text:
Vagus Nerve Stimulation
Revision Date(s) 05/12/14; 05/13/13; 06/12/12; 03/08/11; 01/12/10; 01/13/09; 10/14/08; 01/08/08; 09/12/06; 09/13/05; 10/12/04; 09/12/03; 01/08/02; 06/02/00; 01/07/99; 06/25/98
*Medicare has a policy.
Vagus nerve stimulation may be considered medically necessary as a treatment of medically refractory seizures.
Vagus nerve stimulation is considered investigational as a treatment of other conditions, including but not limited to heart failure, fibromyalgia, depression, essential tremor, obesity, headaches, tinnitus, and traumatic brain injury.
Non implantable vagus nerve stimulation devices are considered investigational for all indications.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric and Neurologic Disorders
Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
Medically refractory seizures are defined as seizures that occur in spite of therapeutic levels of antiepileptic drugs or seizures that cannot be treated with therapeutic levels of antiepileptic drugs because of intolerable adverse effects of these drugs.
Vagal nerve stimulation (VNS) requires not only the surgical implantation of the device, but also subsequent neurostimulator programming, which occurs intraoperatively and typically during additional outpatient visits. There are CPT codes that specifically describe the neurostimulator programming and analysis of cranial nerve stimulation (i.e., vagus nerve) as follows:
Stimulation of the vagus nerve can be performed by means of an implantable stimulator within the carotid artery sheath. This technique has been proposed as a treatment for refractory seizures, depression, and other disorders.
Significant advances have occurred in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, however, 25% to 50% of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs. Vagus nerve stimulation (VNS) has been investigated as a treatment alternative in patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed.
While the mechanisms for the therapeutic effects of VNS are not fully understood, the basic premise of VNS in the treatment of various conditions is that vagal visceral afferents have a diffuse central nervous system projection, and activation of these pathways has a widespread effect on neuronal excitability. Surgery for implantation of a vagal nerve stimulator involves wrapping two spiral electrodes around the left vagus nerve within the carotid sheath. The electrodes are connected to an infraclavicular generator pack. The programmable stimulator may be programmed in advance to stimulate at regular times or on demand by patients or family by placing a magnet against the subclavicular implant site. In 1997, the U.S. Food and Drug Administration (FDA) approved a VNS device called the NeuroCybernetic Prosthesis (NCP®) system through the Premarket Approval (PMA) process. The device was approved for use in conjunction with drugs or surgery "as an adjunctive treatment of adults and adolescents over 12 years of age with medically refractory partial onset seizures."
Since 1997, it has been reported that recipients of a vagus nerve stimulator have experienced improvements in mood. Therefore, there has been research interest in VNS as a treatment for refractory depression. On July 15, 2005, Cyberonics received PMA supplement approval by FDA for the VNS Therapy™ System "for the adjunctive long-term treatment of chronic or recurrent depression for patients 18 years of age or older who are experiencing a major depressive episode and have not had an adequate response to four or more adequate antidepressant treatments."
VNS therapy has also been investigated for use in other conditions such as headaches, obesity, and essential tremors.
Cerbomed has developed a transcutaneous VNS (t-VNS®) system that uses a combined stimulation unit and ear electrode to stimulate the auricular branch of the vagus nerve, which supplies the skin over the concha of the ear. Patients self-administer electric stimulation for several hours a day; no surgical procedure is required. The device received the CE mark in Europe in 2011, but has not been FDA approved for use in the U.S. Electrocore has developed a noninvasive VNS (gammaCore®) that is currently being investigated for headache; the device does not have FDA approval.
Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
This policy was created in 2000 and updated periodically with literature review. The most recent update covered the period from January 1, 2013, through February 5, 2014.
The review of evidence in this section will pertain to implantable vagus nerve stimulators unless otherwise indicated. The evidence on nonimplantable vagus nerve stimulators will be discussed separately.
Treatment of Seizures
The policy regarding treatment of seizures has expanded the indications over time but was originally based, in part, on a 1998 TEC Assessment (1) that offered the following conclusions:
Based on this TEC Assessment, earlier versions of this policy supported the use of VNS for partial-onset seizures for patients older than 12 years of age.
Tecoma and Iragui observed in a 2006 review that, since approval of VNS for partial seizures, a number of case series including patients with generalized seizures have been published. These series report seizure reduction rates similar to or greater than those reported in partial epilepsy and note that "this body of evidence suggests that VNS has broad antiepileptic efficacy."(2) The authors suggest that these results may be particularly important because resective epilepsy surgery is generally not feasible in these patients.
Other reports published since that time is consistent with their observations. In a French study of 50 consecutive refractory adolescents and adults who were not eligible for surgery and 11 of whom had generalized epilepsy, 58% were classified as responders at three years' follow-up. (3) Generalized epilepsy was predictive of a better outcome than partial epilepsy seizures. Seizure reduction of 61% was also reported in a case series of 12 patients with drug-resistant idiopathic generalized epilepsy.(6) Garcia-Navarrete et al evaluated outcomes after 18 months of follow up for a prospectively-followed cohort of 42 patients with medication-resistant epilepsy who underwent VNS implantation.(7) Subjects' seizure types were heterogeneous, but 52% had generalized epilepsy. Pharmacotherapy was unchanged during the course of the study. Twenty-seven subjects (63%) were described as "responders," defined as having a 50% or greater reduction in seizure frequency compared with the year before VNS implantation. The reduction in seizure frequency was not statistically significantly different between subjects with generalized and focal epilepsy.
Since publication of the 1998 TEC assessment, there has been interest in expanding the use of VNS to younger patients. Several studies have now reported results that support the safety and efficacy of the device in children with refractory seizures. (8) For example, 60 pediatric patients were treated as part of the double-blind clinical trials conducted to support the FDA application. (9) At 18 months, the median reduction in seizure frequency was 50%, similar to the results achieved in adults. Adverse events were also similar to those recently reported in adults, (10) and none resulted in termination of stimulation. Hornig et al. reported on a case series of 19 pediatric patients, with observation periods ranging up to 30 months. (11) Overall, 50% of patients had a 50% reduction in seizure frequency. Patwardhan et al. reported that among 38 patients aged 11 months to 16 years with medically refractory seizures, both generalized and partial-onset, 29% had a greater than 90% reduction in seizure frequency after VNS implantation, while 39% had 50% to 90% reduction. (12) Healy et al reported that among 16 patients younger than 12 years who underwent VNS implantation at a single center, 9 (56%) experienced a reduction in their seizure frequency of 50% or more.(13) Results from an add-on study to a randomized controlled trial (RCT) designed to compare high-output with low-output VNS stimulation among 41 children with medically refractory epilepsy suggest that VNS does not have adverse effects on cognitive or psychosocial outcomes.(14)
Similar to adult studies, pediatric studies suggest that VNS improves seizure frequency in generalized epilepsy syndromes. In a multicenter study of 28 children with refractory seizures, You et al reported that 15 children (53.6%) showed a greater than 50% reduction in seizure frequency and 9 (32%) had a greater than 75% reduction, and there were no significant differences when groups were compared by seizure type or etiology. (4) Tecoma and Iragui cite a multicenter retrospective analysis of 50 children with Lennox-Gastaut syndrome (LGS) treated with VNS. (2) Median seizure reduction at 6 months was 88% for tonic seizures and 81% for atypical absence. You et al. compared VNS and total corpus callosotomy for LGS. (5) Of the 14 patients who underwent a corpus callosotomy, 9 (64%) had a greater than 50% reduction in seizure frequency and 5 (36%) had a greater than 75% reduction. Of the 10 patients who underwent VNS implantation, 7 (70%) had a greater than 50% reduction in seizure frequency and 2 (20%) had a greater than 75% reduction. For 24 children with LGS or LGS-like syndrome who underwent VNS implantation, Cukiert et al reported that at least a 50% seizure frequency decrease was seen for 35 different seizure types.(15)
The major limitations of VNS are the following issues: stimulation generally does not completely eliminate seizures, and it is not possible to predict which patients will optimally respond. One meta-analysis that included 74 retrospective and prospective studies assessing VNS efficacy in seizures found that predictors of efficacy included generalized epilepsy or mixed seizure types (compared with partial-onset seizures) and age younger than 18 years.(16) In 2013, Arya et al reported results of a single-center retrospective chart review that included 43 pediatric patients who underwent VNS implantation over a 5-year period; the authors found that absence of magnetic resonance imaging lesion predicted a good outcome.(17) These studies support the use of VNS in children, in patients with generalized epilepsy, and in those who are not candidates for surgery (ie, no identified structural brain abnormality).
The evidence on the efficacy of VNS for treatment of refractory seizures consists of 2 RCTs and numerous uncontrolled studies. The RCTs both reported a significant reduction in seizure frequency for patients with partial-onset seizures. The uncontrolled studies have consistently reported large reductions for a broader range of seizure types in both adults and children. The large reduction in seizures includes substantial numbers of patients who achieve a greater than 50% reduction in seizure frequency.
Treatment of Refractory Depression
Interest in the application of VNS for treatment of refractory depression is related to reports of improvement in depressed mood among epileptic patients undergoing VNS.(18) TEC Assessments written in 2005 and updated in 2006 concluded that evidence was insufficient to permit conclusions of the effect of VNS therapy on health outcomes.(19,20) The available evidence for these TEC Assessments included study groups assembled by the manufacturer of the device (Cyberonics) and have since been reported on in various publications.(21,22) Analyses from these study groups were presented for U.S. Food and Drug Administration (FDA) review and consisted of a case series of 60 patients receiving VNS (Study D-01), a short-term (i.e., 3-month) sham-controlled RCT of 221 patients (Study D-02), and an observational study comparing 205 patients on VNS therapy with 124 patients receiving ongoing treatment for depression (Study D-04). (23) Patients who responded to sham treatment in the short-term RCT (approximately 10%) were excluded from the long-term observational study.
