text:
The Unified National Population Registry Moves Forward
Diego Piacentini
How we managed to revive a project considered (by most) to be hopeless
Questo articolo è disponibile anche in italiano
In a post we wrote at the end of July, we announced our plan for completing one of the most complex tasks: a unified National Population Registry as the essential backbone of the Italian digital infrastructure, without which the digitization of the Public Administration would be impossible. This is the reason why the Digital Transformation Team is working on the improvement and execution of this platform, making ANPR one of the milestones for the digital transformation of the country.
But why is a unified registry so important for the State and, above all, for the citizen?
ANPR is a complex project which includes among its relevant stakeholders 8,000 Municipalities and 40 software houses; the Ministry of the Interior is the owner – so to speak – and Sogei the project executor. In addition, there are other entities which are indirectly involved in the project such as ISTAT, the Revenue Agency, INPS and Civil Motorization Office as well as the Ministry of Foreign Affairs.
Simplifying and organizing this complex puzzle was our first concern.
With the signing of the new contract for the ANPR project in August, the Digital Transformation Team has assumed the role of Program Office for ANPR; thus, we are not only taking over the plan, which should be agreed upon by all the software houses, but we are also dealing with the technological evolution of the platform. In short, we assumed a great responsibility in re-launching and developing ANPR, since it's a project in which we strongly believe. Why? Let's go over one reason at the time.
ANPR: a single Municipality of 60 million inhabitants
The National Resident Population Registry is a large project on a national scale: a single database containing all personal data of the resident population in Italy and of the Italian citizens living abroad (who have registered with the AIRE – Registry of Italian Residents Abroad). It's a fundamental component of the operating system of the country as it is the essential infrastructure; it's the foundation upon which we are building all the other components of the system that will help us beat the challenge of the country digital transformation.
As a platform, ANPR represents an advantage not only for Municipalities (in administrative and economic terms) but also for citizens.
We'll give you a few examples.
Have you ever made a change in residence to a new Municipality? In addition to providing the APR4 form, the documents and various certifications, the change requires that the Municipality notify all the other offices involved, for example, the Civil Motorization Office or the INPS. This complexity is caused by that fact that not only the different registries do not communicate with each other but also the different Public Administrations. Furthermore, many communications are still processed manually; hence, municipalities are robbed – so to speak- of valuable time while the quality and accuracy of data is often compromised.
What happens on the ANPR platform, on the other hand, is very different. For the already integrated Municipalities, the change of residence process is an immediate operation that doesn't require any physical correspondence between the Administrations. Moreover, there's no longer a need for Municipalities to notify other bodies such as the Civil Motorization Office, INPS and, soon, ISTAT, directly.
The benefit of having all data on a single national system –and not just in the silos of a single Municipality – is the establishment of a single communication network, an intersection of roads that will lead us all towards a single, boundless Municipality, as big as Italy itself. This system will lead to using the identical method of data description, information storage and certification.
In the very words of Romano Minardi, who more than a year ago led the integration of the first Municipality (Bagnacavallo) into ANPR:
The experience of the Municipalities that have merged into the national registry proves that switching to ANPR is possible: the system works. Now, it is the right time to make that journey. It doesn't make any sense waiting or waiting for somebody else that will do it for you.
It's time to do it. With a wider migration to the ANPR platform, new advantages will emerge which will become more and more evident with the launch of central digital services. What do we mean by this? For example, Municipalities could use ANPR certificates to replace their online certification systems, often costly to maintain, and launch or even offer it as a new service (in case they don't yet have it).
Furthermore, citizens of Municipalities that migrated to the ANPR platform could print their certificates and personal online data, without having to go in person to their Municipality of residence and without the Municipality itself having to bear the cost of these services: a sort of self-service for registry certificates.
This is still an intermediate stage as the 'era of certification' should have already been over some time ago (and it will have to end soon anyway). Certificates should no longer be required and in a few years we will finally be living in a world without registry certificates. Indeed, we'd like to remind you that Public Administrations are no longer required by law to request certificates.
From now on, we need to work on the digitalization of the processes between Public Administrations and private agencies so that the systems may communicate with one another and obtain information without requiring a citizen to present a paper document.
These are just a couple of examples of the usefulness of the platform; this invaluable networks would be built day by day to achieve positive externalities. Much has been accomplished in last few months; we'd like to tell you more.
The work done on ANPR by the Digital Transformation Team
One of our first steps was to communicate exclusively to the Municipalities, through documents, which explain simply and precisely, all the advantages and simplifications brought about by the adoption of ANPR. The documents had different purposes; they were meant to explain step-by-step the operational changes that the migration to ANPR will entail for the Administrations; provide a list of FAQs on procedures; present a timetable (we estimated a maximum of two months for the integration of the Municipalities into a compatible management software); discuss the new opportunities that will become available. In the end, we decided to regularly update all Municipalities and the managers in charge, through a regular newsletter on ANPR (if you're interested in following the developments of the project, you can subscribe here).
In addition, we have created a dashboard that collects and aggregates all ANPR data, which is, of course, in continuous evolution. It's an important tool that allows anyone to have a graphic update of the project progress,with up-to-date numbers on the Municipalities.
The most recent data shows how today the project involves over six million inhabitants; there are 1000 Municipalities preparing to integrate themselves into ANPR (and are therefore in the pre-takeover phase), and 50 active ones (many of which have only adopted ANPR in the last few weeks).
These numbers correspond to roughly 10% of the population and are, as such, still too small.Yet, they are representative of the new life of ANPR; it's restarting and the acceleration it's finally undergoing.
From the beginning, we understood the importance of coordinating with the software houses that are supporting the Municipalities in the migration process. We engaged their relevant associations in order to have one representative who could act as a reference during the drafting of the Municipalities Migration Plan.
We provided them with an online platform where they could enter dates (or at least time intervals) for the migration; it allowed us to compile the first operative Plan for ANPR which is updated daily and is available on the dashboard.
We are also working with the software houses and with Sogei to make the process – which includes, for instance, the distribution of smart cards to prefectures – traceable and "industrial".
Change Management and Test Environment
In the spirit of Open Government (which includes open documentation, data and software codes), ANPR is available on the Developers Italia community starting from the community's launch.
We are using this platform to work with collaborative tools accompanied by moderation, consultation and review processes; exactly as it occurs on GitHub, our main support tool, and thanks to which we have collected over 500 issues and 1300 comments.
But that's not all. Through GitHub, we have also been able to track changes and compile the first version of Change Management; the document describes the processes to be adopted to manage the software changes that are required by ANPR, and the basic tools that are needed to plan the work still to be done with Sogei.
When this process of implementation, which includes the writing of the software itself as well, will be completed, ANPR will be a totally transparent platform, fully compatible with the spirit of the developer community.
We are also working on a free test environment which everyone (and not just the software houses that already have a Municipality client) can interface. Such a service is a fundamental requirement as an open source SDK (Software Development Kit) for ANPR.
A great effort has been made in these few months but much remains to be completed. Firstly, we need to make sure that ANPR becomes a platform adopted by the majority of Municipalities (the clear target is 8,000 Italian Municipalities); then, we must continue to work in parallel with the improvement of the service, planning new features and possibilities for the platform.
In short, there are still many things left for us to do and many goals that we've set towards which we are still working.
Improve the product and offer direct services to citizens
We want to make ANPR a service that continuously evolves and can concretelyimprove the life of the citizen. For example, thanks to a self-service that will print all our data, we won't have to resort to paper forms or self-certifications. ANPR is (and increasingly will be) an essential component of the concept of digital citizenship. Its successful completion is a mission that the Digital Transformation Team has made its own, and for which it is working tirelessly.
Extend the functionality of ANPR
It's important to emphasize that ANPR is not a finished, static project. It is a moving target; it is the mirror of our registry and society and, as such, it evolves. It follows, of course, the evolution of our country, and represents a profitable exchange between citizens and their Municipalities, thanks to the feedback and comments from its users. It's an open dialogue, in the understanding that we should work together to reach our collective goal; we are all finishing a marathon that is just at the beginning and more is still to be run.
We wish to conclude with an important information. The ANPR project is one of the first cases of digital transformation financed through European funds, in particular, the Operational Program for Governance and Institutional Capacity (1), and the first in the context of the Three Year Plan for Information Technology of the Public Administration.
We've been working with the Ministry of Public Administration, the Cohesion Agency and ANCI to make sure that in this process of transition to ANPR, Municipalities are supported by an economic contribution that does not require complex bureaucratic procedures.
We issued a call for Municipalities to be reimbursed upon completion of the full transition to ANPR and according to their demographic classification. It's a new, simple and direct model in which we strongly believe, and which, we hope, will help to further accelerate the project.
(1) The PON Operational Program for Governance and Institutional Capacity, financed by the European Union through the Agency for Territorial Cohesion (all information can be found here), is aimed at strengthening the administrative, institutional and digitalization capacity of the Public Administration.
Mirko Calvaresi
Technical Project Manage
Commissioner for Digital Transformation Italian Government , Italian Presidency of the Council of Ministers
General Manager Apple Europe (1987-1999) Sr VP International Consumer Business Amazon.com (2000-2016)


