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FRESNO, Calif. – No one understands the importance of healthy living more than competitive athletes. That is why Fresno State baseball assistant coach Pat Waer, senior shortstop Pat Hutcheson and junior catcher Austin Wynns stepped off the diamond and into the classroom to speak about living drug and alcohol-free lifestyles. Continue reading Fresno State helps Raise Youth Awareness
Tag Archives: Community Service
Boston College participates Red Bandanna Run
CHESTNUT HILL, Mass. – The Boston College baseball team took part in the seventh annual Welles Remy Crowther Red Bandanna Run on October 15 to support the Welles Remy Crowther Charitable Trust.
The baseball, softball and fencing teams competed and volunteered in the race while the field hockey and women's lacrosse teams offered their services as well. Continue reading Boston College participates Red Bandanna Run
UCF gives back to Orlando Little Leaguers
ORLANDO, Fla. (UCFAthletics.com) – It has been a busy fall for the UCF baseball team on and off the diamond. With the start of fall baseball last week, the Knights have been improving on their fundamentals while also helping little leaguers around the Orlando area the past three weekends with theirs as well. Continue reading UCF gives back to Orlando Little Leaguers
Texas Tech Participates in Race For The Cure
LUBBOCK, Texas – The Texas Tech baseball program was among over 8,000 participants at the 2011 Susan G. Komen Race for the Cure on Saturday morning at the Lubbock Memorial Civic Center.
Texas Tech head coach Dan Spencer and his son, Wade, participated in the 5K race while the team lined the streets and encouraged all of runners in the race and helped navigate the course. Continue reading Texas Tech Participates in Race For The Cure
Virginia Tech baseball continues its "19 Ways"
BLACKSBURG, Va. – Virginia Tech baseball will continue its "19 Ways" initiative, which was a challenge for the baseball team to find 19 ways to make a difference. The program, which was introduced last year by head coach Pete Hughes and who wears No. 19 for the Hokies, is a chance for the players to get involved and give back to the community. Continue reading Virginia Tech baseball continues its "19 Ways"
Cincinnati Welcomes Alex Massengill To Bearcat Family
CINCINNATI – The University of Cincinnati baseball team has adopted 10-year-old cancer survivor Alexander Massengill as an honorary teammate through The Friends of Jaclyn Foundation, head coach Brian Cleary announced Wednesday.
"We're glad to have Alex as a part of the team," said Cleary. "I expect his involvement will be a great benefit to our players." Continue reading Cincinnati Welcomes Alex Massengill To Bearcat Family
URI Participates in Southern New England Autism Walk
KINGSTON, R.I. – On Sunday, Sept. 18, the Rhode Island baseball team took part in the 2011 Southern New England Walk Now for Autism Speaks event, held at Colt State Park in Bristol, R.I. It marked the fifth consecutive year that the Rams participated in the walk.
"The opportunity to participate in an event such as the Autism Walk is truly and uplifting experience," said Rhody baseball senior Ty Muller. "Its great to get the guys together and do something like this off the field – something that helps make a difference in others' lives." Continue reading URI Participates in Southern New England Autism Walk
Missouri and Iowa to face off for Joplin Little League
COLUMBIA, Mo. – The Mizzou baseball program has teamed with the Daniel Boone & Diamond Council Little Leagues, BC Baseball and The Callaway Bank to host the University of Iowa in pair of fall exhibition games that will benefit the Joplin Little League program in its efforts to rebuild the program following the devastating tornado that hit the area back in May. The games will be played on Oct. 8-9 at Taylor Stadium and tickets are just $5 with all proceeds going directly to the City of Joplin Little League program. Continue reading Missouri and Iowa to face off for Joplin Little League
TCU's Jim Schlossnagle Introduces The RB Eye Foundation
FORT WORTH, Texas – TCU baseball head coach Jim Schlossnagle announced the creation of the RB Eye Foundation, a non-profit organization created to promote healthy vision in children. The foundation will hold its first event, Eye on the Ball, Saturday, Oct. 15. Continue reading TCU's Jim Schlossnagle Introduces The RB Eye Foundation
FAU Baseball Comes Together to Support Palm Beach Teen's Cancer Battle
Boca Raton, FL – Teamwork was on full display for the Florida Atlantic University baseball team as coaches, players and support staff shaved their heads in support of a local teen's battle with cancer. The event hit home more considering the teen was a brother of one of the players. Continue reading FAU Baseball Comes Together to Support Palm Beach Teen's Cancer Battle


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Morning Links: Has climate change created a new literary genre?
April 20, 2013 | 10:00 am
By Dan Eldridge
Has Climate Change Created a New Literary Genre? (NPR)
What Kids Think of Books, Reading and Technology
{Infographic} (E-Book Friendly)
Bill for compulsory science fiction in West Virginia schools
(The Guardian)
Sydney bookseller holds Kindle 'amnesty' (The Bookseller)
30 Things to Tell a Book Snob (Booktrust)
Kindle Daily Deals: The Thirteenth Tale by Diane Setterfield (and 3 others)
* * *
Related Posts:

subset: commoncrawl


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Monty Williams Ideal Coach for Austin Rivers in New Orleans Due to Approach, Relationship With Doc Rivers
Originally written on NESN.com | Last updated 6/29/12
If Austin Rivers ever gets out of line, all Monty Williams needs to do is ask, "Do you want me to call your parents?" Williams would never do such a thing, of course, but he would not have to make a threat or literally pick up the phone to get such a message across. The New Orleans Hornets' third-year coach is a close friend of Austin's parents, Doc and Kristen, going back to Doc and Williams' days as teammates. It could be awkward if Rivers, who has been saddled with the reputation of having a toxic attitude, got out of...
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Baby's weight and VBAC
Comments (4)
I think your u/s tech needs to stick to her job. However, I will say many docs are scared of bigger babies because they never see them - there would be a lot more if it were not for induction and c/s rates. Most people are not carrying their babies until labor begins. Also, there is a miniscule chance of shoulder dystocia with bigger babies - and guess what, they can be sued for shoulder dystocia but not for a RCS. Bigger babies do not lessen your chance of an succesful VBAC and they most certainly do no raise any risk in the pregnancy either. (The big baby card is one of the most common cop outs given to VBAC moms. Come over to the VBAC Support group and you will see a post or two a week on "baby size") A doctor who will not support vaginal birth because the baby "may" be bigger is doctoring out of fear and not knowledge.
Yes! They are wonderful! SOOOOO supportive and knowledgable! You will love them!


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Caldecott Honor
Sam & Dave Dig a Hole is exactly what it sounds like. Two boys start digging a massive hole to see what they might find. Such an activity is a tried and true milestone for any child explorer, but few make it as deep as this pair does.
Journey is Aaron Becker's first picture book, and what a debut! Using his artistic prowess rather than text, Becker delivers a blockbuster fantasy adventure worthy of the multiplex, with sweeping landscapes, amazing sets, and glorious detail.
The gray of winter is dismal enough to turn even the cheeriest of smiles upside down. Extra Yarn, by Mac Barnett, is a much needed pick-me-up during these dreariest of times.
Annabelle finds a box of multicolored yarn in the snow. When she takes it home to knit a sweater, she finds that she still has more. So Annabelle makes a sweater for her dog, too. No matter how much she knits, the box always has extra yarn in it.
Faith Ringgold is an artist who uses different materials to tell the stories that are important to her family and her people. Whether working with quilting squares, African masks, paint and brush, or her own words, Faith gives the rich colors and textures a life of their own. There's motion in her work, a striving upward and pushing at the edges of her world.
Taro Yashima is the assumed name of children's author and illustrator Jun Atsushi Iwamatsu. Born in the Japanese countryside to a local doctor and his wife, as a young man he found the rise in militarism prior to his country's invasion of China and attack on America to be very much against his personal beliefs. He and his wife Tomoe, also an artist, joined peaceful protest groups called "culture clubs" that used their art to make anti-authoritarian statements about Japan's government and the harsh conditions people lived under to support the military as it readied for war.
Everybody knows that rabbits love carrots. Jasper Rabbit, in Creepy Carrots by Aaron Reynolds, is no exception. Jasper especially loves the carrots that grow in Crackenhopper Field. The problem is that Jasper can't get enough carrots, yanking and ripping them from the ground every chance he gets. That is, he did until the carrots started following him. Jasper is convinced that the carrots are creeping up on him.
It sounds almost too perfect to be true. Famed primate expert Jane Goodall had a stuffed toy chimpanzee as a little girl. She went everywhere with it, and together they explored the mysteries of nature.
Me...Jane is Patrick McDonnell's peacefully expressive interpretation of Goodall's childhood through his art, actual photographs of Jane, and the drawings of her youth. Jane starts out a very curious young girl, studying all sort of animals around her home. That curious nature leads to many answers.
Children's author and illustrator Margot Zemach was born into a show business family--her father was a theater director, and her mother was an actress. Growing up, she drew imaginatively costumed characters to retell her favorite fairy stories and folktales, something she continued to do as an adult that would lead her to worldwide fame.
As she wrote in her autobiography, Self-Portrait: Margot Zemach: "I can create my own theater and be in charge of everything. When there is a story I want to tell in pictures, I find my actors, build the sets, design the costumes and light the stage. . . . If I can get it all together and moving, it will come to life. The actors will work with each other, and the dancers will hear the music and dance. When the book closes, the curtain comes down."
"I have always thought my best stuff was in my sketchbooks. I have hundreds and hundreds of sketchbooks. I like to work at night, I suppose because that's when my defenses are sort of low. I have my most creative ideas at night. I'm less inhibited, and I really let it rip."