The primary outcome evaluated was the relief of depression symptoms that can usually be assessed by any one of many different depression symptom rating scales. A 50% reduction from baseline score is considered to be a reasonable measure of treatment response. An improvement in depression symptoms may allow reduction of pharmacologic therapy for depression, with a reduction in side effects related to that form of treatment. In the studies evaluating VNS therapy, the 4 most common instruments used were the Hamilton Rating Scale for Depression, Clinical Global Impression, Montgomery and Asberg Depression Rating Scale, and the Inventory of Depressive Symptomatology (IDS).
Several case series studies published before the randomized trial showed rates of improvement, as measured by a 50% improvement in depression score of 31% at 10 weeks to greater than 40% at 1 to 2 years, but there are some losses to follow-up. (24-26) Natural history, placebo effects, and patient and provider expectations make it difficult to infer efficacy from case series data.
The randomized study (D-02) that compared VNS therapy with a sham control (implanted but inactivated VNS) showed a non-statistically significant result for the principal outcome.(22,23) Fifteen percent of VNS subjects responded versus 10% of control subjects (p=0.31). The Inventory for Depressive Symptomatology Systems Review (IDS-SR) score was considered a secondary outcome and showed a difference in outcome that was statistically significant in favor of VNS (17.4% vs 7.5%, respectively, p=0.04).
The observational study that compared patients participating in the RCT and a separately recruited control group (D-04 vs D-02, respectively) evaluated VNS therapy out to 1 year and showed a statistically significant difference in the rate of change of depression score. (21,23) However, issues such as unmeasured differences between patients, nonconcurrent controls, differences in sites of care between VNS therapy patients and controls, and differences on concomitant therapy changes raise concern about this observational study. Analyses performed on subsets of patients cared for in the same sites, and censoring observations after treatment changes, generally showed diminished differences in apparent treatment effectiveness of VNS and almost no statistically significant differences.(23) Patient selection for the randomized trial and the observational comparison trial may be of concern. VNS is intended for treatment-refractory depression, but the entry criteria of failure of 2 drugs and a 6-week trial of therapy may not be a strict enough definition of treatment resistance. Treatment-refractory depression should be defined by thorough psychiatric evaluation and comprehensive management. It is important to note that patients with clinically significant suicide risk were excluded from all VNS studies. Given these concerns about the quality of the observational data, these results did not provide strong evidence for the effectiveness of VNS therapy.
In addition to the results of the TEC Assessment, several systematic reviews and meta-analyses have addressed the role of VNS in treatment-resistant depression.
A systematic review of the literature for VNS of treatment-resistant depression identified the randomized trial previously described among the 18 studies that met the study's inclusion criteria. (27) VNS was found to be associated with a reduction in depressive symptoms in the open studies. However, results from the only double-blind trial were considered to be inconclusive. (22,23) Daban et al. concluded that further clinical trials are needed to confirm efficacy of VNS in treatment-resistant depression.
In a meta-analysis that included 14 studies, Martin and Martin-Sanchez reported that among the uncontrolled studies in their analysis, 31.8% of subjects responded to VNS treatment. (29) However, results from a meta-regression to predict each study's effect size suggested that 84% of the observed variation across studies was explained by baseline depression severity. Berry et al reported results from a meta-analysis of 6 industry-sponsored studies of safety and efficacy for VNS in treatment-resistant depression, which included the D-01, D-02, Bajbouj et al (D-03), D-04, and Aaronson et al (D-21) study results. (30) In addition, the meta-analysis used data from a registry of patients with treatment-resistant depression (335 patients receiving VNS and treatment as usual and 301 patients receiving treatment as usual) that were unpublished at the time of the meta-analysis publication (online site, ClinicalTrials.gov identifier: NCT00320372). The authors report that adjunctive VNS was associated with a greater likelihood of treatment response (odds ratio, 3.19; 95% confidence interval [CI], 2.12 to 4.66). However, the meta-analysis did not have systematic study selection criteria, limiting the conclusions that can be drawn from it.
In 2013, Aaronson et al. reported results from an active-controlled trial in which 331 patients with a history of chronic or recurrent bipolar disorder or major depressive disorder, with a current diagnosis of a major depressive episode, were randomized to 1 of 3 VNS current doses (high, medium, low). (31) Patients had a history of failure to respond to at least 4 adequate dose/duration of antidepressant treatment trials from at least 2 different treatment categories. After 22 weeks, the current dose could be adjusted in any of the groups. At follow-up visits at weeks 10, 14, 18, and 22 after enrollment, there was no statistically significant difference between the dose groups for the study's primary outcome, change in IDS score from baseline. However, the mean IDS score improved significantly for each of the groups from baseline to the 22-week follow-up. At 50 weeks of follow-up, there were no significant differences between the treatment dose groups for any of the depression scores used. Most patients completed the study; however, there was a high rate of reported adverse events, including voice alteration in 72.2%, dyspnea in 32.3%, and pain in 31.7%. Interpretation of the IDS improvement over time is limited by the lack of a no treatment control group. Approximately 20% of the patients included had a history of bipolar disorder; as such, the results may not be representative of most patients with treatment resistant unipolar depression.
Other case series do not substantially strengthen the evidence supporting VNS. A case series study by Bajbouj et al. that followed patients for 2 years showed that 53.1% (26/49) patients met criteria for a treatment response and 38.9% (19/49) met criteria for remission. (32) A small study of 9 patients with rapid-cycling bipolar disorder showed improvements in several depression rating scales over 40 weeks of observation. (33) Another case series by Cristancho et al. that followed patients for one year showed that 4/15 responded and 1/15 remitted according to the principal response criteria.(34)
Adverse effects of VNS therapy included voice alteration, headache, neck pain, and cough, which are known from prior experience with VNS therapy for seizures. Regarding specific concerns for depressed patients such as mania, hypomania, suicide, and worsening depression, there does not appear to be a greater risk of these events during VNS therapy.(23)
There is 1 RCT evaluating the efficacy of VNS for resistant depression. This study reported only short-term results and found no significant improvement for the primary outcome with VNS. Other available studies, which include nonrandomized comparative studies and case series, are limited by relatively small sizes and the potential for bias in selection; the case series are further limited by the lack of a control group .Given the limitations of this literature, combined with the lack of substantial new clinical trials, the scientific evidence is considered to be insufficient to permit conclusions concerning the effect of this technology on major depression.
Other Conditions
Treatment of Essential Tremor
Handforth et al. studied VNS in nine patients with essential tremor. (35) Four weeks after implantation of the VNS device, tremor assessment using a masked videotape of patients was performed. Raters found no improvement in upper -extremity tremors. Therefore, the authors of the study concluded that VNS is not likely to have any clinically meaningful effect in essential tremor treatment.
Treatment of Headaches
Drawing on the analgesic effects noted with VNS in the treatment of depression, Mauskop evaluated VNS in 5 patients with severe, refractory chronic cluster and migraine headaches. (36) Mauskop reported excellent results in 1 patient who was able to return to work and significant improvement in 2 patients. Other than nausea developed by 1 patient, VNS was well -tolerated. Cecchini et al. evaluated VNS in 4 patients suffering from daily headache and chronic migraine. (37) However, these studies are too small to draw conclusions on the effects of VNS for the treatment of headache, and further study is needed.
Treatment of Obesity
Unintended weight loss has been observed in participants in studies of VNS, prompting interest in use of the technology to prevent or treat obesity. Bodenlos et al. investigated whether VNS might affect food cravings in patients with chronic, treatment -resistant depression. (38) They recruited 33 participants and divided them into 3 groups; 11 subjects receiving VNS for depression, 11 patients with depression but not receiving VNS, and 11 healthy controls. Most participants (42%) had a body mass index (BMI) in the normal range. Participants viewed food images on a computer in random order and then a second time in the same order and were asked after each viewing how much they would like to eat each food if it were available and how well they would be able to resist tasting each one. VNS devices were turned on for one viewing and off for the other. The depression VNS group had greater differences in food cravings between viewings in the sweet food category than the other 2 groups. No significant differences between groups were found for foods in proteins and vegetables/fruits categories. A significant proportion of the variability in VNS-related changes in cravings for sweet foods was attributed to clinical VNS device settings, depression scores, and BMI. A number of limitations in the study prevent drawing conclusions about the impact of VNS on eating behavior including small study size, selection and lack of randomization, heterogeneity of groups with respect to depression, BMI, and age. Comorbidities including anxiety and medical conditions and drugs that might influence food intake and cravings were not considered. Large, well-designed and executed controlled studies are needed to evaluate the impact of VNS on eating behavior and obesity.
Treatment of Chronic Heart Failure
A case series Phase II trial of VNS therapy for chronic heart failure was found. (39) In this study, De Ferrari et al. showed improvements in New York Heart Association class quality of life, 6-minute walk test, and left ventricular ejection fraction. These case series findings require confirmation in controlled clinical trials. A randomized study of VNS for heart failure is currently recruiting patients, according to clinicaltrials.gov.
