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Integrative Medicine, Complementary and Alternative Medicine and Health Round-up #79: May 2014
-Three Federal agencies announced a request for comments on Section 2706, Non-Discrimination in Health Care-respond by June 1
-AAMC's leading workforce research conference switches focus from "physician" to "health workforce," includes integrative health and medicine disciplines
-RWJF report finds limited impact of Choosing Wisely campaign in combating the 30% of the medical industry that is waste
Urging responses on 2706
Integrative Pain Treatment
-Samueli studies in Pain Medicine underscore new directions in integrative pain treatment
-U.S. Senate Committee on Veteran's Affairs examines alternatives to pain drugs
-US Health and Human Services on combating opioid addictions: Use more drugs!
-Twitter chat on CAM and back pain produces surprising dismissal of "CAM" from NCCAM tweeter
-Canadian firm urges multidisciplinary approach to pain treatment, but with limited team
-AANP survey of Medicare recipients finds high interest in use of naturopathic doctors and in non-pharma treatment
-CDC report stimulates flurry of news accounts on regional trends in "CAM" use
-Cleveland Clinic Chinese herb program with Crane Herb makes huge waves in media
-New School in New York City pioneers auricular acupuncture and acupressure in university setting
-A snapshot of the size and maturation of the licensed integrative health and medicine fields
Philanthropic Partners
-Emerson Ecologics grants funds to IHPC's cost-effectiveness project, Foundations Project and NY NDs
-Health Partners, BCBS and Tufts make grants to Pathways for Wellness
Academic Health
Loeb: "hope not the same as optimism ..."
-IOM workshop features presentations on community-based integrative health education led by Southern California University of Health Sciences Robb Russell, DC
-Southwest College of Naturopathic Medicine opens clinic in Adelante Health System
-George Washington University launches online integrative medicine program
-NUHS chiropractor Daniel Straus, DC chairs Florida medical district board of directors
-Ohio State University (OSU) integrative medicine program hosts the mindfulness Congressman, Tim Ryan
-National College of Natural Medicine announces Masters in Global Health
-Persevering in cause work: Paul Loeb's The Impossible Will Take a Little While and how "hope is not the same thing as optimism"
Respond by June 1
Three Federal agencies announced request for comments on Section 2706, Non-Discrimination in Health Care: respond by June 1
In a document that is "a request for information regarding provider non-discrimination," the Departments of Labor, Health and Human Services (HHS), and the Treasury are requesting comments on all aspects of the
interpretation of section 2706, the Non-Discrimination in Healthcare section. The request comes following the inter-governmental disputes on interpretation in which U.S. Senator Tom Harkin (D-Iowa) chastised HHS for violating Congressional intent. (These are captured in Beltway Battle Over Patients' Rights to Integrative Medicine and Health.) The request states that it "includes but is not limited to comments on access, costs, other federal and state laws, and feasibility." The comment period began March 6, 2014 and runs for 90 days. The Integrative Healthcare Policy Consortium (IHPC) is working on this, according to Alyssa Wostrel, MBA, executive director. The organization is collaborating with MPA Media, publisher of Acupuncture Today and Massage Today. Each of these publications sent out the IPHC's survey on issues regarding 2706 to its readers. These will be compiled and reported to the three agencies.
Comment: This is a time to act! Terrific to see IHPC and MPA media collaborating. If you have anything relevant to share, do so. The request is a broad net: " ... includes but is not limited to comments on access, costs, other federal and state laws, and feasibility." Get your comments and experience in.
AAMC: opening to other disciplines
Leading workforce research conference switches from "physician worforce" to "health workforce" focus and includes integrative health and medicine disciplines
On May 1-2, 2014, the American Association of Medical Colleges (AAMC) hosted its annual gathering of 200 plus of the nation's top researchers on the nation's workforce requirements. Only this year, rather than being called the "Physician Workforce" conference the event was titled: AAMC's 10th Annual Health Workforce Research Conference: Finding the Right Fit - The Workforce Needed to Support the Affordable Care Act. AAMC's leader on the conference Clese Erickson, MPAff, shared that the shift in conference's content preceded the shift in name. Since the 2010 Future of Nursing report and the passage of the Affordable Care Act put a focus on team care, AAMC's conferences have increasingly focused on contributions of nurses and physicians' assistants, and more recently health coaches, social workers and community health workers. The 2014 iteration was the first to include a plenary segment on "Integrative Health and Medicine," which was presented by this writer in his capacity as executive director of the Academic Consortium for Complementary and Alternative Health Care (ACCAHC). Slides available here: Doing Well by Doing Good: Building the Case for Broad Workforce Partnerships Finding the Right Fit: The Workforce Needed to Support the ACA: Integrative Health and Medicine (May 2014). ACCAHC also presented a poster on its Project for Integrative Health and the Triple Aim (PIHTA), a focus of the oral presentation.
How to contribute in the emerging system
Comment: Credit the AAMC for widening the circle and, in general, creating such a stimulating conference. As my fellow panelist Leon Assael, DMD told the assembled crowd: "This is not about counting noses [of types of providers]. It's not about 'access.' It's about outcomes." Another of the session's panelists, Lloyd Michener, MD, spoke about community and public health interventions that can significantly disrupt overutilization patters and create huge savings. Michener shared how huge reductions in need for ER and other services can come by getting out of the system and clinical care and directly building relationships with individuals and their community support teams. These powerful outcomes present challenges for all clinicians, and quite likely, for the assembled workforce experts whose business has historically been MD-centric and health system-centric.
Campaign to end medical waste and harm
RWJF-funded report finds impact, but limited, of Choosing Wisely campaign in combating the 30% of waste in the medical industry
"Some experts say as much as 30 percent of the health care delivered in the United States is duplicative or unnecessary; may not improve people's health; and may even be harmful." So leads the e-mail boost from the Robert Wood Johnson Foundation of a new RWJF-sponsored survey of physicians on the successes of the Choosing Wisely campaign. The exceptional campaign, funded by $2.5-million from RWJF, attempts to have professions self-govern to limit waste. Each specialty is asked to select certain of their own over-performed or over-ordered procedures and tests that they will seek to use less. Among findings: 21% of MDs say they are aware of the campaign. Of those, 62% are more likely to have reduced the number of times they recommended a test or procedure because they learned it was unnecessary, versus 45% for those who are unaware of the Choosing Wisely. In more general findings: 73% perceive of all MD respondents believe unnecessary tests and procedures are a "very or somewhat serious" problem, 72% believe that an average doctors prescribes at least one unnecessary item a week, and 58% believe they themselves are the best people to manage the problem. Said Richard J. Baron, MD, president and CEO of the ABIM Foundation, the Choosing Wisely sponsor: "Old habits are hard to break, but this research suggests that America's physicians are slowly making progress in efforts to reduce unnecessary care."
Campaign's key funder
Comment: More urgency and outrage with the slowness of the uptake of this campaign, fine as it is, is in order. Do the math: the 30% that is waste equals nearly $1-trillion per year. The one procedure per week that is perceived by slightly over 70% of MDs to be over-performed does not come even close to representing 30%. Notably, 30% of MDs don't even think they have a hand in the waste. This waste represents a huge opportunity cost to efforts to fund teachers, parks, schools, health care, environmental initiatives, and more. The initiative is excellent. Yet can practitioners engage this transformation in practice with the ferocity needed through self-policing? Notably, only 15% thought the government should get involved in any way. Through one means or another, more fire in the campaign is necessary.
In an interesting note, the ABIM Foundation's campaign is expanding to include non-MD provider organizations. These include the American Dental Association, American Physical Therapy Association and the American Academy of Nursing. These will each release lists of medical tests and procedures which will be their profession's targets. What might such lists be for chiropractors, or naturopathic doctors, or massage therapists, or others in the integrative health and medicine communities? Or, as one practitioner has suggested to me, does an excess of "health creating" activity only lead to positive side-effects and more health creation?