I recently got an old CP-16A and am trying to restore it to working condition however it has one problem. When I plug it in to ac and run it nothing happens. If I leave the run button on for several minutes it will eventually start to run but very slowly. After a few more minutes it will start to run faster but never reaches sync speed (the red light is always on). If at any point I turn the run switch off the process starts back from the beginning. The power supply is good, it's giving off 20 vdc at 3 amps and I tested the camera with another power supply alligator clipped to the battery terminals and got the same results. Any help would be greatly appreciated. I'm trying to repair this myself without having to send it in. I'll link a video where you can see the speed ramping up and down on it's own. At the point I'd taken the video the camera had been powered on about 10 minutes.
Inside the CP16s there is a memory battery. When this deteriorates, it may ooze onto a crystal module directly attached to the motor control board. It is quite a mission to get at it. You might strike lucky if the crystal module is covered with dried ooze and is successfully cleaned off but more likely it will have been damaged.
Ken Hale at Whitehouse Audiovisual may have the necessary replacement PCB but I have not been in touch now for several years. There was a new digital replacement motor control system and rear control panel developed and sold. I don't know if the designer/builder/vendor is still trading or has any remaining inventory to sell.


Barton Rovers suffered a last-gasp 2-1 defeat at Beaconsfield SYCOB on Saturday.
The visitors looked lively from the start as Elliott Bailey and the in-form Connor Calcutt sent efforts narrowly wide.
However, the hosts took the lead on 37 minutes when Beaconsfield's Aaron Minhas tried his luck from 30 yards, and fired a wonder strike that gave Rovers keeper Tom no chance as it nestled in the top corner.
Barton were behind for just four minutes though, restoring parity when Tommy Smith headed home from his namesake Charlie Smith's corner.
The second half saw Rovers upping the tempo as Calcutt had two efforts fall just wide before Luke Knight watched in agony as his thunderous strike hit the inside of the post, flew along the goal line and stayed out.
The visitors then forced a series of corners, but Beaconsfield remained organised and kept the scores level.
They then broke Barton hearts in the 93rd minute, as Callum Bunting netted with what was the last kick of the game.
Speaking afterwards, Rovers boss Jimmy Gray said: "I don't know how we came out of that game with nothing after all the chances we had, but again we have failed to put them away.
"Beaconsfield were a cracking footballing side but we should have put the game to bed.
Rovers are now back at home for two games as they entertain Aylesbury United on Saturday and then Northwood on Tuesday.


You may need to reboot your Mi Pad in recovery mode if you want to install a custom ROM or if you want to install a utility or a file that cannot be installed using the standard Android interface that comes with your Mi Pad.
For example, suppose you have is a zip that you would like to install but you cannot install zip files running the normal Android MUI interface that comes with Mi Pad. In order to do that, you need to reboot your Mi Pad in recovery mode. When you reboot in recovery mode, if you have the needed file and if you have it stored in the root folder of your internal storage, it asks you whether you would like to install the file and you can install it.
There was a reason why I needed to know how to reboot my Mi Pad in recovery mode: I wanted to run the f.lux app on my Mi Pad and in order to run f.lux you need root access to your device.
It's a software utility that allows you to filter out the infamous blue light from your computer screen or from your mobile phone. In the evening and at night, the blue light that comes from your electronic devices can disturb your circadian cycle and you may find it difficult to fall asleep. This is why people are constantly looking for solutions that can filter out the blue light.
Anyway, I will write about this topic some other day, because right now I'm talking about how to reboot your Mi Pad in recovery mode. Unfortunately, in Mi Pad, f.lux doesn't work even after getting the root access – maybe there is some screen issue.
No, this doesn't work. This shows a strange sort of monkey on the screen and tragically, the monkey doesn't go anywhere and you have to force-restart your Mi Pad.
and your Mi Pad reboots in recovery mode.


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We now supply the Greek and international market with the new ultramodern frame that combines Solid Wood with an outer coating made of Aluminum or Bronze.
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Air permeability: Category 4 (maximum permissible) at a wind speed of 115 km/h.
Water tightness: Method A - Class E 1050, rain at a wind speed of 149 km/h (more than the maximum permissible limit).
Strength: Class 5 C (maximum accessible class).
Energy saving: Thermal transmission between 0.8 W/m²K and 1.2 W/m²K with high performance glass, magnetron coating and argon gas filling.
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text:
Q: Center alignment not consistent I'm trying to get the duration and current time text to stay centered vertically. Why is it that sometimes it will no center, and other times if I do a refresh, it works suddenly, even though I didn't change any code?
Here's a screenshot of it not working: Not Working
And here's another after doing a hard refresh, but not changing any of the code: Working
It's almost as if it's a hit or miss.

        <button id="playpause-button">

        </button>

        00:00

        00:00

        <button id="rewind-button">

        </button>

        <button id="speed-button">

        </button>

        <button id="captions-button">

        </button>

        <button id="volume-button"></button>

Here's the CSS sheet:
.player-controls {
    background: #2f2f2f;
    display: block;
    padding: 0;
    margin: 0 auto;
    text-align: left;
    width: 840px;
    height: 52px;
    user-select: none;
}

.player-controls button {
    background-color: Transparent;
    background-repeat:no-repeat;
    border: none;
    cursor:pointer;
    overflow: hidden;
    outline:none;
    color: #fff;
}

.time-rail-container {
    width: 443px;
}

.player-controls > div {
    margin: 0 0 5px 0;
    display: inline-block;
}

#playpause-button,
#rewind-button,
#speed-button,
#captions-button,
#volume-button {
    padding: 0;
    margin: 0 1px 0 0;
    width: 56px;
    height: 50px;
}

.time-container {
    height: 50px;
    line-height: 50px;
    text-align: center;
}

#duration,
#currenttime {
    vertical-align: middle;
}

A: I echo user "Sticker"s advise... Try to add vertical-align:middle CSS to .player-controls button like below : here is a plunker https://plnkr.co/edit/tldchkIWflEDUFBQxZIw?p=preview
.player-controls button {
    background-color: Transparent;
    background-repeat:no-repeat;
    border: none;
    cursor:pointer;
    overflow: hidden;
    outline:none;
    color: #fff;
    vertical-align:middle;
}