Treatment of Fibromyalgia
Lange et al. conducted a Phase I/II trial of VNS of 14 patients with fibromyalgia. (40) At 3 months, 5 patients had attained efficacy criteria based on a composite measure of improvement of fibromyalgia symptoms. At 11 months, 8 patients met efficacy criteria. This single -arm trial does not provide sufficient evidence for efficacy of VNS for this indication.
Treatment of Tinnitus
A 10-patient case series by De Ridder et al suggested that VNS may be associated with clinical improvements in patients with tinnitus.(41)
Treatment of Traumatic Brain Injury
Shi et al have FDA approval to conduct a small pilot study to evaluate VNS in the treatment of traumatic brain injury.(42)
Non implantable VNSs
Two small case series were identified that used a transcutaneous stimulator (t-VNS device) for treatment of medication refractory seizures. In a small case series of 10 patients with treatment resistant epilepsy, Stefan et al reported that 3 patients withdrew from the study, while 5 of 7 patients reported a reduction in seizure frequency.(43) In another small case series, He et al reported that among 14 pediatric patients with intractable epilepsy who were treated with bilateral t-VNS stimulation, of the 13 patients who completed follow-up, mean reduction in self-reported seizure frequency was 31.8% after 8 weeks, 54.1% from week 9 to 16, and 54.2% from week 17 to 24.(44)
Ongoing Clinical Trials
A search of the website ClinicalTrials.gov identified the following comparative studies of VNS that are currently enrolling patients:
For patients with refractory seizures, evidence from randomized controlled trials and multiple observational studies supports a reduction in seizure frequency following vagus nerve stimulation (VNS). A TEC Assessment concluded that the evidence is sufficient to permit conclusions on the efficacy of this technique for treatment of refractory seizures. Therefore, VNS may be considered medically necessary for patients with refractory seizures.
For patients with depression, there is some evidence supporting improvements in depressive symptoms after VNS. However, there are a number of limitations of these data, including uncertain clinical significance, lack of evidence on durability, and lack of comparison with alternative treatments. As a result, it is not clear if VNS is as effective as alternatives for specific populations of patients with depression, and VNS is considered investigational for this indication.
For other conditions, including but not limited to headaches, obesity, essential tremor, heart failure, fibromyalgia, tinnitus, and traumatic brain injury, the evidence is limited and not sufficient to permit conclusions on efficacy. VNS is considered investigational for these indications.
The evidence is insufficient to allow conclusions on the efficacy of transcutaneous VNS, and there are no transcutaneous stimulation devices that have FDA approval; therefore, transcutaneous VNS is considered investigational.
Practice Guidelines and Position Statements
In 1999, the American Academy of Neurology (AAN) released a consensus statement on the use of VNS in adults that stated, "VNS is indicated for adults and adolescents over 12 years of age with medically intractable partial seizures who are not candidates for potentially curative surgical resections, such as lesionectomies or mesial temporal lobectomies."(45) The AAN released an update to these guidelines in 2013 that stated, "VNS may be considered for seizures in children, for LGS [Lennox-Gastaut-syndrome]-associated seizures, and for improving mood in adults with epilepsy (Level C). VNS may be considered to have improved efficacy over time (Level C)."(46)
The American Psychiatric Association guidelines on the treatment of major depressive disorder in adults, updated in November 2010, includes the following statement on the use of VNS: "Vagus nerve stimulation (VNS) may be an additional option for individuals who have not responded to at least four adequate trials of antidepressant treatment, including ECT [Electroconvulsive therapy]," with a level of evidence III (May be recommended on the basis of individual circumstances).(47)
Medicare National Coverage Policy
Medicare has a national coverage determination for VNS. Medicare coverage policy notes that "Clinical evidence has shown that vagus nerve stimulation is safe and effective treatment for patients with medically refractory partial onset seizures, for whom surgery is not recommended or for whom surgery has failed. Vagus nerve stimulation is not covered for patients with other types of seizure disorders that are medically refractory and for whom surgery is not recommended or for whom surgery has failed." Effective for services performed on or after May 4, 2007, VNS is not reasonable and necessary for resistant depression.(48)
Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
with connection to two or more electrode arrays
Revision or removal of cranial neurostimulator pulse generator or receiver
Percutaneous implantation of neurostimulator electrodes; cranial nerve
Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
Revision or replacement of cranial nerve (e.g., vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
Removal of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
Electronic analysis of implantation of neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
Complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour
Complex spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour
Electronic analysis of implantation of neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour
Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour
ICD-9 Procedure
Implantation or replacement of intracranial neurostimulator lead(s)
Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable
Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable
Insertion or replacement of other neurostimulator pulse generator
Insertion or replacement of single array rechargeable neurostimulator pulse generator
Insertion or replacement of dual array rechargeable neurostimulator pulse generator
ICD-9 Diagnosis
Essential and other specified forms of tremor (benign)
Generalized nonconvulsive epilepsy without mention of intractable epilepsy
Generalized nonconvulsive epilepsy with intractable epilepsy
Generalized convulsive epilepsy
Generalized convulsive epilepsy without mention of intractable epilepsy
Generalized convulsive epilepsy with intractable epilepsy
Petit mal status
Grand mal status
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures
Localization-related (focal)(partial) epilepsy and epileptic syndromes with simple partial seizures
Infantile spasms
Epiliepsia partialis continua
Other forms of epilepsy and recurrent seizures
Unspecified epilepsy without mention of intractable epilepsy
Unspecified epilepsy with intractable epilepsy
Classical migraine without mention of intractable migraine
Classical migraine with intractable migraine, so stated
Common migraine
Common migraine without mention of intractable migraine
Common migraine with intractable migraine, so stated
Variants of migraine
Variants of migraine without mention of intractable migraine
Variants of migraine with intractable migraine, so stated
Other forms of migraine
Other forms of migraine without mention of intractable migraine
Other forms of migraine with intractable migraine, so stated
Migraine, unspecified
Unspecified migraine without mention of intractable migraine
Unspecified migraine with intractable migraine, so stated
Migraine, unspecified, without mention of intractable migraine with status migrainosus
Migraine, unspecified, with intractable migraine, so stated, with status migrainosus
Epilepsy and recurrent seizures; code range
Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach (open, percutaneous, percutaneous endoscopic)
Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach
Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not
Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach
Implantable neurostimulator electrode, each
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator
Implantable neurostimulator radiofrequency receiver
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
External recharging system for battery (internal) for use with implantable neurostimulator
Type of Service
Place of Service
Add to Surgery Section - New Policy
Coding Update - 1999 CPT coding release.
Replace Policy - Added cross-references to other stimulation policies.
Replace Policy - Title change; revised new indication for children, investigational as a treatment for depression. Held for notification, published 4/15/02.
Replace Policy - Information update; policy statement unchanged.
Replace Policy - Policy reviewed with literature search. FDA information and a reference added. Statement on investigational status of VNS treatment for essential tremor added.
Replace Policy - Policy updated with literature review and FDA approval of VNS for depression. Added headaches and essential tremor as investigational in the policy statement; remaining policy statements unchanged.
Codes updated - No other changes.
Disclaimer and Scope update - No other changes.
Replace Policy - Policy updated with June 2006 TEC Assessment (treatment-resistant depression) and literature review for other indications; policy statement unchanged; references added.
Replace Policy - Policy updated with literature search; no change in policy statement. References and codes added.
Replace Policy - Policy updated with literature search; no change in policy statement. References and codes added.
Replace Policy - Policy updated with literature search. Policy statement revised to indicate the VNS may be considered medically necessary in refractory seizures (both partial and generalized) and is investigational in treatment of obesity. References added.
Replace Policy - Policy updated with literature search; no change to the policy statements. Rationale extensively reorganized and condensed. References added.
Replace Policy - Policy updated with literature search; references 30-32 have been added. No change to policy statements. ICD-10 codes added.
Deleted codes 64568, 64569, 64570 and 64573 removed.
Replace policy. Policy updated with literature search, references 26-28, 33, 34 added. Policy statement updated to include the addition of heart failure and fibromyalgia to the list of investigational conditions.
Update Related Policy – Add 2.01.50. Update coding section – ICD-10 codes are now effective 10/01/2014.
Coding update. New CPT codes 0312T – 0318T, effective 1/1/13, added to policy.
Update Related Policies. 2.01.50 replaced with 2.01.526.
Update Related Policies. Change title to policy 2.01.526.
Replace policy. Policy reviewed. Rationale section reformatted for readability, references renumbered to match the changes. A literature search through January 2013 did not prompt additions to the reference list. Vagus nerve blocking therapy codes (0312T-03127T) removed as inappropriate for this policy. Policy statement unchanged.
Annual Review. Policy updated with literature review through February 5, 2014. References 7, 13-17, 29-31, and 41-44 added. Policy statement updated to include the addition of tinnitus and traumatic brain injury to the list of investigational conditions. Rationale section reorganized.
Update Related Policy. Add 7.01.143.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).


