compared using multi-variate analyses. Written questionnaire responses were used to determine recovery time as well as number and type of symptoms experienced. Written questionnaires revealed that within 24 hours of the test, 85 % of controls indicated full recovery, in contrast to 0 % CFS patients. The remaining 15 % of controls recovered within 48 hours of the test. In contrast, only 1 CFS patient recovered within 48 hours. Symptoms reported after the exercise test included fatigue, light-headedness, muscular/joint pain, cognitive dysfunction, headache, nausea, physical weakness, trembling/instability, insomnia, and sore throat/glands. A significant multi-variate effect for the SF-36 responses (p < 0.001) indicated lower functioning among the CFS patients, which was most pronounced for items measuring physiological function. The authors concluded that these findings suggest that post-exertional malaise is both a real and an incapacitating condition for women with CFS and that their responses to exercise are distinctively different from those of sedentary controls.
Porter et al (2010) systematically reviewed the current literature related to alternative and complementary treatments for myalgic encephalomyelitis/CFS and fibromyalgia. It should be stressed that the treatments evaluated in this review do not reflect the clinical approach used by most practitioners to treat these illnesses, which include a mix of natural and unconventionally used medications and natural hormones tailored to each individual case. However, nearly all clinical research has focused on the utility of single complementary and alternative medicine interventions, and thus is the primary focus of this review. Several databases (e.g., PubMed, MEDLINE,((R)) PsychInfo) were systematically searched for randomized and non-randomized controlled trials of alternative treatments and non-pharmacological supplements. Included studies were checked for references and several experts were contacted for referred articles. Two leading subspecialty journals were also searched by hand. Data were then extracted from included studies and quality assessments were conducted using the Jadad scale. Upon completion of the literature search and the exclusion of studies not meeting criterion, a total of 70 controlled clinical trials were included in the review. Sixty of the 70 studies found at least one positive effect of the intervention (86 %), and 52 studies also found improvement in an illness-specific symptom (74 %). The methodological quality of reporting was generally poor. The authors concluded that several types of alternative medicine have some potential for future clinical research. However, due to methodological inconsistencies across studies and the small body of evidence, no firm conclusions can be made at this time. Regarding alternative treatments, acupuncture and several types of meditative practice show the most promise for future scientific investigation. Likewise, magnesium, l-carnitine, and S-adenosylmethionine are non-pharmacological supplements with the most potential for further research. Individualized treatment plans that involve several pharmacological agents and natural remedies appear promising as well.
Sanchez-Barcelo et al (2010) noted that the efficacy of melatonin has been assessed as a treatment of aging and depression, blood diseases, CFS, cardiovascular diseases, diabetes, fibromyalgia, gastrointestinal tract diseases, infectious diseases, neurological diseases, ocular diseases, rheumatoid arthritis, as well as sleep disturbances. Melatonin has been also used as a complementary treatment in anesthesia, hemodialysis, in vitro fertilization and neonatal care. The conclusion of the current review is that the use of melatonin as an adjuvant therapy seems to be well- founded for arterial hypertension, diabetes, glaucoma, irritable bowel syndrome, macular degeneration, protection of the gastric mucosa, side effects of chemotherapy and radiation in cancer patients or hemodialysis in patients with renal insufficiency and, especially, for sleep disorders of circadian etiology (e.g., jet-lag, delayed sleep phase syndrome, sleep deterioration associated with aging) as well as in those related with neurological degenerative diseases (e.g., Alzheimer) or Smith-Magenis syndrome. The utility of melatonin in anesthetic procedures has also been confirmed. More clinical studies are needed to clarify whether, as the preliminary data suggest, melatonin is useful for treatment of CFS, fibromyalgia, infectious diseases, neoplasias or neonatal care.
In a randomized, placebo-controlled, double-blind trial, The and colleagues (2010) examined the effect of ondansetron, a 5-HT(3) receptor antagonist, on fatigue severity and functional impairment in adult patients with CFS. A total of 67 adult patients who fulfilled the CDC criteria for CFS and who were free from current psychiatric co-morbidity participated in the clinical trial. Participants received either ondansetron 16 mg per day or placebo for 10 weeks. The primary outcome variables were fatigue severity (Checklist Individual Strength fatigue severity subscale [CIS-fatigue]) and functional impairment (Sickness Impact Profile-8 [SIP-8]). The effect of ondansetron was assessed by analysis of co-variance. Data were analyzed on an intention-to-treat basis. Thirty-three patients were allocated to the ondansetron condition, 34 to the placebo condition. The 2 groups were well-matched in terms of age, sex, fatigue severity, functional impairment, and CDC symptoms. Analysis of co-variance showed no significant differences between the ondansetron- and placebo-treated groups during the 10-week treatment period in fatigue severity and functional impairment. The authors concluded that these findings demonstrated no benefit of ondansetron compared to placebo in the treatment of CFS.
Alraek et al (2011) performed a systematic review of randomized controlled trials (RCTs) of complementary and alternative medicines (CAM) treatments in patients with CFS/myalgic encephalomyelitis (ME) was undertaken to summarize the existing evidence from RCTs of CAM treatments in this patient population. A total of 17 data sources were searched up to August 13, 2011. All RCTs of any type of CAM therapy used for treating CFS were included, with the exception of acupuncture and complex herbal medicines; studies were included regardless of blinding. Controlled clinical trials, uncontrolled observational studies, and case studies were excluded. A total of 26 RCTs, which included 3,273 participants, met the inclusion criteria. The CAM therapy from the RCTs included the following: mind-body medicine, distant healing, massage, tuina and tai chi, homeopathy, ginseng, and dietary supplementation. Studies of qigong, massage and tuina were demonstrated to have positive effects, whereas distant healing failed to do so. Compared with placebo, homeopathy also had insufficient evidence of symptom improvement in CFS. Seventeen studies tested supplements for CFS. Most of the supplements failed to show beneficial effects for CFS, with the exception of NADH and magnesium. The authors concluded that the results of this systematic review provided limited evidence for the effectiveness of CAM therapy in relieving symptoms of CFS. However, the authors were not able to draw firm conclusions concerning CAM therapy for CFS due to the limited number of RCTs for each therapy, the small sample size of each study and the high risk of bias in these trials. They stated that further rigorous RCTs that focus on promising CAM therapies are warranted.
An UpToDate review on "Clinical features and diagnosis of chronic fatigue syndrome" (Gluckman, 2013a) states that "The United States Centers for Disease Control and Prevention and the International Chronic Fatigue Syndrome Study Group published guidelines in 1994 regarding the standard evaluation in a patient suspected of having CFS. Patients with CFS must have clinically evaluated, unexplained, persistent, or relapsing fatigue plus four or more specifically defined associated symptoms. After a thorough history and physical examination, the patient is asked to keep temperature and weight records and limited laboratory testing is performed including: (i) complete blood count with differential count, (ii) erythrocyte sedimentation rate, (iii) chemistry screen, (iv) thyroid stimulating hormone level, and (v) other tests when clinically indicated. Expensive immunologic tests and serologies are not useful. We do not routinely perform serologies for EBV, CMV, or Lyme disease, or test for antinuclear antibodies. In the setting of low pretest probability, any positive test is likely to be a false positive result, which may complicate the evaluation".
An UpToDate review on "Treatment of chronic fatigue syndrome" (Gluckman, 2013b) states that "A number of medications and special diets have been evaluated in patients with CFS, but none has proved successful. Among the modalities that have been tried are immune serum globulin, rituximab, acyclovir, galantamine, fluoxetine and other antidepressants, methylphenidate and modafinil (stimulants), glucocorticoids, amantadine, doxycycline, magnesium, evening primrose oil, vitamin B12, Ampligen, essential fatty acids, bovine or porcine liver extract, dialyzable leukocyte extract, cimetidine, ranitidine, interferons, exclusion diets, BioBran MGN-3 (a natural killer cell stimulant), and removal of dental fillings".
Knight et al (2013) noted that a range of interventions have been used for the management of CFS/ME in children and adolescents. Currently, debate exists as to the effectiveness of these different management strategies. These researchers synthesized and critically appraised the literature on interventions for pediatric CFS/ME. CINAHL, PsycINFO and Medline databases were searched to retrieve relevant studies of intervention outcomes in children and/or adolescents diagnosed with CFS/ME. Two reviewers independently selected articles and appraised the quality on the basis of predefined criteria. A total of 24 articles based on 21 studies met the inclusion criteria. Methodological design and quality were variable. The majority assessed behavioral interventions (10 multi-disciplinary rehabilitation; 9 psychological interventions; 1 exercise intervention; 1 immunological intervention). There was marked heterogeneity in participant and intervention characteristics, and outcome measures used across studies. The strongest evidence was for cognitive behavioral therapy (CBT)-based interventions, with weaker evidence for multi-disciplinary rehabilitation. Limited information exists on the maintenance of intervention effects. The authors concluded that evidence for the effectiveness of interventions for children and adolescents with CFS/ME is still emerging. Methodological inadequacies and inconsistent approaches limit interpretation of findings. Moreover, they stated that there is some evidence that children and adolescents with CFS/ME benefit from particular interventions; however, there remain gaps in the current evidence base.
Powell et al (2013) stated that the hypothalamic-pituitary-adrenal (HPA) axis is a psycho-neuroendocrine regulator of the stress response and immune system, and dysfunctions have been associated with outcomes in several physical health conditions. Its end product, cortisol, is relevant to fatigue due to its role in energy metabolism. These investigators examined the relationship between different markers of unstimulated salivary cortisol activity in everyday life in CFS and fatigue assessed in other clinical and general populations. Search terms for the review related to salivary cortisol assessments, everyday life contexts, and fatigue. All eligible studies (n = 19) were reviewed narratively in terms of associations between fatigue and assessed cortisol markers, including the cortisol awakening response (CAR), circadian profile (CP) output, and diurnal cortisol slope (DCS). Subset meta-analyses were conducted of case-control CFS studies examining group differences in 3 cortisol outcomes: (i) CAR output; (ii) CAR increase; and (iii) CP output. Meta-analyses revealed an attenuation of the CAR increase within CFS compared to controls (d = -0.34) but no statistically significant differences between groups for other markers. In the narrative review, total cortisol output (CAR or CP) was rarely associated with fatigue in any population; CAR increase and DCS were most relevant. The authors concluded that outcomes reflecting within-day change in cortisol levels (CAR increase; DCS) may be the most relevant to fatigue experience, and future research in this area should report at least one such marker. Moreover, they stated that results should be considered with caution due to heterogeneity in 1 meta-analysis and the small number of studies.
Furthermore, an UpToDate review on "Clinical features and diagnosis of chronic fatigue syndrome" (Gluckman, 2014a) does not mention the use of salivary cortisol assessments as a diagnostic tool.
Sulheim et al (2014) explored the pathophysiology of CFS and assessed clonidine hydrochloride pharmacotherapy in adolescents with CFS by using a hypothesis that patients with CFS have enhanced sympathetic activity and that sympatho-inhibition by clonidine would improve symptoms and function. Participants were enrolled from a single referral center recruiting nationwide in Norway. A referred sample of 176 adolescents with CFS was assessed for eligibility; 120 were included (34 males and 86 females; mean age of 15.4 years). A volunteer sample of 68 healthy adolescents serving as controls was included (22 males and 46 females; mean age of 15.1 years). The CSF patients and healthy controls were assessed cross-sectionally at baseline. Thereafter, patients with CFS were randomized 1:1 to treatment with low-dose clonidine or placebo for 9 weeks and monitored for 30 weeks; double-blinding was provided. Data were collected from March 2010 until October 2012 as part of the Norwegian Study of Chronic Fatigue Syndrome in Adolescents: Pathophysiology and Intervention Trial. Clonidine hydrochloride capsules (25 µg or 50 µg twice-daily) versus placebo capsules for 9 weeks. Main outcome measure was number of steps per day. At baseline, patients with CFS had a lower number of steps per day (p < 0.001), digit span backward score (p = 0.002), and urinary cortisol to creatinine ratio (p = 0.001), and a higher fatigue score (p < 0.001), heart rate responsiveness (p = 0.02), plasma norepinephrine level (p < 0.001), and serum C-reactive protein concentration (p = 0.04) compared with healthy controls. There were no significant differences regarding blood microbiology evaluation. During intervention, the clonidine group had a lower number of steps per day (mean difference, -637 steps; p = 0.07), lower plasma norepinephrine level (mean difference, -42 pg/ml; p = 0.01), and lower serum C-reactive protein concentration (mean ratio, 0.69; p = 0.02) compared with the CFS placebo group. The authors concluded that adolescent CFS is associated with enhanced sympathetic nervous activity, low-grade systemic inflammation, attenuated HPA axis function, cognitive impairment, and large activity reduction, but not with common microorganisms. Low-dose clonidine attenuated sympathetic outflow and systemic inflammation in CFS but has a concomitant negative effect on physical activity; thus, sympathetic and inflammatory enhancement may be compensatory mechanisms. They stated that low-dose clonidine is not clinically useful in CFS.