A: It is because it isn't sure what to be referencing for the vertical-align since not all the elements you are trying to align are next to each other. Instead of aligning those two vertically, you need to set the vertical align on all of the elements inside of the player-controls.
.player-controls > * {
    vertical-align: middle;
}

redpajama_set_name: RedPajamaStackExchange


The only limit a science-fiction author has is his. Or you can highlight how it smells to be Jean-Baptiste Grenouille from famous novel Perfume: The Story of a Murderer. It has a great influence on the reader's decision..
They are generally plain-looking, not flashy and filled with facts. Increasing mortality in middle-aged whites was matched by increasing morbidity. Mortality by poisoning, suicide, chronic liver disease, and cirrhosis, white non-Hispanics by 5-y age group. Like any corporate..
money into space exploration because Earth is on a certain path to destruction. However, one needs to learn a few things to make the composition worth reading. An essay hook is the first one or two sentences of your essay. Thats exactly what the leaders of the tiny island nation of Guam tried to answer. Here, we will be talking about self-introduction essay, and look into different example such as personal essay which you may refer.
You may also see personal essay examples samples, how to Write a Self-Introduction Essay. Simplify your work Use simple words and language. The first impression of your essay is established by its introductory paragraph. They hardly need any attention, and they wont be around for too long. You can introduce your point of view through a relevant"tion. As a writer, your first priority is to make sure that you are keeping your audience in mind and writing for them and to them. If you have an interesting take on a subject, readers will want to see where you came up with your idea. So, the very first step in writing a strong essay hook is to do some planning. For example, your thesis might read: "In the modern age, online dating apps what needed on a college paper like Tinder provide a wider variety of romantic options than young people have ever had before.". Agree or not, but these words from The Alchemist determine. It can be a provocative question, an anecdote, a narrative (short any intriguing paradox, surprising information etc.


Specifies whether a Unix window manager can automatically place a stack's window when the stack is opened.
Use the windowManagerPlace property to determine how the stack window is placed on Unix systems.
The windowManagerPlace of a stack is true or false.
If the windowManagerPlace property is true, the window manager uses the "mwm" resources "clientAutoPlace" and "interactivePlacement" to set the location of the window when the stack is first opened.
If the windowManagerPlace is false, the stack's rectangle property is used to set its location.