text:
Novosibirsk is located on the river Ob and has two bridges across it. In 2010 the construction of the third bridge began. Nowadays builders have started erections of an interchange on the left bank, drilled piles, stocks and piers for the bridge arch.
Piers №14 and №15 are ready for launching.
Launching of the 6th-10th bridge spans.
The mouth of the river Inya, the upper tributary of the Ob.

subset: commoncrawl


text:
Taylor Swift's headed in one direction: across the pond to England for a showdown with her ex, boy bander Harry Styles, three weeks after their split.
The We Are Never Getting Back Together singer, 23, arrived via private jet at London's Luton airport, clad in a heavy green coat and sipping on a Diet Coke. She checked into a hotel near the teen idol's home, a source told the UK Sun.
PHOTOS: Taylor Swift And Harry Styles In The Park
"There's talk of a meeting with Harry being on the cards," the source told the English publication, adding that Taylor "has no obvious reason or promo duties in London this week."
The timing couldn't be better, the source said, adding, "Harry has just got back from a small tour in Japan with the band, and now has four days off."
PHOTOS: Taylor Swift In December's Cosmo
The 18-year-old One Direction singer and Swift split after just two months together.
Taylor didn't mention being in the UK (or Harry) in a tweet early Tuesday, saying, "It's official – 'I Knew You Were Trouble' is #1 on pop radio!! You guys are unbelievable. I'm smiling SO big right now."
PHOTOS: Selena Gomez & Taylor Swift Hang Out
The beautiful country crooner, well known for singing about her break-ups, has also dated celebrities such as Conor Kennedy, John Mayer, Jake Gyllenhaal, Joe Jonas, Taylor Lautner and Cory Monteith.
Taylor Swift Mortified By Mocking! Embarrassed Her Love Life Is Taking Center Stage
Carrie Underwood Snubs Taylor Swift, 'I'm Not Close To Her'
Taylor Swift Tries To Hook Up With Bradley Cooper But He's Just Not That Into Her!
Recording A Hate Song For Harry? Taylor Swift Hightails It To The Studio After Styles Split


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Midwest residents were cleaning up Sunday after several tornadoes Saturday left one man dead and one Kansas town nearly destroyed.
At least 20 tornadoes were reported across three states Saturday: 14 in Kansas, five in Oklahoma, and one in Missouri.
In the small town of Reading, Kan., twisters ripped through the area and left more than 20 homes destroyed and 200 more damaged.
"Lots of damage all over town, the farther south in town the more damage there is. Lots of trees down, large trees, there's buildings that have been totally devastated," said Coffee County Emergency Coordinator Russel Stukey.
One fatality and several injuries were reported in connection with the twisters, according to authorities.
"Everything is destroyed. We're going to have to stay strong for the community," one resident told Kansas City ABC News affiliate KMBC.
Power was knocked out Saturday and roads in and out of area were closed, KMBC reported.
According to Sharon Watson with the Kansas State Division of Emergency Management, there was also hail as large as a baseball reported throughout northeast part of the state.
"We've been fortunate so far to not have as much damage as we have seen in the past, such as the year 2007 when the town of Greensburg was basically destroyed, a town of 1,500," Watson said.
Kansas Gov. Sam Brownback declared a state of emergency for at least 16 counties.
Although there have already been several devastating tornadoes this year, experts have seen no indication of an upward trend in either tornado intensity or numbers.
"There is very little increase in the total number of tornadoes and we don't see any increase in the number of violent tornadoes," Greg Carbin, a meteorologist with the National Weather Service's Storm Prediction Center, told ABC News. "It's just that these things are coming and they're very rare and extreme and they happen to be hitting populated areas. So right now no indication of an upward trend in the strong to violent tornadoes that we're seeing."
NOAA says the main cause for the tornadoes this year has been a prolonged stretch of warm, humid air from the Gulf of Mexico, which has been colliding with cooling air, creating ripe conditions for tornadoes.
ABC News' Jackie Meretsky and the Associated Press contributed to this report.


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40+ Years Strong
The Toronto Rape Crisis Centre / Multicultural Women Against Rape celebrated its 40th anniversary on February 14th 2014. 40 years of survivors celebrating our resiliency and collective work to end sexual violence in our communities.
All of our services are free and confidential and our space is fully accessible!
We are moving!
After 22 years in our current home, and 40 years in the downtown core, the TRCC/MWAR will be saying goodbye to the neighborhood soon. We are currently looking for a new home and will keep you updated. Wherever we end up, we look forward to continuing our work while building communities and reaching survivors. We look forward to celebrating and welcoming you to our new space. Stay tuned for more updates.


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Al and Larry Ubell, Gurus of How-To
Wednesday, January 09, 2008
Comments [12]
Suggestion for the lady with the moth problem:
Check old woolen rugs, particularly on stairways to basements, etc, because larvae can grow there
We just took one of the stained glass windows out of a brownstone in Brooklyn in order to install a bulkhead, and the owner's looking to get rid of it, if the previous caller would like it...
My recently purchased 1940's apartment has some plaster issues.
Apparently, when the windows were installed they destroyed the integrity of the casing. It's all crumbly and the metal is exposed. Can I just scrape off the plaster and put a skim on the metal, or will it, too, crumble? Also, the plaster in the bathroom has some puckering and flaking at the perimeter of a previous ceiling patch. IT's over the tub. Is there any hope of repairing and then keeping this nice, in a room with only a small window as ventilation?
Please don't talk about snaking toilets during lunch time!
Al & Larry - any way to try to clear the toilet without pulling it?
No snaking sinks anymore...try flexisnake. Costs a couple of dollars and does the work!
A local store in Brooklyn has been doing its own construction building a "front porch" in a very makeshift way that I can not imagine is up to code (i.e. hanging a French door parallel as to be a window). I've not noticed a building permit and worry that this make shift patio is not safe.
Is there a number to call as a concerned citizen to have the building inspected?
I am always listening your program. Is great all that information you have done to us. Now I have a question. At midnight, may be when all the system is off, the heating system installed at my apartment is doing some nasty noise. Is something like exploding once and once and once. I was talking about it to the owner but he said that the noise is normal. Do you have any idea what can we do?
We have an unfinished basement. Whenever it rains water appears. Sometimes it's near the wall but most times it's in the center of the basement. What can I do? Who should I call?
Our basement flooded this past April. We had a carpet and it had to be removed. What would you recommend to do with the floor? I am dying to put another carpet down, but my husband wants nothing to do with it!
ps we have installed a french drain, and we have been in the house for 6 years and it has only flooded once.
Are attic fans generally necessary or will sofit, gable, and ridge vents be enough to prevent mold? Are solar fans any good?
How important is it to remove black mold in the attic?
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Many people are aware that turtles and other reptiles can carry Salmonella bacteria, but not many know that amphibians can carry it, too. The U.S. Centers for Disease Control and Prevention (CDC) has reported a number of outbreaks of Salmonella infection associated with handling reptiles and amphibians or their habitats. Reported outbreaks include:
In most of the outbreaks reported, the majority of illnesses occurred in children less than 10 years of age, whose illness can be severe and require hospitalization.
This doesn't mean amphibian and reptile owners should get rid of their pets. What it does mean is that amphibian and reptile handlers and owners should take precautions to protect themselves and their families. Simple, common sense measures can significantly reduce your risk of amphibian- or reptile-associated Salmonella infection, including:
For more information about reptiles, amphibians and Salmonella:
AVMA resources
Association of Reptile and Amphibian Veterinarians:
*note: although these materials specifically address reptiles, the information and recommendations also apply to amphibians.
National Association of State Public Health Veterinarians
U.S. Centers for Disease Control (CDC)
U.S. Food and Drug Administration
Copyright ©
2015 American Veterinary Medical Association


