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Fetal surgery is being investigated for specific congenital abnormalities that are associated with a poor postnatal prognosis. Prenatal surgery typically involves opening the gravid uterus (with a Cesarean surgical incision), surgically correcting the abnormality, and returning the fetus to the uterus and restoring uterine closure. Minimally invasive procedures through single or multiple fetoscopic port incisions are also being developed.
Most fetal anatomic malformations are best managed after birth. However, advances in methods of prenatal diagnosis, particularly prenatal ultrasound, have led to a new understanding of the natural history and physiologic outcomes of certain congenital anomalies. Fetal surgery is the logical extension of these diagnostic advances, related in part to technical advancement in anesthesia, tocolysis, and hysterotomy.
This policy will pertain to fetal surgery performed for the following clinical conditions:
Fetal Urinary Tract Obstruction
Although few cases of prenatally diagnosed urinary tract obstruction require prenatal intervention, bilateral obstruction can lead to distention of the urinary bladder and is often associated with serious disease such as pulmonary hypoplasia secondary to oligohydramnios. Therefore, fetuses with bilateral obstruction, oligohydramnios, adequate renal function reserve, and no other lethal or chromosomal abnormalities may be candidates for fetal surgery. The most common surgical approach is decompression through percutaneous placement of a shunt or stent. Vesico-amniotic shunting bypasses the obstructed urinary tract, permitting fetal urine to flow into the amniotic space. The goals of shunting are to protect the kidneys from increased pressure in the collecting system and to assure adequate amniotic fluid volume for lung development.
Congenital Diaphragmatic Hernia (CDH)
CDH results from abnormal development of the diaphragm, which permits abdominal viscera to enter the chest, frequently resulting in hypoplasia of the lungs. CDH can vary widely in severity, depending on the size of the hernia and the timing of herniation. For example, late herniation after 25 weeks of gestation may be adequately managed postnatally. In contrast, liver herniation into the chest prior to 25 weeks of gestation is associated with a poor prognosis, and these fetuses have been considered candidates for fetal surgery. Temporary tracheal occlusion using a balloon is being evaluated for the treatment of CDH. Occluding the trachea of a fetus prevents the normal efflux of fetal lung fluid, which results in a build-up of secretions in the pulmonary tree and increases the size of the lungs, gradually pushing abdominal viscera out of the chest cavity and back into the abdominal cavity. It is believed that this, in turn, will promote better lung maturation. Advances in imaging have resulted in the ability to detect less severe lesions, which has resulted in a decrease in mortality rates for defects detected during pregnancy. Due to these changes over time, concurrent controls are needed to adequately compare pre- and postnatal approaches.
Congenital Cystic Adenomatoid Malformation (CCAM) or Bronchopulmonary Sequestration (BPS)
CCAM and BPS are the two most common congenital cystic lung lesions and share the characteristic of a segment of lung being replaced by abnormally developing tissue. CCAMs can have connections to the pulmonary tree and contain air, while BPS does not connect to the airway and has blood flow from the aorta rather than the pulmonary circulation. In more severe cases, the malformations can compress adjacent normal lung tissue and distort thoracic structure. CCAM lesions typically increase in size in mid-trimester and then in the third trimester either involute or compress the fetal thorax, resulting in hydrops in the infant and sometimes mirror syndrome (a severe form of pre-eclampsia) in the mother. Mortality is close to 100% when lesions are associated with fetal hydrops (abnormal accumulation of fluid in two or more fetal compartments). These patients may be candidates for prenatal surgical resection of a large mass or placement of a thoraco-amniotic shunt to decompress the lesion.
Sacrococcygeal Teratoma (SCT)
SCT is both a neoplasm with the power of autonomous growth and a malformation made up of multiple tissues foreign to the region of origin and lacking organ specificity. It is the most common tumor of the newborn and generally carries a good prognosis in infants born at term. However, in utero fetal mortality approaches 100% with large or vascular tumors, which may become larger than the rest of the fetus. In this small subset, SCT is associated with fetal hydrops, which is related to high output heart failure secondary to arteriovenous shunting. In some cases, mothers of fetuses with hydrops can develop mirror syndrome.
Myelomeningocele is a neural tube defect in which the spinal cord forms abnormally and is left open, exposing the meninges and neural tube to the intrauterine environment. Myelomeningocele is the most common cause of spina bifida, and depending on the location, results in varying degrees of neurologic impairment to the legs and bowel and bladder function, brain malformation (i.e., hindbrain herniation), cognitive impairment, and disorders of cerebrospinal fluid circulation, i.e., hydrocephalus requiring placement of a ventriculoperitoneal shunt. Traditional treatment consists of surgical repair after term delivery, primarily to prevent infection and further neurologic dysfunction. Fetal surgical repair to cover the exposed spinal canal has been proposed as a means of preventing the deleterious exposure to the intrauterine environment with the hope of improving neurologic function and decreasing the incidence of other problems related to the condition.
Cardiac Malformations
In utero interventions are being investigated for severe narrowing in one of the cardiac outflow tracts (aortic valve or pulmonary valve), a condition which causes progressive damage to the heart in utero. In utero intervention has been proposed for the following lethal cardiac conditions: critical pulmonary stenosis, critical aortic stenosis, and hypoplastic left heart syndrome (HLHS). Critical pulmonary stenosis or atresia with intact ventricular septum is characterized by a very narrow pulmonary valve without a connection between the right and left ventricles. Critical aortic stenosis with impending HLHS is a very narrow aortic valve that develops early during gestation that may result in HLHS. In utero aortic balloon valvuloplasty has been suggested as a way to relieve aortic stenosis in an attempt to preserve left ventricular growth and halt the progression to HLHS. HLHS with intact atrial septum describes the absence of a connection between the left and right atrium. A subset of fetuses with HLHS will present with severe cyanosis and require immediate postnatal intervention to survive. In utero septostomy has been performed in an attempt to improve postnatal survival for this condition.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Medically Necessary
Vesico-amniotic shunting as a treatment of urinary tract obstruction may be considered medically necessary in fetuses under the following conditions:
Open in utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt may be considered medically necessary under the following conditions:
In utero removal of sacrococcygeal teratoma may be considered medically necessary under the following conditions:
In utero repair of myelomeningocele may be considered medically necessary under the following conditions:
In utero repair of myelomeningocele is considered experimental, investigational and unproven in the following situations:
Other applications of fetal surgery are considered experimental, investigational and unproven, including but not limited to, temporary tracheal occlusion as a treatment of congenital diaphragmatic hernia or treatment of congenital heart defects.
The 2011 Agency for Healthcare Research and Quality (AHRQ) assessment identified 26 publications representing 25 unduplicated reports on fetal interventions for obstructive uropathy. From the 3 prospective cohorts and 8 retrospective cohorts identified, 24 fetuses had placements of shunts, 11 had other treatments for posterior urethral valves, 14 had no fetal intervention, and 13 pregnancies were terminated due to poor prognosis. Overall, 53% to 66% of infants who had shunt placement survived short term. However, more than half of otherwise normal infants who have only isolated bladder outlet tract obstruction and do not have multiple anomalies or syndromes, do not recover normal renal function in childhood, and the majority require dialysis and renal transplantation. In addition, a proportion of affected infants have clusters of syndromic features that are not readily diagnosed prenatally, increasing morbidity among survivors. For example, in a follow-up of 18 male children who had survived prenatal vesicoamniotic shunting (follow-up ranged from 1-14 years), parents and physicians reported the children to be neurodevelopmentally normal, with the majority having acceptable renal and bladder function and satisfactory self-reported quality of life. (4) One-third of the children required dialysis or transplantation, and one-half exhibited respiratory, growth and development, or musculoskeletal abnormalities. There is a need to better identify appropriate surgical candidates and clarify health outcomes in children who do and do not receive fetal intervention to inform decision making. One publication describes the design of a multicenter randomized trial of percutaneous shunting for lower urinary tract obstruction (PLUTO) that will assess whether intrauterine vesicoamniotic shunting improves pre- and perinatal health outcomes in comparison with conservative, noninterventional care. (5)
In 1999, the TEC Assessment concluded that temporary tracheal obstruction met the TEC criteria as a treatment of congenital diaphragmatic hernia, based in part on a case series. (6) However, in 2003, Harrison and colleagues, the same authors who reported on the original case series, reported the results of a randomized trial of fetoscopic tracheal occlusion compared with standard postnatal care. (7) Enrollment was stopped at 24 women due to the unexpectedly high 90-day infant survival rate with standard care, and thus the safety monitoring board concluded that further recruitment would not result in a significant difference between the groups. In addition, the fetal surgery group had higher rates of prematurity and lower birth weights. Based on the results of this randomized trial, the policy statement was revised to indicate that tracheal occlusion is considered experimental, investigational and unproven. The survival rate in the standard treatment group was 73%, considerably higher than the estimated survival rate of 37% based on historical controls. The survival of infants with a lung-to-head ratio (LHR) greater than 1.0 was 100% in both groups. In other publications, survival has been reported to be approximately 10% for children with isolated congenital diaphragmatic hernia who have left-sided lesions, liver herniation, and an LHR of less than 1.0 during mid-gestation. (8) In this subgroup, temporary placement of a detachable balloon to occlude the trachea was reported to result in a survival rate of 55% (35 cases), compared with 8% survival in a group of contemporary controls treated by postnatal therapy.