Integrative pain content in key journal
Samueli work in Pain Medicine underscores new directions in self-care for integrative pain treatment
The Volume 15, S1, 2014 issue of Pain Medicine, the official journal of the American Academy of Pain Medicine, is devoted to sharing outcomes of the Rapid Evidence Assessment of the Literature (REAL) self-care for pain completed by a team lead by Cindy Crawford at the Samueli Institute. The special issue is entitled, on the cover: Are Active Self-Care Complementary and Integrative Therapies Effective for Management of Chronic Pain? A Rapid Evidence Assessment of the Literature and Recommendations from the Field. The issue opens with a column from Samueli CEO Wayne Jonas, MD then follows with two powerful calls-to-action co-authored by former Army Surgeon General Eric Schoomaker, MD, PhD. Schoomaker is credited with stimulating the Department of Defense's exploration of integrative practices.
Comment: This is a coup, in a journal for some old line pain practitioners. Side note: Under my ACCAHC hat, referenced above, I was part of a team that chose to honor both Schoomaker and integrative pain leader, now deceased, Rick Marinelli, LAc, ND, by sponsoring Schoomaker's May 15, 2014 talk at the International Congress on Integrative Medicine and Health. It will run as the ACCAHC-Rick Marinelli, ND, LAc Lectureship. Schoomaker is a remarkable influencer. If only he'd had a chance to talk to the Canadian team, the NCCAM tweeter, and the HHS, below!
Sanders: urging more integrative options
U.S. Senate Committee on Veteran's Affairs promotes alternatives to pain drugs
"With chronic pain affecting more than half of all veterans eligible for VA health care, the Senate Committee on Veterans' Affairs today looked at efforts by the Department of Veterans Affairs to increase access to therapies like acupuncture and yoga as alternatives to addictive narcotics." So opens the April 30, 2014 release from the Committee on Veterans Affairs. The hearing highlighted recent reports that "the department's Opioid Safety Initiative launched last fall in Minneapolis already has begun to yield results. The facility has decreased its use of high-dose opioids by nearly 70 percent."
Comment: Notably, especially given the item immediately below, in the release US Senator Bernie Sanders (I-VT) "praised the National Center for Complementary and Alternative Medicine at the National Institutes for Health for identifying non-narcotic alternatives to treating chronic pain and mental health conditions." They added: "The center has made groundbreaking contributions that helped expand viable and safer treatment options."
HHS: urging more pharmaceutical drugs
US Health and Human Services on combating opioid addictions: Use more drugs!
The U.S. Department of Health and Human Services recently published an editorial in the New England Journal of Medicine to "outline a national response to the epidemic of prescription opioid overdose deaths." The title of the press release from the agency on this publication read like this: "HHS leaders call for expanded use of medications to combat opioid overdose epidemic." The subhead noted that the commentary "describes that vital medications are currently underutilized in addiction treatment services and discusses ongoing efforts by major public health agencies to encourage their use." The April 23, 2014 NEJM article is entitled Medication-Assisted Therapies-Tackling the Opioid Overuse Epidemic. "Fortunately," the agency heads write, "clinicians have three types of medication-assisted therapies (MATs) for treating patients with opioid addiction: methadone, buprenorphine, and naltrexon." The commentary is devoted to ways these drugs might be more effectively pushed and initiatives underway to get them into people's hands.
Comment: It is beyond my expertise to judge whether greater use of these "MAT's" will be valuable components of an optimal solution to the nation's opioid addiction problem. But HHS's failure to mention non-pharmacological approaches to treatment makes one wonder how closed a tribe is running our top non-military agencies on pain treatment. There seems to be a sort of "better dead than red" logic that forecloses on the ability of these leaders, amidst this crisis, to even mention the potential value in complementary and integrative approaches. Get your heads out of the sand! When will HHS be finally detailing a long list of agency initiatives to expand use of non-pharmacological approaches - self-care and clinician-delivered? The NCCAM blast, below, does not help.
Briggs: hardly the agency's view
Twitter chat on CAM and back pain produces surprising dismissal of "CAM" from NCCAM tweeter
The NIH National Center for Complementary and Alternative Medicine (NCCAM) held a Twitter chat (#nccamchat) on low-back pain on April 24, 2014. In the midst of it, an unidentified NCCAM staffer tweeted: "Don't use complementary approaches to replace conventional care or delay seeing a health care provider about a health problem." This stimulated one of NCCAM's top opponents to reply: "Better yet, just don't use CAM."
Comment: This must be the comment of a newbie to NCCAM. The agency's own publications strongly rebuke this position - as the Sanders comment in the item on the US Senate hearing, above, notes. Nor is this what we hear from Josephine Briggs, MD, NCCAM director. Basically this says: Don't explore CAM to delay opioids! It would be good for Briggs to spend one of her blogs correcting this and explaining how this might have happened. The staffer was in engaging not it "groundbreaking contributions that helped expand viable and safer treatment options" but rather a cementing of prejudice-base policy.
Canadian firm urges multidisciplinary approach to pain treatment, but with limited team
Meantime, across the border, Cira Medical Services has published a report showing that Chronic Pain costing Canadian economy up to $60 billion annually in lost productivity. They promote a multidisciplinary approach to bettering treatment and lowering costs. The study has the promising title of Chronic Pain: The Importance of a Multidisciplinary Approach to Diagnosis and Treatment [the link was broken when I sought to upload but they sent me a PDF]. The view of what might be considered on these multidisciplinary teams reached only as far as exercise, behavioral health and stretching. Massage is the only "CAM" that made their consideration.
Comment: I contacted the Cira team with a link to some evidence that might have helped in "widening the circle" of who should be in these teams. It is a little surprising to see something out of Canada so retro.
Seniors like access to NDs, conservative care
AANP survey of Medicare recipients finds high interest in potential use of naturopathic doctors and in non-pharma treatment
The American Association of Naturopathic Physicians (AANP) has announced results of a survey of Medicare recipients. The survey found that "55% of older Americans who live in states that license naturopathic physicians would consider seeking care from a naturopathic physician." Medicare does not presently cover care from naturopathic doctors. In addition, "75% of Medicare beneficiaries prefer that their doctor use natural therapies first, such as improved diet or supplements, before prescribing drugs or surgery." Four-in-ten seniors are worried about adverse effects of prescription drugs. The survey is part of the organization's plan to have the ''Medicare Naturopathic Physician Access Act" introduced in Congress.
AANP CEO Jud Richland commented: "The study is a wake-up call to policy makers. Seniors are saying loud and clear that they want Medicare to provide access to holistic care providers such as licensed naturopathic physicians. Millions of Americans have paid Medicare taxes all their working lives, but when the time comes to participate in Medicare, they find that the services they want aren't available." Ancillary materials published with the survey and part of the campaign to introduce the Access Act include: Naturopathic Medicine Lowers Health Care Costs and Naturopathic Approaches to High-Cost Diseases and A Proposal to Modernize Medicare. The study, conducted by Infosurv, surveyed 384 individuals 65 years of age and older who live in states that license naturopathic physicians. Details from the survey report, entitled "Older Americans Views on Naturopathic Physicians in Medicare," are available here.
AANP's Richland: step #1 is useful data
Comment: This survey and the materials prepared for it are good stepwise moves to create a base for the AANP's campaign. These follow another step - the AANP's win last year when it was successful in pushing a resolution through the U.S. Senate that spoke favorably about the potential value of naturopathic physicians in combating expensive chronic diseases. That was the first time that "naturopathic medicine" was named in a Congressional act. Curious how the Medicare campaign will go and whether they can secure federal inclusion with regulation in just 18 states. Notably, direct-entry midwives were successful in inclusion, albeit limited, in the Affordable Care Act relative to Medicaid coverage despite regulation in just 26 states. Surely it was good news for the AANP effort that the state of Maryland, home of US Senate Appropriations Committee chair Barbara Mikulski (D-MD), chose a month ago to license these practitioners.