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holy shat i would love revis island. and only 6 mill in salary
holy shat i would love revis island. and only 6 mill in salary
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id swap 1st round picks to get him but remember wed have to resign him next year.
The Future Jacksonville Jaguars Power Couple
Worth the shot. Then, getting rid of that busted Ross. Let Mathis walk. Put Cox on a 1-year prove it deal.
Shaolin Scobee
Wow that would be awsome
Cox and Revis , Holy ****
Id give them a 2nd and 5th or swap 1st or whatever it takes really
A Heat Steal
Hassan Whiteside
MJD and a 4th
I think its gonna take more then people expect since he is the best cb in football
Id be willing to give
Swap 1st
Give them a 3rd this year and next
A Heat Steal
Hassan Whiteside
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They wouldent do that
Maybe just Revis for that much
A guy who can lock down any WR every game in his prime
A Heat Steal
Hassan Whiteside
Yea the need for a new contract is the major red flag
The Future of The Jacksonville JaguarsDuuuuuuuvvvvaaaaaaaalllll
I dont want Revis too much money for this team with all of our team needs. Id rather spread the money out.
Cut Ross
and sorry but AluAlu has to go , It looks like he'll never turn into what we hoped
A Heat Steal
Hassan Whiteside
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PRLog - Dec. 4, 2012 - TORONTO -- Social Media is becoming a mandatory requirement for small business. It allows them to interact with customers regularly, build relationships, answer questions in real time and ultimately increase sales. But with so much time and energy focused on running the business where do they find the time? The Money? The expertise? Where do they start?
Message Post
The team of entrepreneurs at http://buildchatter.com understood this quite well and saw this as an opportunity to change the way small business does social media forever. The goal was to develop a complete application suite that could be used and shared at minimal or no cost. "Our mission is to empower all small businesses, regardless of their budget, with the tools needed to maintain an effective, easy to use and fundamentally sound social media program." Say's John Macintosh company President and Co-Founder.
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In addition to the FREE Socialite platform Build chatter provides a wide range of Marketing, Promotion and Engagement tools for pennies a day. "We are confident our solution has everything small businesses have been looking for in one package."
The suite includes tools for content generation, competitor and influencer research, social stores, interactive Facebook contests, sweepstakes, quizzes and more. You can sign up for your free account today at http://buildchatter.com


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I figured it's about time we opened up a place for bump discussions and belly shots. I'm one of the ppl who is technically due at the end of August but we all run late in my family.
Today is 14 weeks.
I don't have a bump per se - more of a doughy look like I've been eating too much ice cream! I've gained close to 7lbs so far.
p.s. I've never done selfies. It's harder than I thought it would be!
We have a belly thread started, just bumped it up Love the belly shots, they're my favorite part of the ddc!
Katie, married to my beloved Paddy
Catherine Anne "KJ" born November 10th, 2011
I'll have to get cracking and take a photo too though I'm not terribly excited about showing off my belly haha. I've always been an hourglass figure and carried a little extra on my belly, so I thought I would take longer to show. However, I've been looking quite pregnant! Even when I lost weight due to morning sickness, I still gained weight on my belly. Bummer. Oh well, at least I'm still at that phase where people would be too scared to ask directly as I could simply be a little plump But my 12 week scan is this friday. If all goes well *fingers crossed*, we'll start telling people.
I've been waiting to take belly shots until 12 weeks. I felt like it would be a good celebratory milestone pic! But I do already look 6 mos! Some of the bloating has gone down but last night I had a lot of salty blue corn chips and salsa (like I simply couldn't get enough of it might as well have drank it straight from the jar!) and whoa! I bloated up to mammoth proportions! I'll have to do my selfie this Sunday (12 weeks) and first thing in the morning when it looks most realistic!
You all look so great! This is exciting!
fragolina - Your T-rex makes me giggle. I am opposite - I have monkey arms!
You are pretty much right at 14 weeks, right? Your belly looks great - I can't imagine on your teeny tiny frame that there's anywhere for a baby to go but up and out!
pandorash - I will prob do next pic with a tight shirt. My belly is just way too jiggly/doughy and white. Normally I have a slim waist profile and abs are present. I guess my 40yo body isn't handling the weight gain so gracefully!
crickets - at 11ish weeks I was so reactive bloat-wise to anything with spice. I craved it but then I'd blow up like a balloon and be burping forever. That's when I got the gas-x. Only had to use it off and on for about 7-10 days. I'm glad that phase seems to be behind me!
anyalily - love the word "wombular"! I got a pair of leggings and jeans from Motherhood the other day (my first mat clothes) and wow how comfy. I'm normally very casual around the house so my loose lounge pants are my go-to choice. Are you doing mat clothes or just comfy loose stuff?
OOHHHHH you all look so great! So wonderful! Motivated we call that 'creamy' in my Irish family! LOL. I'm typically a creamy gal as well but something happened to me once I moved out west for a few years and now I can actually manage a tan. Strange but true. I am pretty pale too and I promise to share my belly pic on Sunday at 12 weeks.
MM - Nice belly!
I was always that way (very white) until we moved to Florida when I was 13. After years of sun exposure I'm now an off-white perma-tanned color in comparison. Sadly still not much tanning capacity though - and with the SPF 2000 I wear it's good my DH likes me pale!
Your sun exposure has obviously been limited - will make for some young, pretty skin even when you're older. Jealous.
So should we just make this the official belly thread now? I think I can delete the old one since I started it... Just wanna make sure they are all in the same place!
Katie, married to my beloved Paddy
Catherine Anne "KJ" born November 10th, 2011
@innacircle- You're too sweet! I've been feeling like an overweight cow (and making most of the appropriate noises) from being so uncomfortable and having my center of gravity shift so quickly. My midwife showed me where my uterus was and I was shocked that it's so low and I'm so big above that! So when DH pat my belly yesterday I asked him if he was getting acquainted with my digestive system. His face --->
And yep, 14 weeks tomorrow!
mrskatie - We'd love to see your belly here! When will you be 10 weeks?
fragolina - your account of the digestive system was a good one! Funny what our our non-healthcare DHs don't realize sometimes! I'm feeling fluffy too - I went and got some maternity clothes from motherhood bc normal clothes just feel binding on my midsection. OMG so comfy - glad I didn't wait. Now my belly and intestines can feel free to stretch out a bit. Ahhhhh....
Oh yes, lots of room! Prairie skirts with loose elastics under my belly, unbuttoned pants with a belly band and fold over yoga pants. Ahhhhhhh, wonderful! The reason we were both kind of shocked about the fact that baby is so low is because my stomach is SO firm, absolutely no fluff in sight! Just non-budging round middle with boobs, a big head and sticks for limbs
I've had weird lumpy bloat for the last week or two and now the last few days I've had a bump. I'm definitely getting bloated still, but now there's a bump! I didn't show until at least 15 weeks, more like 17. But I look like I did at 15 with my first. Roughly. I'm 10 weeks I was 20lbs heavier during that pregnancy though. Started 170 with her, 150 with this one. 5'6"
Happily married 06/2013 DD1 (S) 04/2012
missed mc 04/2013 at 9 weeks Due 09/2014
Ok I caved.
They said at my apt. yesterday baby was measuring 11 weeks 6 days (not 3 like I thought) so that would mean 12 today. LOL
To heck with it!
Sorry for terrible gritty pic, was in bedroom early morning with cell and not the greatest light. But here's my buddah! I will add a better one in a couple days.
Ok I caved.
They said at my apt. yesterday baby was measuring 11 weeks 6 days (not 3 like I thought) so that would mean 12 today. LOL
To heck with it!
Sorry for terrible gritty pic, was in bedroom early morning with cell and not the greatest light. But here's my buddah! I will add a better one in a couple days.
Wow Crickets - lookin great!
I like your rationale on the 12-week timing... perfect. I imagine there's not much hiding that bump as you're obviously a slim person. Does everyone know?
p.s. your "creamy" is like my version of being fully tanned!
Thanks innacircle! Don't be fooled, haha! There was no daylight then just lamplight and it makes me look more tan than I am. I do have a 'golden' tone but nothing near what the pic is showing, lol. I WISH.
Yeah people have been looking at me sideways for weeks. We're starting to let it leak. After seeing the ultrasound and hearing heartbeat yest etc. we're feeling a bit more comfy but still trying to wait it out to tell all till end of 12th week. :-)
Ha! I also like this word "wombular!"
I don't know that I look a lot different than usual either, though I was a little pudgy around the middle before my miscarriage this fall, but...now I don't feel the need to suck my belly in...baby justifies the gut! Actually, I don't seem to be able to suck the gut in anymore, I guess this is the difference.
Also, it feels much tighter in there and maybe looks a little tighter on the outside so I am more inclined to let the "wombular" area show.
You'd think I'd be diligently checking out my belly these days, but since it's been so cold and I'm always bundled up I don't really take the regular opportunity. I was noticing that all of your belly shots look full and round and mine just looks flabby... so I investigated. Turns out all of the fluff you see in my pic (the part that protrudes in front of a line from my rib cage to my hip bones) is just a thick "donut of fat" that circles my belly button now. I have never had fat on my belly, and for it to show up when I'm expecting a bump well... I feel a bit hoodwinked. I showed DH this morning and he was really surprised by it too. The flab isn't just limited to the "donut" either - it's a nice little blubber jacket coating my whole midsection. What a treat.
innacircle! I thought you had the perfect little beginnings of a baby bump!
I just realized mine is the only belly shot facing the other direction! Maybe its cause I'm partial to my tatoo. LOL! I'll do the next one from the other angle!
It's a GREAT tattoo, keep it on that side!!
Thanks fragolina!
When my dad passed 3 years ago I got it in honor of him. It's hard to tell in pic but hawk is flying with a Celtic cross with his initials. He loved hawks and eagles and right around the time of his death we saw hawks everywhere. The morning he passed my husband and I were walking our dog and in our little city streets a hawk swooped down within 2 feet of our heads and then swooped back up and soared away. We knew that was my dad. So I definitely love the tattoo myself but then I'm partial.
OK here's the 15 weeks pic. Crickets, I switched directions so you don't have to feel like you're the only one any more. Sadly my selfie skills have not improved!
No bump, but everything in front of that dimple area on my hip is new - more of a fullness than anything. It's surprising how much a change like that can alter how clothing fits!
Yayy! You have a wee bump! Totally changes the way things fit! My belly looks much the same as my last shot if not a big smaller since I started eating a bit healthier! I'll take a shot in a few days! Thanks for the directional shift innacircle!
My reaction to your pic was Oh my goodness - look at that pregnant cutie! Wow - you show it well!
I don't know why it is so diff either.
I have a very, very short torso (I can barely fit 2 fingers bw my ribs and hips) so there really is nowhere for the baby to go but out. The only thing I can think of is that it must be related to my tipped uterus.
Your belted top is quite elegant by the way. I hope I can pull it together like that!
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great kid band. everything they do needs to be directed towards kids.Published 10 months ago by 8-10weekshippiing!
I like that these are fun, educational songs to play for my children---but despite all of the other reviews I still found the songs pretty annoying. Read morePublished 16 months ago by Junebug05
Will definitely recommend particularly if you like TMBG. The book is very well made and illustrated nicely. Music and lyrics are excellent. Read morePublished on February 22, 2013 by paraddy
My granddaughter seemed to liked it. But, this was so long ago and was a gift so I can't rate very well.Published on January 11, 2013 by Phyllis Baxter
This is not my favorite They Might Be Gaints item, but it is still good. It holds true to other things published by them, just not the best. Read morePublished on January 8, 2012 by Janelle Wood
I much prefer this version of Bed Bed Bed to their version on the Children's song CD. The songs are nice and my boys who are 2 and 4 enjoy them. Illustrations are nice.Published on November 29, 2011 by Kevin
This is very unique... which is the norm for They Might Be Giants, but it's sweet and fun for kids.
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Science News Archive - July 30, 2009
The US climate bill would allow states that are profoundly dependant on greenhouse-gas releases fuels to have more carbon credits on a per capita basis.
An international research team has developed a mathematical and cartographical model that make it possible to view how Mediterranean landscapes evolve in the aftermath of forest fires.
Two researchers from the Polytechnic University of Catalonia (UPC) and the University of Aberdeen in the United Kingdom have shown for the first time that the law of brevity in human language.
Researchers aboard drilling vessel Chikyu report successful completion of first riser-drilling operations in earthquake zone.
It seems that humans are not the only creatures possessing the ability to appreciate good music.
Researchers at the University of Leicester have paved the way for the first ever use in Europe of an insect (biocontrol) to combat an invasive plant species in Britain.
A giant new machine called' Oyster' designed to harness the power of ocean waves and turn it into 'green' electricity is being installed on the seabed off the Atlantic shores of the Orkney Islands.
The InForm project will provide a boost to an exciting area of research known as formulation science.
Alloying elements in bronze sculptures give clues about artist, date, origin and authenticity.
To understand how climate change may affect species survival, we need to understand how climate influences their time-keeping.
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The African-American Book Group will discuss Black Orchid Blues by Persia Walker. Newcomers are welcome.
Meet former federal prosecutor and critically acclaimed author Allison Leotta for a discussion and signing of her new book. It's a spellbinding thriller about a prosecutor who comes home to defend her sister against accusations of murder.
Hetty "Handful," growing up as a slave in early 19th century Charleston, recalls the night her mother told her how their African ancestors could fly over trees. And so begins a sweeping novel about a girl who believes she will one day fly to freedom.