The 2011 AHRQ technology assessment identified 25 publications with 21 unduplicated populations from 10 U.S. sites, 9 European sites, 3 multinational sites, and 5 other countries, for a total of 335 cases. The single randomized controlled trial (RCT) was by Harrison et al. (reference 7, described above), with follow-up reported by Cortes et al. in 2005. (9) Growth failure occurred in 56% of controls and 86% of infants who had occlusion. No neurodevelopmental differences were observed between groups with follow-up at 1 or 2 years of age. This randomized study reinforces the importance of a concomitant control group, as the survival for CDH with postnatal repair also improved over time. Also noted were results of the Fetal Endoscopic Tracheal Occlusion (FETO) Task Group in Europe, which is using a control group of 86 fetuses with left-sided CDH and liver herniation, managed expectantly and live born after 30 weeks of gestation. In this control group, the survival rate increased from 0% for LHR of 0.4 to 0.7 to approximately 15% survival for LHR of 0.8 to 0.9, 65% for LHR of 1.0 to 1.5, and 83% survival for LHR of 1.6 or more. This ongoing series currently has an 11% survival for LHR less than 1, which can be used as a reference value for Europe, but not for the United States.
The 2011 literature update identified a number of papers, all from non-U.S. centers that examined tracheal changes including tracheomegaly and intermittent collapse of the posterior wall of the trachea observed after fetal balloon tracheal occlusion in severe CDH. Fayoux and colleagues report that tracheal widening and elongation and relaxation of the posterior tracheal wall intermittently obstructing the lumen during tidal breathing were seen in 7 consecutive infants who underwent fetoscopic balloon tracheal occlusion. (10) In the 5 survivors, the changes were not symptomatic except for a barking cough during increased respiratory efforts. No new studies compared outcomes of fetal balloon tracheal occlusion with current management of diaphragmatic hernia.
The 2011 AHRQ assessment identified 17 publications describing 6 distinct cohorts and 4 case series from 7 academic centers in the United States, South America, Europe, and Asia. Of approximately 401 infants believed to have CCAMs, 54 had thoracoamniotic shunting and 3 had open procedures, with the goal of decompressing the lung lesion. An additional 13 fetuses with BPS were described. In the cohorts, 44% to 100% of infants who had thoracoamniotic shunts survived to birth or through neonatal hospitalization; there was an overall survival rate of 54% in the literature. For fetuses with hydrops, survival was 20% to 30% following surgical treatment compared with 5.7% for untreated hydrops. Since some infants with large CCAMs respond to in utero medical treatment with steroids, failure to respond to steroids may be an entry criterion for future surgical interventions.
At the time of the 1999 TEC Assessment, the published literature included only 4 cases of fetal surgery for SCT. However, in utero surgery resulted in prenatal resolution of hydrops, healthy long-term survival, and normal development in some children. These results were impressive given the near-certain fetal mortality if fetal hydrops is left untreated. For example, in a 2004 report of 4 cases of open surgical resection of SCT, Hedrick and colleagues reported 1 neonatal death and 3 survivals with a follow-up range of 20 months to 6 years. (11) Complications other than the fetal death included 1 embolic event, 1 chronic lung disease, and 1 tumor recurrence. The 2011 AHRQ assessment identified a total of 7 retrospective cohorts and case series from 3 academic fetal surgery groups in the U.S. and U.K. The 17 fetuses reported to be treated with open surgery were compared with 94 cases with other interventions or no intervention; however, the expectant management cases were less severe. Other ablation methods included alcohol sclerosis (all 3 cases died), radiofrequency ablation (RFA) (4 of 7 survived), and laser ablation (all 4 died). For open surgical procedures, the survival rates were 33% to 75%. All fetal and neonatal deaths occurred among patients with hydrops or with prodromal cardiovascular changes concerning for developing hydrops. Challenges in this area are the early and reliable detection of development of hydrops and the timing of the fetal intervention. (3)
The endoscopic approach has been abandoned due to high mortality, however, more than 200 fetuses with myelomeningocele have undergone open surgical repair in the United States. (3) All of the 25 reports on open surgery that were identified in the 2011 AHRQ assessment were based on 4 series of patients from 4 academic medical centers in the United States. Two of the studies had concurrent comparisons. (12, 13) One of these analyzed the first 29 cases of open myelomeningocele repair at Vanderbilt University Medical Center, finding significant reductions in the need for postnatal shunt placement (51% vs. 91%) and reduced hindbrain herniation (38% vs. 95%). However, both prospective studies found that in utero repair was associated with greater rates of oligohydramnios (48% vs. 4%), lower gestational ages (33 vs. 37 weeks), and no difference in lower extremity function.
In 2011, results of the National Institutes of Health (NIH)-sponsored RCT, the Management of Myelomeningocele Study (MOMS) comparing prenatal repair with standard postnatal repair were published. (14) The trial began in 2003 and was expected to enroll 200 women ages 18 years or older who were pregnant with fetuses with myelomeningocele. Women assigned to have prenatal surgery were scheduled for surgery within 1 to 3 days after they were randomized and stayed near the MOMS center until they delivered by C-section. Women in the postnatal group traveled back to their assigned MOMS center to deliver, also by C-section, around the 37th week of their pregnancies. Follow-up on the children was scheduled to be performed at 1 year and 2 ½ years of age to evaluate motor function, developmental progress, and bladder, kidney, and brain development. There was a voluntary moratorium in the United States on conducting in utero repair of myelomeningocele outside of this trial. (3)
The inclusion criteria for MOMS included singleton pregnancy, myelomeningocele with the upper boundary located between T1 and S1, evidence of hindbrain herniation, gestational age of 19.0 to 25.9 weeks at randomization, normal karyotype, U.S. residency, and maternal age at least 18 years. Major exclusion criteria were fetal anomaly unrelated to myelomeningocele, severe kyphosis, risk of preterm birth, placental abruption, body-mass index of 35 or greater, contradiction to surgery including previous hysterotomy in the active uterine segment. Surgeons had performed at least 15 cases before this randomized study. Primary outcomes were a composite of fetal or neonatal death or the need for a cerebrospinal fluid shunt (shunt placement or meeting criteria for shunt) at 12 months and a composite score of the Mental Development Index of the Bayley Scales of Infant Development II and the child's motor function at 30 months adjusted by level of lesion. Secondary outcomes were surgical and pregnancy complications and neonatal morbidity and mortality. Women were randomized to treatment group in 1:1 ratio.
Recruitment for the trial, planned to include 200 subjects, was stopped at 183 subjects when a clear advantage of prenatal intervention was apparent. The report includes 158 woman randomized before July 1, 2009. Outcomes up to 30 months are based on 138 women randomized before December 1, 2007. Groups were similar other than that there were more female fetuses and the lesion level was more severe in the prenatal surgery group. Two perinatal deaths occurred in each treatment group. Both deaths in the prenatal surgery group occurred on the fifth postoperative day, a still birth at 26 weeks and a neonatal death due to prematurity at 23 weeks' gestation. Two neonates in the postnatal surgery group died with severe symptoms of the Chiari II malformation. Fetal or neonatal death or the need for shunt occurred in 68% of infants in the prenatal-surgery group and in 98% of the postnatal-surgery group (relative risk [RR], 0.70; 97.7% confidence interval [CI], 0.58 to 0.84; p<0.001). Shunts were placed in 40% of the prenatal-surgery and in 82% of postnatal-surgery groups (p<0.001). At 12 months, 4% of infants in the prenatal-surgery group had no evidence of hindbrain herniation versus 36% in the postnatal-surgery group. There was one death in each group between 12 and 30 months (coxsackie septicemia in a child who received prenatal surgery and complications of chemotherapy for choroid plexus carcinoma in a child who received postnatal surgery). The composite of score of Bayley Scales and motor function adjusted by lesion level at 30 months was significantly better in the prenatal surgery group: mean 148.6 +/- standard deviation (SD) 57.5 in the prenatal surgery group (n=64) versus mean 122.6 +/- SD 57.2 in the postnatal surgery group (n=70) (p=0.007).
Maternal morbidity and complications related to prenatal surgery included oligohydramnios, chorioamniotic separation, placental abruption, and spontaneous membrane rupture. At delivery, an area of dehiscence or a very thin prenatal uterine surgery scar was seen at delivery in one third of mothers who had prenatal fetal surgery (all subsequent pregnancies should be delivered by cesarean before the onset of labor). The average gestational age of babies in the prenatal surgery group was 34.1 weeks, and 13% were delivered before 30 weeks of gestation. One-fifth of infants in the prenatal surgery group had evidence of respiratory distress syndrome, which was likely related to prematurity. The authors observed that "in the case of infants with low lumbar and sacral lesions, in whom less impairment in lower-limb function may be predicted, the normalization of hindbrain position and the minimization of the need for postnatal placement of cerebral spinal shunt may be the primary indication for surgery." They caution that the potential benefits of fetal surgery must be balanced against the risks of premature delivery and maternal morbidity and that continued assessment is required to learn if early benefits of prenatal surgery are sustained and the effects of fetal surgery on bowel and bladder continence, sexual function, and mental capacity. They warn that results of this trial should not be generalized to centers with less experience or to patients who do not meet eligibility criteria.
Uncontrolled Series
A 2004 report by Bruner et al. described minimum 12-month follow-up of 116 fetuses after intrauterine repair of spina bifida (myelomeningocele or myeloschisis). (15) Sixty-one fetuses (54%) required ventriculoperitoneal shunt placement for hydrocephalus. Statistical analysis revealed that fetuses were less likely to require ventriculoperitoneal shunt placement when surgery was performed at 25 weeks or earlier, when ventricular size was less than 14 mm at the time of surgery, and when the defects were located at L4 or below. Johnson and colleagues reported on the results of a series of 50 fetuses who underwent open fetal closure of a myelomeningocele between 20 and 24 weeks' gestation. (16) Fetal selection criteria included the presence of hindbrain herniation and sonographic evidence of intact neurologic function, i.e., movement of the lower extremities and absence of clubfoot deformities. Perinatal survival was 94%, with a mean age at delivery of 34 weeks. All fetuses demonstrated reversal of hindbrain herniation; 43% required ventriculoperitoneal shunting compared to 68-100% in historical controls, depending on the location of the myelomeningocele. Another study reporting leg function at longer follow-up showed no difference between patients treated with fetal surgery at 20 to 28 weeks versus traditional surgery. (12)