Reports regional differences in CAM use
CDC report stimulates flurry of news of regional trends in CAM use: self-care West vs "adjust-me" bread-basket?
The US Centers for Disease Control and Prevention's April edition of the National Center for Health Statistics Data Brief describes regional trends in the use of complementary and alternative medicine (CAM). The media picked it up widely. Here's Health Day on April 16, 2014: "Folks on the West Coast are faithful followers of yoga and meditation. Midwesterners turn to chiropractors or osteopathic doctors for their aches and pains. And nearly one in every five Americans uses herbal supplements like ginseng, Echinacea, ginkgo biloba and St. John's Wort." How much more? "Yoga with deep breathing or meditation is about 40% more common in the Pacific and Mountain states than in the country overall [and] use of chiropractic or osteopathic manipulation is nearly twice as high in the Dakotas and Minnesota down to Kansas and Missouri than the rest of the United States." Roughly 18% of Americans use herbal supplements, more than double that of the next most popular complementary medicines. These are chiropractic and osteopathic manipulation (8.5%) and yoga (8.4%). People living in southern and Mid-Atlantic states have less use for complementary or alternative medicine.
Comment: These data suggest that the "Left Coast" is more engaged in self-care while the center of the country relies on practitioners for their ills. (However, massage use was found to be higher in the West.) Meantime, it does not bode well for the support of federal policy-makers that they are located smack in the Mid-Atlantic region where people "have less use for complementary and alternative medicine."
Huge visibiliy via Cleveland Clinic choice
Cleveland Clinic Chinese herb program with Crane Herbs makes huge waves in media
The Time Magazine feature "Cleveland Clinic's New Medicine" was here. The Wall Street Journal's "A Top Hospital Opens to Chinese Herbs as Medicines" is here. "Can Herbs Help? Dr. Oz Explains Eastern Medicine" is here. Katie Couric's Today Show piece on it, "Why One Hospital is Turning to Chinese Medicine" is here. Links to each of these are in this press release from the operation behind the story, Crane Herb Companies, the supplier of the product. Crane sources their supplies via KPC Herbs, which requires the most rigorous testing of herbs in that category, according to Crane officials. Couric's Today Show segment included a series of leading questions that promoted integrative care. Cleveland Clinic lists a broad array of conditions for which they argue that the herbs may be useful. Notably, the American Botanical Council took on Time for its fallacious assertion that there are no regulations for herbs.
Comment: The Couric show featured interviews with a Yale-based integrative medical doctor, David Katz, MD, MPH, and Pina LoGiudici, ND, LAc who fielded her lobs. Following the interview, Katz wrote an exceptional piece in Huffington Post on how to think about evidence in the integrative dialogue. The Cleveland Clinic move, and Crane Herbs work behind the scenes, created a huge jolt of generally friendly integrative health media.
Detox needling on college campus
The New School in New York City pioneers auricular acupuncture and acupressure in university setting
A recent issue of Guidepoints, the newsletter of the National Acupuncture Detoxification Association features the Provision of Auricular Acupuncture and Acupressure in a University Setting, as a report in the Journal of the American College of Health was titled. The program is at The New School in New York City. The program focuses on auricular acupuncture's use "as a tool to enhance harm reduction and (better) mental health services." The Guidepoints issue features an interview with two of the co-authors, Rachel Knopf, MPH and Tamara Oyola-Santiago, MPH. Each was were trained at the field's mothership, the Lincoln Recovery Center in the South Bronx. Treatment is through The New School's student health center. They reportedly work in tandem with both medical and mental health teams. They also provide acupressure in other settings at the University. They promote the program, which is typically used for substance issues, as a stress management technique and for "general wellness."
A snapshot of the size and maturation of the licensed integrative health and medicine fields
So what was we talking about when we look at the licensed "complementary and alternative medicine (CAM)" or integrative health and medicine disciplines? The following chart, from page 10 of the 2013 Clinicians and Educators Desk Reference on the Licensed Complementary and Alternative Healthcare Professions (CEDR) provides these data.
Accrediting
by U.S.
Acupuncture and
(medicine)
88^
Direct-entry
* Current number. The 2013 book says 16.
^ Accredited by Commission on Massage Therapy Accreditation.
Source: Academic Consortium for Complementary and Alternative Health Care (2013)
Great data/info on CAM disciplines
In addition, current numbers of integrative health and medicine practitioners educated or certified to a set standard are: roughly 2,800 medical doctors and doctors of osteopathy certified by the American Board of Integrative Holistic Medicine; 1,100 medical doctors and doctors of osteopathy who have completed the University of Arizona Fellowship in Integrative Medicine; and 1,349 board certified holistic nurses (as various levels of nurse certification and training) via the American Holistic Nurse Credentialing Corporation.
Comment: The total here is roughly 387,500 licensed "CAM" plus another officially board certified group of approximately 4,000 integrative MDs/DOs and holistic nurses. For reference, there are roughly 880,000 licensed medical doctors and some 3.3 million nurses. These are typically, whether their preference or not, entrenched in a disease-focused industry. The numbers suggest that it serves those in this field to work in a coordinated fashion to advance the values, practices and disciplines associated with integrative health and medicine. The book that includes this chart is freely available as a PDF at this site.
Much visibility at relatively low cost
Emerson Ecologics grants funds to IHPC's cost-effectiveness project, Foundations Project and NY NDs
Emerson Ecologics is the largest distributor of natural products to professionals in the United States, representing over 275 brands. In 2012, to respond to the chaos of multiple requests for financial support from the associations and institutions linked to the professionals they serve, Emerson established an annual $25,000 grant award program. Emerson announced the 2014 winners here: 1) The Foundations of Naturopathic Medicine project ($7800), led by Pamela Snider, ND, to support a residency; 2) the New York Association of Naturopathic Physicians ($10,000) for licensing efforts; and 3) the Integrative Healthcare Policy Consortium ($7200) for a cost effectiveness booklet. They also announced an in-kind donation to the Patriot Project.
Comment: News of these awards strike me in multiple ways. First, I am pleased Emerson is making awards. Many companies don't. Second, often I know the awardees and thus am aware of the intended good work so am happy that their projects will get a boost. Third, associated with a not-for-profit as I am, I wonder why I didn't get a proposal submitted! Then, finally, I cannot help but seek some perspective on the size of these grants relative to Emerson's revenues and all the hoopla that surround the awards. How big a commitment is $25,000 for Emerson? I could not find anything on line about the closely-held firm's revenues or profits. I'd that this fits into the marketing budget like a handful of full-page ads. Still, these sums all mean a great deal to the small budgets off which these organizations work - with each dollar multiplied many times by volunteerism. So, thanks, Emerson - and hey, consider upping your annual amount, eh?
Pathways: recipient of multiple area grants
Health Partners, BCBS, Tufts, etc. - payers and insurers in grants to Pathways for Wellness
The May 2014 newsletter for Pathways to Wellness, one of clinics for the delivery of acupuncture, massage and other integrative services most thoroughly integrated into its local community - Boston, in Pathways' case - announced an impressive list investment partners. These included: 1) Tufts Health Plan Foundation awarded $20,000 to provide home care acupuncture and massage services to elder clients in their homes; 2) Partners Healthcare awarded $20,000 to support operations plus $5,000 as a Gold level sponsor of our Longwood Symphony Orchestra benefit concert (see below); 3) BCBS of Massachusetts Foundation awarded $5,000 for the redesign of the center's website, and 4) the Boston Redevelopment Authority awarded $20,000 to support the construction costs of Pathways' new facility. In addition, the same newsletter noted $11,000 raised from the Longwood Symphony benefit.
Comment: The Pathways to Wellness operation has been enmeshed in care delivery in Boston for a quarter of a century. Great to see these grants and, in the interest of recognizing full value, maybe one or more might consider adding a zero to their next contribution!
Russell: SCUHS educator at IOM