From: Ways of Telling: Conversations on the Art of the Picture Book, edited by Leonard S. Marcus. p. 96; pp. 82-106 are on James Marshall
Throughout the 1970s and 1980s, James Marshall's whimsical drawings added humor to dozens of children's picture books. While many were made for other writers' works, including classics such as Mother Goose, Edward Lear, and Ogden Nash, he was also a talented writer on his own. Indeed, he became one of the most popular and prolific illustrators in children's publishing. In high school, however, he wasn't so much about the art--though he did doodle, as he called it--as about the music which he saw as a way to get a scholarship to college far away from swampy Texas town where his family lived.
In Grandpa Green, Lane Smith tells the story of one man's life through his passion. Topiary gardeners shape bushes and trees into fantastic sculptures of whatever they desire. We meet Grandpa Green as a gigantic bushy baby, sprinkling tears with the words, "He was born a really long time ago," beneath.
We go on to explore Grandpa's life through the garden, with different sculptures illustrating each step in his life. He grows up on a farm, escapes into the wonder of tales like The Wizard of Oz, goes to war, and starts a family. Smith combines the lush greens of the topiary scultpures with very thin black lines for tree trunks, branches, animals in the garden, and the great-grandson who narrates the story. That choice allows the sculptures to pop off the page like a vibrant special effect.


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And this the last time he'll have me crying in my hands
So I'm heading to the club trying to find a man'
Bitch you headed to the club trying to find a man?
What is you saying?
from Big Sean (Ft. Suai) – Love Song Lyrics on Genius
hes saying that him and his girl are suppose to be working things out but shes talking about going to find a man, so its like shes talking about hhim doing wrong but shes doing wrong too
To help improve the quality of the lyrics, visit Big Sean (Ft. Suai) – Love Song Lyrics and leave a suggestion at the bottom of the page


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News & Public Affairs
2014 Florida State of the State address sounds like Rick Scott campaign speech listen03/04/14 Janelle Irwin
WMNF Drive-Time News Tuesday Listen to this entire show:
Tags: Rick Scott, Charlie Crist, Nan Rich, 2014 legislative session, public education, State of the State, immigration reform, school vouchers, Medicaid
Florida Governor Rick dropped some not-so-subtle digs at former Governor Charlie Crist during the State of the State address Tuesday. The 30-minute speech sounded like an election-year campaign stump.
Be the first to comment
The race for the governors mansion is expected to...
Republicans fire back at Crist for saying Floridians are dying without Medicaid expansion listen02/07/14 Seán Kinane
WMNF Drive-Time News Friday Listen to this entire show:
Tags: Charlie Crist, Rick Scott, Nan Rich, Medicaid, Medicaid expansion, SEIU
Former Governor Charlie Crist is causing a stir with comments Friday morning on MSNBC. He criticized Governor Rick Scott and the Republican-led Florida Legislature for not accepting funds for Medicaid expansion under the federal Affordable Care Act. He cited information from a labor union saying six people died in the state each day because they lacked the expanded health coverage.
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And I am told by friends at [SEIU] that means that six people in Florida die every day as a result of that....
Residents speak out to Pinellas legislators about marijuana and Medicaid listen01/27/14 Samuel Johnson
WMNF Drive-Time News Monday Listen to this entire show:
Tags: Pinellas County, Medicaid, marijuana, Weed, Jeff Brandes, Larry Ahern, medical marijuana
On Monday the Florida Supreme Court approved language for the medical marijuana constitutional amendment. Since last week it raised enough signatures, it will be on November's ballot.
Two supporters who signed up to address the Pinellas County Legislative Delegation didnt show up to their meeting Monday in Largo. But one opponent, pharmacist Larry Golbom, said marijuana might be as dangerous as alcohol.
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The reality is that marijuana is n...
Pat Kemp talks with Dr. Jay Wolfson of the USF College of Health listen10/22/13 Pat Kemp
Last Call Tuesday Listen to this entire show:
Tags: Dr. Jay Wolfson, Medicaid
Pat Kemp talks with Dr. Jay Wolfson of the USF College of Health about the Affordable Health Care Act and Medicaid expansion in Florida.Be the first to comment
Will Weatherford still supports Stand Your Ground and opposes FL Medicaid expansion listen09/11/13 Naveen Sultan
WMNF Drive-Time News Wednesday Listen to this entire show:
Florida House Speaker Will Weatherford defended his views on education and the stateâs Stand Your Ground Law to members of the Suncoast Tiger Bay Club in St. Petersburg Tuesday. Weatherford also stood by his opposition to expanding Medicaid in Florida under the new federal health care law.
Speaker Weatherford told members of Tiger Bay multi-generational poverty exists but the answer to fix this crisis is not through government assistance programs such as Medicaid. He spoke strongly again...Be the first to comment
Kids Healthcare Foundation reaches out to Tampa's uninsured children listen07/02/13 Roberto Roldan
WMNF Drive-Time News Tuesday Listen to this entire show:
More than 2 million children in Florida are enrolled in the Florida KidCare Program, but itâs estimated that 35,000 qualifying children in the Tampa Bay area remain uninsured.
To help remedy that, the Kids Healthcare Foundation provided information and application assistance Tuesday afternoon at the Glazier Childrenâs Museum in Tampa.
Melanie Hall, the executive director of...Be the first to comment
Hillsborough County Republican lawmakers reminisce on session with Brandon Chamber of Commerce listen05/29/13 Janelle Irwin
WMNF Drive-Time News Wednesday Listen to this entire show:
After both chambers of the Florida legislature failed to agree on how to take care of some of the stateâs uninsured, some Hillsborough County Republicans still arenât sure what will happen with Medicaid expansion. During a Brandon Chamber of Commerce luncheon Wednesday, Senator Tom Lee responded to pleas for lawmakers to go into special session to figure it out.
The Florida Senate passed a bill that would have u...Be the first to comment
Healthcare advocates swarm House Speaker Will Weatherford's Wesley Chapel office: VIDEO listen03/25/13 Janelle Irwin
WMNF Drive-Time News Monday Listen to this entire show:
This month, both chambers of the Florida legislature rejected expanding Medicaid under the federal healthcare law. On Saturday seventy-five activists crowded the small parking lot in front of Florida House Speaker Will Weatherfordâs Wesley Chapel office. Activists marched almost a mile along a busy stretch of highway and demanded that Weatherford and other state lawmakers change their minds.
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âI see so many children who need medical care whose parents cannot afford to take them anywh...
Former Florida Governor Bob Martinez says Medicaid expansion would be costly listen03/15/13 Janelle Irwin
WMNF Drive-Time News Friday Listen to this entire show:
Former Florida Governor Bob Martinez stayed in line with Republican talking points during a luncheon at the Centre Club in the Westshore District in Tampa today. The former Democratic Tampa mayor turned Republican touched on everything from transit to healthcare in front of about 40 local business leaders.
According to Martinez, he was a Democrat for 27 years â he calls it his minority period â but for the last 30 years he has been a Republican. And like most Republicans he said he...Be the first to comment
Medicaid and Florida03/13/13 Warren Elly
Last Call Wednesday Listen to this entire show:
As Republicans in the Congress and the State House push back against the 2012 election returns⦠at their political peril some say, insisting that the majority of Americans support higher taxes for the rich and health care reformâ¦
Those critics say the GOP may be divided over issues like Immigration, but continues, for example here in Florida, over its own Republican Governorâs objections, to pursue an agenda to deny Medicaid expansion in Florida to a million poor and uninsured...Be the first to comment
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CUMBERLAND – Blackstone Valley Prep Mayoral Academy's elementary school building has begun to take shape at the former Currier Park on Broad Street near Town Hall, and is expected to open to students in the fall.
That was the forecast offered by Robert Bellafiore, a spokesman for Civic Builders, on Friday as workers from H.V. Collins, Civic's contractor, continued to erect steel beams at the site.
"Steel will be going up for the next four weeks, and the building should be enclosed by the end of June," Bellafiore said. "It will be occupied in the fall, that is the bottom line right now," he said.
Full story appears on page A1 of Monday's Times and Monday's Call.
[1] mailto:email@example.com
[2] http://www.pawtuckettimes.com/sites/default/files/040514NewCharterSchool2.jpg


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SAN FRANCISCO, CA - MAY 28: A sale pending sign is posted in front of a home for sale on May 28, 2013 in San Francisco, California. According to the Standard & Poor's Case-Shiller index, U.S. home prices surged 10.9 percent in March compared to one year ago, the largest gain since 2007. Phoenix, Arizona recorded the largest gains with prices spiking 22.5 percent and San Francisco, California was a close second with gains of 22.2 percent. (Photo by Justin Sullivan/Getty Images) ORG XMIT: 169717890 ORIG FILE ID: 169597697 / Justin Sullivan Getty Images
Home prices continued to surge in July, up 12.4% vs. a year ago and 1.8% from June, market researcher CoreLogic says.
Looking ahead, price growth is expected to slow as seasonal demand wanes and higher interest rates have a "marginal" impact on demand, says Mark Fleming, CoreLogic chief economist.
Markets hit during the downturn continue to lead the price recovery.
Year over year, Nevada prices were up 27%, followed by California at 23.2%, Arizona at 17%, Wyoming, 16.4%, and Oregon 15%, CoreLogic's data shows.
Home prices have been up year over year for 17 months. CoreLogic predicts they'll be up 0.4% in August from July.
Meanwhile, the foreclosure crisis continues to abate.
Separately today, mortgage tracker Lender Processing Services reports that foreclosure starts for the 12 months ended in July were at their lowest level since 2007.
CoreLogic is just one company that tracks home price trends. Last week, S&P's Case-Shiller 20-city home price index showed June prices up 12.1% over 12 months.