Also, an UpToDate review on "Treatment of chronic fatigue syndrome" (Gluckman, 2014b) does not mention the use of clonidine as a therapeutic option.
The National Institute for Health and Clinical Excellence's guideline on "Chronic fatigue syndrome/myalgicencephalomyelitis (or encephalopathy): Diagnosis and management of CFS/ME in adults and children" (NICE, 2007) stated that the following drugs should not be used for the treatment of CFS/ME:
In a 12-week, randomized, double-blind study, Arnold et al (2015) compared duloxetine 60 to 120 mg/day (n = 30) with placebo (n = 30) for safety and effectiveness in the treatment of patients with CFS. The primary outcome measure was the Multidimensional Fatigue Inventory general fatigue subscale (range of 4 to 20, with higher scores indicating greater fatigue). Secondary measures were the remaining Multidimensional Fatigue Inventory subscales, Brief Pain Inventory, Medical Outcomes Study Short Form-36, Hospital Anxiety and Depression Scale, Centers for Disease Control and Prevention Symptom Inventory, Patient Global Impression of Improvement, and Clinical Global Impression of Severity. The primary analysis of efficacy for continuous variables was a longitudinal analysis of the intent-to-treat sample, with treatment-by-time interaction as the measure of effect. The improvement in the Multidimensional Fatigue Inventory general fatigue scores for the duloxetine group was not significantly greater than for the placebo group (p = 0.23; estimated difference between groups at week 12 = -1.0 [95 % CI: -2.8 to 0.7]). The duloxetine group was significantly superior to the placebo group on the Multidimensional Fatigue Inventory mental fatigue score, Brief Pain Inventory average pain severity and interference scores, Short Form-36 bodily pain domain, and Clinical Global Impression of Severity score. Duloxetine was generally well-tolerated. The authors concluded that the primary efficacy measure of general fatigue did not significantly improve with duloxetine when compared with placebo. They stated that significant improvement in secondary measures of mental fatigue, pain, and global measure of severity suggested that duloxetine may be effective for some CFS symptom domains, but larger controlled trials are needed to confirm these results.
Courtois et al (2015) stated that patients with long-lasting pain problems often complain of lack of confidence and trust in their body. Through physical experiences and reflections they can develop a more positive body- and self-experience. Body awareness has been suggested as an approach for treating patients with chronic pain and other psychosomatic conditions. These investigators evaluated the effectiveness of body awareness interventions (BAI) in fibromyalgia (FM) and CFS. Two independent readers conducted a search on Medline, Cochrane Central, PsycINFO, Web of knowledge, PEDro and Cinahl for RCTs. They identified and screened 7.107 records of which 29 articles met the inclusion criteria. Overall, there is evidence that BAI has positive effects on the Fibromyalgia Impact Questionnaire (FIQ) (MD -5.55; CI: -8.71 to -2.40), pain (SMD -0.39, CI: -0.75 to -0.02), depression (SMD -0.23, CI: -0.39 to -0.06), anxiety (SMD -0.23, CI: -0.44 to -0.02) and Health Related Quality of Life (HRQoL) (SMD 0.62, CI: 0.35 to 0.90) when compared with control conditions. The overall heterogeneity is very strong for FIQ (I(2) 92 %) and pain (I(2) 97 %), which cannot be explained by differences in control condition or type of BAI (hands-on/hands-off). The overall heterogeneity for anxiety, depression and HRQoL ranges from low to moderate (I(2) 0 % to 37 %). The authors concluded that body awareness seems to play an important role in anxiety, depression and HRQoL. Moreover, they stated that interpretations have to be done carefully since the lack of high quality studies.
Blundell et al (2015) stated that there has been much interest in the role of the immune system in the pathophysiology of CFS, as CFS may develop following an infection and cytokines are known to induce acute sickness behavior, with similar symptoms to CFS. Using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines, a search was conducted on PubMed, Web of Science, Embase and PsycINFO, for CFS related-terms in combination with cytokine-related terms. Cases had to meet established criteria for CFS and be compared with healthy controls. Papers retrieved were assessed for both inclusionary criteria and quality. A total of 38 papers met the inclusionary criteria. The quality of the studies varied; 77 serum or plasma cytokines were measured without immune stimulation. Cases of CFS had significantly elevated concentrations of transforming growth factor-beta (TGF-β) in 5 out of 8 (63 %) studies. No other cytokines were present in abnormal concentrations in the majority of studies, although insufficient data were available for some cytokines. Following physical exercise there were no differences in circulating cytokine levels between cases and controls and exercise made no difference to already elevated TGF-β concentrations. The authors concluded that the finding of elevated TGF-β concentration, at biologically relevant levels, needs further exploration, but circulating cytokines do not seem to explain the core characteristic of post-exertional fatigue.
Experimental and Investigational Therapies:
An UpToDate review on "Treatment of systemic exertion intolerance disease (chronic fatigue syndrome)" (Gluckman, 2016) states that "Galantamine is a centrally acting acetylcholinesterase inhibitor that has been used to treat Alzheimer disease. In the largest and best designed randomized, double-blind, controlled trial that has been performed for the treatment of CFS/SEID, 434 patients at multiple centers were randomly assigned to one of four doses of galantamine or placebo. At 16 weeks, there was no benefit from galantamine in the primary end point (improvement in the Clinical Global Impression Scale) or in any secondary end points. Intramuscular immunoglobulin injections appeared to be beneficial in one small controlled trial. However, this finding is in contrast to the more general experience. Controlled trials of intravenous immune globulin yielded conflicting and unimpressive results with a high incidence of adverse effects. There were no differences in B cell levels between patients in the rituximab group who achieved a response compared with those who did not achieve a response. Though intriguing, these findings are too preliminary to support the use of rituximab, a drug that can cause immunosuppression and serious complications. This study needs to be repeated with a larger number of patients …. Rintatolimod is an investigational immune modulator and antiviral drug that has been approved for the treatment of CFS/SEID in Canada and Europe. It improved measures of exercise performance in two randomized trials; however, the clinical implications were unclear. Treatment with this drug should be considered experimental until more studies have been done".
|CPT Codes/ HCPCS Codes / ICD-10 Codes
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":
|CPT codes covered if selection criteria are met:
|70551 - 70553
|Magnetic resonance (e.g., proton) imaging, brain (including brain stem
|70554 - 70555
|Magnetic resonance imaging, brain, functional MRI
|Basic metabolic panel (Calcium, ionized)
|Basic metabolic panel (Calcium, total)
|General health panel
|Electrolyte panel
|Hepatic function panel
|81000 - 81099
|Thyroid stimulating hormone (TSH)
|Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)
|Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
|complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)
|Sedimentation rate, erythrocyte; non-automated
|Antinuclear antibodies (ANA)
|Rheumatoid factor; qualitative
|Skin test; tuberculosis, intradermal
|Borrelia burgdorferi (Lyme disease) confirmatory test (e.g., Western Blot or immunoblot)
|Borrelia burgdorferi (Lyme disease)
|Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
|younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist
|95808 - 95811
|CPT codes not covered for indications listed in the CPB:
|Unstimulated salivary cortisol activity:
|No specific code
|72195 - 72197
|Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s), with contrast material(s), or without contrast material(s), followed by contrast material(s) and further sequences
|73218 - 73223
|Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s), with contrast material(s), or without contrast material(s), followed by contrast material(s) and further sequences
|73718 - 73723
|Magnetic resonance (e.g., proton) imaging, lower extremity, other than joint; without contrast material(s), with contrast material(s), or without contrast material(s), followed by contrast material(s) and further sequences
|74181 - 74183
|Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s), with contrast material(s), or without contrast material(s), followed by contrast material(s) and further sequences
|Magnetic resonance spectroscopy
|Bone and/or joint imaging; tomographic (SPECT)
|Brain imaging, tomographic (SPECT)
|Brain imaging, positron emission tomography (PET); metabolic evaluation
|perfusion evaluation
|Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT)
|Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)
|B cells, total count
|Natural killer (NK) cells, total count
|T cells; total count
|absolute CD4 and CD8 count, including ratio
|absolute CD4 count
|Antibody; Candida
|cytomegalovirus (CMV)
|cytomegalovirus (CMV), IgM
|enterovirus (e.g., coxackie, echo, polio)
|Epstein-Barr (EB) virus, early antigen (EA)
|Epstein-Barr (EB) virus, nuclear antigen (EBNA)
|Epstein-Barr (EB) virus, viral capsid (VCA)
|herpes simplex, type 1
|herpes simplex, type 2
|Candida species, direct probe technique
|Candida species, quantification
|Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention
|Limited bilateral noninvasive physiologic of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels)
|Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more level(s), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia)
|Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediatley after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking, and time to recover), complete bilateral study
|Noninvasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography)
|Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
|Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
|Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
|Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
|Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient
|2-4 patients
|5-8 patients
|Other CPT codes related to the CPB:
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure)
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)
|Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial
|Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
|Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug provided in a facility (List separately in addition to code for primary procedure)
|Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)
|Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion
|HCPCS codes not covered for indications listed in the CPB:
|Dynamic infrared blood perfusion imaging (DIRI)
|Therapeutic procedures to increase strength or endurance of respiratory muscles (i.e. breathing retraining), face to face, one on one, each 15 minutes (includes monitoring)
|Injection, acyclovir, 5 mg
|Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
|Injection, clonidine hydrochloride (HCL), 1 mg
|Injection, cosyntropin, not otherwise specified, 0.25 mg
|Injection, cosyntropin (Cortrosyn), 0.25 mg
|Injection, methylprednisolone acetate, 20 mg
|Injection, methylprednisolone acetate, 40 mg
|Injection, methylprednisolone acetate, 80 mg
|Injection, dexamethasone acetate, 1 mg
|Injection, dexamethasone sodium phosphate, 1 mg
|Injection, immune globulin,(Privigen), intravenous, non-lyophilized (e.g, liquid), 500 mg
|Injection, gamma globulin, intramuscular, 1 cc
|Injection, immune globulin, (Bivigam), 500 mg
|Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg
|Injection, immune globulin (hizentra), 100 mg
|Injection, gamma globulin, intramuscular, over 10 cc
|Injection, immune globulin, (Gamunex-c/Gammaked), nonlyophilized (e.g. liquid), 500 mg
|Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg (Carimune, Gammagard S/D, Polygam)
|Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg
|Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g. liquid), 500 mg
|Injection, immune globulin, (flebogamma/flebogamma DIF), intravenous, non-lyophilized (e.g., liquid), 500 mg
|Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin
|Injection, immune globulin, intravenous, non-lyophilized (eg, liquid), not otherwise specified, 500 mg
|Injection, dexamethasone sodium phosphate, 1 mg
|Injection, hydrocortisone sodium phosphate, up to 50 mg
|Injection, hydrocortisone sodium succinate, up to 100 mg
|Injection, ondansetron hydrochloride, per 1 mg
|Injection, prednisolone acetate, up to 1 ml
|Injection, methylprednisolone sodium succinate, up to 40 mg
|Injection, methylprednisolone sodium succinate, up to 125 mg
|Injection, triamcinolone acetonide, preservative free, 1 mg
|Injection, triamcinolone acetonide, not otherwise specified, 10 mg
|Injection, triamcinolone diacetate, per 5 mg
|Injection, triamcinolone hexacetonide, per 5 mg
|Methylprednisolone, oral, per 4 mg
|Prednisolone, oral, per 5 mg
|Prednisone, immediate release or delayed release, oral, 1 mg
|Dexamethasone, oral, 0.25 mg
|Injection, rituximab, 100 mg
|Ondansetron 1 mg, oral, FDA approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
|Ondansetron, oral, 4 mg (for circumstances falling under the Medicare statute, use HCPCS Q code)
|ICD-10 codes covered if selection criteria are met:
|Chronic fatigue, unspecified
|Other malaise and fatigue