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Why is NVIDIA against 3DMark03?
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Sayonara !!!
Join Date: Jan 2003
Location: Austin, Texas
Posts: 9,297
Originally posted by StealthHawk
as if their support should mean anything to us. i'm sorry if this sounds like a pathetic attempt to grasp at straws....but really it isn't.
great, Dell, the people advertising the highest end P4 systems with TNT2 and gf2mx chips in magazines and slogans like "all i need is more power than my friends" or other such rubbish.
and then of course we have Intel's advertising schemes: Pentium4 with NetBurst architecture, it makes the internet fly!
the reason it matters is that these companies have influence... dont forget intel makes boards and intel actually has a far larger slice of the cpu market than amd... dell is a big seller of intel parts exclusively intel desktops)
so these things add up... ie.. give credible weight to the legitimacy of 3dmark03 as a legit benchmark...
its just the way it is...
now when it comes to advertising... yer opening a can of worms slamming other companies in defense (in a manner of speaking) of nvidia
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Online pirates thrive on legitimate ad dollars
Friday - 6/6/2014, 1:54am EDT
AP Business Writer
LOS ANGELES (AP) -- Movie and music piracy thrives online in part because crafty website operators receive advertising dollars from major companies like Comcast, Ford and McDonald's.
That's the conclusion of several recent reports that shed light on Internet piracy's funding sources.
Content thieves attract visitors with the promise of free downloads and streams of the latest hit movies, TV shows and songs. Then they profit by pulling in advertising from around the Internet, often concealing their illicit activities so advertising brands remain unaware.
Pirate websites run ads that are sometimes covered up by other graphics. They automatically launch legitimate-looking websites as pop-up windows that advertisers don't realize are associated with piracy. At the end of the day, the pirate website operators still receive a check for serving up a number of views and clicks.
The illicit activity is estimated to generate millions of dollars annually. That's only a small portion of the roughly $40 billion of online ad spending every year. Yet it is helping to feed the creation of millions of copyright-infringing websites that provide stolen content to a growing global audience.
"(Companies) placed their ads on the assumption that they were going to be on high-quality sites and they're not," said Mark Berns, vice president of MediaLink LLC, a consulting firm that produced a study looking into the practice called "Good Money Gone Bad."
The study, commissioned for the Digital Citizens Alliance, a Washington-based group that advocates for a safer Internet, sampled 596 of the worst-offending websites. Researchers discovered that the infringing websites were displaying ads from 89 premium brands like Walmart, McDonald's, Google, Microsoft and Ford.
"It's certainly fair to say that millions of dollars in revenue from premium brand ads are supporting content theft sites," Berns said.
That's similar to an estimate from DoubleVerify, an online fraud protection company. According to a DoubleVerify report released last May, rogue website operators cheat mainstream advertisers out of $6.8 million each month, mainly by "laundering" ad traffic in ways that are hard to detect.
"There's growing awareness of the unscrupulous tactics that sites will go to to collect their dollars," said DoubleVerify chief operating officer Matt McLaughlin.
Several advertisers and top technology firms that operate ad networks -- like Google and Microsoft -- say the fraud is difficult to stop. Ads for Google's Chromecast streaming device and Microsoft's Bing search engine were among those that appeared on pirate websites.
Microsoft said in a statement that while it monitors where its ads end up, it sometimes relies on others bringing infractions to its attention "to take actions on non-compliant sites."
Google said it invests significant resources to keep its and its partners' ads from appearing on pirate sites and requires users of its AdSense service to agree to its anti-piracy policies. "When we find violators of these policies, we'll take the appropriate actions -- including blacklisting URLs and, in some cases, ending our relationships with publishers -- as quickly as possible," a spokesman said in a statement.
Several companies listed in the report as having advertised on pirate websites declined to comment, including Comcast, Ford, Toyota, McDonald's, L.L. Bean, Cablevision, Time Warner Cable, and Target.
Dish Network said in a statement that it applies "industry-leading standards ... to continually take measures that prevent our advertising from appearing on pirate sites."
Wal-Mart Stores Inc. spokesman Dan Toporek said the company blocked tvboxnow.com, a website the Alliance report found received its ads. Toporek said the Walmart logo may have been used by a third party that wasn't so careful.
Yet it is easy to find legitimate advertisers on websites that peddle in copyright infringement.
When The Associated Press typed in the Web address www.uploadhouse.com -- a domain that Google said it removed 97 times from its search results because of copyright infringement notices -- one of the first ads on the home page was for an HP Chromebook 11, "made with Google."
Content theft website operators are based all over the world in countries like Russia, Australia and Indonesia. Most shy away from attention. Several people who registered websites identified by Google's Transparency Report as frequent targets of copyright notices didn't respond to messages seeking comment.
The AP received an anonymous response from the email address listed as belonging to the registrant of piracy website SevenTorrents.org. The respondent said that while some advertisers prevent their ads from going on the site, others don't.
"Famous advertising companies like RightMedia blocked this site, I just let other advertisers which do not use those services (place) ads," the respondent wrote. "They are paying."