text:
Liushi Manorial Museum
Dayi Liushi manoral museum is located at No.15, Jingui street, Anren Town, Dayi County, Chengdu City, Sichuan Province. It is one of the important historical sites and representative buildings in modern China. The museum was founded in October 1958; in 1958, it was officially planned to build Dayi landlords' manor Museum; in early 1997, "Dayi landlord manor exhibition hall" was officially renamed as "Dayi Liu manor Museum".
Dayi Liu manor Museum covers an area of more than 70000 square meters, with a building area of 21055 square meters, which is the architectural style of Bazi in Western Sichuan. The buildings, collections, clay sculptures and remains of the museum are important objects for understanding and studying the politics, economy and culture of China's semi colonial and semi feudal society, as well as the history of warlords, folklore and modern residential buildings in Sichuan, and also a cross-section of the development history of modern Chinese society.
In 2001, it was rated as a national AAAA tourist attraction by the National Tourism Administration, and was rated as a national third-class Museum by the State Administration of cultural relics in 2009. It is a national key cultural relics protection unit, an excellent patriotism education base of national cultural relics system, and a national youth education base.
Liu's manor complex was built in the late Qing Dynasty and completed in the late Republic of China.
In 1932, Liu Wencai built the south of the manor.
In 1942, Liu Wencai built the northern part of the manor for himself and his brother Liu Wenhui.
In 1932, Liu Wencai, who had been the general tax office of Xufu (Yibin) and director of the tobacco and wine public sales Bureau, returned to his hometown and built a manor on a large scale.
In 1958, Dayi landlord manor exhibition hall was officially established. In October of the same year, Dayi landlord manor exhibition hall was formally established. After the Third Plenary Session of the 11th Central Committee of the CPC, it was on the right track of museum development.
In 1982, the museum began to collect and sort out the documents and materials in the museum and compile the museum records.
In 1984, the exhibition hall of landlord manor was transferred from Chengdu to Dayi County.
In May 1993, the landlord manor was named as the third batch of Chengdu patriotism education bases by Chengdu municipal Party committee and municipal government.
On August 30, 1995, it was named the patriotic education base of Dayi County.
In November 1996, as one of the important historical sites and representative buildings in modern times of China and Tong, it was announced as one of the fourth batch of national key cultural relics protection units by the State Council.
In early 1997, "Dayi landlord manor exhibition hall" was officially renamed "Dayi Liu manor Museum". In May of the same year, Liu's manor was awarded the title of "excellent patriotism education base of national cultural relic system" by the State Administration of cultural relics.
In 1999, Dayi Liu's manor museum was listed as one of the six priority scenic spots by Sichuan Provincial People's government, and was listed in the master plan of Sichuan tourism development.
In May 2000, Dayi Liu manor museum was named the national youth education base by the Central Committee of the Communist Youth League.
In November 2001, Dayi Liu's manor was rated as a national AAAA tourist attraction by the National Tourism Administration.
In May 2009, Liu's manor was announced as a national third-class Museum by the State Administration of cultural relics.
architectural composition
Dayi Liu manor museum is the architectural style of Bazi in Western Sichuan. The Museum covers an area of more than 2107 square meters between the north and the south. The old manor is an irregular polygon, surrounded by 6-meter high wind and fire brick walls, 7 gates, 27 patios, more than 180 houses and 3 gardens. Inside the manor, there are heavy walls and alleys, thick doors and iron locks, and the secret rooms are in disorder. The whole manor is like a dark labyrinth building. There are rectangle, square, trapezoid, rhombus and other shapes; there are hundreds of ornaments such as carved door wire. The interior of the manor is divided into hall, living room, reception room, accounting room, employment yard, rent collection yard, granary, secret Treasury, water prison and Buddha Hall, moon watching platform, Xiaoyao palace, garden, orchard, etc.
The basic display of the museum is composed of preface hall, employment yard, Liu Wencai's living scene, large clay sculpture "Rent Collection Yard", manor cultural relics museum and so on.
The Museum of Liu's manor in Dayi has formed five basic exhibitions:
1. The restoration display of Liu Wencai and his family's living scene in the manor's husband's hall, and the large clay sculpture "Rent Collection Yard" group sculpture.
2. The folk customs exhibition of the West Sichuan Folk Museum, which is held at the old site of the manor new residence, reproduces the folk customs in the production and life of the people in Western Sichuan.
3. Display the excellent collections of the manor Cultural Relics Museum held in Liu Wencheng mansion.
4. The restoration exhibition of Liu's ancestral residence was held in the original site of Laowuji, the birthplace of Liu's family, in 2003.
5. The sculpture of folk houses in Western Sichuan and the display of modern calligraphy and painting in the former site of Liu Wenzhao mansion.
Main attractions
Laolaoguan
When Liu Wencai was alive, ordinary people were not allowed to enter her husband's hall. On the left side of the manor gate is the "farmhouse", and on the right side are "western style living room" and "Chinese style living room". Going forward is Liu Wencai's inner garden. Walking inside is Liu Wencai's inner courtyard. There is a longevity hall in the inner courtyard, which worships the spiritual throne of Liu's ancestors. On the right side of the longevity hall is a room with two entrances. There is a magnificent large dragon bed in the room. The gilded dragon bed covers an area of 9 square meters and is composed of 4 columns, 4 doors and bed surface.
Rent Collection House
"Rent Collection House" is displayed in Liu Wencai manor, Dayi County, Sichuan Province. It was created from June to October 1965. It is a large modern clay sculpture group of China. The author is Sichuan Academy of fine arts and folk artists.
According to the situation of the landlord's rent collection at that time, the "Rent Collection House" was conceived and created on the spot. It was composed of seven groups of images: paying rent, checking rent, wind Valley, fighting, accounting, forced rent and resistance. The whole process of rent collection, which is the main means of landlords' exploitation of peasants, is shown in the form of continuous plots. A total of 114 real size characters are created.
"Rent Collection House" was reproduced and exhibited in Beijing from 1965 to 1966, which caused great repercussions. Since then, he has exhibited in Albania and Vietnam. In 1988, he toured Japan with a copy of the new copper plated FRP material.
Miss building
Miss building, also known as "xiulou", is located in the north of the rent collection courtyard and the east side of the main gate of the husband's hall. Miss building is the courtyard of the courtyard. The columns on both sides of the gate are cinnabar. The rectangular white porcelain plate inlaid above the lintel has the words "Xiang Cheng Wu Fu". The top of the board is a relief white peony, which is elegant. It is a brick and wood structure, all of which are made of green brick and white line column wall frame, especially exquisite and unique. The six sides of the zanjian roof permeate the Chinese and Western architectural style of the semi feudal and semi colonial period of the 1920s and 1930s.
Value of cultural relics
The Museum of Liu's manor in Dayi witnessed the social and historical changes, and showed the architectural skills and traditional rural culture in Western Sichuan in modern times. The buildings, collections, clay sculptures and remains of the museum are important objects for understanding and studying the politics, economy and culture of China's semi colonial and semi feudal society, as well as the history of warlords, folklore and modern residential buildings in Sichuan, and also a cross-section of the development history of modern Chinese society.
The whole manor is a group of Chinese and Western style buildings. It not only has the legacy of Chinese feudal mansion, but also embodies the closed social characteristics of feudal society, reflects the feudal order and the hierarchical relationship between the superior and the inferior, and absorbs the characteristics of Western castles and church buildings, which are particularly prominent in the new residence buildings. The main style of manor architecture embodies the traditional Chinese aesthetic orientation, and integrates the western aesthetic characteristics in details. This Chinese and Western Manor building complex is mainly composed of brick and wood structure, reflecting the development process of modern residential buildings in Western Sichuan in the 1920s and 1930s. It is not only a typical architectural form and style of modern Sichuan landlord manor, but also a group of residential buildings with typical local characteristics formed by absorbing western architectural civilization and combining with traditional Chinese architectural culture, It has high historical, artistic, cultural relics and scientific and technological value.
As of March 2015, there are more than 27000 cultural relics and collections in Dayi Liu's manor Museum; 1848 cultural relics above grade III, including 15 national first-class cultural relics, 21 second-class cultural relics and 1813 third-class cultural relics. It includes a set of red sandalwood inlaid marble tables and chairs in the Qing Dynasty. Among them, eight chairs are 108 cm high, 99 cm wide and 60 cm deep, inlaid with 27 beads of various colors and surrounded by flower patterns decorated with mother of pearl.
The museum has a large number of cultural relics and rich connotations, such as the relics of the Taiping Heavenly Kingdom, such as Chinese style red sandalwood and mother of Pearl marble furniture, nine story hollow carving ivory ball, 13 floor hollow carving ivory tower, clay sculpture "Rent Collection Yard", Mr. Zhang Daqian's couplets, and Liu Wen's colorful pasted golden dragon holding pillars to step back into a big flower bed. Among them, there are hundreds of maps of military operations and administrative divisions during the period of "defense area system" of Sichuan warlords, as well as hundreds of tax revenue, land tax pre levy (from 1930 to 1976), and hundreds of supporting documents for borrowing military rates. There are a large number of physical objects reflecting the cruel economic exploitation of farmers by the landlord class in modern times, such as the land lease, house lease, and so on There are thousands of books, tenant lists, land tax receipts, tax receipts and so on. There are all kinds of gold and jade inlaid furniture, a large number of gold and silver jewelry, antiques, calligraphy and paintings.
Bus: No.11, No.13, No.15
Automobile: Chengdu Wenjiang Chongzhou Dayi
Express highway to Dayi County (52 kilometers), and then through 12 kilometers of secondary road to Anren Town, manor is located in Anren town.
Summer (May 1 - October 7)
Ticket time: 9:00-17:00 (closed at 17:30)
Winter (October 8 - April 30)
Ticket selling time: 9:00-16:30 (closed at 17:15)
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Obama: Europe should better integrate Muslims
Jan 17, 2015, 2:42 am SGT
http://str.sg/8D7
WASHINGTON (AFP) - US President Barack Obama on Friday urged European governments to try to better assimilate their Muslim minority populations as they respond to extremist attacks like last week's shootings in Paris.
At a White House news conference with British Prime Minister David Cameron, his first foreign guest since last week's Charlie Hebdo massacre, Obama said the allies would stand by France.
But he also warned that the answer to the recent violence must not simply be a security crackdown.
"I know David joins me when I say that we will continue to do everything in our power to help France seek the justice that is needed, and that all our countries are working together seamlessly to prevent attacks and to defeat these terrorist networks," Obama said.
Obama said the Paris attacks "underscored how terrorist groups like Al-Qaeda and ISIL (ISIS) are actively trying to inspire and support people within our own countries to engage in terrorism."
The US leader said the 2013 Boston marathon bombing showed that the United States was not entirely safe from Islamic militant cells, but suggested that it had had more success than others in integrating minorities.
"Our biggest advantage, major, is that our Muslim populations feel themselves to be Americans and there is this incredible process of immigration and assimilation that is part of our tradition," he said.
"There are parts of Europe in which that's not the case... it's important for Europe not to simply respond with a hammer and law enforcement and military approaches to these problems."
And he added: "There also has to be a recognition that the stronger the ties of a North African or a Frenchman of North African descent to French liberties, that's going to be important over time."
He said the United States would hold a summit in February on countering violent extremism and the threat of radicalised Islamist fighters returning to their home countries from the war in Syria.
"David and the United Kingdom continue to be strong partners in this work, including sharing intelligence and strengthening border security," he said, dubbing Britain an "indispensable ally."
THREATS TO STABILITY
Cameron said the two had agreed to set up "a joint group to identify what more we can do to counter the rise of domestic violent extremism and to learn from one another."
He described the battle facing Western governments as a "long, patient and hard struggle" and dubbed the enemy a "poisonous fanatical death cult... perverting the religion of Islam."
The United States and Britain already cooperate closely in global electronic surveillance, and Cameron said the two leaders had agreed to deepen their cooperation on cyber-security.
In a separate statement, the White House said the US National Security Agency and FBI would form a joint cyber-security cell with British domestic intelligence MI5 and eavesdropping agency GCHQ.
This will speed intelligence sharing and strengthen the allies' defences against cyber-attacks from foreign governments and criminals, the leaders said.
The partners will begin their reinforced cooperation with a year-long exercise to test and strengthen the defences of the financial sector.
In recent weeks, Washington has been embarrassed by the seizure of a military Twitter account by Islamic militant sympathisers and angered by North Korea's alleged hacking of Hollywood studio Sony Pictures.
But trans-Atlantic partnership has also had successes.
A young hacker – suspected of taking part in attacks that shut down online gaming platforms over Christmas – was arrested Friday in a joint operation with the FBI and British police.
Obama, 53, is beginning his last two years in office, while Cameron, 48, is preparing for general elections in May that are expected to be very close and could mark the end of his coalition government.