In three papers, investigators at the University of Pennsylvania reported outcomes of myelomeningocele repair in 54 patients treated before the voluntary moratorium. (17-19) At median follow-up of 66 months (range 36-54 months), 37/54 (69%) walk independently, 13/54 (24%) are assisted walkers, and 4/54 (7%) are wheelchair dependent. The strongest factors predicting a lower likelihood to walk independently were higher level lesion (>L4) and the development of clubfoot deformity after fetal intervention. The majority of independent ambulators, and all children who require assistive devices to walk, experience significant deficits in lower extremity coordination. (18) Thirty children returned at 5 years of age for neurocognitive examination. In this highly selected group, most children had average preschool neurodevelopmental scores, and children who did not require shunt placement were more likely to have better scores. (19) A survey of 48 families focused on hindbrain herniation (HH)-associated brainstem dysfunction, e.g., apnea, neurogenic dysphagia, gastro-esophageal reflux disease, neuro-ophthalmologic disturbances. (17) Half of the children required shunting. At a median age of 72 months, 15 non-shunted and 10 shunted children were free of HH symptoms. There were no HH-related deaths, and no children developed severe persistent cyanotic apnea. Most children had no or only mild brainstem dysfunction. The authors conclude that reversal of HH after fetal surgery may help reduce the incidence and severity of brainstem dysfunction.
Investigators at a German center performed a retrospective analysis of expectantly managed patients who received surgical intervention within 2 days of birth at their institution and compared them with reports of outcomes after fetal surgery from other centers including those noted above and to data from historical controls. (20) Patients were born between 1979 and 2009 and are now 13.3 +/- 8.9 (mean +/- standard deviation [SD]) years old. Gestational age at birth in the expectantly managed group was 37.8 weeks, significantly higher than in the prenatal surgery patients. In the expectantly managed group, shunt placement was required in 69.8% at mean age of 16.0 +/- 10.7 days, which is less than for historical controls and comparable to data reported on patients who received fetal surgery. The authors suggest that inconsistency in clinical criteria for shunting used in studies might contribute to differences in this outcome. Among their expectantly managed patients, 56.4% were assisted walkers and 64.1% attended regular classes, both comparable to historical controls. Noting the discrepancy in the rate of assisted walkers and wheelchair users between expectantly managed patients/historical controls and patients who received surgery, the authors observe that the mean age of the study population was 21.7 years for historical controls, 13.3 years for their population, and only 67.0 months after fetal surgery. They cite earlier papers reporting mobility decreases from early childhood to the early teens including one reporting that "the percentage of patients ambulating the majority of time decreased from 76% at 0-5 years to 46% at 20-25 years, with a flattening beyond 10 years". (21)
The 2011 AHRQ technology assessment included the following evidence on fetal surgery for cardiac malformations:
The AHRQ report concluded that overall, procedures for severe fetal cardiac anomalies are in an early stage. Preliminary work is being reported in a few highly specialized centers that are establishing the groundwork for feasibility and future directions for outcomes research in this area. The authors concluded that the most pressing challenge in this area is the ability to identify the "right" patient whose care would be compromised by waiting to do a postnatal repair.
McElhinney et al. analyzed their experience with 70 prenatal balloon aortic valvuloplasties attempted in midgestational fetuses between March 2000 and October 2008 for critical aortic stenosis with evolving hypoplastic left heart syndrome to identify factors associated with procedural and postnatal outcomes. (22) Median gestational age was 23.2 weeks (range, 20-31 weeks). Technical success was achieved in 52 fetuses. Compared to 21 untreated comparison fetuses, subsequent prenatal growth of the aortic and mitral valves, but not the left ventricle, was improved after intervention. Nine pregnancies did not reach viable term or preterm birth. Seventeen patients had a biventricular circulation postnatally, 15 of them from birth. Two of these patients had no neonatal intervention. Sixteen were alive at a median age of 2.1 years (range, 4 months-7 years). The other patient died of unrelated causes. Guidelines for assessing the potential for a biventricular circulation changed over the period of the study and became more selective. Larger left heart structures and higher left ventricular pressure at the time of intervention were associated with biventricular outcome. The authors conclude that further investigation is required before it is possible to predict whether fetal intervention will result in improved left heart growth and postnatal survival with a biventricular circulation, and "the potential benefits of fetal intervention must be weighed against the risk of technical failure, fetal demise, aortic regurgitation, and potential long-term adverse events that have yet to be identified".
The use of fetal surgery for other defects is expanding; recent case reports include prenatal correction of cleft lip and palate and decompression of the fetal trachea. (23, 24)
A review of 187 maternal-fetal surgeries performed at the University of California San Francisco Fetal Treatment Center found significant short-term maternal morbidity but no maternal deaths. (25) Post-surgical complications included increased rates of cesarean birth, treatment in intensive care, prolonged hospitalization, and blood transfusion.
No new studies of fetal surgery for other applications were identified for this update.
Due to a number of factors, including the rarity of the conditions and the small number of centers specializing in fetal interventions, the evidence on fetal surgery remains limited. Fetal surgery for many congenital conditions, including diaphragmatic hernia and heart defects, has not been shown to improve health outcomes in comparison with postnatal treatment. The available evidence is insufficient to demonstrate that fetal tracheal occlusion and aortic valvuloplasty provides improved health outcomes. For these and other applications of fetal surgery that are currently considered experimental, investigational and unproven, additional studies are needed to identify appropriate candidates and to evaluate longer term outcomes compared with postnatal management.
For conditions leading to fetal hydrops (certain cases of congenital cystic adenomatoid malformation, bronchopulmonary sequestration, or sacrococcygeal teratoma), for which mortality approaches 100%, fetal surgery may be considered medically necessary. Vesico-amniotic shunting for bilateral urinary tract obstruction may also be considered medically necessary to minimize the effects of this condition on kidney and lung development. Additional studies for these surgeries are needed to better define the appropriate surgical candidates, the most effective timing of the interventions, and the long-term health outcomes in surviving children.
Data from the MOMS trial show that prenatal repair of myelomeningocele reduces the need for shunting in the first 12 months after delivery and improves a composite measure of mental and motor function, with adjustment for lesion level, at 30 months of age. Prenatal surgery also improves the degree of hindbrain herniation and the likelihood of being able to walk independently when compared with postnatal surgery. The long-term impact on function needs to be evaluated, and benefits must be balanced against risks to mother and child. Thus, fetal surgery may be considered medically necessary following informed decision-making for cases of prenatal myelomeningocele that meet the criteria of the MOM study.
Practice Guidelines and Position Statements
The American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics and the American Academy of Pediatrics Committee on Bioethics issued a committee opinion on maternal-fetal intervention and fetal care centers in 2011. (26) The committee recommended that:
A consensus, endorsed by the International Fetal Medicine and Surgery Society proposes the following criteria for fetal surgery (8):
"1. Accurate diagnosis and staging possible, with exclusion of associated anomalies
2. Natural history of the disease is documented, and prognosis established
3. Currently no effective postnatal therapy
4. In utero surgery proven feasible in animal models, reversing deleterious effects of the condition
5. Interventions performed in specialized multidisciplinary fetal treatment centers within strict protocol and approval of the local Ethics Committee and with informed consent of the mother or parents."
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member's benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
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Mom of girl, 4, shot in the head: 'She's opening her eyes; she's kicking her legs'
Jacele Johnson, a 4-year-old girl shot in the head Friday night on the South Side, is "responsive" but remains in critical condition, her mother said.
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A day after announcing a venue change, Riot Fest organizers sent an email on Thursday to people who purchased early bird tickets, notifying them that the tickets will be honored at its new home in Chicago's Douglas Park and offering a full refund until Monday if they no longer want to go to the...
Just two months into the baseball season, the Cubs are exceeding fans' expectations and creating a national buzz with one of the best records in the National League.
Seven-year-old Elijah Dace didn't know he had been shot until his older brother, running behind him, saw a hole in the little boy's jacket.
Cyclists worried about cars crashing into them now can test out Chicago's first concrete curb-protected bike lane.
After marching to McDonald's Oak Brook campus Thursday morning, 10 protesters from a crowd of more than 1,000 were allowed on McDonald's property to deliver a petition with more than 1 million signatures calling for $15-per-hour wages for the company's front-line workers.
While Chicago and a handful of other cities nationwide are poised to boost the minimum wage and low-wage work becomes a hot topic on the state and federal levels, a few hundred protesters took to McDonald's headquarters in suburban Oak Brook Thursday to demand a $15 wage and the right to unionize.
Good news for summer job seekers: Jobs should be more plentiful this year and a majority of employers have jobs paying more than $15 per hour, according to a new report.