text:
Bus Driver APK
Bus DriverHelp me share this apk games guys .. :)
Games Description
Take the wheel and step on the gas in Dr. Panda's Bus Driver! Your job is to pick up a number of cute animal passengers and take them where they want to go! Even the youngest players will have a blast while driving with Dr. Panda's Bus Driver's intuitive and easy to use controls.
The world in Dr. Panda's Bus Driver is randomly generated as you play, so there is always a brand new world to discover! Kids can take it slow and enjoy the craggy mountains, raging waterfalls and beautiful fields of lavender, or go at top speed with a fun-filled rocket-boost and get animals to where they want to be… fast!
Don't forget to paint and customize your bus before you take it out! Once you've designed the perfect bus, take it to the road and drive for as long as you want to.
Game features: • World is generated new every time for nearly endless play • Fill up the gas, go through a car wash, and more! • Paint and customize your bus, then take it for a drive! • Drawbridges, railroad crossings, tunnels and dozens of other fun features fill the world • Take it slow and enjoy the scenery or go at top-speed! It's up to you • Kid-friendly interface so everyone can enjoy the game, no matter how big small • No in-app purchases • No third party ads
- Type: Interest
- Language: Multilingual
- Provides: Unknown
- Tariff: Free
- File size: 41.41 MB
- Downloads: 2046
- Updated: 2013-12-17 00:00:00
This APK clear from malwere