Warm summer nights were made to be outside! Why not catch a family-favorite movie while doing so, at one of Longmont's favorite parks!
The Historic Westside Neighborhood Association in Longmont bring you the annual Outdoor Cinemas at Thompson Park! They'll have four free movies this summer between August 4 and September 8! Bring the family, a blanket, some snacks if you like (some refreshments will be provided) and maybe some bug spray, as they all start at dusk!
They'll also be collecting non-perishable items for the local food pantry at each show- so, come out and be a part of the community spirit this summer!


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Inclusive Language and Content
Original Articles| June 01 2018
Evolution of Neuroprosthetic Approaches to Restoration of Upper Extremity Function in Spinal Cord Injury
Kevin L. Kilgore, PhD;
Kevin L. Kilgore, PhD
1MetroHealth Medical Center, Cleveland, Ohio
2Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
3Case Western Reserve University, Cleveland, Ohio
Corresponding author: Kevin L. Kilgore, PhD, MetroHealth Medical Center, 2500 MetroHealth Drive, OBC N5-56, Cleveland, OH 44109; phone: 216-957-3657; email: klk4@case.edu
Anne Bryden, MA, OTR/L;
Anne Bryden, MA, OTR/L
Michael W. Keith, MD;
Michael W. Keith, MD
Harry A. Hoyen, MD;
Harry A. Hoyen, MD
Ronald L. Hart, MS;
Ronald L. Hart, MS
Gregory A. Nemunaitis, MD;
Gregory A. Nemunaitis, MD
P. Hunter Peckham, PhD
Top Spinal Cord Inj Rehabil (2018) 24 (3): 252–264.
https://doi.org/10.1310/sci2403-252
Guest Access
Kevin L. Kilgore, Anne Bryden, Michael W. Keith, Harry A. Hoyen, Ronald L. Hart, Gregory A. Nemunaitis, P. Hunter Peckham; Evolution of Neuroprosthetic Approaches to Restoration of Upper Extremity Function in Spinal Cord Injury. Top Spinal Cord Inj Rehabil 1 June 2018; 24 (3): 252–264. doi: https://doi.org/10.1310/sci2403-252
Background: Spinal cord injury (SCI) occurring at the cervical levels can result in significantly impaired arm and hand function. People with cervical-level SCI desire improved use of their arms and hands, anticipating that regained function will result in improved independence and ultimately improved quality of life. Neuroprostheses provide the most promising method for significant gain in hand and arm function for persons with cervical-level SCI. Neuroprostheses utilize small electrical currents to activate peripheral motor nerves, resulting in controlled contraction of paralyzed muscles. Methods: A myoelectrically-controlled neuroprosthesis was evaluated in 15 arms in 13 individuals with cervical-level SCI. All individuals had motor level C5 or C6 tetraplegia. Results: This study demonstrates that an implanted neuroprosthesis utilizing myoelectric signal (MES)–controlled stimulation allows considerable flexibility in the control algorithms that can be utilized for a variety of arm and hand functions. Improved active range of motion, grip strength, and the ability to pick up and release objects were improved in all arms tested. Adverse events were few and were consistent with the experience with similar active implantable devices. Conclusion: For individuals with cervical SCI who are highly motivated, implanted neuroprostheses provide the opportunity to gain arm and hand function that cannot be gained through the use of orthotics or surgical intervention alone. Upper extremity neuroprostheses have been shown to provide increased function and independence for persons with cervical-level SCI.
functional electrical stimulation, myoelectric control, neuroprosthesis, spinal cord injury, upper extremity function
Spinal cord injury (SCI) occurring at the cervical levels can result in significantly impaired arm and hand function. Traditionally, rehabilitation has focused on restoring function through conservative measures such as strengthening and exercise, splinting and orthotics, and adaptive equipment to facilitate increased independence in performing activities of daily living. After maximizing these conservative interventions, many individuals with tetraplegia seek additional options to improve hand function, such as surgical reconstructive procedures. People with cervical-level SCI desire improved use of their arms and hands, believing that regained function will result in improved quality of life.1–3 The most common type of reconstructive surgery for restoring upper extremity function in people with tetraplegia is a tendon transfer. A tendon transfer is a surgical procedure in which the tendon insertion of a redundant voluntary muscle is detached and sewn into that of a paralyzed muscle.4,5 In addition, there has been recent attention to the feasibility of using microsurgical nerve transfers to restore function after cervical SCI, which can potentially complement existing methods for restoring function.5,6 Despite these surgical alternatives, there is still significant need for improved hand and arm function in SCI.
Neuroprostheses provide the most promising method for significant gain in arm and hand function in persons with cervical-level SCI. Neuroprostheses utilize small electrical currents to activate peripheral motor nerves, resulting in controlled contraction of paralyzed muscles for a desired activity. The fundamental aspects of electrical activation of nerves are well understood, and the safe levels of stimulation for long-term use have been established.7 Muscle contractions can be orchestrated to produce coordinated grasp opening and closing; thumb opening, closing, and positioning; wrist extension/flexion; forearm pronation; and elbow extension for individuals with C5 and C6 neurological level of injury. The individual controls the desired activity through the electrical activation of paralyzed muscle through recorded myoelectric signals from retained voluntary muscle activation. Neuroprostheses can be coupled with tendon transfers in order to maximize function.8 The objectives of neuroprostheses are to reduce the need of individuals to rely on assistance from others, reduce the need for adaptive equipment, reduce the need to wear braces or other orthotic devices, and reduce the time it takes to perform tasks. Typically, patients use the neuroprosthesis for such tasks as eating, drinking, personal hygiene, writing, and office tasks.
The first upper extremity neuroprosthesis was implanted in a human subject in 1986.9 Early neuroprostheses required donning external components to operate the system.10 Results of the first clinical trial have been previously published by Peckham and colleagues.11–17 A second-generation neuroprosthesis internalized the control source using myoelectric recording electrodes to capture voluntary signals to control opening and closing of the hand.18–21 In addition to implanting the control source, this system provided four additional channels of stimulation to refine additional functional activities. This article summarizes the results of a clinical study of this second-generation neuroprosthesis and compares the implementation strategy and outcomes with the first-generation system. The results of the first three subjects implanted with the second-generation device were previously published19 and are included in the complete cohort data presented in this article.
Neuroprosthesis design
The IST-12 neuroprosthesis has the potential to provide grasp and release, forearm control, and elbow extension for individuals with cervical-level SCI. The system consists of an implanted stimulator-telemeter (IST) with the capacity to stimulate 12 paralyzed muscles and to record the myoelectric signals (MES) from two muscles under voluntary control (see ref. 19 for design details). The most novel feature of the IST-12 neuroprosthesis compared to the earlier eight-channel design11 is the elimination of the external control source. This is achieved through the use of implanted MES recording electrodes and MES processing circuitry in the implanted device. The system is driven from an external power and processing unit, which is connected to a coil that the participant places on the skin over the implanted device.
An important aspect of the myoelectric recording circuit design in the IST-12 is the ability to record MES in the presence of the large stimulus artifacts produced by 12 stimulating electrodes.22 The stimulation pulses used to activate paralyzed muscle normally will saturate MES amplifiers so that the ability to record a usable signal is lost.18,20 Therefore, it is necessary to remove the stimulus artifact from the MES recording. This was accomplished by implementing several design features. First, all stimulus pulses are grouped together at the beginning of each stimulus period so that their artifact is not spread throughout the stimulation sequence. Second, during the MES integration window, the stimulating electrode recharge current path is disconnected. Third, the MES integrator is enabled only during the MES window. Fourth, outside the MES window, the variable gain is set to the minimum value. Fifth, during stimulation, the front-end multiplexer entirely disconnects the MES processor from the MES electrodes. In vivo studies in animals demonstrated the ability of this processing to eliminate stimulus artifact even when the recording electrodes are within a few centimeters of the stimulating electrode.20
The myoelectric signal is rectified, filtered, and integrated within the IST-12 device. The value of the integrated signal is sampled at the end of the integrating window, and the data are transmitted to the external controller. The IST-12 has four programmable amplifier gains, from 200 to 4000, which can be controlled on a sample by sample basis.