subset: commoncrawl


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You won't believe how small the world's deadliest animal is
Lions and sharks might look terrifying, but the animals that kill the most humans seem, on the surface, far more innocuous. Dogs, flies, snails and mosquitoes are much more dangerous...
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Reykjavík is the capital and largest city of Iceland, and the world's most northern national capital. It is located in southwestern Iceland, on the southern shore of Faxaflói Bay. It is the heart of Iceland's economic and governmental activity. Today, Reykjavík is the only metropolitan area in Iceland. As it is only slightly south of the Arctic Circle, Reykjavik receives only four hours of daylight on the shortest day in winter. During the summer, the nights are almost as bright as the days. It has continued to see population growth in past years as well as growth in areas of commerce and industry.
As your horse's warm breath hangs thick in the air in a landscape of vast Icelandic lava fields, you and your family will feel as though you've stepped into an ancient fairy tale world of mythical proportions.
Experience Iceland's pristine nature, in an adventurous tour which offers great potential for outdoor activities such as snowmobiling, horseback riding, cave exploring, hiking, swimming, skiing, river rafting, kayaking, and legendary whale watching. Make the most of your Icelandic experience on this guided tour and talk with our specialists for a custom quote.
(Reykjavik, Budir, Ranga)
From glaciers to geysers, highlands to hot springs, Iceland has it all. Majestic scenery abound, discover exciting vistas at every turn.
Explore a land of steaming hot springs, glaciers, waterfalls, active volcanoes, geysers and unique wildlife in Iceland. Continue to the Faroe Islands,a nation of eighteen small islands of which seventeen are inhabited with a total of less than 50.000 people and with more than 3-4 million sea birds – a dream for the ornithologists and all nature lovers.
Enjoy a Winter Adventure in spectacular Iceland including a variety of shared tours, activity, leisure time and spectacular winter scenery!
Iceland - Enjoy this stunning country with its off-the-beaten-path activities. Private and shared tours throughout.
If the fountain of youth actually exists, you'll find it in Reykjavik. A journey through an other-worldly landscape of rugged lava fields reveals the celebrated Blue Lagoon where you'll feel the healing power of its mineral-rich geothermal waters.
Ring in the New Year Scandinave-style on this celebratory Icelandic adventure! Watch the spectacle that erupts when 600 tons of fireworks are lit all in one evening, and explore the natural wonders that make this region famous: golden waterfalls, ice fields, and lagoons.
Discover majestic wilderness in Narsarsuaq -the gateway to South Greenland, with its pristine wilderness, clean air and water, and the majesty of the surrounding mountains and glaciers.
As the midnight sun illuminates the soaring icebergs of the Arctic Circle in warm tones of red, watch giants sheets of ice fall into the ocean in Mother Nature's most breath-taking natural symphony.
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Death toll at 37 as Iran wraps up quake rescue
TEHRAN—Rescuers Wednesday wound up operations after pulling 20 people from the rubble of an earthquake that struck near the port city of Bushehr, killing 37 people but sparing Iran's sole nuclear power plant.
"With the rescue operation being wrapped up no one is left under the rubble," the Fars news agency quoted the head of Iran's Red Crescent rescue corps, Mahmoud Mozafar, as saying.
According to latest media reports, 37 people were killed and 850 others injured in the 6.1 magnitude quake that struck on Tuesday.
At least 20 people were rescued from the rubble, according to Fars, which added that some 700 homes had been destroyed.
Mozafar said efforts were now focused on relief operations and around 1,000 tents had been set up in quake-hit areas.
Fars said blankets and food have also been sent to stricken areas.
Iran said it had informed the International Atomic Energy Agency that there has been no damage to the nuclear power plant in Bushehr, nearly 90 kilometers (55 miles) northwest of quake's epicenter, and no radioactive release.
Iran's atomic chief Fereydoon Abbasi Davani said that the power plant was not operational when the quake struck as it was " under maintenance", Iranian media reported.
The facility's chief engineer, Mahmoud Jafari, told Arabic-language Al-Alam television that "no operational or security protocols were breached" by the quake.
The nuclear power plant in Bushehr, a long-delayed project finished by Russia, is yet to become fully operational.
Tuesday's quake coincided with Iran unveiling a uranium production facility and two extraction mines in centre of the country.
Iran is at loggerheads with world powers over its development of a controversial nuclear program, which the Western and Israel suspect is aimed at military objectives despite repeated denials by Tehran.
The 6.1 magnitude quake hit at 4:22 pm (1152 GMT) on Tuesday at a depth of 12 kilometers (7.5 miles), in the area of Kaki, according to the Iranian Seismological Center which has registered more than a dozen after shocks, the strongest at 5.3 magnitude.
The US Geological Survey, which monitors quakes worldwide, ranked the quake at a more powerful 6.3 magnitude.
In Dubai, hundreds of kilometers down the Gulf from Bushehr and home to the world's tallest building, Burj Khalifa, local media reported that several high-rise buildings were briefly evacuated.
Iran sits astride several major fault lines and is prone to frequent earthquakes, some of which have been devastating.
A double earthquake, one measuring 6.2 and the other 6.0, struck northwest Iran in August last year, killing more than 300 people and injuring 3,000.
In December 2010, a big quake struck the southern city of Bam. It killed 31,000 people — about a quarter of the population — and destroyed the city's ancient mud-built citadel.
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OAK CREEK Apartments401 New Brunswick Ave, East Brunswick, NJ 08816 View On Map (732) 254-4488
For rates, availability, and other information fill out the availability request form and a representative from OAK CREEK Apartments will contact you shortly
Oak Creek is located in the Somerset Area in the 08816 zip code. View this apartment on a map.
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NEW YORK ( TheStreet) -- The last time I discussed Bank of America (BAC - Get Report), I told you the stock was fairly priced. I didn't see the justification for more gains, even though I was willing to look at the glass-half-full side of the story.
Since then, however, the stock has shot up an additional 12% and breaking that all-important $15 mark last week.
Look, I'm not blaming Bank of America. Other than smiling and saying "thank you," there's not much a company can do when the Street falls in love with its stock. While Bank of America has certainly become a pleasant turnaround story, I can't say that the stock, which closed Wednesday at $14.60, makes sense at this level -- not at a P/E of 31, which is more than three times that of JPMorgan Chase (JPM).
I'm not saying Bank of America's growth is not impressive. In fact, I've said on more than one occasion that the pace of Bank of America's recovery was faster than it had fallen. But I don't believe that investors who are enamored with Bank of America's notable growth truly appreciate the depths the bank had reached. To say it another way, the giant leaps are indeed remarkable. But it's also because Bank of America was so far behind.What's more, when compared to the likes of Wells Fargo (WFC), the deficits Bank of America still has to work with become more noticeable, including fee income, which was down 4% in the recent quarter due to lower trading. Granted, Bank of America's 6% growth in operating revenue was 5% better than Wells Fargo's, but the bank also posted a 1% sequential decline in net interest income. I won't disagree that there are still plenty of legacy issues impacting upon Bank of America's performance. But the same explanation can't be used to justify the premium the stock price commands, not when net interest margin (NIM) and earnings assets are underperforming. What's more, it also looks as if JPMorgan is outperforming Bank of America in mortgage originations.