subset: commoncrawl


text:
The Horse Forum (http://www.horseforum.com/forumindex.php)
- Horse Riding (/horse-riding/)
- - Riding my appaloosa (http://www.horseforum.com/horse-riding/riding-my-appaloosa-69925/)
Riding my appaloosa
I got my appaloosa horse, Reggie, about 6 months ago, he is a good horse but I have had problems staying on him and staying balanced especially when I am running/loping on him. I ride with a western saddle and when I run with him I always have to take the reins in one hand and hang on to the horn with my other hand and still i feel very unsteady. He seems to be a sort of 'narrow' and thin/bony horse but I do feed him well, I think that might just be the way he is. Does anyone have any tips for me on how to feel more comfortable and steady when loping?
Thanks for any help!
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text:
The "doctor bag" featured in this issue's Antiques Corner spurred a memory in me. It was the early 1970s in our little Midwestern town. At our home on Water Street, I was recovering from a mild case of the mumps, while my brother was in the middle of a much more intense case. Fearing he was on the losing end, my parents moved him to their first-floor bedroom instead of upstairs in his room, so they could keep a watchful eye on him. Then they placed a call to the town doctor, who showed up with his black bag and disappeared into the bedroom for what seemed like hours. The rest of us kids waited in the living room and spoke in hushed tones. Nobody played, nobody made any trouble, and nobody asked Mom and Dad any questions.
"Uptown" in my small hometown in northwest Ohio was a half block south of our house and four blocks to the west along the lengthy main street, which crossed the river. In those days of the mid-1940s, it was safe for us kids to walk, run or play anywhere in town as long as our parents gave permission. Since I had already run errands for them uptown, my folks decided that at age 9 1/2, I was...


text: Helmut M++ller-Br++hl was a highly respected German conductor whose long association with the Cologne Chamber Orchestra, both in concert and in the recording studio, won over a large following from critics and the public alike. He recorded for a number of major labels, including Naxos, EMI, and Koch Schwann. Helmut M++ller-Br++hl was born in Br++hl, Germany. He showed musical talent early on, but did not give serious thought to a career in music until after concluding studies ... Read more


text:
Bible Reference Books
Use a Bible reference book to get more out of your Bible study, including complete Bible concordances and Bible dictionaries. Reference Bible handbooks help answer common questions and bible companions are helpful aids as you seek deeper understanding of the text.
Zondervan's Compact Bible Dictionary
T. Alton Bryant, Zondervan Publishing, Zondervan Publishing$14.99
The Baker Illustrated Bible Dictionary
Mark Strauss, Peter Enns, Tremper III Longman, Tremper Longman III$29.97
Strong's Concise Concordance & Vine's Concise Dictionary of the Bible
James Strong, William E. Vine, W. E. Vine$19.97
Pocket Bible Dictionary: Nelson's Pocket Reference Series
Thomas Nelson, Thomas Nelson, Thomas Nelson Publishers$5.99
New International Encyclopedia of Bible Difficulties
Gleason L. Archer Jr, Gleason Leonard Archer Jr., J. D. Douglas, Frede...$26.99
New Combined Bible Dictionary and Concordance
Baker Book House, Baker Publishing Group, New Combined Bible Dictionar...$9.97
Nelson's Student Bible Dictionary: A Complete Guide to Understanding the World of the Bible
Ronald F. Youngblood, F. F. Bruce, R. K. Harrison, R. K. Harrison, R. ...$6.97
Nelson's Compact Series: Compact Bible Dictionary
Herbert Lockyer, F. F. Bruce, Frederick Fyvie Bruce, H. Lockyer, R. K....$6.97
Illustrated Dictionary of the Bible
Herbert Lockyer, F. F. Bruce, Frederick Fyvie Bruce, H. Lockyer Sr, R....$15.97


text:
Bern's Steak House
By ShuffleCloud LLC
Open iTunes to buy and download apps.
Stay up to date on your mobile device for the world renowned restaurant, Bern's Steak House, and its siblings: Epicurean Hotel, Bern's Fine Wines & Spirits, and our signature annual event, Bern's Winefest. See Menus, check hours, make reservations, get directions, maps and programs for Winefest events, as well as information on our in-house events and more, all on your iphone, ipad, and ipod touch.
Included in this app:
- Current Menus, Specials and Tastings for Bern's Steak House, Epicurean Hotel and Haven
- One touch dialing and directions to get to the Bern's restaurants.
- Live Twitter and Facebook posts
- Photo gallery and videos
- Interactive Winefest Map for Bern's Winefest 2015
- Request Reservations for Bern's.
- Push notifications to receive timely reminders of happenings and events.
What's New in Version 1.4
- Updated for iOS 8.0
- All new menus for: Berns Steak House, Haven, Epicurean, BFW and Winefest
- Updated push notifications
- New look and feel
iPhone Screenshots
- Free
- Category: Food & Drink
- Updated: Feb 01, 2015
- Version: 1.4
- Size: 4.6 MB
- Language: English
- Seller: ShuffleCloud LLC
- © ShuffleCloud LLC
Compatibility: Requires iOS 7.0 or later. Compatible with iPhone, iPad, and iPod touch.