Participant selection criteria
Candidates considered for implantation included individuals with cervical SCI. Subjects had International Standards for Neurological Classification of SCI (ISNCSCI) motor score at the C5 or C6 and were classified as American Spinal Injury Association Impairment Scale (AIS) group A or B (motor complete).23 Based on the International Classification for Surgery of the Hand in Tetraplegia (ICSHT), subjects were classified as group O/Cu:0 through O/Cu:3.24 Candidates were required to be in generally good health, have minimal upper extremity contractures, be medically stable, have electrically excitable muscles,25 and have good social support.
Testing timeframe
Functional testing was performed at key points in time throughout the study. Baseline measurements were made prior to surgery, generally within a month prior to the surgery date. Testing was repeated at approximately 3 months after surgery, upon completion of rehabilitation period of training in use of the neuroprosthesis.
The goal of this study was to demonstrate that the use of MES-controlled grasp function can be achieved in a fully implanted neuroprosthesis. Outcome measures presented in this paper focused on the domain of body function and structures (BFS) as identified by the World Health Organization's (WHO) International Classification of Function (ICF).26 Specific outcome measures include grip strength, range of motion, and a basic test of grasp function (the Grasp and Release Test [GRT]).
Stimulated range of motion
Range of motion of the hand and arm was measured according to standard occupational therapy techniques using a hand-held goniometer.27 Finger and thumb range of motion was measured with the wrist splinted in neutral. Finger extension and flexion was measured using stimulation parameters in each subject's palmar grasp pattern. Thumb extension and flexion was measured using stimulation parameters in each subject's lateral grasp pattern.
Grasp strength
Grasp strength was measured using a standard B&L (Model PG30; B&L Engineering, Tustin, CA) pinch meter that was modified with an "L"-shaped extension to better accommodate the tetraplegic hand. This extension increased the sensitivity of the device, and measured units are converted based on a calibration factor as a result of the extension.11 Strength was measured for both lateral and palmar prehension. Measurements were made prior to implantation and approximately 3 months post implantation. Postsurgery measurements were made with the neuroprosthesis turned on and off.
Grasp and Release Test
The GRT was developed by the Cleveland FES Center to detect changes in hand function after implantation of an upper extremity neuroprosthesis.28 This pick-and-place test requires the participant to unilaterally acquire, move, and release six objects varying in weight and size. Three of the objects require use of a lateral grasp; the other three require palmar grasp. The participant completes a pretest to determine how many of the six objects can be successfully grasped, moved, and released. A main test follows to measure number of repetitions achieved in three 30-second trials for each object that was successfully passed in the pretest. The psychometric properties of the GRT were further established by Mulcahey and colleagues.29 The GRT was administered prior to surgery and 3 months post surgery. Postsurgery tests are conducted with the neuroprosthesis on and off.
Differences in grasp strength and range of motion were analyzed using paired t tests. The proportion of subjects who were able to increase the number of objects they could manipulate in the GRT was compared to the proportion without the neuroprosthesis using the Wilcoxon rank-sum test.
Fifteen arms in 12 individuals with motor level C5 or C6 tetraplegia were implanted with the IST-12 device and evaluated, as detailed in Table 1. In this cohort, a total of 16 IST-12 devices were implanted, with most individuals receiving one device to provide function in one arm. However, three individuals received bilateral function (a device for each arm) and one individual received two devices to provide function in the upper arm and shoulder as well as the hand. Two of the 12 participants were female. Average age at implantation was 37 years (range, 26–56). Average time from injury to implantation was 5.5 years (range, 1–21).
Study cohort demographic summary.
All of the participants except for one had voluntary upper extremity reconstructive procedures to augment function provided by the implanted neuroprosthesis, as shown in Table 1. Almost half of these participants underwent surgical reconstruction and postoperative training prior to neuroprosthesis implantation, while the remaining participants underwent the surgical reconstruction in the same procedure as the neuroprosthesis implantation. The most common procedure was a transfer of the posterior deltoid or biceps into triceps to provide elbow extension, followed by brachioradialis (Br) transferred to either extensor carpi radialis brevis (ECRB) or flexor pollicis longus (FPL) for wrist extension or thumb pinch, respectively. The single individual who did not receive voluntary reconstructive procedures was not a candidate for them due to lack of voluntary donor muscles (ISNCSCI C5, ICSHT Group 0).
In order to evaluate the evolution of the extent and types of surgical procedures performed in the 15 IST-12 arms, we compared the procedures performed with the first 15 Freehand subjects implanted at our site. This data are summarized in Table 2, and they indicate significant changes over time despite that fact that the distribution in the level of injury is similar between the two groups. In the Freehand cohort, multiple synchronization procedures were performed in the extrinsic finger muscles in an attempt to gain synchronous flexion and extension of the digits, whereas the IST-12 cohort had none of these procedures. Six subjects in the Freehand cohort had a thumb interphalangeal (IP) joint arthrodesis, but this was generally abandoned in favor of an FPL split tendon transfer in which one slip of the distal FPL tendon is transferred to the insertion of the EPL, providing IP joint stability when the FPL muscle is activated while still allowing IP joint flexibility in the passive condition. Other procedures performed to correct finger posture deformities, such as the flexor digitorum superficialis (FDS) Zancolli lasso and the FDS instrinsicplasty procedures, were performed in the Freehand cohort but not in the IST-12 cohort. Finally, transfer of the voluntary (not paralyzed) Br to provide thumb flexion was performed in nearly half of the IST-12 cohort, whereas it had not been performed previously in any of the Freehand cohort.
Surgical procedure comparison
Electrode placement and movement patterns provided
The eTable (supplemental digital content) shows the muscles that have been implanted with stimulating and recording electrodes. Each system was customized to the participant's physiological characteristics and functional goals. Each implanted device activates 12 muscles and records MES from two voluntary muscles. As such, individuals with one unilateral device have 12 paralyzed muscles activated and use two muscles where voluntary function is retained to control the function of the arm. The bilateral participants have this same distribution in each arm, and the one participant with two devices to activate one arm has 24 paralyzed muscles activated in the hand, arm, and shoulder.
The Freehand System could activate eight muscles, and thus the IST-12 allowed activation of four additional muscles. In 13/15 arms, two of these additional electrodes were placed in the finger intrinsic muscles to provide improved finger IP extension and metacarpophalangeal (MCP) flexion. The remaining two electrodes were generally placed in muscles that provided specific functions consistent with the goals and physiology of each subject. This allowed the majority (8/15) arms to gain triceps activation and 6/15 arms to gain wrist flexion via the palmaris longus (PL). Additional functions provided included forearm pronation and shoulder stabilization. In 4/15 subjects, multiple electrodes were placed in the extrinsic finger flexors and/or extensors.
All but one of the IST-12 participants controlled hand opening and closing proportionally through activation of wrist extension. Voluntary wrist extension was achieved through activation of the extensor carpi radialis longus (ECRL) or through tendon transfer of Br to the extensor carpi radialis brevis (ECRB). In the latter case, the recording electrode was placed on the Br muscle. The second recording electrode of each system was typically reserved as a logic source or a way to activate certain features of the system such as change grasp patterns.19 The muscles most commonly reserved for this function included the platysma and the trapezius. These muscles could also be used for proportional control of grasp if the wrist extensor was too weak to provide a reliable signal. The participant with two implanted devices for unilateral function also had recording electrodes placed on his middle deltoid and biceps for control of arm and trunk function.
Motor patterns
All IST-12 participants were provided with lateral and palmar hand grasp patterns, as described elsewhere.30 Additional grasp patterns were provided that were customized to specific functional needs of the user and included a "sandwich" grasp (light palmar pinch with finger IP joints extended), pointer grasp (index finger extension, other fingers flexed), "cashew" (fine index finger and thumb tip pinch), and grasps designed for use of cell phones.