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- Shopping Bag ( 0 items )
From the Publisher"...inspiring, innovative, challenging...Sylvester's feminist voyage through International Relations has produced some extraordinarily good work." Contemporary Sociology
"...a tantalizing read that teases the reader into critical reflection about feminist theory and IR theory as much through its style as through it substantive claims. Most of all, it provokes the reader through its refusal to assert any definitive conclusion about what feminism brings to IR or IR to feminism. The book is more than an intellectual autobiography (though it certainly is that)—it is also a serious contribution to the ongoing dialogue between feminist and IR theory." Ethics & International Affairs
"Christine Sylvester's enormous versatility as a scholar is evident in this compilation of her many essays...Feminist International Relations is an important book for students of IR, not only because it brings together in one place [her] many writings, but also because it pushes scholars of IR to reckon with the enormous fecundity of feminist approaches and their ability to open up new ways of 'sighting,' 'siting,' and 'citing.' She is a bold and imaginative thinker and writer, and her feminist interventions in IR challenge a field in which 'a conversation, to say nothing of a debate, on gender and IR has simply not occupied any center stage.'" Perspectives on Politics
"For the patient patient and the initiated, the collection provides insight on how a feminist approach to international relations developed (although omitting a number of important works) and what methods might usefully advance the approach. Recommended for graduate and research collections." Choice


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Layers of deep-orange sweet potatoes, golden butternut squash, crunchy pecans and tender, crisp apples come alive with the flavors of vanilla, cinnamon and nutmeg for the perfect side that's sure to become a new holiday tradition.
2 pounds sweet potatoes, peeled and cubed
1 1/2 pounds butternut squash, peeled and cubed
2/3 cup packed light brown sugar, divided
3 eggs, beaten
6 tablespoons butter, melted, divided
2 teaspoons McCormick® Pure Vanilla Extract
2 teaspoons McCormick Gourmet™ Cinnamon, Ground Saigon , divided
1/2 teaspoon McCormick Gourmet™ Nutmeg, Ground
3/4 teaspoon salt
1 cup chopped pecans
2 Golden Delicious apples, peeled and thinly sliced
Cook sweet potatoes in water to cover in large saucepan about 20 minutes or until tender. Drain. Meanwhile, cook squash in another saucepan about 10 minutes or until tender; drain.
Preheat oven to 350°F. Mix 1/3 cup of the brown sugar, eggs, 2 tablespoons of the butter, vanilla, 1 1/2 teaspoons of the cinnamon, nutmeg and salt. Reserve 1/4 cup mixture for squash.
Puree sweet potatoes with remaining egg mixture in food processor until smooth. Spread in greased 13x9-inch baking dish or 3-quart casserole. Sprinkle evenly with pecans.
Puree squash with reserved 1/4 cup egg mixture in food processor until smooth. Spread over pecan layer. Arrange apple slices on top of squash layer. Mix remaining 1/3 cup brown sugar and 1/2 teaspoon cinnamon. Sprinkle over apples. Drizzle with remaining 4 tablespoons butter.
Bake 45 to 50 minutes or until center is set. Let stand 10 minutes before serving.
(Amount per serving)
Delicious and easy to make!
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Pronunciation: Je travaille le lundi
Added on: 2009-12-26 Listened: 2.6K timesin: learning French, I work on Mondays, Business phrases in French
Pronunciation in French [fr]
- Pronunciation by brunett83 (Female from France)
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Here are 3 healthy slow cooker recipes that are low in fat and high in flavor!
An interview with the co-discoverer of one of the biggest breakthroughs in cancer research
If you're lactose intolerant, you probably avoid most dairy products. But as it turns out, not all dairy is off limits. Read on to learn how you can get some dairy back in your diet.
Dr. Jose Gonzalez-Garcia provides insight to the most commonly asked question about the transfer of HIV between partners.
Fend off colds and the flu with these disease-fighting foods
Here are 15 ways to help prevent lung cancer.


text: Vengeful Red is described as a "deep cool red." It's a vibrant, medium-dark red with cool, blue undertones and a luminous sheen. It had fully opaque color coverage applied to the lips, and it went on evenly and smoothly. This color wore well for six and a half hours and left a stain behind, and the formula was somewhat hydrating. Marc Jacobs Beauty Neo-Noir (126) (P, $30.00) is very similar. Urban Decay 69 (P, $22.00) is less glossy. Edward Bess Eternal Passion (P, $32.00) is similar. Maybelline On Fire Red (P, $7.49) is a little brighter. MAC Eden Rouge (LE, $16.00) is more matte. Guerlain Vega (P, $35.00) is a touch darker. Buxom Scoundrel (P, $21.00) is brighter. See comparison swatches.


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Investment Management Update - January 2015
Discussion and Analysis -
Last week, the Securities and Exchange Commission proposed to amend SEC Rule 15b9-1 under the Securities Exchange Act of 1934, which exempts certain broker-dealers from membership in a...more
Investment Management Update - January 2015
This podcast is a recording of the January 2015 webinar that Pepper partner Gregory J. Nowak participated on for West LegalEdcenter.
Mr. Nowak discussed a regulatory outlook...more
In this issue:
- NASDAQ Proposes Internal Audit Function Requirement for Listed Issuers
- FINRA's Frequently Asked Questions on Electronic Blue Sheet Submissions Updated Regarding Order Execution Time
In this issue:
- Nallengara to Replace Cross as Corp. Fin. Chief
- FINRA Rule Relating to Private Placements of Securities Effective December 3
- Additional Guidance on FINRA's Suitability Rule
- No-Action...more
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We know we can't use characters from the shows and movies, but what about dialogue?
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Lt. Commander
Join Date: Dec 2007
Posts: 120
# 7
Thanks a lot for your answers, guys!
You've really helped me out!
Originally Posted by
You know, I see this said quite often around here but it's not exactly true. According to the Foundry terms of use, "you may use the names of characters (past or present) from the Star Trek Properties." What you can not do is use the actor's likeness. If you take a look at Cryptic missions, you'll notice Worf is now white or that Scotty and McCoy don't really look like the actors who portrayed them.
Yeah, sorry about that; I should've been more specific, but, since it was almost 4 AM, I wasn't thinking very straight. :p


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Brandon Saad praise, Tampa Bay advances and more ...
In 2010, Brandon Saad was considered a top-five selection for the 2011 Entry Draft. The United States National Team Development Program product signed with the Saginaw Spirit and posted 55 points -- 27 goals -- over 59 games during his draft year, and he experienced a freefall in draft rankings.
The Chicago Blackhawks plucked Saad at 43rd overall during
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1975 Porsche 911 Tagra '75 Porsche 911 Targa chassis#9115211030 engine#64J03364 in red with black interior and equipped with power windows, air conditioning and a... More
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This 1967 Porsche 912 Soft-Window Targa is a wonderful example for restoration. White with Black interior. It's missing motor it's motor but comes complete... More
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A midengine design and classic Porsche styling, not to mention sublime steering and brakes, give this 2003 Porsche Boxster a unique combination of traits... More
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The Porsche 944 is quite possibly the biggest bang for the buck in sports cars, and this ultra-clean 1985 944 has a lot going... More
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This early production 1987 944 (10/1986), was ordered with M-418 body side moldings, M-425 rear wiper/washer, M-431 4-spoke sport leather steering wheel, M-454 cruise... More
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YOU ARE LOOKING AT A 1997 PORSCHE BOXSTER CONVERTIBLE WITH 43,000 ORIGINAL MILES. THIS CAR HAS A CLEAN CAR FAX AND CURRENT INSPECTION. 2.5... More
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PORSCHE: 1972 914 2.0, 2-owner 67,000-mile rust-free GA car, new guards red paint, new correct expensive black interior, chromed bumpers, new rubber seals, new... More


text:
Norway has decided to follow the European Union (EU) in imposing sanctions on Russia over the Ukraine crisis, the Norwegian foreign ministry said Saturday.
Norway would do exactly the same as the EU when it came to financial sanctions against Russia, said Norwegian Foreign Minister Boerge Brende Friday, according to Xinhua.
"This means that a number of key Russian politicians and officials are no longer welcome in Norway, either visiting or passing through. They will not have access to the assets they may have in Norway," said Brende.
The sanctions will be implemented very quickly, the Norwegian foreign minister said.