text:
19429 Surnames | 123697 Records | 2645 Reunions
Dead Fred asks:Are you a Desperate Genealogist?
Click the e-book above for details!
Dead Fred's Genealogy Photo Archive, a free, fun photo genealogy research web site devoted to helping you visualize your heritage!
Get the latest info about DeadFred and MORE in our E-Newsletter Relatively Speaking.
Photo Thumbnail
Click image for
larger view.
1 photos in database by this submitter.
Order The Desperate Genealogist's Idea Book: Creative Ways to Outsmart Your Elusive Ancestors (eBook).You can also order The Desperate Genealogist's Idea Book in hardcopy format by clicking here.
Photo #69385
Last Name: Aiken
First Name : William
Middle Name:
Subject's City: East Armuchee
Subject's State: GA
Subject's County: Walker
Subject's Country: United States
Date: 1921-1940
Photographer's City:
Photographer's State:
Type** : B&W
Comments: William Aiken (Nee: ) | East Armuchee GA United States | 1921-1940 | Comments: Mr. Aiken is listed in the 1880 Census in the home of William J. Love. He was sometimes known as Bill Love.
Digital Image Only? NO
Everyone Listed In This Photo:
To view all records posted by this submitter, click here:
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text:
While reading a cooking magazine I ran across an ad for Acorn Spring
Farms, www.dwarfcitrus.com, saying they have Thai cooking essentials including
Kaffir lime trees for indoor containers. Since we were recently talking about
those I thought some of you might find this interesting.
zone 7
West TN
To sign-off this list, send email to email@example.com with the
message text UNSUBSCRIBE GARDENCHAT


text:
Instructors wishing to join REPs UK with qualifications gained in Australia, New Zealand or South Africa may join through one of the following routes;
membership of the relevant Register within that country
This letter of portability should be sent with your application form and additional supporting documents to the address below.
All members of the Register, regardless of which pathway you register through, are required to hold a minimum of £5 Million civil liability insurance. This may be purchased through REPs, or you can provide evidence of an insurance policy you already hold. For details of REPs Insurance please check details of our insurance policy here.
Joining Checklist -
To complete your application you will need:
- Registration form
- Confirmation of Insurance - If you will not be purchasing insurance through REPs, please provide a copy of your own insurance policy, or if you are covered by your employers insurance please provide a signed letter from your employer confirming this.
- Payment - Please include a cheque or include your card details on your application form.
Please post your completed application form and all supporting documents to:
Chelsea Close
Off Amberley Road
Leeds LS12 4HP
We aim to process your complete application for registration within 28 days of receipt and we will post out your certificate of registration, membership card and other materials in our welcome pack. Overseas/older qualifications may take longer to be assessed.


text:
Distances are calculated in a straight line and may not reflect actual travel distance.
Let us help calculate the repayments on this property.Use our mortgage calculator
A beautifully refurbished, spacious and bright raised ground floor apartment, laterally converted across two period buildings. The flat offers excellent reception space, with 3.75 metre ceiling heights, whilst the building benefits from a resident porter. The new lease expires on 01/05/2140.
Eaton Square is one of the premier addresses in prime central London and the apartment benefits from being located in one of the best positions within the square, overlooking the gardens and down the length of the southern terrace. It is also situated moments from the internationally renowned boutiques and restaurants of both Knightsbridge and Sloane Square.
Contact branch for relevant Energy Performance Certificate


text:
Together's only reply to that letter was to ask for confirmation that Mark's colleague was actually a solicitor. When confirmation was supplied, Together came back with: 'Thank you for your letter . . . As you will appreciate, Together is covered by the Data Protection Act, and so all details of our members are kept strictly confidential.'
His solicitor was not asking for any information. She simply requested that Mark's money be refunded to him. Mark by now had lost patience with Together. He decided to issue a county court summons. He was surprised at just how easy it turned out to be. All he had to do was go to his local county court - here he was acting in the capacity of an ordinary citizen, not as a member of the legal profession - and explain that he wanted to get his money, pounds 1,000, reimbursed from a company he believed was in breach of contract. He was then handed several forms, plus eight pamphlets written with plenty of diagrams and arrows.
'The language is very simple,' says Mark. 'Anyone could do it. It's a summons by numbers, literally.' He paid a fee, which he specified in his claim would be included in the amount he was seeking to recover. The summons was automatically issued the next morning. Together had 14 days to respond.
Less than a week later, the company agreed to give Mark his money back.
More recently, I contacted Together's London headquarters and explained that I was writing about Mark's case for the Independent. Soon after, Together's director of marketing, Marjorie Kaufman, rang from the company's head office in America. Mark's file, plus all relevant information, had been sent to her. Her first comment was to ask if Mark really was a barrister. I assured her that he was.
Continuing with the utmost politeness, she indicated that she didn't quite know what the problem was since Together had authorised a full refund upon learning of Mark's dissatisfaction. Not so, I countered. The company had not agreed to refund anything until it received a summons. Moreover, pounds 50 of the pounds 1,050 fee he had originally paid Together was not covered by the summons and was still outstanding; although an insubstantial amount in itself, Mark had expressed to Together his wish to have that reimbursed as well, on point of principle. The company had refused. Mark did not feel this was the behaviour of an organisation wishing to make amends. Ms Kaufman continued: 'My understanding was that the final pounds 50 was still pending, but that he was okay with it.'
He most certainly was not.
'Let me look into that,' she responded, with the same unwavering politeness. She later told me that Together would refund the pounds 50.
I also put to Ms Kaufman that Mark received regular phone calls from Together prior to joining, but once he did sign on, the assiduous attention dried up. He felt that he had to continually prod the company to remind it of his existence. 'I'm going to look into it for you,' Ms Kaufman repeated. Something she could state categorically, though, was that the two women who had been referred to Mark were currently, according to the files she had in front of her, 'on hold' - the company was not sending men to them at the moment - because 'they have both found successful matches and are in happy relationships right now through us'.
I subsequently managed to contact one of those women. She was shocked. 'I am not in any relationship]' she wailed. 'In fact, just two weeks ago they introduced me to someone, so how could they do that if I was 'on hold'?'
She has been referred to nine men through Together. 'With the matches they sent me there really was no compatibility at all,' she states emphatically. 'I am very unhappy with the company. And every one of the men I have talked with has also expressed the same disappointment. When I signed up the people (at Together) seemed so professional, and they made you feel they were going to really look after you and make sure you got the right person with everything matching appropriately. But I don't think they've done anything of the sort.'
Westminster trading standards department has received more than 100 complaints regarding Together - the only introduction agency it has received complaints about. High on the list of grievances are what people have reported to be Together's 'hard sell' tactics to procure clients, and failure to provide the service that was originally agreed. The company is also the subject of an investigation by the Office of Fair Trading. An OFT spokeswoman said: 'Such an investigation is a serious matter. We don't go into something like this lightly. Obviously we have been concerned enough to look at this firm in particular.'
''Basically the message is that we have had some management problems in London,' said Ms Kaufman in my last conversation with her, this being the first time she had acknowledged any difficulties. 'And this has been happening over the past year. With this in mind, we sent over a different management team to resolve all the issues. So we are working on it very aggressively right now.' When I asked for more details of the problems and methods of rectifying them, she became impatient. 'No, I can't really get specifically into the logistics of the whole thing.'
No, she also knew nothing of money being paid back in London to disappointed clients. And when I reminded her again about the woman I had contacted who had refuted Ms Kaufman's claims that she was currently in a good relationship with a man whom she had found through the company (another matter Ms Kaufman was 'going to look into' for me), she retorted: 'No, I can't respond to that, because I don't have those details.'
'You know, if you want to sit here and go through every little instance . . .' Ms Kaufman said. When pressed further that this was by no means a small matter since it was the basis on which she had earlier defended the company, she cut off any more discussion with: 'I'm not free to comment.'
I contacted Westminster trading standards again. The spokesman there found what I had to say disquieting. 'A short while ago they were giving us the brush-off. A few weeks on, and they've made an effort. A few weeks from now, I don't know where we'll be.'
Brian Pappas, president of Together Introduction Ltd, said in a letter to the Independent this week:
'As a first point, there was a factual mistake in your article (23 April). The price for our 36-membership referral programme is pounds 2,110, not pounds 3,110 as you stated.
'Together has been in business for 20 years, and we have 130 offices worldwide. We have helped hundreds of thousands of people develop meaningful relationships, with several thousand marriages as a result. In fact, we are truly a company that cares about people, and we have been involved with charity events in the US and Canada for years. These efforts have raised hundreds of thousands of dollars. We're currently seeking a charitable cause in the UK.
'Ours is an extremely personal business. It's important to us that our members are happy with our service. The vast majority of our clients are quite pleased with our highly personalised approach. Unfortunately, from time to time, some of our members are unhappy with our service. In these cases, we first try to work with them to resolve the problem, and where appropriate we will refund their membership fees. This is exactly what happened with the gentleman you featured in your article.
'Any service business will experience a certain per cent of dissatisfied customers, and the figure for Together is quite low. With over 5,000 members in the UK, we've had approximately 100 complaints - 2 per cent. This means that over 97 per cent of our membership appreciates our services.'Reuse content