Copyright 2015 USATODAY.com
Read the original story: CoreLogic: Home prices continue to climb


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Money not well spent
Uganda has spent over 600 million shillings on PR trying to deal with the backlash over the anti-gay law.
In an attempt to clear the country's image after legalizing the Anti-Homosexuality Act, they spent 614 million Ugandan shillings ($208,000, €195,000).
Aston Kajara, the State Minister for Finance in charge of privatization, said Uganda needed some good publicity in the US congressional caucus after the president's visit.
'When the president [Yoweri Museveni] came back he told us that even at the hotel they had booked for him had to be changed.
Country's leading gay rights activist, Frank Mugisha, reveals his strategy
LGBTI people in Uganda live with the threat of even more draconian legislation hanging over them. But there is hope.
Under a proposed new law, which is yet to be debated in parliament, even someone sending a text message mentioning homosexuality could be criminalized. Landlords would be punished for renting homes or offices to gay people – effectively making all gay people homeless.
But it is not only the haters who can strategize.
Local authorities in Munich refused refugees asylum because 'Uganda's government does enough to protect gays'
German local authorities refused two gay refugees asylum because they consider Uganda a safe place to live for LGBTI people.
Kyabangi and Sekulima (their last names have been omitted for their safety) fled Uganda because they were threatened and fell victim to homophobic attacks.
They met in a detention centre in Munich in 2011 and became close friends, and are now fighting together to stay safe.
German site throws the book at Yoweri Museveni
A German dating site has given a book on homosexuality in animals to the notoriously anti-gay Ugandan President Yoweri Museveni for Christmas.
Biological Exuberance – Animal Homosexuality and Natural Diversity was written by the Canadian biologist Bruce Bagemihl and documents homosexual behavior in more than 450 animal species.
Gleichklang.de sent a copy to both the presidential office in the capital Kampala and the Ugandan embassy in Berlin.
'NGOs and whites come deceiving you that circumcision and condom use are the best ways to protect yourself'
Ugandan president Yoweri Museveni has said people living with HIV 'have betrayed their families' and advised youths to completely abstain from pre-marital sex as the way to prevent infection.
The notoriously anti-gay leader made the comments on Monday (1 December) to a group of youths at a World Aids Day event in Kabarole District, the Daily Monitor reported.
Activists say the country's anti-gay laws are scaring tourists away
Uganda's president accused tourism authorities of not marketing the country properly and said the east African nation was a better holiday destination than Spain.
President Yoweri Museveni said the Tourism Promotion Board should be renamed the 'tourism suppression board' as it touted 'only some chimpanzees and so on,' in an opinion piece published in the New Vision newspaper on Wednesday (26 November).
'The biggest problem with tourism is poor promotion,' he said.
Edwin Sesange, gay rights activist, gives the whole picture of what is going on in his country
The Anti-Homosexuality Act is dead. Out of the ashes comes the Prohibition of Promotion of Unnatural Sexual Practices Bill. If this is passed, it will be one of the most evil and draconian anti-LGBTI laws in the world.
It seems lawmakers have learned their lessons when it came to drafting a bill, forcing us to jump a lot more hurdles.
Would replace Anti-Homosexuality Act that was struck down earlier this year
Anti-gay legislators in Uganda aren't giving up.
Three months after the Anti-Homosexuality Act was struck down on technical grounds, new legislation has been drafted that is even more draconian than what was previously in place.
A human rights lawyer, Nicholas Opiyo, obtained a leaked copy of the proposed legislation and describes it as 'even worse, even more draconian,' according to BuzzFeed.
'We are still on course and in fact we are more energized that our culture, our norms, our religious norms are protected.'
Uganda lawmakers will return after a small recess determined to fast-track a new anti-gay bill next Tuesday (4 November).
Following the parliament's embarrassing defeat at the hands of the Constitutional Court in August, legislators say they are insistant that the law must be back as soon as possible.
UK's Africa minister too sick to attend, but was going to refuse to speak to Yoweri Museveni anyway
The UK government is buying dinner for the anti-gay Uganda president Yoweri Museveni but have promised they have no plans to actually speak to him whatsoever this evening (21 October).
For the past two days, the Uganda president has been a high-profile speaker at the business forum The Global African Investment Summit in London.
To top it off, he is scheduled to appear at the Foreign and Commonwealth Office ministerial dinner and drinks reception at Lancaster House tonight.
Uganda President Museveni says he still wants to persecute gays, but not if the African country loses money through lack of foreign trade because of it
The president of Uganda is having second thoughts about anti-gay laws, not because he has changed his mind on homosexuality, but because he fears for the Ugandan economy.
President Yoweri Museveni still wants to presecute gays, but doesn't want Uganda to pay the price if foreign traders refuse to do business with the African country.
His comments were made yesterday (Friday 3 Ocotber) and were reported in the New Vision newspaper.
Museveni said he still wants to enforce harsh punishments on gays in Uganda, but not if foreign traders desert him.
Uganda's President Museveni is struggling to find accommodation during a trip to Texas where he is seeking to encourage tourism and investment in his country despite its persecution of LGBTI people
Uganda's President Yoweri Museveni is struggling to find a hotel to stay in as he prepares to meet with potential investors in his country this weekend in Irving, Texas.
President Museveni had been due to stay at the Irving Four Seasons hotel. However the hotel cancelled the booking after a blog post in the Dallas Voice noted his country's record of persecuting LGBTI people and attempts to pass draconian laws to silence them.
David Bahati, the author of the draconian anti-gay bill struck down by Uganda's Constitutional Court in August, gave notice yesterday that he will reintroduce the bill during this sitting of parliament
Like a killer in a horror movie, Uganda's controversial Anti-Homosexuality Law that would have seen people jailed for life for 'aggravated' homosexuality and repeat offenses is back from the dead after its author, National Resistance Movement MP David Bahati, gave notification to his parliament's deputy speaker of his intention to bring the bill back again.
The Zimbabwean president made the comment while visiting China but left without a single yuan in aid or soft loans
Zimbabwean president Robert Mugabe has said he prefers aid from China because Beijing did not force Africa to 'embrace homosexuality' like the West.
'Whereas Europe and America, when they give little funding assistance to countries they always attach conditions,' he told a Chinese TV interviewer. 'And that is our objection.'
He continued, 'We know they are negative because the approach of China is quite different from their own approach. As I said, they want to use aid to control. China uses aid to promote the African personality.'
Edwin Sesange, Uganda gay rights activist, calls on the world to continue fighting for LGBTI rights in his country
Uganda's anti-gay law is no more, and even the President might be changing his views. Could we finally be moving in the right direction?
President Yoweri Museveni's recent comments, after the Constitutional Court nullified the law, are right. A bill like this is difficult to pass.
There are clearly so many open LGBTI people in Uganda that criminalizing them all would be a massive headache.
Appearing to come back from the US with a change of heart, the Ugandan president has urged MPs to think of international relations before bringing back the anti-gay law
Uganda President Yoweri Museveni has urged lawmakers to not 'rush' bringing back the Anti-Homosexuality Act.
Parliament is desperate to recover after the humiliating loss at the Constitutional Court last week when it nullified the anti-gay law due to lack of quorum.
With Speaker Rebecca Kadaga and over 200 MPs vowing to bring back the law as quickly as possible, the president is advising caution.
After flying back from a visit to see President Barack Obama at the White House, Museveni told MPs the law was not a priority for the country's development.
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Doctor Who
Doctor Who is back on our screens and we're celebrating the iconic TV series. Geronimo!
We regret that due to the technical limitations of our site, we are unable to offer eBooks or Audio Downloads to customers outside of the UK.
For further details please read our eBooks help.
Doctor Who is back on our screens and we're celebrating the iconic TV series. Geronimo!
George R. R. Martin's A Song of Ice and Fire is one of the most successful fantasy series ever written.
Here you can browse Harry Potter books, eBooks and some choice collectibles, including The Creature Vault,
Including details of the Waterstones exclusive edition!
What's it like in the days just before your book is released? Bookseller Lucy Hounsom on the excitement of the publication of her first novel and being shelved amongst her favourite authors.
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Sorry to hear about the death of Raymond MacDonald. He was the oldest son of Emma MacDonald Parsons. He passed away Mothers Day morning.
Trudy Thornton, because of health, is staying with her daughter. She would welcome cards. Address is Lisa LaRock, 6 Redmond Rd, Gansvoort, NY 12831.
No one was seriously injured in an early morning accident on Saturday. A car driven by Alfred Tennyson and a pickup with trailer driven by Andy Cleveland. Also, in pickup was: Joe and Annie Cleveland and Tara Cleveland.
Happy Birthday
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Enjoy each and every day.
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Sacral Nerve Neuromodulation/Stimulation
Effective Date September 8, 2014
Revision Date(s) 09/08/14; 06/09/14; 06/10/13; 06/12/12; 07/12/11; 08/10/10; 07/14/09; 11/13/07; 08/08/06; 08/09/05; 09/14/04; 05/13/03; 04/09/02; 09/21/00; 01/04/00; 03/02/99
*Medicare has a policy.
Urinary Incontinence and Non-obstructive Retention
Other urinary/voiding applications of sacral nerve neuromodulation are considered investigational, including but not limited to treatment of stress incontinence or urge incontinence due to a neurologic condition, e.g., detrusor hyperreflexia, multiple sclerosis, spinal cord injury, or other types of chronic voiding dysfunction.
Fecal Incontinence
Sacral nerve neuromodulation is investigational in the treatment of chronic constipation or chronic pelvic pain.