text:
Flight Status
1,000 - 5,000 downloadsAdd this app to your lists
+ By TouchMeme
With Flight Status, you can track flight delays, view flight arrival and departure times, terminal and gate numbers, baggage claim info and much more. Flight Status app also supports interactive maps.
You can check the status of the flights by Flight Number or by Route. The Trips module lets you save and track flights.
Here are the key highlights of this application...
* Check the status of all flights worldwide
* Supports 4300+ Airports and 1200+ Airlines
* Displays Terminal, Gate & Baggage Claim Information
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* Searches flights by Flight Number & Route
* Check Flight Status for worldwide flights 1 year in advance by flight number
* Flights Notifications keeps you updated on flight information. Included some free notifications for saved flights. Can purchase additional notifications
* Zoomable Maps for all flights worldwide
* Two Map Style options available to choose from
* Maps available for individual flights as well as flights between two airport
* Track flights by saving flights to the trips module
* Sync your flights from TripIt (In-App purchase) and get updated status info
* Sync your flight info with Mocha.co, online flight planner application
and much more...
The information displayed in this app is gathered from FlightStats.com which is a very reliable sources of information for tracking flights.
If you have any feedback/suggestions/issues, please email us at email@example.com.
KW: flight status, flight tracker, flight, track flights, airport, terminal, flighttrack
Tags: source code for flight tracker in, show flight status, ifly pro, pagina para flight status, flightstats flight tracker, flight track stopped, flight status phones, info mocha.co.in.
* Added support for more devices
* Supports Nexus 7 tablet along with other tablets
* Improved the status interface
* Bug fixes and other enhancements
(42 stars)
You have to pay for an extra app, which wouldn't let me set up an account, to actually update flight status. What's the point?
(42 stars)
Paid for this app, then they changed their name, now I can't download it without paying $5 for it again?
(42 stars)
(42 stars)
Installed the app after paying for it only to try and open it and just get a message telling me it is unlicensed and I need to purchase it! How many times am l supposed to buy it? I wish I could get 3pounds for nothing! (That's a lot of 3 pounds!) No comms...no stars buyer beware!
(42 stars)
Map is awesome, but would like option to show time in a fixed time zone!


text:
- Introduction
- Childhood and youth
- Prerevolutionary military and political career
- Revolutionary leadership
- Presidency
- Cabinet of Pres. George Washington
Prerevolutionary politics
Washington's contented life was interrupted by the rising storm in imperial affairs. The British ministry, facing a heavy postwar debt, high home taxes, and continued military costs in America, decided in 1764 to obtain revenue from the colonies. Up to that time, Washington, though regarded by associates, in Col. John L. Peyton's words, as "a young man of an extraordinary and exalted character," had shown no signs of personal greatness and few signs of interest in state affairs. The Proclamation of 1763 interdicting settlement beyond the Alleghenies irked him, for he was interested in the Ohio Company, the Mississippi Company, and other speculative western ventures. He nevertheless played a silent part in the House of Burgesses and was a thoroughly loyal subject.
But he was present when Patrick Henry introduced his resolutions against the Stamp Act in May 1765 and shortly thereafter gave token of his adherence to the cause of the colonial Whigs against the Tory ministries of England. In 1768 he told George Mason at Mount Vernon that he would take his musket on his shoulder whenever his country called him. The next spring, on April 4, 1769, he sent Mason the Philadelphia nonimportation resolutions with a letter declaring that it was necessary to resist the strokes of "our lordly masters" in England; that, courteous remonstrances to Parliament having failed, he wholly endorsed the resort to commercial warfare; and that as a last resort no man should scruple to use arms in defense of liberty. When, the following month, the royal governor of Virginia dissolved the House of Burgesses, he shared in the gathering, at the Raleigh Tavern in Williamsburg, that drew up nonimportation resolutions, and he went further than most of his neighbours in adhering to them. At that time and later he believed with most Americans that peace need not be broken.
Late in 1770 he paid a land-hunting visit to Fort Pitt, where George Croghan was maturing his plans for the proposed 14th colony of Vandalia. Washington directed his agent to locate and survey 10,000 acres adjoining the Vandalia tract, and at one time he wished to share in certain of Croghan's schemes. But the Boston Tea Party of December 1773 and the bursting of the Vandalia bubble at about the same time turned his eyes back to the East and the threatening state of Anglo-American relations. He was not a member of the Virginia committee of correspondence formed in 1773 to communicate with other colonies, but when the Virginia legislators, meeting irregularly again at the Raleigh Tavern in May 1774, called for a Continental Congress, he was present and signed the resolutions. Moreover, he was a leading member of the first provincial convention or revolutionary legislature late that summer, and to that body he made a speech that was much praised for its pithy eloquence, declaring that "I will raise one thousand men, subsist them at my own expense, and march myself at their head for the relief of Boston."
The Virginia provincial convention promptly elected Washington one of the seven delegates to the first Continental Congress. He was by this time known as a radical rather than a moderate, and in several letters of the time he opposed a continuance of petitions to the British crown, declaring that they would inevitably meet with a humiliating rejection. "Shall we after this whine and cry for relief when we have already tried it in vain?" he wrote. When the Congress met in Philadelphia on September 5, 1774, he was in his seat in full uniform, and his participation in its councils marks the beginning of his national career.
His letters of the period show that, while still utterly opposed to the idea of independence, he was determined never to submit "to the loss of those valuable rights and privileges, which are essential to the happiness of every free State, and without which life, liberty, and property are rendered totally insecure." If the ministry pushed matters to an extremity, he wrote, "more blood will be spilled on this occasion than ever before in American history." Though he served on none of the committees, he was a useful member, his advice being sought on military matters and weight being attached to his advocacy of a nonexportation as well as nonimportation agreement. He also helped to secure approval of the Suffolk Resolves, which looked toward armed resistance as a last resort and did much to harden the king's heart against America.
Returning to Virginia in November, he took command of the volunteer companies drilling there and served as chairman of the Committee of Safety in Fairfax county. Although the province contained many experienced officers and Col. William Byrd of Westover had succeeded Washington as commander in chief, the unanimity with which the Virginia troops turned to Washington was a tribute to his reputation and personality; it was understood that Virginia expected him to be its general. He was elected to the second Continental Congress at the March 1775 session of the legislature and again set out for Philadelphia.
Revolutionary leadership
Head of the colonial forces
The choice of Washington as commander in chief of the military forces of all the colonies followed immediately upon the first fighting, though it was by no means inevitable and was the product of partly artificial forces. The Virginia delegates differed upon his appointment. Edmund Pendleton was, according to John Adams, "very full and clear against it," and Washington himself recommended Gen. Andrew Lewis for the post. It was chiefly the fruit of a political bargain by which New England offered Virginia the chief command as its price for the adoption and support of the New England army. This army had gathered hastily and in force about Boston immediately after the clash of British troops and American minutemen at Lexington and Concord on April 19, 1775. When the second Continental Congress met in Philadelphia on May 10, one of its first tasks was to find a permanent leadership for this force. On June 15, Washington, whose military counsel had already proved invaluable on two committees, was nominated and chosen by unanimous vote. Beyond the considerations noted, he owed being chosen to the facts that Virginia stood with Massachusetts as one of the most powerful colonies; that his appointment would augment the zeal of the Southern people; that he had gained an enduring reputation in the Braddock campaign; and that his poise, sense, and resolution had impressed all the delegates. The scene of his election, with Washington darting modestly into an adjoining room and John Hancock flushing with jealous mortification, will always impress the historical imagination; so also will the scene of July 3, 1775, when, wheeling his horse under an elm in front of the troops paraded on Cambridge common, he drew his sword and took command of the army investing Boston. News of Bunker Hill had reached him before he was a day's journey from Philadelphia, and he had expressed confidence of victory when told how the militia had fought. In accepting the command, he refused any payment beyond his expenses and called upon "every gentleman in the room" to bear witness that he disclaimed fitness for it. At once he showed characteristic decision and energy in organizing the raw volunteers, collecting provisions and munitions, and rallying Congress and the colonies to his support.
The first phase of Washington's command covered the period from July 1775 to the British evacuation of Boston in March 1776. In those eight months he imparted discipline to the army, which at maximum strength slightly exceeded 20,000; he dealt with subordinates who, as John Adams said, quarrelled "like cats and dogs"; and he kept the siege vigorously alive. Having himself planned an invasion of Canada by Lake Champlain, to be entrusted to Gen. Philip Schuyler, he heartily approved of Benedict Arnold's proposal to march north along the Kennebec River in Maine and take Quebec. Giving Arnold 1,100 men, he instructed him to do everything possible to conciliate the Canadians. He was equally active in encouraging privateers to attack British commerce. As fast as means offered, he strengthened his army with ammunition and siege guns, having heavy artillery brought from Fort Ticonderoga, New York, over the frozen roads early in 1776. His position was at first precarious, for the Charles River pierced the centre of his lines investing Boston. If the British general, Sir William Howe, had moved his 20 veteran regiments boldly up the stream, he might have pierced Washington's army and rolled either wing back to destruction. But all the generalship was on Washington's side. Seeing that Dorchester Heights, just south of Boston, commanded the city and harbour and that Howe had unaccountably failed to occupy it, he seized it on the night of March 4, 1776, placing his Ticonderoga guns in position. The British naval commander declared that he could not remain if the Americans were not dislodged, and Howe, after a storm disrupted his plans for an assault, evacuated the city on March 17. He left 200 cannons and invaluable stores of small arms and munitions. After collecting his booty, Washington hurried south to take up the defense of New York.
Washington had won the first round, but there remained five years of the war, during which the American cause was repeatedly near complete disaster. It is unquestionable that Washington's strength of character, his ability to hold the confidence of army and people and to diffuse his own courage among them, his unremitting activity, and his strong common sense constituted the chief factors in achieving American victory. He was not a great tactician: as Jefferson said later, he often "failed in the field"; he was sometimes guilty of grave military blunders, the chief being his assumption of a position on Long Island, New York, in 1776 that exposed his entire army to capture the moment it was defeated. At the outset he was painfully inexperienced, the wilderness fighting of the French war having done nothing to teach him the strategy of maneuvering whole armies. One of his chief faults was his tendency to subordinate his own judgment to that of the generals surrounding him; at every critical juncture, before Boston, before New York, before Philadelphia, and in New Jersey, he called a council of war and in almost every instance accepted its decision. Naturally bold and dashing, as he proved at Trenton, Princeton, and Germantown, he repeatedly adopted evasive and delaying tactics on the advice of his associates; however, he did succeed in keeping a strong army in existence and maintaining the flame of national spirit. When the auspicious moment arrived, he planned the rapid movements that ended the war.
One element of Washington's strength was his sternness as a disciplinarian. The army was continually dwindling and refilling, politics largely governed the selection of officers by Congress and the states, and the ill-fed, ill-clothed, ill-paid forces were often half-prostrated by sickness and ripe for mutiny. Troops from each of the three sections, New England, the middle states, and the South, showed a deplorable jealousy of the others. Washington was rigorous in breaking cowardly, inefficient, and dishonest men and boasted in front of Boston that he had "made a pretty good sort of slam among such kind of officers." Deserters and plunderers were flogged, and Washington once erected a gallows 40 feet (12 metres) high, writing, "I am determined if I can be justified in the proceeding, to hang two or three on it, as an example to others." At the same time, the commander in chief won the devotion of many of his men by his earnestness in demanding better treatment for them from Congress. He complained of their short rations, declaring once that they were forced to "eat every kind of horse food but hay."
The darkest chapter in Washington's military leadership was opened when, reaching New York in April 1776, he placed half his army, about 9,000 men, under Israel Putnam, on the perilous position of Brooklyn Heights, Long Island, where a British fleet in the East River might cut off their retreat. He spent a fortnight in May with the Continental Congress in Philadelphia, then discussing the question of independence; though no record of his utterances exists, there can be no doubt that he advocated complete separation. His return to New York preceded but slightly the arrival of the British army under Howe, which made its main encampment on Staten Island until its whole strength of nearly 30,000 could be mobilized. On August 22, 1776, Howe moved about 20,000 men across to Gravesend Bay on Long Island. Four days later, sending the fleet under command of his brother Adm. Richard Howe to make a feint against New York City, he thrust a crushing force along feebly protected roads against the American flank. The patriots were outmaneuvered, defeated, and suffered a total loss of 5,000 men, of whom 2,000 were captured. Their whole position might have been carried by storm, but, fortunately for Washington, General Howe delayed. While the enemy lingered, Washington succeeded under cover of a dense fog in ferrying the remaining force across the East River to Manhattan, where he took up a fortified position. The British, suddenly landing on the lower part of the island, drove back the Americans in a clash marked by disgraceful cowardice on the part of troops from Connecticut and others. In a series of actions, Washington was forced northward, more than once in danger of capture, until the loss of his two Hudson River forts, one of them with 2,600 men, compelled him to retreat from White Plains across the river into New Jersey. He retired toward the Delaware River while his army melted away, until it seemed that armed resistance to the British was about to expire.