IOM workshop features presentations on community-based integrative health education led by Southern California University of Health Sciences Robb Russell, DC
The two day workshop on May 1-2, 2014 at the Institute of Medicine (IOM) Global Forum on Innovation in Health Professional Education was entitled Scaling-up Best Practices in Community-Based Health Professional Education. Among the presenters in a poster session on May 1, 2014 and in a May 2, 2014 webinar from the workshop was Robb Russell, DC, the director of the Centers of Excellence at Southern California University of Health Sciences (SCUHS). Russell presented on two community-based models of integrative care delivery. One was at Venice Family Clinic, directed by Myles Spar, MD, a 2013 Bravewell Collaborative award winner, and the second a Canadian College of Naturopathic Medicine (CCNM) project with Brampton Community Hospital. The Venice clinic's pain-focused services include a collaboration that involves students and faculty from UCLA, SCUHS, and two acupuncture and Oriental medicine schools: Emperor's College and Yosan College. The Toronto-based CCNM project is brings naturopathic medical students into a hospital environment. Spar, and CCNM's Nick De Groot, ND were part of a team with Russell that developed the poster and presentation as part of their participation organized through the Academic Consortium for Complementary and Alternative Health Care (ACCAHC). ACCAHC is a member of the IOM Global Forum. The poster and presentation are available at this link. A separate, longer presentation on the CCNM-Brampton collaboration is here.
Spar: part of ACCAHC team on poster, presentation
Comment: The odd irony is that while the Affordable Care Act is pushing care and health professional education out into communities - thus the focus of this workshop - many institutions in the licensed integrative health space, like SCUHS and CCNM, are already in the community yet better meet new populations by forming such partnerships, even in hospitals. It was a pleasure, as a member of Russell's team, to see this integrative health and medicine content featured at the IOM. The two articles immediately below are additional examples of community integration of integrative health and medicine educational programs.
New clinic in Adelante system
Southwest College of Naturopathic Medicine opens clinic in Adelante Health System
Tempe, Arizonza-based Southwest College of Naturopathic Medicine (SCNM) reports a new relationship with Adelante Healthcare Mesa in its Spring 2014 magazine, SCNM Now. The Adelante system was developed in 1979 by community members to serve underserved populations. It now operates in seven communities, including Mesa. Notes fourth-year naturopathic medical student Tracey Cook: "We've seeing people who have never health of naturopathic medicine. It's exciting to educate people and show them what we are capable of." The most common condition seen by student clinicians at the Adelante facility is diabetes. This is the most recently established of the multiple SCNM Community Medicine initiatives.
Chiropractor-educator on medical district board
NUHS chiropractor Daniel Straus, DC chairs Florida medical district board of directors
Volume 50, No. 1 of the newsletter for alumni of the National University of Health Sciences (NUHS) and this release share that Daniel Strauss, DC, dean of the College of Professional Studies of the university's Florida campus has been elected to chair the board of directors of the Pinellas Park Medical District (PPMD). The medical district is comprised of health care providers, hospital administrators, educators, and health care support services in the Pinellas Park area. The sponsors of the PPMD include Northside Hospital, St. Petersburg College, and the Pinellas Park Chamber of Commerce. The note mentions this appointment as "a great example of National's commitment to integrative medicine." NUHS has programs in chiropractic medicine, naturopathic medicine, acupuncture and Oriental medicine and massage therapy.
Comment: Always good to see this level of community participation of integrative health and medicine practitioners, especially as awareness heightens of the critical importance of integration in community and public health of clinicians of all types. NUHS's commitment to integration has also been evidence in its Gold Level sponsorship of the Center for Optimal Integration: Creating Health.
Heyman: heads up GWU program
George Washington University launches online integrative medicine program
In a partnership with the Metabolic Medicine Institute, George Washington University is launching an online integrative medicine program according to this April 24, 2014 release. The release suggests that graduates will
have the "requisite skills to oversee a practice in integrative medicine, as well as balance the business, regulatory, and legal aspects of clinical care." In addition, they will learn to gather outcomes data. The later is presented as a "distinguishing feature" of the program. Andrew Heyman, MD, MHSA is the leader of the program. The Metabolic Medical Institute describes itself as "a medical organization dedicated to promoting health and prevention of disease by educating health professionals, researchers and the public." Those who complete the 18 credit hours of the program will earn a certificate. The programs is open to those with "a degree in a health related field and a GPA of 3.0 or higher."
Comment: While the release notes the existence of a new American Board of Integrative Medicine, the program does not appear to be tracking students to that end. It is interesting to see the business model of broad inclusiveness of all licensed professions as potential students.
Ryan: passion for mind-body
Ohio State University (OSU) integrative medicine program hosts mindfulness Congressman Ryan
The April 2014 newsletter from the OSU integrative medicine program featured the visit of Congressman Tim Ryan (D-OH). The ex-football player and military man is author of A Mindful Nation: How a Simple Practice Can Help is Reduce Stress, Reduce Performance and Recapture the American Spirit. He champions mindfulness and wellbeing. The focus of the OSU event, which included a "World Cafe" interactive segment, was on how OSU can foster a "culture of mindfulness" at the university.
Parker: co-chairs new global health department
National College of Natural Medicine announces Masters in Global Health
Portland, Oregon-based National College of Natural Medicine (NCNM) will soon offer a Global Health Masters' Degree, according to this April 30, 2014 release from the institution. NCNM's provost and vice president for academics, Andrea C. Smith, EdD, states that a global health degree is "a natural fit for NCNM." The reasons: "The college's core naturopathic and Chinese medicine programs have global origins. In the less developed areas of the world, integrative therapies, such as plant medicine, mind-body medicine, nutrition and physical medicine are both available and cost-effective. Natural medicine is ideal for countries with low economic resources and limited access to Western medicine." Tabatha Parker, ND, the co-founder and director of Natural Doctors International will serve as a co-director of the program. Parker has been the leading force for global services learning in her profession, mainly through a clinic on the island of Ometepe, Nicaragua. She has worked with W.H.O. and was recognized in 2011 by Utne Reader as a Global Visionary.
Comment: This is a terrific move for NCNM. How reasonable to have a workforce abroad of practitioners who respect and are knowledgeable about global healing traditions and, in the case of naturopathic doctors at least, are deeply versed in Western medical sciences and have a scope that allows prescriptions for basic public health needs. The potential employment for these graduates should be a no-brainer, if only lower-chakra prejudices could be dissolved.
Loeb's book: "Hope is not the same ..."
Persevering in the cause: Paul Loeb's The Impossible Will Take a Little While and how hope is not the same thing as optimism
Author and expert on citizen action issues Paul Loeb has sold 170,000 copies of his Soul of a Citizen: Living with Conviction in Challenging Times. Paul is a good friend of this writer. In fact, that book includes a short couple of pages on me and my own "cause" work in integrative health and medicine. His newest book, the collection of short essays beautifully titled The Impossible Will Take a Little While (from the Billie Holiday line) gave me the credo for everything I do professionally. People wonder sometimes how I stay active and hopeful given the power of the US medical industry's continuous feeding on the increase of disease. In the book, Czech artist-dissident-president Vaclav Havel has this to say about the distinction between "hope" and "optimism." Havel writes: "Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out." Hope, in Havel's framing, is a verb. Engagement allows hope. The reverse, in my experience is also true: disengagement creates pessimism. This collection of essays and anecdotes from scores of inspirational, progressive leaders is food for the soul. These short pieces are, as Loeb aptly named an earlier book, hope in hard times. If you are practicing hope, you will find much to aid and abet you here. If you are not, buy it to refine your scoffing