text:
Lost Password?
We offer you this space to share your knowledge about Magento and learn from our experienced customers.
Home › Forums › Reply To: breadcrumbs not working › Reply To: breadcrumbs not working
Andrei, I can help you include them if you'd like. I put them in HelloPodcast which doesn't have them included either.


text:
FT. WORTH, TEXAS -- I just bought a 2007 Dodge 2500. This truck is brand new leftover on the lot. I haven't even made one payment and only have 760 miles on it and it is at the dealer because of supposed water in the fuel or contaminated fuel as they are calling it. The kicker is, since it is supposedly contaminated, that the factory warranty will not cover it. This has led to a repair bill of over $1000 as of now to drain the fuel tank and change filters. Yes that is all.
Now they tell me that this did not fix the problem and they will have to replace the whole fuel system including injectors which will cost anywhere around $ 10-15000, all of which is not covered under warranty. The funny part is, if there is one, is that when I called the dealer and told them of the problem, they told me to tow it in and they would take care of it. No problem. So much for that BS.
Facts About Dodge of Naperville, Burke Automotive's Ugly Duckling!!! Read before buying or servicing your vehicle. If you live in Naperville or the surrounding area, do not go to Dodge of Naperville at Ogden and Jefferson. The old Kohler Dodge is now owned by Burke Automotive who also owns Jeep, Hummer, KIA and now they are also a Dodge dealer. Burke Automotive is a great dealership to do business with. Just not their Dodge store in West Naperville.
The technicians at Jeep are non-union and can actually get in trouble by their supervisor if they don't fix your vehicle. At Dodge the union techs couldn't care less about you or your vehicle and there are no consequences if they screw up your vehicle or do not fix it right.
There is no management at the Dodge store and Ed Burke himself never shows his face around the dealership. Naperville Dodge/Jeep/Hummer is his pride and joy and that is fine. It does not make sense why he keeps his Naperville Dodge store open. It is an ugly duckling. You will be treated much better if you go to the Lisle location. I have been very happy with the Burke Automotive Group and cannot understand why he keeps that store open.
I have a 2001 Dodge 3/4 ton diesel and have had A/C problems since I purchased it new. I have had to have 4 evaporator cores installed (so far) and charging the system with dye added numerous times. It was cooling for about a month but now is only lasting a week. No one seems to be able to find a leak anywhere.
VICTORIA, TEXAS -- I have an eighteen month old 2006 Dodge 3500. The a/c quit blowing out the appropriate vent and Dodge told me I have to have the "blend" door replaced. It has come apart. The bill is going to be over $500.00 to change out the $30.00 door. This appears to be a "known" problem and Dodge informed me they are not going to do anything about it.
RALEIGH, NORTH DAKOTA -- Where do I begin.... I went to Dodge to purchase a new vehicle (Dodge Stratus). 2 days later my family and I left to enjoy a vacation at the beach. About an hour into the drive, the engine light came on and the car started to buck uncontrollably. Obviously we exited and found somewhere safe to stop since the car was in no means drivable.
First I called the salesman we purchase the car from and told him of my disappointment. Next I called the 24hr. Roadside service. I was told there would be a tow truck within an hour (for any of you that have a 6 month old baby, an hour is eternity). An hour came and went, and still no tow truck so, I phoned again. Apparently they were lost (even though they had my phone number they still never called).
So finally after a total of 1 1/2 hours, the tow arrived. I phoned customer service and they told me that I would either be able to get a rental from the local Dodge dealership or I would be reimbursed for a rental elsewhere (as long as the rate was under $30/day, yea right). Once I got to the Dodge dealership, I immediately spoke with a salesperson who then handed me a phone book and told me to call a car rental company since they did not have any available.
By this time, it was almost 6:30pm and as luck would have it, the rental car companies in the area all close at 6:00. So, as a stranded customer, you can imagine my anger. The manager notice my frustration and basically told me, "There is nothing we can do since you did not purchase the car here" (Nice attitude to take with a lady standing there with a baby). Plus, the service area was closed so no one could even tell us what was wrong with the car.
Once again, I called the Customer Service number. To my surprise, they too close up at 6:00pm. Basically, we were stranded. My husband and I decided to try driving the brand new piece of junk home. Luckily, the bucking had stopped. We made it home.
We went to the dealership where we purchased the car early the next morning. To my surprise, there had been an error in the paperwork which made the contract void, Guess who had that Brand New Piece of Junk now.... Not me : )
OREGON -- We did purchase one used car through you last fall & are happy with this purchase. We thought about a Magnum Hemi for myself. I really liked this car. It was one of 2 top choices. We needed, however, to wait on any purchase until we sold our Ford full-sized van. We need the extra funds to work it all out.
We also realized with our lifestyle & work we really needed a good towing vehicle. So a truck was in order. We did not purchase any of your trucks though I liked the megacab. The main reason we didn't go with your megacab was that Dodge wouldn't even give us a trade in value for my van. It was worth something as it was in great shape, etc... Actually I felt like they "dismissed" my vehicle pretty quickly. I think they said they "couldn't even give me $1800" for it. This was a very negative remark from them. So we were on hold again til I sold the van.
I went to Nissan 2 months later to look at a Murano for a friend & just looked at their trucks for fun. I knew I had to sell my van 1st. So wasn't "really" looking. They asked what it would take to get me into a truck & I said jokingly, 4 grand! I figured this would help with 8-10 months of car payments &/OR it would get them to stop trying to sell me something I couldn't afford right then!! Well they said "let's look at the van & work out the figures...." We decided on a Titan LE Crew Cab.
One reason we went with them was the interior size, esp. the back seat area. Second reason - they offered me cash for the van. Nissan bought my van for $*** CASH. I got the check within 2 weeks of my purchase. They did work it out & we all were very happy. I now can use this money to make the payments in bad $ crunch months (we are self-employed). (I don't know if they always do this or just in my case).
Sometimes it is just a waiting game, but other times it just needs the right person to "make something happen". They were more than willing to work it out. I felt Dodge wasn't. My friend bought a repo'd '06 Titan & Nissan gave me $100 check for "bird-dogging" for them. I am happy!
Thanks for helping with the used car (Intrepid). You guys did work that out for us! No hard feelings! We will keep you in mind if someone asks me about Dodge dealers. You can remove my name from your list now. Thanks for trying or not. Nissan & Toyota's are the vehicles to buy. America is too cheaply made right now. Nissan spent 6+ hours locating just the right truck for me. They fixed a problem door handle & washed it afterwards! Good job Nissan!!
I have a 97 Dodge Dakota which I took to my mechanic to fix the A/C. Turns out, it needed what would be its 3rd evaporator. My mechanic (no, not Safford) stated it was the third Dodge truck in two weeks he has had to do the same thing. One was a 99 Durango and the other a 01 Ram 1500. He stated the evaporators are thin aluminum, designed to cool better. But apparently, they are too thin and fail quite a bit. So I am on a pace to replace this part every 2-3 years at about $700 a pop. Anyone else have a late model Dodge with premature A/C problems?