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Return Code -2147467259 on Software Mgmt Job
I created a batch file to import a registry setting into HKCU and set the software management policy to "Repeat this task for each logged on user". It runs just fine if manually executed but for some strange reason when the scheduled job fires off, it fails where I get return code -2147467259 in the Symantec Management Agent's task history. However, if I click the Application Task in the SMA to run it, it completes successfully. This is the first s/w delivery job in SMP 7.1 SP2 MP1.1 I had to set up with a run once per user option. Has anyone else seen this type of behavior before?
Comments 10 Comments • Jump to latest comment
As well as running it at user logon I think you have to run it as the logged in user.
Your error code is a bit of a cryptic one:
Run-time error '-2147467259 (80004005)':
Method 'SetFocus' of object 'CommandBarPopup' failed
Authorised Symantec Consultant (ASC) with Endpoint Management Limited, an Authorised Symantec Delivery Provider based in the UK.
Connect Etiquette: Please "Mark as Solution" posts that fix your problem.
I'm already running the batch file as the currently logged in user as this was necessary to change something in HKCU. Anyway, I have since found the following article which got me a bit farther after changing the run from "Hidden" to "Minimized".
Now the scheduled policy fires off without that odd runtime error at the get-go where the SMA shows "Success" for the batch file execution. However, Task History indicates a -1 return code with no change performed in the registry. I believe that something's quirky with the "timeout" command (available on a Win7 box) to pause the batch file for 5 seconds and the way Altiris runs the batch file minimized.
In my batch file I'm copying in a .reg file to the workstation then doing a "reg import", executing timeout then deleting the reg file to clean things up. However, I'm thinking maybe the pause isn't working and the delete is occurring before the reg import gets a chance to do its job. The batch file runs just fine manually but it could be one of those odd situations as mentioned in the tech article. I have yet to test another way to handle the pause and will do so next week.
Based upon TECH209838 and my testing, I seriously think there's a bug in how Software Management Solution executes policies where you want to run the job only when a user is logged on, need to do so under their credentials, and to run once per user (and maybe only with batch files?...who knows). When the scheduled policy fires off, my first detection check says "Failure" instead of "Not Detected" or "Detected" with a return code of -1. Manually running the job via the SMA works as expected.
After looking at TECH209838 again, the only other option I didn't try was opposite to what the article mentioned (i.e. "It may also be necessary to enable the setting Allow user to interact with installing software.") as a possible resolution. I tried unchecking this box and rescheduled my job after which it completed successfully! Exit code was 1 this time around instead of -1 but I never paid attention to return codes from batch files. Main thing was that my registry got updated for HKCU.
For this latest run, I manually did Settings->Update in the SMA to force a configuration update after which my jobs fired off. However, want to be absolutely sure my policies will fire off without human intervention so I deleted the registry key (I imported via the previous job run) on a couple of my test VMs I've been playing around with and rescheduled the policy for tomorrow. Will keep you guys posted.
You maybe coulf try without the batch file. If you put the reg key in the Package then just have this command line:
CMD/ C "regedit.exe /S yourregfile.reg"
Authorised Symantec Consultant (ASC) with Endpoint Management Limited, an Authorised Symantec Delivery Provider based in the UK.
Connect Etiquette: Please "Mark as Solution" posts that fix your problem.
Unfortunately my previously scheduled job again had a "Failure" status (return code -1) during the detection phase on both of my test VMs this morning. I'm giving changing the extension from bat to cmd a shot. Now with the cmd change, I scheduled my policy to fire off a few minutes ahead, did an Update in the SMA Settings where it successfully completed.
However, I've seen this behavior before where my forcing the SMA to "prematurely" update its settings has the job completing successfully. What I'm trying now is I created a new schedule, left the default 00:00 time but changed Advanced settings for tomorrow's date so the jobs should kick off as soon as I log into each of my test Win7 VMs tomorrow.
Think I previously mentioned that this is the first s/w management (7.1) job where I had to run once per user under their credentials. I've pushed out other .bat files under System Account with no problems so I believe this is a bug with a certain combination of Run options. Maybe SMP 7.5 fixes these issues? ;-)
Try it on a "proper" PC. I've had HKCU Detection Rules fail quite often on my VMWare Worksation VMs but they seem to work in live on real PCs.
Edit: I always put it down to the fact that my VM builds aren't proper production ones, we don't have a VM build as such and/or it's using NAT.
Authorised Symantec Consultant (ASC) with Endpoint Management Limited, an Authorised Symantec Delivery Provider based in the UK.
Connect Etiquette: Please "Mark as Solution" posts that fix your problem.
Taking your suggestion and testing on physical boxes as well. Trying to find some "guinea pigs" at the moment. Hopefully results will be similar since we're considering using VDI in certain situations.
As for VMware Workstation, I usually set mine to Bridged to more closely emulate an actual production PC.
I'm not allowed, strictly only one MAC per switch port - temporary exceptions for PXE booting to build only.
Authorised Symantec Consultant (ASC) with Endpoint Management Limited, an Authorised Symantec Delivery Provider based in the UK.
Connect Etiquette: Please "Mark as Solution" posts that fix your problem.
New Quote from Wikipedia
The only known difference between .cmd and .bat file execution is that in a .cmd file the ERRORLEVEL variable changes even on a successful command that is affected by Command Extensions (when Command Extensions are enabled), whereas in .bat files the ERRORLEVEL variable changes only upon errors.
The source for the Wikipedia quote above is actually based on this news group posting.
The differences between .CMD and .BAT as far as CMD.EXE is concerned are: With extensions enabled, PATH/APPEND/PROMPT/SET/ASSOC in .CMD files will set ERRORLEVEL regardless of error. .BAT sets ERRORLEVEL only on errors.