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© Volkswagen
From Autoblog
Making high-performance batteries for electric vehicles is a complicated, time-consuming process. So much so that engineers at Volkswagen have started using a quantum computer to simulate chemical structures like lithium-hydrogen and carbon chains much faster. The idea is to continue using quantum computing to eventually develop a sort of blueprint for tailor-made batteries that can be optimized for different features, like weight reduction, power density, or power cell assembly.
"We are working hard to develop the potential of quantum computers for Volkswagen," said scientist Florian Neukart in a statement. "The simulation of electrochemical materials is an important project in this context. In this field, we are performing genuine pioneering work. We are convinced that commercially available quantum computers will open up previously unimaginable opportunities. We intend to acquire the specialist knowledge we need for this purpose now."
Volkswagen is collaborating with Google and D-Wave, who provide the quantum systems that can be used to speed up the development of algorithms. Teams in Munich and San Francisco realize they're only at the beginning of this kind of work, said the company in a statement. So don't expect these batteries to show up in your next electric vehicle.
This article originally appeared on Engadget, your guide to this connected life.
Autos - U.S. Daily News: Volkswagen using quantum computers to build better EV batteries
https://3.bp.blogspot.com/-qYgac-9qJIs/Wx4TAx9ZveI/AAAAAAAAPYw/1LR3w8XUimQ4LXgC4-qbIp3zQydsibvigCLcBGAs/s1600/1.jpg
https://3.bp.blogspot.com/-qYgac-9qJIs/Wx4TAx9ZveI/AAAAAAAAPYw/1LR3w8XUimQ4LXgC4-qbIp3zQydsibvigCLcBGAs/s72-c/1.jpg
https://autos.dailynews.us.com/2018/06/volkswagen-using-quantum-computers-to.html