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Definition of Terms
Inappropriate surgical candidates - include patients with bleeding, anatomical limitations, skin disease at risk for infection, psychiatric disease, or who are pregnant. (28)
Overactive bladder (OAB) - The International Continence Society states that overactive bladder syndrome (OAB) "is defined as urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence." Available at: http://wiki.ics.org/Overactive+Bladder
Sacral nerve neuromodulation involves several steps that are identified by the following codes:
Sacral nerve neuromodulation (SNM), also known as sacral nerve stimulation (SNS), is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder or rectal function. This policy addresses use of SNM in the treatment of urinary or fecal incontinence, urinary or fecal nonobstructive retention, and chronic pelvic pain in patients with intact neural innervation of the bladder and/or rectum.
Treatment using SNM, also known as indirect SNS, is one of several alternative modalities for patients with fecal or urinary incontinence (urge incontinence, significant symptoms of urgency-frequency, nonobstructive urinary retention) who have failed behavioral (e.g., prompted voiding) and/or pharmacologic therapies. Urge incontinence is defined as leakage of urine when there is a strong urge to void. Urgency-frequency is an uncontrollable urge to urinate, resulting in very frequent, small volumes and is a prominent symptom of interstitial cystitis (also called bladder pain syndrome). Urinary retention is the inability to completely empty the bladder of urine. Fecal incontinence can arise from a variety of mechanisms, including rectal wall compliance, efferent and afferent neural pathways, central and peripheral nervous systems, and voluntary and involuntary muscles. Fecal incontinence is more common in women, due mainly to muscular and neural damage that may occur during vaginal delivery.
The SNM device consists of an implantable pulse generator that delivers controlled electrical impulses. This pulse generator is attached to wire leads that connect to the sacral nerves, most commonly the S3 nerve root. Two external components of the system help control the electrical stimulation. A control magnet is kept by the patient and can be used to turn the device on or off. A console programmer is kept by the physician and used to adjust the settings of the pulse generator.
Before implantation of the permanent device, patients undergo an initial testing phase to estimate potential response to treatment. The first type of testing developed was percutaneous nerve evaluation (PNE). This procedure is done with the patient under local anesthesia, using a test needle to identify the appropriate sacral nerve(s). Once identified, a temporary wire lead is inserted through the test needle and left in place for 4 to 7 days. This lead is connected to an external stimulator, which is carried by patients in their pocket or on their belt. The results of this test phase are used to determine whether patients are appropriate candidates for the permanent device. If patients show a 50% or greater reduction in symptom frequency, they are deemed eligible for the permanent device
The second type of testing is a 2-stage surgical procedure. In the first stage, a quadripolar-tined lead is implanted (stage 1). The testing phase can last as long as several weeks, and if patients show a 50% or greater reduction in symptom frequency, they can proceed to stage 2 of the surgery, which is permanent implantation of the neuromodulation device. The 2-stage surgical procedure has been used in various ways. These include its use instead of PNE, for patients who failed PNE, for patients with an inconclusive PNE, or for patients who had a successful PNE to further refine patient selection.
The permanent device is implanted with the patient under general anesthesia. An incision is made over the lower back, and the electrical leads are placed in contact with the sacral nerve root(s). The wire leads are extended through a second incision underneath the skin, across the flank to the lower abdomen. Finally, a third incision is made in the lower abdomen where the pulse generator is inserted and connected to the wire leads. Following implantation, the physician programs the pulse generator to the optimal settings for that patient. The patient can switch the pulse generator between on and off by placing the control magnet over the area of the pulse generator for 1 to 2 seconds.
Regulatory Status
In 1997, the Medtronic Interstim® Sacral Nerve Stimulation system received U.S. Food and Drug Administration (FDA) approval for marketing for the indication of urinary urge incontinence in patients who have failed or could not tolerate more conservative treatments. In 1999, the device received FDA approval for the additional indications of urgency -frequency and urinary retention in patients without mechanical obstruction.
In 2006, the Medtronic Interstim II System received FDA approval for treatment of intractable cases of overactive bladder and urinary retention. The new device is smaller and lighter than the original system and is reported to be suited for those with lower energy requirements or small stature. The device also includes updated software and programming options. In 2011, the Medtronic InterStim® System received FDA approval for the indication of chronic fecal incontinence in patients who have failed or could not tolerate more conservative treatments. The InterStim device has not been specifically approved by FDA for treatment of chronic pelvic pain.
Note: This policy does not address pelvic floor stimulation, which refers to electrical stimulation of the pudendal nerve. Pelvic floor stimulation is addressed in a separate in policy. In addition, this policy does not address devices that provide direct SNS in patients with spinal cord injuries. An example of such a device is the VOCARE® sacral nerve stimulator, which is intended for patients with complete spinal cord injury and neurogenic bladder.
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.
Given the detailed patient selection criteria, individual case review may be required.
This policy was originally based on TEC Assessments from 1998 and 2000, (1, 2) which focused on sacral nerve neuromodulation (SNM) for urge incontinence and urinary urgency/frequency, respectively. The literature has been periodically updated using the MEDLINE database. The most recent literature review was performed through March 5, 2014.
Urinary Incontinence
Three randomized controlled trials (RCTs) on SNM for urinary incontinence have been conducted. The larger study was sponsored by Medtronic and submitted to the U.S. Food and Drug Administration (FDA) as part of the approval process. (3) Findings have not otherwise been published. Based on this RCT, the 1998 TEC Assessment concluded that SNM reduced urge incontinence compared with control patients. (1) This well-designed trial, using standardized clinical and functional status outcomes measurements, enrolled patients with severe urge incontinence who had failed extensive prior treatments. The magnitude of effect (approximately one-half of the patients became dry, three-quarters experienced at least 50% reduction in incontinence) was fairly large, probably at least as great as with surgical procedures, and larger than expected from a placebo effect or from conservative measures such as behavioral therapy or drugs. The therapy evaluation test, in which the device is turned off and patients thus serve as their own controls, provided further evidence that the effect on incontinence is due to electrical stimulation and demonstrates that the effect of SNM is reversible. The cohort analysis of the clinical trial provides some evidence that the effect of SNM is maintained for up to 2 years. There was a high rate of adverse events reported in this clinical trial. Most of the adverse events were minor and reversible; however, approximately one-third of patients required surgical revision for pain at the operative sites or migration of the leads.
In this RCT, 177 of 581 patients had urinary retention. Patients with urinary retention reported significant improvements in terms of volume catheterized per catheterization, a decrease in the number of catheterizations per day, and increased total voided volume per day. At 12 months postimplant, 61% of patients had eliminated the use of catheterization. A total of 220 of 581 (38%) had significant urgency-frequency symptoms. After 6 months, 83% of patients with urgency-frequency symptoms reported increased voiding volumes with the same or reduced degree of frequency. At 12 months, 81% of patients had reached normal voiding frequency. Compared with a control group, patients with implants reported significant improvements in quality of life (QOL), as evaluated by the Short-Form 36-Item Health Survey.
An additional prospective RCT of 44 patients with urge incontinence was published in 2000. (4) At 6 months, the implant group showed significantly greater improvement on standardized clinical outcomes, compared with those receiving conservative therapy. The magnitude of effect was substantial.
In 2014, a third RCT was published by Siegel et al.; this was an industry-sponsored FDA-mandated postapproval study. This study compared SNM using a 2-stage surgical procedure with standard medical therapy.(5) Study inclusion criteria included a diagnosis of overactive bladder (at least eight voids per day and/or at least 2 involuntary leaking episodes in 72 hours) and a failed trial of at least one anticholinergic or antimuscarinic medication. In addition, there needed to be at least one such medication that had not yet been attempted. Patients with neurologic diseases and with primary stress incontinence were excluded. A total of 70 patients were allocated to SNM and 77 to standard medical therapy. Of the 70 patients in the SNM group, 11 elected not to receive test stimulation with the tined lead and 8 received the lead but did not receive a full system implant due to lack of response to a 14-day test stimulation period (response was defined as at least a 50% reduction in average leaks and/or voids). Patients in the medical treatment group tried the next recommended medication or restarted a discontinued medication. In an intention-to-treat analysis, the therapeutic success rate at 6 months was 61% in the SNM group and 42% in the standard medical treatment group; the difference between groups was statistically significant (p=0.02). QOL at 6 months was a secondary outcome. Several validated QOL scales were used, and all favored the SNM group compared with the standard medical treatment group (p<0.002 for all comparisons).
In addition to the RCTs, Case series have been published in recent years. For example, A 2011 series by Groen et al. in The Netherlands reported the longest follow-up. (6) A total of 60 patients had at least 5 years of follow-up after SNM for refractory idiopathic urge urinary incontinence. Success was defined as at least a 50% decrease in the number of incontinent episodes or pads used per day. The success rate was 52 of 60 (87%) at 1 month and gradually decreased to 37 (62%) at 5 years. The number of women who were completely continent was 15 (25%) at 1 month and 9 (15%) at 5 years. At the 5-year follow-up, SNM was still used by 48/60 (80%) women. A total of 57 adverse events were reported in 32 of 60 (53%) patients. The most frequent adverse events were hardware-related or pain or discomfort. There were a total of 23 reoperations in 15 patients. In most cases, pain problems were managed conservatively.
Findings from a large prospective series were reported in 2009 by White et al. (7) The study focused on complications associated with SNM in 202 patients with urge incontinence, urinary urgency, or urinary retention. At a mean follow-up of 37 months (range, 7–84), 67 patients (30%) had experienced adverse events that required either lead or implantable pulse generator revisions. Complications included pain (3%), device malfunction secondary to trauma (9%), infection (4%), postoperative hematoma (2%), and lead migration (6%). In addition, 5% of patients underwent elective removal, 4% had device removal due to lack of efficacy, and 2% required removal due to battery expiration. At the last follow-up, 172 patients (85%) had functional implanted units.