Elbow extension was provided by electrical stimulation of the triceps muscle, often in combination with a tendon transfer (the triceps tendon is not disconnected when the tendon transfer is performed). Forearm pronation was provided by stimulation of the pronator quadratus (PQ). Both elbow extension and forearm pronation is controlled through voluntary activation of the antagonist muscles.31,32 In some cases, separate grasp patterns are provided with these functions (eg, lateral grasp without elbow extension and lateral grasp with elbow extension). Stimulation of pectoralis (Pec), supraspinatus (SS), and rhomboids was performed to provide shoulder stabilization during reaching movements.
Stimulation produced active extension and flexion for all five digits in all 15 arms studied. As shown in Figure 1, the median total range of motion for the fingers varied from 105° for the long finger to 41° for the small finger. The median range of motion for the thumb was 41°, noting that, for most hands, the thumb IP joint range of motion was limited surgically. No subject had any active movement in their fingers or thumb when the stimulation was turned off.
Stimulated range of motion for all 15 hands in the study. Each region represents the median joint range of motion obtained in the study. Movement was obtained for the proximal two joints in all digits for all hands. Range was recorded with the wrist splinted in neutral and stimulation of the lateral (thumb range) or palmar (finger range) pinch. CMC = carpometacarpal joint; DIP = distal interphalangeal joint; MP = metacarpal phalangeal joint; PIP = proximal interphalangeal joint.
There was a significant difference in grasp strength with the neuroprosthesis turned on compared to off for both lateral and palmar grasp for all 15 arms evaluated in this study (p < .0001), as shown in Figure 2. Additionally, there was a significant difference in postsurgery strength with the neuroprosthesis turned off compared to presurgery measurements for both lateral (p = .0043) and palmar (p = .0094) grasps. Three arms displayed mildly decreased strength (less than one-half pound) in lateral grasp post surgery with the neuroprosthesis turned off compared to pre surgery. Similarly, three arms showed mildly decreased (less than one-third pound) palmar grasp post surgery.
Lateral and palmar grasp force obtained for all 15 hands in the IST-12 study, with comparison to the Freehand cohort.11 Black line indicates the median and the boxes represent the second and third quartiles. Every hand improved in pinch strength with the neuroprosthesis. Pinch strength without the neuroprosthesis is generally due to passive tenodesis grip. NP = neuroprothesis.
The strength data from the IST-12 were compared to strength data collected in the clinical trial for the Freehand System.11 Figure 2 shows the comparison of strength from 50 arms with the Freehand System and 15 arms with the IST-12 device. The strength due to the stimulated grasp patterns is similar for either generation, whereas the IST-12 cohort had significantly stronger lateral and palmar strength prior to intervention and after surgical intervention with the stimulation turned off.
Figure 3 shows the number of objects each person in the IST-12 study was able to successfully manipulate or "pass" prior to surgery and 3 months post surgery with the neuroprosthesis turned on and off. Out of 15 arms tested, all but one were able to pass at least two objects (92%) of the six possible prior to surgery, and one subject could pass four of the six objects prior to surgery. Three months post surgery, all participants could pass at least five out of the six possible objects with the neuroprosthesis turned on. Eight participants passed all six objects (62%) and five participants passed five of the six objects (38%). The objects most often failed included the two heaviest objects – the weight (three cases) and the tape (two cases). Most of the participants passed the same number of objects post surgery with the neuroprosthesis off compared to pre surgery. However, three of the 13 participants passed one additional object and one of the 13 participants passed two additional objects. Three of the four participants who made improvements also had a voluntary tendon transfer of Br-FPL between the presurgery and postsurgery testing. The other participant had the same tendon transfer prior to study entry. The number of objects passed when participants used the neuroprosthesis exceeded the number passed by the participants with the Br-FPL transfer.
Grasp and Release Test results of the 15 IST-12 arms studied. Using the neuroprosthesis (NP), all 15 arms could pass at least five of the six objects, whereas only one hand could pass as many as four objects prior to implantation (or after implantation with the NP turned off).
The adverse events experienced in this series of subjects are summarized in Table 3. In the single case of the stimulator infection, no outward signs of infection were apparent. The subject was undergoing a surgical procedure to reposition the implant. Upon surgical exposure, the tissue capsule around the implant was brownish in color and a culture revealed a low-grade infection. The implant was removed with the proximal portion of the leads distal to the connector site, and the area was allowed to heal. The infection resolved without any further treatment. This subject had experienced a trauma to the implant region secondary to being dropped during a wheelchair transfer on an airplane and experienced significant bruising near the implant. This incident may have contributed to the subsequent infection. The incident occurred 18 months after the original implantation of the device.
Summary of adverse events
One subject had an episode of cellulitis in his dorsal forearm. The cause for the cellulitis was unknown and, as a precaution, the five electrodes that were positioned in the subject's dorsal forearm were removed, including the leads extending into the upper arm. The infection subsequently resolved. The volar electrodes and implanted stimulator remain implanted in that subject with no further incident. This subject also has an implanted device in the opposite arm, which remained unaffected.
In one subject, the leads exiting the implant appeared to be very superficial as they crossed over the top of the deltoid muscle. Due to concern that one or more of these leads might erode through the skin, a preemptive procedure was performed to re-route the leads more caudally and less superficial. This procedure was performed within 2 months of the initial implant, and no further incident was encountered.
One IST-12 device stopped responding after 3 years. The device has not been removed and the cause of this failure is unknown at this time.
Revision surgeries were performed in eight of the 15 arms, as outlined in Table 1. The revision procedures for subjects A, I-R, and J-L have been previously discussed.19 Three of the eight procedures involved revising either stimulation or recording electrode locations to improve functions, and three involved procedures to refine the passive positioning of the fingers or thumb.
This study confirms the high success rate for neuroprosthetic approaches in the upper extremity. In our cohort of 15 arms across 13 subjects, a useful hand grasp with significantly increased pinch force and range of motion was achieved in every arm with the IST-12 neuroprosthesis. These results match the results obtained with the earlier generation of neuroprosthesis, where 100% of that cohort also achieved increased grip strength.11 The high success rate is due, in large part, to the fact that subject screening using surface stimulation25 is a good predictor of functional movements. In addition, the technology has a predictable and well-characterized effect on muscle contraction, and the coordination of electrical stimulation into purposeful movements is a well-established process.30 This is in contrast to implanted devices that rely on neuromodulation approaches, where the mechanism of action is not precisely known, such as spinal cord stimulators. These devices tend to have success rates of approximately 50%.33
A key improvement in the second-generation neuroprosthesis was the use of an implanted control source, specifically MES. The results of this study demonstrate that implanted MES control in neuroprostheses is a viable and highly desirable option. All subjects were able to control grasp opening and closing proportionally, using one of their MES channels, typically the wrist extensor. It was possible to obtain a usable MES during stimulation in all subjects. Our study also demonstrates that MES can be recorded from implanted recording electrodes during stimulation of nearby muscles. For example, myoelectric signals could be recorded from the ECRL during stimulation of the extensor digitorum communis (EDC) where the stimulating and recording electrodes are within 5 cm of each other.