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Rowdy Rathore prabhu deva News
Ajay Devgn and Deepika Padukone in Prabhu Deva's next action comedy film
The Son of Sardaar actor will romance Dips for the first time in Pradhu Deva's upcoming venture
Prabhu Deva is on a roll these days. The actor has proved that his filmmaking talents match, if not surpass, his dancing skills, as his first two Bollywood movies proved to be Rs 100 crore hits. And now, the Rowdy Rathore director is Click here to read more
Akshay Kumar: Don't touch my collar!
Akshay Kumar is all set to rock the big screen yet again in his Rowdy Rathore avatar. We take a look at some of his more fiery dialogues
Akshay Kumar has always been rough, tough and macho. Most of his early films had seen him mouth plenty of over-the-top punchlines. With Rowdy Rathore hitting the screens today, we translated the most iconic of his lines into English. Our effort will either make you cringe or crack up. Enjoy! Click here to read more
ROWDY RATHORE trailer: Is Akshay Kumar copying Salman Khan?
The Khiladi Kumar's next film has the same ingredients – lots of dhishoom dhishoom, dialoguebaazi and a little bit of mohabbat, just like Dabangg dude's recent blockbusters
If you look at the trailer of Akshay Kumar's Rowdy Rathore, which was launched at a public dais with the aam janta (public), it reminds us all of Salman Khan's recent hits, Wanted, Ready, Dabangg and Ajay Devgn's Singham. However, the Khiladi superstar doesn't think so and he doesn't feel he is competing with the current undisputed badshaah of the box-office. Click here to read more
'Rowdy Rathore' brings back the trend of handmade posters
There is going to be something new and special about the first look of Akshay Kumar's Rowdy Rathore. The makers of the action flick have roped in painters to hand paint the first poster of the movie. The film, also starring Sonakshi Sinha, is being co-produced by Sanjay Leela Bhansali and UTV, who are trying to revive the culture of handmade posters, which took a back seat in the 1990's. Bhansali and UTV are bringing back the style by roping in painters to make the first look of Akshay in Rowdy Rathore, said a source adding that this is the first time in years that an actor will have his portrait in the get up of his character as a first look. The film is set to be directed by by Prabhu Deva.
Also ReadClick here to read more


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Facelift Plastic Surgery | Rhytidectomy Techniques The Produce Astonishing Results by Dr. Lewis J. Obi.
Exciting New Techniques Coupled with Advanced Technology Allow For Less Bruising, Less Scaring and Faster Recovery Times!
Forget Textbook Facelift Surgery, and benefit from PRP, and other surgical techniques and technology that are less expensive and create lasting results.
As people age, the effects of gravity, exposure to the sun, and the stresses of daily life can be seen in their faces. Also, we lose volume (fat, muscle, etc.) in our faces with age especially in our 40's secondary to hormonal changes. Deep creases form between the nose and mouth; the jawline grows slack and jowly; folds and fat deposits appear around the neck. The volume loss leads to a deflation of the face which also leads to lose skin and sag.
A Facelift, (technically known as rhytidectomy) can't stop this aging process. What it can do however is "set back the clock", improving the most visible signs of aging by removing excess skin, tightening underlying tissues and redraping the skin of your face and neck. Also, muscle bands in the neck are minimized. Because there is also usually a loss of soft tissue volume, Dr. Obi usually performs specialized fat grafting techniques such as (Adivive™ | Lipokit) as well as Brow Lift Surgery, (The LJO Browlift or Entotine), and Eyelid Surgery, (Blepharoplasty) in conjunction with the face lift procedure. Unique to Dr. Lewis Obi's practice is the integration of advanced techniques and technology such as Adivive, Platelet Rich Plasma Therapy, (PRP), Lasers, 3D Imaging, The LJO Brow Lift, and others. In fact, largely because of these advanced and innovative techniques, Dr. Obi was published in the first book on stem cells anesthetic procedures, (Springer Publications 2014).
"LESS IS MORE" reflects the aesthetic sensibility of Dr. Obi's artistry is reflected in the results enjoyed by each of his patients. Optimal results are accomplished with most patients after the initial procedure. However, touch-ups and refinements are not unusual in patients of advanced aging. Patients electing "limited" primary procedures should have realistic expectations as they often decide on pursue more extensive surgery once they develop confidence with Dr. Obi and his staff.
If you're considering a face lift, the following information will give you a basic understanding of the procedure, when it can help, how it's performed, and the results you can expect. Remaining questions about Dr. Obi's different face lift procedures and how they might apply to you can all be addressed in detail during your initial consultation.
The Best Candidates for a Facelift
The best candidate for a facelift is a man or woman whose face and neck have begun to sag, but whose skin still has some elasticity and whose bone structure is strong and well-defined. However, with lasers, new grafting techniques and implants, more corrective surgery is possible in most patients.
Understanding Facial Structure
Most face lift patients are between the age of 35 and 65, but facelifts can be performed successfully on people in their seventies or eighties as well. A facelift can make you look younger and fresher, and it may enhance your self confidence in the process. But it can't give you a totally different look, nor can it restore the health and vitality of your youth. Before you decide to have surgery, think carefully about your expectations and discuss them with Dr. Obi.