A 2009 Cochrane review evaluated the literature on implanted devices for urinary storage and voiding dysfunction in adults. (8) The authors stated that, In spite of methodologic problems (generally poor -quality studies); the evidence "seems clear that continuous stimulation offers benefits for carefully selected people with overactive bladder syndrome and for those with urinary retention but no structural obstruction." They concluded that while some people benefit, more research is needed to improve patient selection, to carry out the implant, and to find why so many fail.
Section Summary
Data from RCTs and case series with long-term follow-up suggest that SNM reduces symptoms of urge incontinence, urgency-frequency syndrome, non-obstructive urinary retention, and overactive bladder in selected patients.
Fecal Incontinence
In 2013, Thin et al. published a systematic review of randomized trials and observational studies on SNM for treating fecal incontinence.(9) A total of 61 studies met eligibility criteria; including at least 10 patients, having a clear follow-up interval and reporting the success rate of therapy based on a 50% or greater improvement in fecal incontinence episodes. Only 2 of the studies were RCTs (Tjandra et al. and Leroi et al studies, described next) and 50 were prospective case series. Data from 2 studies with long-term follow-up could be pooled to calculate median success rates using an intention-to-treat analysis. These median success rates were 63% in the short term (no more than 12 months' follow-up), 58% in the medium term (12-36 months), and 54% in the long term (>36 months). The per-protocol short-, medium-, and long-term success rates were 79%, 80%, and 84%, respectively.
Previously, in 2011, Tan et al. published a meta-analysis of studies SNM for treating fecal incontinence. (10) They identified a total of 34 studies that reported on at least one of their outcomes of interest and clearly documented how many patients underwent temporary and permanent SNM. Only one of these studies was an RCT (Tjandra et al). In the 34 studies, a total of 944 patients underwent temporary sacral nerve stimulation (SNS) and 665 subsequently underwent permanent SNS implantation. There were 279 patients who did not receive permanent implantation, and 154 of these were lost to follow-up. Follow-up in the studies ranged from 2 weeks to 35 weeks. In a pooled analysis of findings of 28 studies, there was a statistically significant decrease in incontinence episodes per week with SNM compared with maximal conservative therapy (weighted mean difference, -6.83; 95% confidence interval [CI], -8.05 to -5.60; p<0.001). Fourteen studies reported incontinence scores, and when these results were pooled, there was also a significantly greater improvement in scores with SNS compared with conservative therapy (weighted mean difference, -10.57; 95% CI: -11.89 to -9.24; p<0.001).
The 2 RCTs are described briefly next:
In 2008, Tjandra et al. published an RCT with 120 patients with severe fecal incontinence. (11) Patients were randomly assigned to receive SNS or best supportive therapy, consisting of pelvic floor exercises with biofeedback, bulking agents, and dietary management with a team of dieticians. Exclusion criteria included neurologic disorders and external anal sphincter defects of more than 120 degrees of the circumference, although a "high proportion" of the patients had pudendal neuropathy. The study was not blinded. Of the 60 patients randomized to SNS, 54 (90%) had successful test stimulation and 53 decided to proceed with implant of the pulse generator. At baseline, the SNS group had an average of 9.5 incontinent episodes per week, and the controls had 9.2. Both groups had an average of 3.3 days per week with incontinence. At 12-month follow-up, episodes had decreased to 1 day per week with 3.1 episodes in the SNS group, but had not changed in the control group (mean, 3.1 d/wk with 9.4 episodes). Complete continence was achieved in 22 of the 53 SNS patients (42%) and 13 patients (24%) improved by 75% to 99%. None of the patients had worsening of fecal continence. Adverse events included pain at implant site (6%), seroma (2%), and excessive tingling in the vaginal region (9%).
In 2005, Leroi et al. in France published an industry-supported double-blind randomized crossover study. (12) Thirty-four patients had successful temporary percutaneous stimulation and underwent permanent implantation of an SNM device. Following a one to three month post-implantation period in which the device was turned on, patients had their device turned on for one month and off for 1 month, in random order. A total of 24 patients (71%) of randomized patients completed the study. There was a statistically significantly greater decrease in fecal incontinence episodes with the device turned on (p=0.03). However, there was also a large decrease in incontinent episodes for the placebo group. The median frequency of fecal incontinence episodes decreased by 90% when the device was in the on position; it decreased by 76% when the device was in the off position.
A key observational study was the 16-site multicenter FDA investigational device exemption study of SNS in 120 patients with fecal incontinence. Findings were initially reported by Wexner et al. in 2010. (13) To be included in the study, patients had to complain of chronic fecal incontinence with duration greater than 6 months or for more than 12 months after vaginal childbirth, defined as greater than 2 incontinent episodes on average per week. All patients had failed or were not candidates for more conservative treatments. Exclusion criteria included congenital anorectal malformation; previous rectal surgery, if performed within the last 12 months (or 24 months in case of cancer); defects of the external anal sphincter over 60 degrees; chronic inflammatory bowel disease; visible sequelae of pelvic radiation; active anal abscesses and fistulae; neurologic diseases such as clinically significant peripheral neuropathy or complete spinal-cord injury; and anatomic limitations preventing the successful placement of an electrode. A total of 285 patients were evaluated for potential enrollment; 133 were enrolled and underwent acute test stimulation, and 120 showed at least 50% improvement during the test phase and received a permanent stimulator. Thirty-four of the 120 patients exited the study for a variety of reasons both related (i.e., lack of efficacy in 6, implant site infection or skin irritation in 5) and unrelated to the implant (i.e., death of a local principal investigator). Analysis based on the initial 133 patients showed a 66% success rate (≥50% improvement), while analysis based on 106 patients who were considered completed cases at 12 months showed an 83% success rate. The success rate based on the 120 patients who received a permanently implanted stimulator would fall between these 2 figures. Of 106 cases included in the 12-month results, perfect continence (100% improvement) was reported in approximately 40%, while an additional 30% of patients achieved 75% or greater improvement in incontinent episodes. Success was lower in patients with an internal anal sphincter defect (65%, n=20) compared with patients without a defect (87%, n=86).
Three-year and five-year findings were subsequently published. In 2011, Mellgren et al. reported on the 120 patients who received a permanently implanted stimulator. (14) Mean length of follow-up was 3.1 years, and 83 (69%) completed at least part of the 3-year follow-up assessment. In an intention-to-treat analysis using the last observation carried forward, 79% of patients experienced at least a 50% reduction in the number of incontinent episodes per week compared with baseline, and 74% experienced at least a 50% reduction in the number of incontinent days per week. In a per-protocol analysis at 3 years, 86% of patients experienced at least a 50% reduction in the number of incontinent episodes per week, and 78% experienced at least a 50% reduction in the number of incontinent days per week. By the 3-year follow-up, a total of 334 adverse events that were potentially device-related had been reported in 99 patients; 67% of these occurred within the first year. The most frequently reported adverse events among the 120 patients were implant site pain (28%), paresthesia (15%), implant site infection (10%), diarrhea (6%), and extremity pain (6%). Six infections required surgical intervention (5 device removals and 1 device replacement). In 2012, Hull et al. reported outcomes in 72 patients (60% of the 120 implanted patients) who had completed a 5-year follow-up visit. (15) Sixty-four (89%) of the patients who contributed bowel diary data at 5 years had at least a 50% improvement from baseline in weekly incontinent episodes, and 26 of the 72 patients (36%) had achieved total continence. It is uncertain whether outcomes differed in the 40% of patients who were missing from the 5-year analysis.
In 2011, Maeda et al. published a systematic review of studies on complications following permanent implantation of a SNS device for fecal incontinence and constipation. (16) The authors identified 94 articles. Most studies addressed fecal incontinence. A combined analysis of data from 31 studies on SNS for fecal incontinence reported a 12% suboptimal response to therapy (149 of 1,232 patients). A review of complications reported in the studies found that the most commonly reported complication was pain around the site of implantation, with a pooled rate of 13% (81/621 patients). The most common response to this complication was repositioning the stimulator, followed by explantation of the device and reprogramming. The second most common adverse event was infection, with a pooled rate of 4% (40/1025 patients). Twenty-five of the 40 infections (63%) led to explantation of the device.
Section Summary
The evidence base consists of two RCTs, observational studies including several with long-term follow-up and systematic reviews of RCTs and uncontrolled studies. Taken together, findings of these studies suggest that SNM/SNS improves outcomes when used for the treatment for chronic fecal incontinence in well-selected patients who have failed conservative therapy.
In 2013, Thomas et al. published a systematic review of controlled and uncontrolled studies evaluating SNS for treatment of chronic constipation. (17) The authors identified 11 case series and 2 blinded crossover studies. Sample sizes in the case series ranged from 4 to 68 patients implanted with a permanent SNS device; in 7 of the 11 studies, fewer than 25 patients underwent SNS implantation. Among the 2 crossover studies, one included 2 patients implanted with an SNS device. The other, a 2012 study by Knowles et al., (18) evaluated temporary stimulation in only 14 patients. Patients were included if they were diagnosed with evacuatory dysfunction and rectal hyposensitivity and had failed maximal conservative treatment. They were randomized to 2 weeks of stimulation with the SNS device turned on and 2 weeks with the SNS device turned off, in random order. There was no wash-out period between treatments. The primary efficacy outcome was change in rectal sensitivity and was assessed using 3 measures of rectal sensory thresholds. The study found a statistically significantly greater increase in rectal sensitivity with the device turned on in 2 of the 3 measures. Among the secondary outcome measures, there was a significantly greater benefit of active treatment on the percentage of successful bowel movements per week and the percentage of episodes with a sense of complete evacuation. In addition to its small sample size, the study was limited by the lack of a wash-out period between treatments i.e., there could have been a carry-over effect when the device was used first in the on position. Moreover, the authors noted that the patients were highly selected; only 14 of the approximately 1,800 patients approached met the eligibility criteria and agreed to participate in the study.