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You can now invite anyone to meet at your favorite Starbucks.
Limited-time feature
34 year old man | Indianapolis, IN, USA | Seeking women 26-38 within 100 miles of Carmel, IN
Active within 24 hours
I moved to Indy two years ago for a new job...
I moved to Indy two years ago for a new job and am quite happy to be back in the Circle City. During my downtime, you will find me running on the Monon, watching the Colts/Pacers/Boilers, or checking out one of the many local breweries/wineries. I am blessed to have a close family including three sisters who keep me on my toes. I have made close friends throughout the country over the years; thus making me one of Travelocity's best customers. When it comes to a relationship, I keep things simple and refuse to get caught up in drama or 'play games'. Call me old school, but I live each day with honesty and integrity. I promise to make you laugh, push you to try new things and expand your outlook; while insisting you do the same. If you are serious about your career and looking for someone (who happens to be quite tall) to build a friendship and hopefully long-term relationship with, then drop me a note!
Alumni connections , Coffee and conversation , Business networking , Cooking , Dining out , Music and concerts , Nightclubs/Dancing , Travel/Sightseeing , Volunteering , Wine tasting
Cycling, Dancing, Running, Swimming, Walking / Hiking, Weights / Machines
I exercise 5 or more times per week.
I like Dogs
Middle of the Road
Matt the Miller's, Stacked Pickle, The Pint House, Scotty's, The Friendly Tavers, and of course BW3. I am a Guinness affectionado; however I have been really impressed with all the local microbreweries popping up in Indy.
Purdue University, West Lafayette, IN
Favorite book: Catcher in the Rye. My favorite season is winter, especially after a big snow storm. I am a huge country music fan; however also enjoy alternative, rock, classical, and dance(bpm). My favorite Netflix series: House of Cards
I love to run and find new trails/paths to take. On the weekends, I will cook a big meal and have friends/family over to share a few bottles of wine. My latest adventure: Ballroom Dancing - Waltz, Rumba, and East Coast Swing.
iCon : Steve Jobs, the Greatest Second Act in the History of Business.
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|What he is looking for
|6'6" (198cms)
|5'0" (152cms) to 6'9" (205cms)
|Body type:
|Athletic and toned
|Slender, About average, Curvy, Athletic and toned
|No preference
|Light brown
|No preference
|No Way
|No Way
|Social Drinker
|Social Drinker
|Financial / Accounting / Real Estate
|No preference
I am a Financial Analyst with a major safety manufacturer in Indianapolis. Working hard and growing my career with the hopes of retiring early and traveling all over the world with someone special!
|I'll tell you later
|No preference
|Never Married
|Never Married
|Have kids:
|Wants kids:
|Definitely, Someday, Not sure
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|Christian / Catholic, Christian / LDS, Christian / Protestant, Spiritual but not religious, Other, Christian / Other
|Graduate degree
|Bachelors degree, Graduate degree, PhD / Post Doctoral
Go Boilermakers!


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|4 LIU basketball players suspended after brawl
|Written by Admin
|Friday, 21 September 2012 09:54
The fight broke out during a welcome-back party for students at the Brooklyn campus last weekend. Police say the four players were arrested Thursday after the track team members filed complaints. They were not seriously injured but were taken to a hospital.
Among those arrested include Julian Boyd, a forward who was named the Northeast Conference player of the year last year, and two high scorers, Jamal Olaswere, Troy Joseph and a fourth player, C.J. Garner. The team is ranked No. 1 in the conference.
The school's provost says no other students were implicated.
It wasn't clear if they had attorneys. They were awaiting arraignment.


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Okay for radio?
Is it okay to power up my new radio without having an antenna attached? I want to check my wiring, and to make sure that the radio in fact works. I know I will not be able to actually receive anything. But is it harmful?
Just DON'T key that mike.
Just to elaborate on what Joe said If you Key the mike without an antenna or some appropiate load connected you WILL burn out the output power amp transistor.
Thanks, guys. I love clear, unambiguous, understandable answers!!
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Jennifer Hudson's colorful photo shoot for the January 2013 issue of Lucky magazine.
Want to see some hilarious celeb pics that will make you LOL? Great, because we have the funniest celeb pics of the week to show you!
Nothing says "vacation" quite like kicking back with an ice cold drink.
Mariah Carey has been struttin' her stuff everywhere lately!
Suit up!


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Rockies top Pirates 7-1
The Pirates got one back in the bottom of the inning on McCutchen's RBI groundout, one of the few hard-hit balls off Rogers.
Notes: Colorado went 31-50 on the road last season. ... Tanner, who died in February at 82, was remembered for being the Pirates' fearless on-field leader. "If he was captain of the Titanic, he would have told the passengers they were stopping for ice," said Greg Brown, one of the team's broadcasters. The Pirates are wearing patches on their jerseys with Tanner's No. 7. His son, Bruce, threw out the ceremonial first pitch to former catcher Manny Sanguillen. ... The Pirates are 4-7 in openers at PNC and 72-53 overall. ... Pittsburgh's Jose Tabata has hit safely in all seven games. ... The Pirates had played 26 straight error-free innings before Walker's miscue in the first.
The Associated Press


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For Peace and Reunification
On June 25, 1950, the U.S. and south Korean traitors started a war against our Republic, war that left indelible scars on the Korean nation. Each year this day comes round, the nation's hatred for the Yankee devils would flare up more fiercely.
Today, 64 years ago, Syngman Rhee and his puppet army, aided and abetted by U.S. warmongers, lit the fuse of war against our Republic. Soon, American troops joined in the war.
The distinction between us and the enemy became clear. It was a war between our young Republic, only two years old then, in one hand and in the other the U.S., - a would-be "world mightiest" and troops of 15 of its satellites, plus south Korean puppet troops. It was a war between allied forces of imperialism and us.
In this war, our army and people were led by the great leader Kim Il Sung, an ever-victorious iron-willed brilliant commander and outstanding military strategist. Our army and people showed matchless bravery and mass heroism in the war and defended the country's freedom and independence with credit.
After three years of fight, the U.S. lost the war. It marked the beginning of U.S. downhill turn toward ruin.
The credit for war victory went to President Kim Il Sung and his original military idea and strategy and tactics, and the credit also went to patriotism and indomitable fighting spirit of our Army and people.
60 and more years have gone by since the war. But war threats have not been removed from the Korean Peninsula due to the incessant war provocations of the U.S. and south Korean war-maniacs.
For the Korean nation who has suffered the holocaust of most outrageous war nothing is more precious than peace and national reunification.
All Koreans, wherever they live, should unite firm in the struggle for peace against war, and frustrate the scheme of the U.S. and south Korean puppets for arms build-up and a new war against our Republic. They must all come out in a nation-wide struggle to drive out of south Korea the U.S. troops of aggression, the very disturber of peace in the Korean Peninsula. All Koreans must turn out in the patriotic struggle for thorough implementation of the June 15 N-S joint declaration and October 4 Declaration.
Let's all fight tenaciously against war schemes of anti-reunification forces at home and abroad and for national reunification, peace and prosperity.