redpajama_set_name: RedPajamaCommonCrawl


text:
Level Walkers
Level List
World Canals Conf 2021
Canal info
Canal History
Canal boat mortgages
Newsletter, Along the Towpath
1785- Patowmack Co. Canal system begun
1802 – Patowmack Co. Canal finished
1828 – C&O Canal begun (July 4)
1831 – Open to Dam 2 (Seneca)
1833 – Open to Dam 3 (Harpers Ferry)
1839 – Open to Dam 6 (above Hancock)
1850 – Complete to Cumberland (October 10)
— Widest, deepest & 6th longest canal in U.S.
— Cost – $13 Million
— Length 184.5 miles
— Elevation change – 605 feet
— 74 Lift locks – 15′ x 90′
— 1 Wood, 11 Stone aqueducts
— 7 Dams
— 6/10 mile long Paw Paw Tunnel
— Approximately 240 culverts
1858 – Steam pump (mouth of South Branch)
1871 – Peak year – 550 boats
1876 – Georgetown Inclined Plane
1879 – 43 phone stations, longest system at time
1889 – Flood (May 30 & June 1) & bankruptcy
1890 – Trusteeship – 1844 bond trustees in control under court supervision
1891 – Canal resumes operations (September)
1894 – C&O Transportation Company
1903 – Canal Towage Company (Boats)
1923 – Last year of navigation
1924 – Floods (March, May) – Canal never reopens
1938 – Sold to U.S. for $2 Million
1954 – Douglas Hike (March 20 – 27)
1961 – National Monument
1971 – National Historical Park (January 8)
Before it was a national park, the Chesapeake & Ohio Canal was one of a network of American canals dug during the late 18th and early 19th centuries to form water highways for commercial trade. These canals were part of the great Industrial Revolution.
This plaque at Monocacy Aqueduct commemorates the canal's landmark status, as designated by the American Society of Civil Engineers
The C&O Canal paralleled the mighty but unnavigable Potomac River and linked Cumberland, Maryland with the nation's capital, using an orderly system of locks to permit heavily laden coal boats to pass to successively lower levels from the mountains to tidewater. The mule teams that pulled the boats along the canal walked on the towpath, guided by the families of the boat captains.
Just as the C&O Canal ran beside the Potomac, the Baltimore & Ohio Railroad ran beside the C&O Canal and soon made boat traffic an outmoded system when compared to the speed of rail transport.
The C&O and other American canals could not compete and fell into commercial disuse in the early 20th century. The towpath was then used only by woodsmen and hikers; occasional storms and floods washed away parts of the banks and structures and trees grew in what was the canal bed
About the C&O Canal National Historical Park
Since the canal was no longer commercially useful, there were plans in the 1950's to bulldoze it and pave a super-highway into Maryland's mountains.
Supreme Court Justice William O. Douglas was one of the few people at the time who realized the historical, cultural, geological and botanical significance of the C&O. He challenged opinion-shapers of his day to walk the length of the 184-mile C&O with him and decide for themselves if it should be destroyed.
They took the walk in 1954 and then joined him in the effort to save the canal. That effort resulted in the formation of the C&O Canal Association, and, 17 years later, in the passage of legislation that created the C&O Canal National Historical Park, now one of the major areas in the National Park System. In the mid 1970's, the canal and towpath were dedicated to Justice Douglas to honor him for his singular contribution to the nation's park system.
The C&O Canal Association continues today with its mission of protecting, preserving and promoting the assets of the C&O Canal Historical Park.
© 2021 C&O Canal Association.


why not find this function ??
because of "=array()" in signature (explicitly closing ")").
Does the function list can order by the first letter??
As far as I remember, the list is sorted by order in which labels are collected from the document.
it's nice if HE can auto sort the function in the navigation bar.
I read this article three times, but I can't find the way to sort the functions by first letter.
There is no way currently.
Labels ("functions") in the list are ordered by position in the document (collection order). The design assumes that you do filtering by some known part to search matching "function" by reducing list.
Maybe Navigation Bar will not be changed at all but I will create new "Function List" Pane plugin.