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Myxedema Coma Center - Oak Lawn, IL
WebMD Physician Directory
Oak Lawn, Illinois
Myxedema Coma
What is myxedema coma?
Myxedema coma is a loss of brain function as a result of severe, longstanding low level of thyroid hormone in the blood (hypothyroidism). Myxedema coma is considered a life-threatening complication of hypothyroidis...
Other Related Myxedema Coma Articles
Emergency Contact for Oak Lawn
Nearby Oak Lawn Hospitals *
Advocate Christ Medical Center
Little Company Of Mary Hospital
Palos Community Hospital
Holy Cross Hospital
Metro South Medical Center
Abraxas Youth And Family Svs
Roseland Community Hospital
St Bernard Hospital
Macneal Hospital
Adventist Lagrange Mem Hosp
University Of Chicago Medicine
Comer Children's Hospital
Jackson Park Hospital
Provident Hosp Of Cook Cnty
Ingalls Memorial Hospital
Advocate Trinity Hospital
RML Specialty Hospital
Saint Anthony Hospital
South Shore Hospital
Hartgrove Hospital
La Rabida Children's Hospital
Mount Sinai Hospital
Edward Hines Jr VA Hospital
John J Madden Mental Health Ctr
Schwab Rehabilitation Hospital
Adventist Hinsdale Hospital
Loretto Hospital
Riveredge Hospital
Loyola Univ Med Ctr
Mercy Hospital & Medical Center
RML Specialty Hospital
Advocate South Suburban Hosp
Jesse Brown VA Medical Center
University Of Illinois Hospital
John Stroger Hospital
Johnston R Bowman Health Center
Rush Oak Park Hospital
Rush University Medical Center
Sacred Heart Hospital
West Suburban Medical Center
Norwegian American Hospital
Westlake Community Hospital
Saints Mary & Elizabeth Med Ctr
Saint Mary & Elizabeth Med Ctr
Elmhurst Memorial Hospital
Franciscan St. James Health
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Rehabilitation Institute Chcg
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Kindred Hospital NW Indiana
Shriners Hospital For Children
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Advocate Good Samaritan Hosp
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Advocate Illinois Masonic Med
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Chicago-Read Mental Health Ctr
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Community Hospital
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Kindred Chicago Lakeshore Hosp
Franciscan St Margaret Health
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Twilight cutie Taylor Lautner was courtside for the Los Angeles Lakers' win over the Charlotte Bobcats Wednesday night at the Staples Center in Los Angeles.
PHOTOS: Taylor Lautner Courtside At Lakers Game
The 17-year-old New Moon star was clad in what must be his favorite outfit: his usual all-black ensemble of a leather jacket, V-neck shirt and designer jeans.
Lautner appears in Valentine's Day, a romantic comedy which hits theaters February 12.


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My Muslim Christmas Story
When I became a Muslim 10 years ago there was no doubt in my mind that Christmas would still be a part of our lives. For me it was one of the most magical parts of childhood. Long before I was an adult worrying about budgets and gifts and... Read more
Recipes Ideas for a Moroccan Passover and Mimouna
Moroccan Food April 15, 2014 1
Passover started last Sunday and while this isn't a holiday that's on the Islamic calendar, it is on the Jewish calendar of which there are many Moroccan Jews. The communities in Morocco today are very small and I can't say I've even met someone who is Jewish and living... Read more
Valentine's Day Meals for Two and Destination Inspired Date Ideas
International FoodTravel January 24, 2014 3
The funny thing about living outside of the United States is that a lot of holidays just come and go. Unless we make a really conscious effort to remember them (like Thanksgiving) they slip by. Earlier this week it dawned on me that Valentine's Day is soon. Truth be... Read more
Celebrating Thanksgiving as an Expat
Last week was American Thanksgiving, and the first holiday we celebrated out of the US. I spent most of the day making all of the staples, roast turkey, stuffing, mashed potatoes, green bean casserole, sweet potatoes, pumpkin and apple pies. The boys didn't really realize it was Thanksgiving,... Read more
Technology Gift Ideas for Global Kids
It's the season for gift guides and it's got me thinking about the things my boys brought to Morocco and what we left behind. Space was (and is!) a big deal, so technology has helped us in many ways. But there are some toys they've really loved having. So,... Read more
Slow Cooker Caramel and Salted Ginger Cheesecake
American Food November 19, 2013 1
MarocBaba looooves caramel. It's his favorite sweet topping. Honestly, I know very few people who dislike it! I've shied away from making my own because it scares me. A year ago I attempted to make it from sugar and well let's just say what I ended up with was... Read more
Creative Gift Ideas for Adults and Kids This Eid
Gift-giving is a tradition in Moroccan, and most Islamic cultures. You wouldn't show up at someone's home for dinner without a small gift for the hostess or children. For Eid-al-Fitr, and Eid-al-Adha gifts take on a more celebratory role. In Islamic countries the practice of gift giving during these... Read more
4th of July Picnic Ideas
American FoodMoroccan Food July 1, 2013 0
This Thursday is the 4th of July and if you're like me, you're looking for the perfect dishes to take to BBQ's, camping, or picnics. It's got to be easy and portable but most of all delicious. Here are a few ideas for your Independence Day Celebration. Lentil... Read more
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Smith's baseline jumper at buzzer beats Suns 99-97
PHOENIX Without Carmelo Anthony and Raymond Felton, the New York Knicks still had enough to eke out a 99-97 victory in Phoenix, thanks to a pair of very late, very tough jumpers by J.R. Smith.
The first was a 15-foot, fadeaway shot from just inside the key to tie it with 10.6 seconds left, the second a 21-footer from the baseline at the buzzer.
"I don't know whatever words you want to use but he loves that moment," Knicks guard Jason Kidd said. "I'm trying to figure out if that last shot was tougher than the one before that he took."
The game-winner came on an inbound pass from Kidd after the Suns turned it over with a second to play.
"It was premeditated," Smith said. "I was walking around the court going, `You are going to make it, you are going to make it.' I was trying to get my form ready before I even thought about taking it. I was trying to go through my mechanics in my head, get my shoulders square to the basket and just let it fly."
Jared Dudley had a career-high 36 for Phoenix, including two free throws that put the Suns ahead 97-95 with 34.5 seconds to go.
New York was without the NBA's No. 2 scorer in Anthony (hyperextended knee) and Felton (finger), both hurt in the Christmas day loss to the Lakers in Los Angeles.
The Knicks said X-rays on Felton's right fifth finger revealed a fracture and the next course of action will be determined after his return to New York.
"We just have to go back and assess it and see where we are and go from there, but again, like I said, injuries occur," New York coach Mike Woodson said. "Key guys get banged up here and there and we have enough guys on our team that guys just got to step up and play until guys get back. That's how it's got to be."
The Suns lost Goran Dragic in the final seconds of the first half when he was undercut by Smith on a layup attempt and fell hard to the floor. Dragic had bruises to his hip, back and wrist. Smith was called for a flagrant foul on the play.
Phoenix coach Alvin Gentry knew there was no intent to injure on Smith's part.
"J.R., he's not that kind of player," Gentry said. "He plays hard and he competes like crazy. It was an accident. It was one of those things that happens."
Chris Copeland and Tyson Chandler added 14 points apiece for the Knicks.
Dudley, whose previous high was 33, was 11 of 17 shooting, 5 of 8 on 3s, and 9 of 9 at the foul line. Marcin Gortat added 13 points for the Suns, who lost their third in a row.
New York led 54-44 at the half and stretched it to 68-54 when Smith made a fadeaway, falling-down 19-footer with 7:13 left in the third. Dudley responded with a 3-pointer and the Suns were off on a 20-4 outburst.