One of the larger case series was published In 2010 by Kamm et al. (19) This was a prospective study conducted at multiple sites in Europe. The study included 62 patients who had idiopathic chronic constipation lasting at least 1 year and had failed medical and behavioral treatments. Constipation was defined as at least one of the following: fewer than 2 bowel movements per week, straining to evacuate in at least 25% of attempts or a sensation of incomplete evacuation on at least 25% of occasions. Forty-five of the 62 (73%) met criteria for permanent implantation during the 3-week trial period. Criteria included an increase in evacuation frequency to at least 3 per week, or a 50% reduction in either frequency of straining during evacuation or in episodes with sensation of incomplete evacuation. After a median follow-up of 28 months (range, 1-55 months) after permanent implantation, 39 of 45 (87%) patients were classified as treatment successes (i.e., met same improvement criteria as were used to evaluate temporary stimulation). There was a significant increase in the frequency of bowel movements from a median of 2.3 per week at baseline to 6.6 per week at latest follow-up (p<0.001). The frequency of spontaneous bowel movements (i.e., without use of laxatives or other stimulation) increased from a median of 1.7 per week at baseline to 4.3 per week at last follow-up (p=0.001). A total of 101 adverse events were reported; 40 (40%) of these were attributed to the underlying constipation or an unrelated diagnosis. Eleven serious adverse events related to treatment were reported (the authors did not specify whether any patients experienced more than 1 serious event). The serious adverse events included a deep postoperative infection (n=2), superficial erosion of lead through the skin (n=1), persistent postoperative pain at the site of implantation (n=2), conditions leading to lead revision (n=4), and device failure (n=2). The study has been criticized for including a large number of patients who had more than 2 bowel movements per week at study entry.
An additional study, published by Maeda et al. in 2010, focused on reporting adverse events. (20) The study was a chart review and included 38 patients with constipation who received permanent SNS after a successful trial period. At the time that charts were reviewed, a mean of 25.7 months had elapsed since implantation. A total of 58 reportable events were identified in 22 of the 38 (58%) patients. A median of 2 (range, 1-9) events per patient were reported; 26 of 58 events (45%) were reported in the first 6 months after device implantation. The most common reportable events were lack or loss of efficacy (26 of 58 events, 45%), and pain (16 events, 28%). Twenty-eight (48%) of the events were resolved by reprogramming. Surgical interventions were required for 19 (33%) of the events, most commonly permanent electrode replacement (14 events). Three of 38 (8%) patients discontinued use of the device due to reportable events.
Section Summary
Only 2 small controlled studies are available, both crossover studies; 1 had only 2 patients and the other had methodologic limitations. In addition, there are several, mainly small, case series. This represents insufficient evidence to permit scientific conclusions about the effect of SNM/SNS on health outcomes in patients with constipation.
Chronic Pelvic Pain
A 2013 systematic review of studies on nerve stimulation for chronic pelvic pain did not identify any RCTs on SNS for treatment of chronic pelvic pain or bladder pain. (21) The published evidence is limited to case series. For example, in 2012 Martelluci et al. reported on 27 patients with chronic pelvic pain (at least 6 months) who underwent testing for SNM implantation. (22) After a 4-week temporary stimulation phase, 16 of 27 patients (59%) underwent implantation of an Interstim device. In the 16 implanted patients, mean pain on a visual analog scale was 8.1 before implantation and 2.1 at the 6- and 12-month follow-ups. An earlier study by Siegel et al. reported on 10 patients and stated that 9 of the 10 experienced a decrease in pain with SNS stimulation. (23)
Section Summary
Data from several small case series with heterogenous patients represents insufficient evidence about the effect of SNM/SNS on health outcomes in patients with chronic pelvic pain.
Trial Stimulation Techniques
As described in the previous background section, there are 2 types of trial stimulation before permanent implantation of a neuromodulation device. These are percutaneous nerve evaluation (PNE) and stage 1 (lead implantation) of a 2-stage surgical procedure. The PNE was the initial method of trial stimulation and has been the standard of care before permanent implantation of the device. In review articles such as Baxter and Kim 2010, lead migration was described as a potential problem with the PNE technique, but no studies were identified that quantified the rate of lead migration in large numbers of patients.(24) The 2-stage surgical procedure is an alternate trial stimulation modality.
Comparative rates of lead migration and rates of progressing to permanent implantation are useful outcomes in that there may be reduced sensitivity of the PNE test due to lead dislodgement. However, due to the potential placebo effect of testing, it is also important to compare the long-term efficacy of SNM after these 2 trial stimulation techniques. In addition, it would be useful to have data on the optimal approach to using the 2-stage surgical procedure. As mentioned previously in the background section, the 2-stage surgical procedure has been used in various ways including instead of PNE, for patients who failed PNE, for patients with an inconclusive PNE, and for patients who had a successful PNE to further refine patient selection.
No RCTs were identified that evaluated long-term health outcomes (e.g., reduction in incontinence symptoms) after trial stimulation with PNE versus stage-1 lead implantation. There are limited data on the issue of rates of failure after SNM in patients selected using the 2-stage test. Leong et al., in a single-center prospective study published in 2011, evaluated 100 urge incontinence patients with both PNE and the first stage of the 2-stage technique (i.e., patients served as their own controls). (25) Patients were first screened with the PNE and, afterwards, with lead implantation. Response to testing was based on diary data for 3 consecutive days after receiving each type of lead. In the test phase, 47 patients (47%) had a positive response to PNE, and 69 (69%) had a positive response to the first-stage lead placement test. All patients who responded to PNE also responded to stage-1 testing. The 69 patients who responded to stage-1 testing underwent implantation. They were then followed for a mean of 26 months, and 2 patients (3% of those with a positive test) had failed therapy. Although this study showed a low rate of failure, only 22 subjects had a successful test with the stage-1 technique but not with PNE. This is a small number of patients on which to base conclusions about the comparative efficacy of the 2 techniques. In addition, the order of testing could have impacted findings. All patients had PNE testing before first-stage lead implantation and could have been biased by their first test. Stronger study designs would be to randomize the order of testing or to randomize patients to receive one type of testing or the other.
In 2002, Scheepens et al. conducted an analysis of 15 patients with urinary incontinence or retention who had a good initial response to PNE but then failed PNE in the longer term (i.e., days 4-7 of testing). (26) These 15 patients underwent stage 1 of the 2-stage technique. One patient failed the first stage and was explanted. Of the remaining 14 patients, 2 were explanted later due to lack of efficacy of SNM. The other 12 patients were followed for a mean of 4.9 years and voiding diary data showed improvement in nearly all incontinence symptoms. There was a low failure rate after stage-1 testing, but this is a small sample size, and stage-1 testing was not compared with another trial stimulation method (e.g., PNE).
In 2010, Marcelissen et al. published findings in 92 patients with urinary symptoms who underwent trial evaluation for SNM treatment. (27) Patients initially underwent PNE (n=76) or stage-1 surgery (n=16). Patients who had a negative PNE (n=41) then underwent stage-1 evaluation. A total of 11 of 16 (63%) patients had a positive initial stage-1 test and were implanted with a SNM device. Thirty-five of 76 (46%) patients had a positive initial PNE test and underwent permanent implantation. There were 41 patients (54% of those undergoing PNE) who had a negative test and then had stage-1 surgical evaluation. Eighteen of 41 (44%) had a positive stage-1 test and underwent implantation. Altogether there were 64 patients who underwent implantation of an SNM device. Mean follow-up was 51 months. Thirty-eight of 64 patients (59%) implanted experienced clinical success at last follow-up, defined as greater than 50% improvement in symptoms reported in a voiding diary. Clinical success rate was not reported separately by trial stimulation method.
Several studies, e.g., Borawski et al. (2006) (28) and Bannowsky et al. (2008), (29) compared the response rates during the test phase in patients with urinary incontinence symptoms and found higher rates of response with the stage-1 test than with PNE. In these studies, more people who received the stage-1 test went on to undergo implantation. The Borawski et al. study was an RCT with 30 patients (13 received PNE and 17 received the stage-1 test). The Bannowsky et al. study was not randomized; 42 patients received a PNE, and 11 patients received a stage-1 test. Neither study, however, followed patients once they had a device implanted, so they do not provide data on the relative success rate of SNM after these 2 test procedures. With this type of study (i.e., without follow-up after implantation), it is not possible to conclude whether the 2-stage procedure reduced false-negatives (i.e., selected more people who might benefit) or increased false-negatives (i.e., selected more people who might go on to fail).
No published studies were identified that compare different trial stimulation techniques in patients with non-urinary conditions e.g., fecal incontinence.
Clinical Trials
Clinical Input Received through Physician Medical Societies and Academic Medical Centers
In response to requests, input was received through 4 Physician Specialty Societies and 2 Academic Medical Centers while this policy was under review in 2012. While the various Physician Specialty Societies and Academic Medical Centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the Physician Specialty Societies or Academic Medical Centers, unless otherwise noted. Reviewers from 2 Specialty Societies and 2 Academic Medical Centers provided opinions regarding the possible medical necessity of implantable leads for test stimulation, as part of a 2-stage process for device implantation. All 4 respondents supported the use of implantable leads for test stimulation as an alternative to percutaneous test stimulation, for patients who failed percutaneous test stimulation and/or for patients with inconclusive percutaneous test stimulation. Reasons for support included a longer period of interrupted treatment with stage-1 stimulation due to less lead migration and a higher rate of positive tests compared with percutaneous test stimulation.