The 80-ball game uses 80 numbered balls in the game, and hence the name. It is one of those Bingo versions that has recently gained popularity on several Bingo sites. Falling in between the more popular 75 and 90 ball games, 80-ball version is similar to 75-ball game except for the two stark differences – the number of balls and the layout of cards. If you already play the 75-ball, understanding this version is a cakewalk.
It is also known as Shutter board bingo owing to the fact that shutters are used to cover the numbers called. This is only the case while playing offline. Most of the online sites use the colouring system in which each column is coloured – red, yellow, blue and silver (from left to right). But, we believe that life gets easier without this colouring system as there isn't any manual marking required, thanks to the auto-daubing feature that we provide.
The cards are made up of 16 boxes from four columns and four rows. Unlike 75-ball bingo game, every box is numbered randomly from 1 to 80. But, there is a column-wise numbering format maintained.
Winning the 80-ball bingo online game requires a player to complete any one line, any 2 lines, any 3 lines or/and finally full house (all the 4 lines). Only the horizontal lines or rows are valid.
Any Line: The first player with one complete row is entitled to the first win.
Any 2 Lines: The first player that covers any two horizontal lines in one single ticket is the winner for this category.
Any 3 Lines: The first player with 3 lines entirely daubed wins this category.
Full House: The player that covers all the four lines or all the numbers in a ticket gets the Full House.
The prize amount is distributed among the above four groups in an ascending order – least for Any Line and most for Full House.
Participating in the bingo game is much the same as with the other bingo online versions. You first select and enter the game of your choice to purchase tickets. You can buy at least 2 or more tickets as per your wish. Here's a tip – when in doubt, just pick your lucky number. And, that's all the work you need to do! Your game automatically begins, and there's a timer on display for reference.
The game begins with the Random Number Generator (RNG) calling the numbers against which your tickets are auto-daubed simultaneously. All the game details including the current round, prize amounts, the winners for each round, each called number, etc. are displayed on the screen. Interestingly, there's a chat room available alongside that allows all our players to talk to each other as well as our loving chat hosts. If that's not enough, there are many bingo games conducted in these chat rooms wherein our players can stand a chance to win other prizes besides the game. So, it would make sense to check out our chat rooms for random games, and participate to amplify your chances of winning.


text:
<?php

defined('C5_EXECUTE') or die(_("Access Denied."));

class PaypalDonationsBoxPackage extends Package {

	protected $pkgHandle = 'paypal_donations_box';
	protected $appVersionRequired = '5.3.1';
	protected $pkgVersion = '1.0.1';

	public function getPackageDescription() {
		return t("Take paypal donations on your site.");
	}

	public function getPackageName() {
		return t("Paypal Donations Box");
	}

	public function install() {
		$pkg = parent::install();

		// install block
		BlockType::installBlockTypeFromPackage('paypal_donations_box', $pkg);
	}