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Merit Routing Assets Database (RADb) to Unveil New Features at NANOG51 in Miami
Merit RADb now provides users with data on status and health of their networks, existing object framework also improved for a better user experience
ANN ARBOR, Mich., Jan. 26, 2011 /PRNewswire-USNewswire/ — Merit Network, Inc. announced today a groundbreaking new feature of their Routing Assets Database (RADb). Merit RADb, the world's largest public Internet routing registry, is now equipped with innovative functions to provide users with critical information on the health of their networks.
Merit Network will present a live demonstration of Merit RADb's new features at NANOG51, January 30-February 2, 2011 in Miami, Florida.
"Merit is excited about this release and Merit RADb's new features," said Merit Network President and CEO, Don Welch. "The new features leverage the current database to tell you more about the health of your network."
According to Merit Network's Director of Research and Development, Manish Karir, the new features represent a fundamental shift in Merit RADb:
"In the previous version of Merit RADb, the Database provided value because it was a repository for information that was used for route troubleshooting, backbone configuration, network planning and more. The new features introduced today add to that value."
"Merit RADb now sends important information back to users through the portal interface, identifying suspected spam or botnet activity," Karir explained. "The improved object framework provides convenient and powerful asset management and diagnostic tools."
Merit RADb's latest addition, "Routing Asset Health," features two new functions that focus on the stability of routes that have been registered in the Database and the reputation of individual hosts within those routing blocks.
"Prefix Alerts" inform users about potential anomalies related to their registered prefixes. Merit RADb accomplishes this by analyzing registered BGP (Border Gateway Protocol) tables and historical origin ASN (Autonomous System Number) information in reference to what is observed in real-time.
Merit RADb has partnered with a number of data providers including Spamhaus, SpamCop, and Shadowserver, as well as several commonly used open data sources such as UCEPROTECT, DShield, and WPBL to better identify suspicious behavior originating from hosts inside a user's network.
"Host Reputation" is a new function that aggregates a substantial amount of security information from this diverse set of data sources about network hosts and displays it all in one accessible location.
"The correlation across multiple data sources is a much stronger indication of true positives that deserve investigation and can help you monitor the perceived health of your network," Karir said.
Merit RADb has improved its user interface, making it easier to view and modify existing information. RADb now features a simplified process by which users access and view core IRR (Internet Routing Registry) function information, registered data consistency, and RIR (Regional Internet Registry) prefix content.
NANOG51 will take place at the Hotel InterContinental Miami from January 30 to February 2, 2011. In addition to a live demonstration of Merit RADb's new capabilities, NANOG51 will include tutorials, presentations, panel discussions and leading-edge networking examples.
About Merit RADb
Merit RADb is a public registry of routing information for networks in the Internet. Hundreds of organizations that operate networks — including ISPs, universities, and business enterprises — publicly publish, or register, their routing information in Merit RADb to facilitate the operation of the Internet. Organizations worldwide use the information in Merit RADb to troubleshoot routing problems, automatically configure backbone routers, generate access lists, and perform network planning. Any Internet user may query Merit RADb for free. Currently, Merit RADb receives about 2,000,000 queries daily from over 2,000 unique hosts. More than 1,800 organizations have registered their routing information in Merit RADb, with new organizations registering every day.
For more information:
About Merit Network
Merit Network Inc., a nonprofit corporation owned and governed by Michigan's public universities, owns and operates America's longest-running regional research and education network. In 1966, Michigan's public universities created Merit as a shared resource to meet their common need for networking assistance. Since its formation, Merit Network has remained on the forefront of research and education networking expertise and services. Merit provides high-performance networking solutions to Michigan's public universities, colleges, K-12 organizations, libraries, state government, healthcare, and other non-profit organizations.
For more information:
SOURCE Merit Network, Inc.


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A cosy family atmosphere! Most of the comfortable rooms in the Alpenblick are strictly no-smoking and have a balcony and some of them have views of the Matterhorn. The restaurant serves hearty farmhouse fare accompanied by a selection of Swiss wines and in fine weather, guests can have the pleasure of dining in fresh mountain air on a flower-decked terrace. The hotel also has a fitness room with sauna and sanarium.
The Hotel Beausite was built in 1830 in typical Swiss chalet style and has remained a gem of incomparable charm ever since. It is situated on Seestrasse, the lakeside road on which the coach bearing no less a guest than Johann Wolfgang Goethe himself once arrived in town. It is also just five minutes from the centre of Interlaken and has something for all guests and all needs, from basic single rooms to deluxe doubles. Plus comfort, warmth and pleasant views throughout.
A real island of enjoyment: the typical chalet-style Hotel Alpenblick Gourmet has been known for years for its warm hospitality and its remarkable food that has won many awards. While discerning connoisseurs treat themselves in the "Gourmetstübli", lovers of authentic Swiss cooking can enjoy selected specialities in the cosy "Dorfstube". And sun-worshippers can simply let their spirits roam free on the idyllic terrace.


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Overview of content related to 'robert gordon university'
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In Web development, a mashup is a Web page or application that uses and combines data, presentation or functionality from two or more sources to create new services. The term implies easy, fast integration, frequently using open APIs and data sources to produce enriched results that were not necessarily the original reason for producing the raw source data. The main characteristics of the mashup are combination, visualization, and aggregation. It is important to make existing data more useful, moreover for personal and professional use. (Excerpt from Wikipedia article: Mashup)
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IWMW 2006: Quality Matters
Adrian Stevenson reports on the 10th Institutional Web Management Workshop held at the University of Bath over 14-16 June 2006.
July 2006, issue48, event report


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The attorneys of Twin Cities Law Firm provide a full spectrum of legal services to business owners, businesses, professionals, and entrepreneurs in Minneapolis, St. Paul, and throughout the Twin Cities metro area. The firm's primary focus is representing business owners and privately owned companies.Example cases
Representing countless Minnesota companies, small businesses, and business owners in lawsuits, complex litigation, deal negotiation, contract issues, trademark, employment law, mergers, sales, and other business issues.
901 Marquette Ave
Suite 1675
Minneapolis MN 55402
Phone calls to the Firm are always free to new clients. Once we understand your legal needs, we can provide a quote before any legal fees are incurred.
Fixed prices are available for many legal services. Other fee structures are also available depending on the type of legal service needed.
Monday through Friday 7 a.m. to 5:30 p.m.
Alissa K. Stoffel
Yes. Our attorneys put client's goals and needs first. The scope of our legal representation is tailored to the specific needs of each client.
The Twin Cities Law Firm has attorneys at various rates and experience levels, to accommodate client needs. Unlike most firms, the Twin Cities Law Firm does not bill clients for both attorneys in a meeting, two attorneys at a hearing, or related excessive expenses like copies, online research fees, etc.
The Twin Cities Law Firm's attorneys work with clients to decide together whether mediation, arbitration, trial, or another approach is best for each particular client's goals.
Yes. The Firm's attorneys provide pro bono legal services through established pro bono agencies.
The business attorneys at Twin Cities Law Firm have top credentials and experience and a track record of exceptional results. The Firm focuses on serving business owners and local companies. The attorneys take a "hands on" approach to legal matters, working to minimize costs and maximize results for business clients.
The more you know about the law, the better your outcome will be when confronted with legal obstacles. Of course, not everyone specializes in law. If you need legal guidance, Twin Cities Law Firm, LLC is here to assist you in as much or as little as you request.
Yes. Whether it's a franchise disclosure document or a standard lease, the lawyers at Twin Cities Law Firm are happy to help review your legal documents.
Yes. At Twin Cities Law Firm we dedicated to providing the best solution for our clients. If representing yourself is important to you, our attorneys will be happy to advise you on your legal rights, options, and strategy.
The Twin Cities Law Firm, LLC is comprised of three staff attorneys, two professional staff, and a team of "of counsel" attorneys including Shirley Chase, the former Commissioner of Labor, who manages the Firm's employment law practice.
The firm's business and litigation chair, Lucas Thompson, formerly worked at Minnesota's largest law firm, Faegre & Benson, was appointed to a clerkship at the Minnesota Supreme Court, and selected as a law journal executive editor at Columbia Law School. Joining Lucas Thompson, attorney Aaron Hall served in a number of large downtown law firms and as in house counsel to a large technology company. Aaron also taught as an adjunct Business Law professor at Concordia University.
The Twin Cities Law Firm has attorneys at various rates and experience levels, to accommodate client needs. Unlike most firms, the Twin Cities Law Firm does not bill clients for both attorneys in a meeting, two attorneys at a hearing, or related excessive expenses like copies, online research fees, etc.
* Nolo has confirmed that every member attorney has a valid license and is in good standing with the state agency that licenses lawyers. Any past disbarments and suspensions (with possible exceptions for minor violations or nonpayment of dues, in our discretion) will be indicated accordingly in the badge. Member attorneys are required to notify Nolo immediately if they become the subject of any disciplinary action by any state licensing agency.


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The bare skin effect with a halo of freshness and light. A subtle combination of pearly shimmer and pigments, Diorskin Nude Shimmer powder is used in a light veil on facial contours to catch the maximum amount of light and create a naturally dazzling glow.
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Diorskin Nude Shimmer powder comes with a mini kabuki brush.
This brush is the perfect ally for bronzing powders. Its rounded shape and dense bristles take up just the right amount of bronzing pigments and blend them into the skin for a smooth and even sun-kissed complexion. Colour is perfectly even, for a true-to-life healthy glow.$52.00
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St. Patrick's Day
St. Patrick's Day, Kosher Style
How an Irish convert to Judaism honors her roots
Why St. Patrick's Day Is My Jewish Family's Favorite Holiday
The parade was what my father first saw when he arrived from Nazi Germany
Jews, Christians, and NPR
All the Christian stories on NPR these days are Jewish
Happy Irish Purim!
St. Patrick's Day is tomorrow
Michael Oren Is Green at Diplomacy
Israeli Ambassador throws St. Patty party, a terrible idea.
Sundown: Helen Thomas in the Centerfold
Plus Hamas clamps down, Schnabel on Schnabel, and more
Happy St. Patrick's Day!
A message from an Irish Jew
A Very Jewish St. Patrick's Day
And why not?


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