There is sufficient evidence to conclude that sacral nerve neuromodulation (SNM)/stimulation (SNS) is effective and safe in selected patients with urge incontinence, urgency-frequency, and non-obstructive urinary retention. In addition, the evidence is considered sufficient for SNM to be an option for the treatment for chronic fecal incontinence in well-selected patients who have failed conservative therapy. Therefore, SNM may be considered medically necessary under specific conditions in the above patients. Not all patients will benefit, and the adverse event rate for this procedure is high. Patients should therefore be provided with adequate information to make an informed choice regarding the potential risks and benefits of this procedure.
Limited evidence reports that more patients have a positive stimulation trial when stage-1 surgery is used compared with percutaneous nerve evaluation and that most patients with a positive stage-1 test experience a reduction in symptoms after permanent implantation. This evidence does not determine with certainty that health outcomes are improved with the stage-1 trial stimulation. However, due to the available evidence, as well as strong clinical support for surgical lead placement as an alternative to percutaneous test stimulation, surgical lead placement may be considered medically necessary for otherwise eligible patients.
The literature on SNS for constipation or chronic pelvic pain remains insufficient to evaluate the effect of this technology on health outcomes; thus SNM is considered investigational for these indications.
Practice Guidelines and Position Statements
National Institute for Clinical Evidence (NICE)
Their 2007 guidance on management of fecal incontinence recommended,
"a trial of temporary sacral nerve stimulation should be considered for people with faecal incontinence in whom sphincter surgery is deemed inappropriate…. All individuals should be informed of the potential benefits and limitations of this procedure and should undergo a trial stimulation period of at least 2 weeks to determine if they are likely to benefit. People with faecal incontinence should be offered sacral nerve stimulation on the basis of their response to percutaneous nerve evaluation during specialist assessment, which is predictive of therapy success." (32)
American College of Gastroenterology (ACG)
A 2004 practice guideline on the diagnosis and management of fecal incontinence found limited evidence in favor of SNS. (33) The ACG concluded that the precise indication for SNS, its comorbidity, its long-term outcome, and efficacy remain to be defined.
American College of Obstetricians and Gynecologists (ACOG)
Medicare National Coverage
Effective January 1, 2002, SNS is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. (36) SNS involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered.
The following limitations for coverage apply to all three indications:
Improvement is measured through voiding diaries. Patients must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.
Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)
Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
Revision or removal of peripheral neurostimulator electrode array
Incision and subcutaneous placement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
Electronic analysis of implanted neurostimulator pulse generator system(may include rate, pulse amplitude, and duration; configuration of wave form; battery status; electrode selectability; output modulation; cycling impedance; and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
Simple spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming
Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour
Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)
Sacral nerve stimulation test lead, each
Neuromuscular stimulator, electronic shock unit
Durable medical equipment, miscellaneous (would include test stimulation lead kit, bulk leads, needles, and cables)
Implantable neurostimulator electrode, each
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
Implantable neurostimulator pulse generator, single array, rechargeable, includes extensions
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
Type of Service
Place of Service
Inpatient / Outpatient
Add to Surgery Section - New Policy
Replace Policy - Content updated; policy statement revised to include new FDA approved indications.
Replace Policy - Policy updated with reference to 2000 TEC assessment; policy statement unchanged.
Replace Policy - CPT code; policy statement unchanged.
Replace Policy - Policy updated; policy statement unchanged. New references added.
Replace Policy - Policy revised and expanded to address neuromodulation to treat fecal incontinence and constipation as investigational.
Replace Policy - Policy updated with literature search; no changes in policy statement.
Codes updated - No other changes.
Disclaimer and Scope update - No further changes.
Replace Policy - Policy updated with literature search; no change to policy statement, however, fecal incontinence (investigational) changed to separate policy indication; references added; Medicare limitations updated.
Cross Reference Update - No other changes.
Replace Policy - Policy updated with literature search; no changes in policy statement; references added; codes added
Code Updates - Code 787.6 added.
Replace Policy - Policy updated with literature search. Policy statement updated and clarified with selection criteria. References added.
Replace Policy - Policy updated with literature review through March 2010; references added and reordered. Policy statement on fecal incontinence has been changed from "investigational" to "may be medically necessary under specific conditions."
Replace Policy - Policy updated with literature search through March 2011. References 7, 24, 26, 27, 29, 30, 34, and 36 added; other references reordered or removed. Policy statements unchanged. ICD-10 codes added to policy.
Related Policies updated; 2.01.27 added.
Replace policy. Policy updated with literature search through February 2012. Rationale and Policy Guidelines re-written. References 5, 13, 14 and 19-24 added; other references reordered or removed. Clinical input added. Implantable lead stimulation added as alternative stimulation method for eligible patients within medically necessary policy statements. Medically necessary policy statement for urinary incontinence changed to 2-part statement (has criteria for test stimulation and for permanent implantation). Material on methods of trial test stimulation added to Background and Rationale sections. Title changed to Sacral Nerve Neuromodulation/Stimulation. Code 64590 removed as it does not apply to this policy.
Update Coding Section – ICD-10 codes are now effective 10/01/2014. Add Related Policy 8.03.01.
Replace policy. Policy updated with literature search through March 13, 2013. Length of successful percutaneous test stimulation in medically necessary statements changed from at least 2 weeks to at least 1 week. Fecal incontinence policy statement separated into 2 statements; 1 on trial stimulation and 1 on permanent implantation. Edits made to statements so that criteria for fecal and urinary incontinence are similar, when applicable. References 12, 13, 16, 17 and 20 added; other references renumbered or removed.
Minor updated. CPT codes 95972 and 95973 listed within the Policy Guidelines extended to the Coding table to reflect consistency. Scope updated to indicate that this policy not part of Medicare Advantage.
Update Related Policies. Delete 7.01.106 and replace with 7.01.553.
Annual Review. Policy updated with literature review through March 5, 2014. References 5, 9, 12, 21, 30-31, and 34-35 added. Overactive bladder added to medically necessary statement on urinary incontinence. ICD-9 and ICD-10 diagnosis and procedure codes removed; this is performed inpatient.
Update Related Policies. Change title to 1.01.17.
Interim Update. Clarification added as #6 criteria under subheading "A" Fecal Incontinence. Specified the length of time after surgery when a trial of sacral nerve neurostimulation may be considered medically necessary. No new references added. Policy statement clarified as noted.
Update Related Policies. Remove 7.01.553 as it was archived.
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).


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The Boeing 777-300ER, which has just passed 10 years of service, is the most successful model in the 777 product range.
The 777 family sits between 301 and 380 passengers and comprises six models: the standard 777-200, the extra range 777-200ER, the larger 777-300, two new longer-range models, the 777-300ER and 777-200LR and the 777 freighter.
Boeing launched its next-generation 777 twinjet, initially called 777-200X/300X in February 2000 to complete the 777 family and compete with Airbus' A340-500/600 high gross weight models.
The 777-300ER, was launched with an order for 10 firm aircraft from Air France. The French carrier took delivery of the first unit, which was leased from ILFC, in April 2004.
The aircraft features 6.5-foot raked and extended wingtips to reduce take off field length, increase climb performance and reduce fuel burn. Because of its longer length, the aircraft uses a new semi-levered gear, which allows it to take off from fields with limited runway length.
The General Electric's GE90-115 is the type's exclusive powerplant certified at 115,300lb. The maximum range with 365 passengers is 7,930 nautical miles, and it is made possible due to a higher maximum take-off weight (MTOW) along with the increased fuel capacity.
The 777-300ER is offered with MTOWs ranging from 725,000lb to 779,00lb with the most prevalent weight being 775,000lb, certified on 243 aircraft, followed by the 750,000lb variant certified on 127 aircraft to date.
The -300ER, which combined the -300's added capacity with the -200ER's range, rapidly became a popular model, gaining orders as airlines replaced four-engine models with twinjets.
As of 19 June 2014, there were 486 commercial aircraft in operation with another 206 units on backlog, according to Flightglobal's Ascend Fleets database.
An estimated 160 aircraft were under operating leases, equivalent to a third of the 777-300ER fleet in service.
Ascend's aviation analyst Marlon Mejia says availability is extremely limited, with very low downtime between leases.
"20 transactions have been recorded since the beginning of 2014, of which eleven were sale and leasebacks on delivery, three were leasebacks, five were purchases with lease attached, and one was in a securitisation. Over 30% of the fleet is on operating lease which indicates very good short-term liquidity for a widebody of its size. This is aided by the single engine choice which facilitates seamless transfer between operators," he says.
Emirates Airline is the largest operator with a 96-aircraft fleet. The Middle East carrier's decision to recently axe its 70 Airbus A350order leaves its widebody fleet centred on the A380 and the 777 products. Emirates, which became a launch customer for the 777X at the Dubai air show last year, with a commitment for up to 200, also indicated that the A350-1000s could operate alongside the 777X.
IBA Group expects many 777-300ER returning off lease from Emirates by 2022 and this will offer many challenges to those lessors faced with a hefty reconfiguration cost and softening lease rentals. "There are however a significant number of 747-400s, 777-200ERs and A340-600s to replace between now and then so ageing 777-300ERs should have a home somewhere," says IBA's senior analyst Jonathan Mcdonald.
Launch customer Air France operates a 38-aircraft fleet while Cathay has 39 aircraft followed by Singapore Airlines with 22 units.
Europe represents 79 aircraft in service with four operators Air France, British Airways, KLM and Turkish Airlines.
At 19 June, backlog from European carrier accounted for 22% of the total backlog.