}

redpajama_set_name: RedPajamaGithub


Lucius grew quite a fanbase. It was a small indie game released in 2012 that I'd vaguely describe as "Satan's low budget version of Hitman", with alot of asterisks added to it. You played as Lucius, a 6-year-old boy with demonic powers that you would control and your goal was to kill the people around your manor without being the suspect of the hideous murders you'd stealthily and creatively commit (albeit the kills themselves were mostly done in a linear click-and-drag on objects manner). It ran like garbage and had a lot of bugs, but it was charming and interesting in its own twisted way.
Lucius 2 brought us more of the same, with added bugs and a bit less linearity, garnering a decent reception.
And now we get Lucius 3… what a train-wreck of a fun time this was. To sum it all up, Lucius 3 has a mediocre plot in a terribly buggy, hideous looking and disappointingly empty open world that somehow manages to keep you on your toes with every day/chapter you unlock. Ultimately, at least from my experience, this game really grabs you with its design during the campaign, but I couldn't help but complain about something every five minutes; the fact I finished it and thoroughly enjoyed the time I spent with it does mean that I will recommend it, but it has way too many issues for it to have a good rating.
The actual storyline is not the best reason to buy this unless you enjoyed the previous plots and you crave for more. Here, you start in a car crash after leaving the events of the second game, resulting in you going back to your old town (of the original game that you never explored as that was exclusively played in the manor, yet can be visited here) and finding a scroll to unlock its powers.
The story is ultimately decent enough to motivate you to go through and really gruesome events enhance the awesomeness of all the evil things you're pulling off without your innocence being questioned. The characters always find you cute anyway; they are just cardboard cutouts of stuff you've seen in other games/movies: the bully kids, the sweet girl that likes you, the overly religious mother, the creepy motel owner, etc. etc.
This allows for really cool homages to movies or other games (which I won't spoil) but also causes some cringe moments, as the voice acting is really bad and in some situations you'll find yourself feeling the gameplay is extremely forced and situational. A few sections, in particular, do this quite heavily ( or more like obviously) as the game hints you towards a way to solve the problem (which is usually a puzzle to kill someone) so that you feel like you barely have any options for your actions.
Which you don't… until the very end when a very awkward ending choice comes up and you can choose the bad or the good ending, one of which feels so stupidly disjointed of the whole franchise that I can't believe this would even be an option at all.
In the end, it's passable enough to not feel like a downside of the game; the added possibility of "secret murders" where you can finish the story without killing some of the characters also adds to the replayability as not only do they not die but you can miss their entire subplots (which are really small but can be interesting nonetheless).
W + Shift plus a few Q and M1 presses. It's a very simplistic game mechanically with lots of problems. You start the game at a friend's house (avoiding prequel spoilers here) and you can then explore the open world, which is a small ocean-side town. All locations are locked from fast travel (which is free, there's no cost for fast travelling, thank goodness) until you discover them (which, like a Fallout game, just requires you to get close), the problem with this is that Lucius can either walk or run/sprint… really, really… REALLY goddamn slow! This makes the early map exploration feel like an absolute chore as places are either really concentrated together, like the neighbourhood, or by an entire piece of forest. There's a faster way to maneuver in the form of shape-shifting into a crow but it controls really bad and the camera on it is confusing and terrible so you're better off running around and memorizing the overall layouts by yourself than barrel-rolling your camera into oblivion in crow mode.
Anyway, you can follow the road or cut a shortcut through the forest, which not only consists of roughly 70% of the map area, but also has absolutely, literally NOTHING to do. No collectibles, no random encounters, no interesting places, no lore, no backstory, no enemies, nothing.
This makes the game's open world feel like a tacked-on feature due to heaps of it being an empty bunch of grass and trees designed to be just filler. I'd rather the developers spend time making a menu-based map and only the actual locations would be playable in, sort of like what Walking Dead: Survival Instinct did (one of the few things it did well, admittedly). This bad taste I have with the open world gets stronger the more I think of the abysmal pop-in the game has, alongside its terrible textures and environment aesthetic (with quite a few lighting problems) on top of the terrible performance (From High to Low preset (as most options don't exist, only a handful), my performance was roughly the same: 60FPS at 1080p with the frequent dip to 35-45 for absolutely no reason) that ultimately can put A LOT of people off. Aside from a few characters and decently detailed in-building environments, the rest of the game looks over 10 years old and putting my computer on its knees to run it at a mix of 40 and 60 FPS is an absolute sin (heh) to the very notion of optimization.
As for the gameplay itself, it's pretty fun! The game works as a sort of puzzle-lite point and click adventure game with some satanic horror sprinkled on top. You can freely enter people's house and explore it all (unless conveniently locked houses that are that way for the sole purpose of letting the campaign go the way the developers intended, making it feel more linear than it really is), find clues about people's lives (and their secrets) to later find their weakness and use that to kill them… "accidentally".
The investigation vibe the game transmits is really interesting and made the whole game for me. Finding and inspecting items, discovering something I shouldn't or managing to find an item that I needed a while ago and go "ah-ha!" felt really great and made the game's total length of 6 hours (with all achievements but one unlocked) feel worth the journey.
The exploration of the environments is quite non-linear, you can tackle some murders sooner or later than you probably will on your first playthrough and the order of them can change too. Some items and places are hidden and require a bit of extra exploration, which also makes the game feel a bit more natural in its side-stories (the main plot still is quite linear, as I mentioned).
A big problem the game has is the UI: the inventory system is dated and clunky. When picking a new item up, it becomes the new active item (the one you can use in environment interactions). Stuff like the collectible bobbleheads will take this slot even though they have no function in the gameplay, so I have to open the inventory and pick the item I wanted to remain active again… it's a really annoying design decision (or omission).
The diary is well designed though, it works as a notebook and the interactions and the interface is intuitive and never gave me problems. The diary has the objective list and detail logs of the people you talk to, as well as of the places you visit and search around.
Another problem worth noting is that some locations are dead and have no role in either the main story or any subplots the game possesses. They are there and it's clear the developers planned chapters (or sub-stories) in those places, like the Halloween party at the cabin (flyers are all over the place about it), but the cabin itself never has anyone there… just some sad empty pizza boxes (literally). This also applies to the hideout (no, not the pizzas). This makes the game feel like something was rushed, probably early development had these two (actually well detailed) locations planned to involve more storytelling or exploration, but ended up locking them and depriving us of any sort of meaningful content besides admiring it for 20 seconds and taking a deep breath in disappointment. I'm assuming future content is probably planned for this if the budget and sales allow it to, which I hope they do.
That music with this scene really didn't fit, for example.
…oh dear God, the voice acting.
Alongside the stiff and awkward facial expressions, the mediocre voice acting enhances the cringe factor of most cut-scenes even more. Mr. Freeman is particularly terrible and Ceefor is just… unnaturally awkward, even for Ceefor himself, which is a pretty weird character. Only McGuffin really has voice acting that I can praise (and maybe Gabriel), albeit weirdly enough, his voice is EXTREMELY low compared to the rest of the voice-overs and the rest of the game itself. I have to double my volume to hear his breath while I will blow my ears out as soon as a new person starts talking. The pitching is really all over the place!
The graphics were already discussed a bit when I talked about the world building and the exploration because I found it was appropriate to approach it right there. Not to sound like a broken record, but the performance is quite abysmal and the game has tons of graphical bugs and glitches: from the uninteresting and very pop-in prone forest with the trees to cut-scenes being textureless scenes that need to load in (the town hall is a prime example of this) before they start playing. The problem is that this happens pretty much always and it looks so terrible, the pop-in isn't even hidden (sometimes I managed to see through buildings) so you're constantly observing these immersion-breaking graphic issues that ultimately take away the experience. The Unity engine is not used well here and the fact of it being open world is one of the likely causes for such issues, as Lucius 1 and 2 did not have these issues, at least not with such severity.
Regardless of the problems, the graphics should never be the reason to buy/play the game and I wouldn't blame anyone for not getting it due to the number of problems the game has.
Lucius 3 is a bit of a "so bad, it's good" kind of game. It could be a really good experience for the end of 2018, but it ends up being missed potential and a mediocre game due to the sheer volume of bugs in the gameplay and the poor graphics that kill the enjoyment of the game at times and when coupled with some overly linear main story design, really shows how the game could've been much more than it really is. Some of these bugs are even game-breaking, though most have been fixed, yet I still managed to find some chapter skipping bugs. That being said, a fun time is to be had here if you can get past its vast number of issues and enjoy its puzzle/investigation based gameplay with some cool deaths to witness. I had an unexpected good time with it despite the mountain of issues, but I can't give it a better score as it has too many problems to allow me to do so. I heavily recommend against its current price tag as it's too short (5-6 hours for a full 100% achievement run) and buggy to be worth the asking price, but it's definitely a fun afternoon when bought at a heavy discount.
Someone who likes writing and gaming alot and decided to make something worthwhile out of that combination. A fan of most game genres, despite being particularly bad at puzzle games. Never refuses the copious amounts of salt of multiplayer opponents.
Y-yep! And yet the story was the first Lucius game's strength, imo.
It was indeed far better than this one. The mystery and the dark theme in the original was stronger and the story didn't feel as convoluted as this one. Here it's more like a "here's a reason to do stuff" which I never felt with the first two.


Community members gathered yesterday to prayer for Tenzin Choeying la, self immolated for Tibet independence on 14th July, 2017 Sarnath, Varanasi INDIA.
May your soul rest in peace. Om mani pad me hun.
Posted on July 22, 2017, in Press Release. Bookmark the permalink.	Leave a comment.