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Is Puffy Persian Kittens incorrect or missing key business information? Update your Hotfrog listing today.
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Welcome to Puffy Persian Kittens of Northern California, home of the cutest and cuddliest Persian kittens available. With fur softer than cashmere and sweet teddy bear personalities, PuffyPersian Kittens offers you the Persian kitten of your dreams.
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Ashford Plumbing Ltd4 Feedback reviews, 100% positive
As a new business my priority is on customer value and satisfaction from first contact to final completion. I have 37 years experience on plumbing and heating systems, including unvented and thermal store cylinders. Power flushing is available also. I am happy to attend...
Latest Central Heating feedback review:
By jo227 on 22nd Aug, 2016
Star property maintenance21 Feedback reviews, 81% positive
Star property maintenance At Star property maintenance we provide a complete 'start to finish' solution for Kitchen & Bathroom Installation and improvements. We also undertake full property renovations to the highest standard. We are a small yet highly skilled team who...
Latest Bathroom Fitting feedback review:
By davidjohn55skycom on 5th Oct, 2016
Amber Home Improvements59 Feedback reviews, 98% positive
I treat every job as if I'm working on my own home, whether it be a full bathroom refurb, a new floor, new shower, even changing a light bulb gets my fullest care and attention. I work hard to keep my customers happy and coming back to me with other jobs, however large or...
Latest Bathroom Fitting feedback review:
By heidicowling on 25th Jan, 2017
Ibuild4u7 Feedback reviews, 100% positive
Hi,I'm Rich Sault,my company is Ibuild4u. I have over 24 years experience in the building trade. All of my work is of high quality at an affordable price.I have a big portfolio behind me and excellent recommendations. Please contact me for a free no obligation quote.fb...
Latest Bathroom Fitting client reference:
Reference taken by MyBuilder on 28th Oct, 2015
RT Bathrooms12 Feedback reviews, 100% positive
I am a Qualified wall and floor tiler, CSCS registered and produce top quality work at good rates. I am a qualified bathroom fitter/plumber, producing top quality bathroom installations and alterations around the midlands for a number of years. ***AT Floors has now...
Latest Bathroom Fitting feedback review:
By john_1959 on 8th Feb, 2017
Maple property services7 Feedback reviews, 100% positive
Maple property services, is a family run business by Murray & Neil. We have been in the building industry for 30 years. Most of our work is through recommendation, commercial & private work welcome. All home improvements-repairs. We give free quotes & are fully insured.
Latest Bathroom Fitting feedback review:
By mikenixon_25 on 10th Feb, 2014
K.E.V Property Maintenance25 Feedback reviews, 100% positive
Hi, i'm Kev. After spending more than 15 years a soletrader in bathroom fitting and general maintenance, a neck injury prevented me from continuing as a full-time fitter. I know use my skills and experience to project manage a team of experienced tradesmen that work...
Latest Bathroom Fitting feedback review:
By hhicks on 9th Oct, 2016
CJ. Property Sevices16 Feedback reviews, 100% positive
My name is Chris Jones, I have been in the trade as a Handyman, for over 25 years, mainly for domestic propertys and small commercial. I started as a qualified electrician,but being able to adapt to most problems or straight forward work I have built up a wealth of knowledge...
Latest Bathroom Fitting feedback review:
By benjemin on 26th Nov, 2015
Guthries home and garden specialist3 Feedback reviews, 100% positive
We specialise in any work around the house and garden from flat pack to exstensions. 30 years experience combined we are a family run business and no how important the family home or garden can be so for a free quote or chat about any work you wish to have done please just...
Latest Bathroom Fitting feedback review:
By n_potts on 6th Dec, 2016
PTP Property Maintenanace20 Feedback reviews, 100% positive
I offer property maintenance services, which includes carpentry, plumbing, heating and general building. I can supply references and show previous jobs carried out. I use specialist tradesmen when required e.g Gas Safe registered for gas appliances. I have Insurance covering...
Latest Bathroom Fitting feedback review:
By alan_1sie on 22nd Dec, 2016
EpM Bathrooms & Kitchens3 Feedback reviews, 100% positive
We are a small building company based in Wem, Shropshire. We specialise in bathroom and kitchen refurbishments and offer a complete package from start to finish. We also carry out building works.
Latest Bathroom Fitting feedback review:
By the_logans on 20th Aug, 2012
3D Ceiling Midlands ltd5 Feedback reviews, 100% positive
We are company called 3D Ceiling Midlands, working on a various projects like 3d ceiling - walls, lightening and many more. If you interested in something modern and exclusive , something you never seen, contact us. Also my team can do tiling, all fittings such as showers,...
Latest Bathroom Fitting feedback review:
By bridget40 on 18th Feb, 2017
A.FISHER PLUMBING SERVICES5 Feedback reviews, 100% positive
My name is Antony and I have been installing bathrooms for 20 years. I do the full and complete refurbishment from plumbing, tiling, plastering and minor building alterations. I have attention to detail and utter respect for customers' home and property.
Latest Bathroom Fitting feedback review:
By winedwards on 29th Sep, 2015
A.S Plumbing & Bathrooms6 Feedback reviews, 100% positive
Hi, we are a small business based in STAFFS. We specialise in bathroom refurbs and tiling. We also specialise in wetrooms. We do the job from start to finish with electrical work and plastering work subbed out to also qualified tradesmen who we've worked with now for a...
Latest Bathroom Fitting feedback review:
By melissa90 on 7th Feb, 2017
Right Building Services12 Feedback reviews, 100% positive
We strive for excellence and customer satisfaction. Serving and meeting your needs by bringing your project or job to completion. No job is too small, we specialise in problem solving & finding solutions that are cost effective... "CUSTOMER SATISFACTION IS OUR...
Latest Bathroom Fitting feedback review:
By sophia_67 on 29th Aug, 2016
Need a tradesman?
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How MyBuilder works
1. Post a job
First, create a job listing for your bathroom fitting project. It's quick, easy and free - the first step to finding recommended bathroom fitters in TF2, Telford.
2. Hire a tradesman
Having met our recommended bathroom fitters in TF2, Telford and read customer reviews, you're ready to decide which bathroom fitters to hire.
3. Leave feedback
After your project is successfully completed, you can leave a review for your bathroom fitters. This review helps you and future MyBuilder users.
What our customers say
- "Great place to find tradesmen to carry out work, and the website is so easy to use. Wish I had known about it a few years ago. "
- Allan Parton
Tradesmen in TF2, Telford
- Architectural Designers
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punctuation within a quotation
if the text within the quotation is a question, but the sentence itself is declarative, should one use a question mark or period at the end of the sentence?
See example:
"What kind of treasure am I storing up," asks the concerned disciple.
asked Sep 17 '13 at 14:29 Steve Curtis New member
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Your answer
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Reputation: 1
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Webex is the next generation of web browsing technology!
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Pomegranate Extract Ellagic Acid 40%
Pomegranate Extract Ellagic Acid 40% is a powder extracted from the rind of the pomegranate fruit. Containing 40% of both ellagic acid and polyphenol, it functions to improve the body's immune function, balance female hormones, and as an antioxidant and anti-cancer. It finds application in health and medicinal foods.
No additional documentation is available. Please visit the supplier's website to contact them for further information.
Hangzhou Greensky Biological Tech. Co. is a modern company engaging in the exploitation, study, sale and production of plant extracts. Their main products found in their portfolio include Lycopene, Nettle Extract, Grape Seed Extract, Artichoke Extract, Marigold Extract, Diosmin, Red Yeast Rice, Cranberry Extract and Bilbery Extract.
Hangzhou Greensky Biological Tech. Co., Ltd.
Hangzhou Greensky Biological Tech. Co., Ltd.目前只在以下作出标识的区域展示其产品资料:
类别产品类型 Categories
- Plants, Fruits, Vegetables, Herbs, Seeds, Algae & Nuts ~ Fruit and Fruit Products ~ Fruit Extracts ~ Pomegranate Extract


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pudding puff
We went to the Kyushu and Okinawa Food Festival at Mitsuwa yesterday. It was so crowded. People really like food. These sweet cream puff pastries with a custardy pudding medallion spliced in to the middle of them were the tastiest things ever! We brought them home because we were full after eating dinner at the market and then we ate them for breakfast this morning. I am considering going back for some more today. They were that good. The fair is still going on for a few more hours. If I could ever replicate this recipe at home that would be just amazing. Maybe dangerous. They also had green tea cake rolls with pudding in the middle which looked so very good on the poster but unfortunately they were sold out. I think they came from miles around for that one. I did try making something like that once but it didn't turn out quite right.


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Is Universal Storefront Services incorrect or missing key business information? Update your Hotfrog listing today.
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Hotfrog Philippines provides information regarding Universal Storefront Services in Cagayan de Oro Misamis Oriental. Universal Storefront Services is located at Cagayan de Oro Misamis Oriental and provides Financial services. Contact them on (088) 449 3052.
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Loan Mart, Loans, listed under "Loans" category, is located at 2248 S Nellis Blvd Las Vegas NV, 89104 and can be reached by 7024579067 phone number. Loan Mart has currently 0 reviews.This business profile is not yet claimed, and if you are the owner, claim your business profile for free. If you are not the owner you can invite this business to join by email or by phone.Browse all Loans in Las Vegas NV. Discover census data for Las Vegas, NV.
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- Home
- Christmas Ornaments
- Animal, Birds, Flowers, Insects, & Nature
- Animal
- Personalized Dog Bone Formed Glass Ornament
Customer Reviews
Average Rating:
(based on 3 reviews)
By Kimberly
Noxen, PA
December 23, 2014
Noxen, PA
December 23, 2014
"I love this, I have ordered a few of these and my pet loving family and friends love this!"
By Vonnie Spang
Lebanon, PA
December 25, 2014
Lebanon, PA
December 25, 2014
"I've bought these for gifts and everyone has asked where I get them. I don't hesitate to tell them!"
January 12, 2015
"The ornament looks nice and it arrived in a timely manner. "