The Africa and the Middle East region account for 165 units, effectively doubling its fleet over the past three years. In addition to Egyptair, Emirates, Etihad and Qatar Airways, Air Austral, Saudia, Ethiopian Airlines, TAAG Angola Airlines have introduced the type to their fleet over the past few years. Backlog is estimated at 73 aircraft, or 36% of total backlog.
Asia-Pacific represents 202 aircraft in service with Air China Air India, Air New Zealand, All Nippon Airways, Biman Bangladesh Airlines, Cathay Pacific Airways, Eva Air, Garuda Indonesia Airways, Japan Airlines, Jet Airways, Korean Air, Philippine Airlines, Pakistan International Airlines, Singapore Airlines, Thai Airways International and Virgin Australia International. Backlog is estimated at 78 aircraft, or 38% of total backlog.
Air Canada and American Airlines are the only North American operators while TAM Linhas Aereas has a 10-aircraft fleet.Backlog is estimated at eight units.
The 777-300ER was a rival to the A340-600 in the long range passenger markets when first launched. These types were designed to provide growth from the A340-300 and 777-200ER markets, replace the 747-200B and complement or be an alternative to the 747-400 on routes such as Europe to Asia, US West Coast; Japan to North America.
Mcdonald says the combination of "9/11" events and global economic contraction of 2008 onwards left the 777-300ER in almost unchallenged position as Airbus could not garner more A340-600 sales. "For many, 777-300ER is now seen as benchmark long-haul twin engine aircraft in the sub A380/747-8I segments. This is a good position to be in though future entrants such as A350-1000 and of course Boeing's own 777-9X are bound to eventually usurp the buoyant position currently occupied by 777-300ER," he says.
The continued demand for this aircraft should ensure the continued stability of the future values for the type, according to Collateral Verification's Gueric Dechavanne. "My only concern may be the Airbus A350-1000 and now the 777X. With the improved economics both models will slow potential 777 orders but I do not see any immediate impact on residual values for quite some time. Once the replacement for the 777, the 777X, starts to deliver in larger numbers, this may then impact the future of this aircraft but it is much too early to tell as to if and when this will take place".
ICF International's principal Stuart Rubin says the 777-300ER will experience "fraternal competition" from the 777-8X and 777-9X models. "These aircraft, planned for entry into service in 2020, will bracket the 777-300ER in terms of payload and range.
"Along with the A350-1000, these aircraft will compete with the 777-300ER but not for several years, which means the 777-300ER will be alone in its market segment over the near term. Incremental product improvement programmes and the recent advent of 330min ETOPS limits further enhance the operational flexibility and capability of the 777-300ER."
Bank's appetite
The second market has been limited so far and the only movements in the 777-300ER market have been around the Indian carriers fleets.
Over the past year Jet Airways has placed a total of five 2007-vintage aircraft under sublease contracts with Etihad Airways and Turkish Airlines.
Garuda has also subleased a 2009-vintage aircraft from Air Austral since April 2013.
The purchase and leaseback market has been centred on new deliveries mainly, with the exception of the Aircastle transaction with the LATAM Airlines Group in February this year.
The US-based lessor signed a sale and leaseback for eight 777-300ER units operated by TAM in a $900 million deal.
The first group of four aircraft, which were manufactured in 2012, have an average lease term of 60 months.
The second group of aircraft, which were manufactured in 2008, is expected to be purchased by Aircastle once the existing financings are repaid and will be leased back to LATAM with lease terms expiring in 2017 and 2018.
Aircastle says the aircraft will come off lease at a time when few comparable new generation aircraft will be available.
The US lessor also acquired a 2007-vintage 777-300ER from Air Canada under a purchase and leaseback agreement last year in August.
Last year Intrepid Aviation purchased a 777-300ER aircraft on lease to Thai Airways International from BOC Aviation. The 2012-vintage aircraft is under a 12-year operating lease with the Thai carrier.
The 777-300ER market is probably the most liquid asset in the widebody market and drives a variety of financings.
China's Bank of Communications Financial Leasing (BoCom Leasing) has closed the purchase and leaseback of two new 777-300ER aircraft with Air China since the beginning of the year.
The Chinese carrier also tapped the capital markets earlier this year for the refinance of one unit. The $124 million US Export-Import (Ex-Im) bond carries a coupon of 2.8% followed two offerings in January worth $262 million: one issuance amounted$130 million at 2.83% yield. The second 12-year issuance priced at 2.897%, again equivalent to mid-swaps plus 66 bps.
In 2013 ICBC Financial Leasing and Garuda Indonesia signed a sale and leaseback transaction for five new 777-300ERs.
Crédit Agricole-CIB underwrote a 12-year finance lease facility covering a new 777-300ER for Emirates Airline earlier this month. The transaction follows the finance lease of another 777-300ER in April with the Dubai-based carrier.
Thai Airways financed a new 777-300ER with a 12-year loan arranged by Crédit Agricole-CIB, the Bank of Tokyo-Mitsubishi UFJ and Kasikornbank Public Company in January. The carrier recently opted for US Export-Import guaranteed financings over commercial debt proposals on three more aircraft of the type delivering through January 2015.
Cathay Pacific funded a new Boeing 777-300ER delivery in January this year through a finance lease facility co-arranged by Standard Chartered and the Commonwealth Bank of Australia (CBA).
Ample bank market capacity has allowed Turkish Airlines to push back a planned capital markets debt issue until at least 2015, as it meets its aircraft financing needs in the bank market. The possible $450 million to $500 million secured enhanced equipment trust certificates (EETC) deal is understood to include only 777-300ER aircraft.
Air Canada first tapped the capital markets with a $714.3 million EETC private placement in April 2013. Proceeds went towards the delivery of five new 777-300ERs.
Last year British Airways financed two new deliveries through its $928.6 million Pass Through Certificates, Series 2013-1 issuance.
Novus Aviation Capital, which has invested in the 777-300ER type along with A330s and A380s over the past few years, recently sold a 2012-vintage aircraft on lease to Emirates to Commerz Real AG.
CMVs and LRs
"The 777-300ER values last decreased at the start of 2014, in line with the usual annual adjustment for depreciation but the variant has largely enjoyed strong and stable market values and lease rates across all vintages. The 777-300ER has benefited from a virtual lack of competition in the segment since the A340-600 was discontinued. Only two orders have been placed in 2014, but the type has a healthy backlog, a still growing customer base, and it continues to be a good replacement for ageing 747-400 fleets and also an up-gauging option from smaller twins," says Mejia. Ascend estimates some slots may be available in 2016, with wider availability from 2017 onwards.
Collateral Verifications says values have dropped by less than 5% over the past year while lease rentals have remained stable. "It shows the desirability of the asset in the current environment," says Dechavanne.
"This level of discounting reflects a normal level of depreciation. With the industry recovery potentially under way, this will bring further stability to the type with a potential increase in value over the next 12 to 18 months, if not earlier."
"Even in the economic downturn of 2008-09, values and lease rates proved remarkably resilient with any easing more the result of reduced interest rates rather than from easing market demand," says Rubin.
Mejia says values are expected to remain steady in the short to medium-term and there has been no immediate negative impact by the announcement of the future 777X, scheduled to enter service in 2019. However as the order backlog starts to reduce, we would not be surprised if Boeing starts to lower new pricing for last-off-the-line units in the 2016-2020 timeframe, and this will have a trickle-down effect on older aircraft values, eventually. The 777X is unlikely to reach critical mass to impact the 777-300ER until the mid-2020s, however the A350-1000 is likely to be entering service earlier and will start to put some pressure on 777-300ER values, especially as the oldest operators such as Air France and Singapore Airlines start retiring aircraft from their fleets. Some of these aircraft will enter the age for major airframe checks, and depending on utilization, also major engine overhauls. These events will be critical in value retention for elder models," he says.
Appraisers were asked to look at the baseline 777-300ER model with 759,600lb MTOW.
MBA says current market values (CMV) equate the base values (BV) for a 2004-vintage model. According to the appraiser, the aircraft has a $88.7 million CMV. ICF International says the 10-year old aircraft is valued at $87.2 million. Ascend says the CMV is $80.8 million while Collateral Verifications has $73.6 million and IBA Group has a $74 million CMV.
A 2006-built aircraft has a $98.8 million CMV for ICF International and $99.9 million for MBA. Collateral Verifications has a $88.6 million valuation while Ascend and IBA Group are the lowest of the three appraisers with $86.9 million and $87 million quotes.
A 2008-vintage is valued by Ascend at $96.6 million and $102.9 million by IBA. Collateral Verifications has a $105.1 million CMV. ICF International and MBA have a $112.3 million and $112.8 million valuation, respectively.
Collateral Verifications says the CMV of a three-year old 777-300ER is $119.3 million while IBA has a $120 million quote. ICF International and MBA have $127.7 million and $125.5 million valuation, respectively, while Ascend is the lowest of the four appraisers with $111.2 million.
Collateral Verifications estimates the monthly lease rates for 2010-vintage at $1.15 million, or 0.96% of the current value of the aircraft. MBA says monthly lease rates range from $1 million to $1.1 million, while IBAhas a $1 million to $1.2 million a month.
ICF International's range is in the $1.05-1.15 million while Ascend has a $1.02 million indicative lease rate for the model.
A 10-year old aircraft would lease for $840,000 a month for Ascend, $850,000 for Collateral Verifications, while MBA lease rates are in the $800-900,000 a month bracket. ICF International's lease rates are between $750,000 and $850,000 a month while IBA's monthly lease rentals are $745-845,000.
A six-years old aircraft would have monthly lease rates in the $940,000 region for Ascend and $1.05 million for Collateral Verifications. ICF International and MBA's lease rates are between $950,000 and $1.05 million. IBA's monthly lease rentals are between $930,000 and $1 million.