The use of myo electric control in neuroprostheses allows considerable flexibility in the control algorithms that can be utilized. In this series of subjects, performance could be improved by customizing the control scheme for each subject. A principal consideration regarding the command control scheme was to make maximal use of muscles with voluntary function. Whenever possible, muscles that are synergists to the function to be provided serve as the control muscle in order to make the control scheme easier to learn. Specifically, in the case of C6 level SCI, the wrist extensors, which are under voluntary control, are direct agonists to grasp closing. Therefore, by using the MES from the wrist extensor to proportionally control grasp closing, a very natural augmentation of the tenodesis function can be achieved. We have previously demonstrated that proportional MES control of grasp provides improved function over other forms of control.18 All control signals are derived from ipsilateral muscles, thus enabling bilateral function to be provided in the future by implementing the system in the contralateral limb. All three subjects implemented with bilateral systems demonstrated the ability to independently control each arm. These results indicate that implanted myoelectric control is a very desirable option for neuroprostheses. Even if other forms of control can be developed (eg, brain–computer interfaces), MES can provide valuable control options for implanted systems.
The study results indicate that every subject improved significantly in pinch force strength. In all cases, the presurgery pinch force was achieved by passive finger and thumb tone augmented with wrist extension. For most subjects, this pinch force is only useful for acquiring light objects, such as a piece of paper. With the neuroprosthesis turned on, pinch force typically doubled or tripled. Most participants also gained pinch force from a tendon transfer and therefore had stronger pinch force even with the neuroprosthesis off after surgery. A small number of subjects had minor decreases in their postoperative pinch force with the neuroprosthesis off, and this is due to a change in hand posture as a result of exercise from the neuroprosthesis.
As demonstrated by the Freehand study results, stimulation of eight forearm and hand muscles can be sufficient to provide functional grasp patterns. The additional channels provided by the IST-12 system provided enhanced opportunities for function. Pinch force results show a trend toward increased grip strength with the IST-12, but a larger cohort would need to be evaluated to establish this. In some cases, intrinsic muscles have been included to enhance the strength of finger flexion. The addition of elbow extension via triceps stimulation is highly desirable to all subjects. Finally, the opportunity to place multiple electrodes in a single muscle allows for later selection of an electrode that gives the best response, further enhancing the function obtained.
Concomitant surgical interventions are a key component in the implementation of neuroprosthetics for upper extremity function.8 These include tendon transfers of muscles under voluntary control, providing function even when the neuroprosthesis is off, as well as tendon transfers of paralyzed muscles to enhance the function obtained from the neuroprosthesis. Other surgical procedures are generally targeted to restoring the passive balance of the hand and arm in order to improve grasp function.
The two most common tendons transfers of voluntary muscles are a transfer for elbow extension (using either posterior deltoid [PD] or biceps [Bi]) and transfer of Br to ECRB for subjects with weak or no wrist extension. One of the primary goals of the Freehand trial was to demonstrate the benefit of the neuroprosthesis alone, and therefore subjects in that trial did not receive tendon transfers that would affect finger or thumb function, allowing clear direct assessment of the impact of the neuroprosthesis. However, with this benefit clearly established, we removed this restriction in the IST-12 trial. As a result, in the IST-12 series, 47% of the arms underwent a Br to FPL tendon transfer, which provided a degree of active on pinch even with the neuroprosthesis off. This is demonstrated by the significant increases in pinch force for the IST-12 cohort with the neuroprosthesis off (Figure 2). In addition, the voluntary use of the FPL could be coupled with the stimulated grasp, allowing subjects to have finer control of thumb positioning. In these transfers we did not disconnect the FPL tendon and therefore, in most cases, we also placed an electrode on the FPL muscle for stimulation. Thus, the Br was used as a tendon transfer donor in 12 of the 15 arms instrumented.
The most significant change in emphasis with respect to the surgical procedures is the reduction of extrinsic finger tendon synchronizations and procedures to restore passive balance to the intrinsic minus hand. In the Freehand cohort, there were 34 of these procedures performed in the 15 arms, whereas none of these procedures were performed in the IST-12 cohort. With respect to the finger synchronization procedures, the goal was to have all four digits close simultaneously or in a cascade (index first, small last). Performing these procedures at the time of electrode placement often provided less than optimal results. It was difficult to balance the active and passive forces at the time of surgery while also placing electrodes on muscles that were not fully exercised. In addition, the healing process for the tendon transfers complicated the postsurgical electrical stimulation protocol, sometimes resulting in tendon adhesions. In the IST-12 cohort, we opted to place the electrodes without synchronization procedures, conduct a period of conditioning to build muscle strength, enable the subject to use the hand functionally, and then make a determination as to whether a follow-up synchronization procedure was necessary. In practice, such a follow-up procedure was not deemed critical in any of the arms studied. We often focused one of the finger flexor electrodes on the index finger to ensure full flexion of that digit. However, as illustrated by the range of motion data, the IST-12 cohort had less range of motion in the small finger. Thus, if additional channels were available, targeting a muscle such as the abductor digiti minimi might be of benefit.
The additional four electrodes with the IST-12 is one contributing factor to the significant reduction in augmentative procedures. The addition of the finger intrinsic muscle activation reduced the need for procedures such as Zancolli lasso or the FDS intrinsicplasty. These procedures were found to be difficult to properly balance and therefore we proposed that a better approach was to place the electrodes to evaluate the need for any subsequent fine-tuning procedures. In practice, few such procedures were performed and only included a procedure to tighten the extensor slips (ring, small) in one arm and a thumb MP capsulodesis and pinning procedure in another arm.
Joint stabilization procedures have also evolved over time. Based on our experience with earlier percutaneous systems, we found that some form of thumb IP joint stabilization was required in order to achieve strong thumb pinch against small objects. This is primarily due to the strong IP flexion activity of the FPL, which is a key thumb flexor. Force generated by the FPL tends to preferentially produce IP flexion. If the tip of the thumb presses against the lateral aspect of the index finger, this strong IP flexion force will create a gap between the surface of the thumb and the flexed index finger. Small objects placed in such a grip will be relatively unstable as, unless they are placed directly under the thumb tip (generally difficult to maintain), very little of the thumb flexion force is directed through the object. If the IP joint is stabilized in full extension (or slight flexion of ~15 degrees), then the thumb flexion force is transmitted directly through small flat objects and the grip on those objects becomes much more stable. Although it should be, in principle, possible to co-contract the FPL and EPL to balance forces across the IP joint and maintain the joint in full extension, in practice we found that this could not be reliably achieved with stimulated muscles. Further, such delicate balances of force cannot be maintained throughout the day as muscles fatigue at different rates based on usage and physiological properties. As a result of these considerations, we sought a surgical approach to stabilization of the thumb IP joint. As Table 2 illustrates, our initial approach was to do a direct thumb IP arthrodesis. This procedure was successful, with no complications in our series, and it was performed routinely. Some subjects were concerned, however, about the loss of movement in that joint. We migrated from this procedure to the FPL split procedure, as described. This has produced the desired results and was performed in 40% of the arms receiving the IST-12 system. In one subject, we subsequently performed an IP arthrodesis because the FPL split transfer stretched out over time and was no longer providing sufficient IP stability. The FPL split is thus a highly recommended procedure for neuroprosthetic upper extremity systems and allows for later IP arthrodesis if necessary.
Infection remains the primary concern with respect to adverse events. Infection requires removal of the infected components. To date, there has not been a case of infection that required removal of the entire system. There was also one case where a revision surgery was performed over concern that a lead was too superficial. These incidents are consistent with the Freehand System experience and with the experience of similar implantable medical devices.11,34,35
The durability of the technology was very high. One stimulator stopped working after 3 years. There have been no cases of electrode lead failure in this cohort. Two cases of intermittent connector function were resolved by replacing the connector assembly in a revision procedure.
Upper extremity neuroprostheses have been shown to provide increased function and independence for cervical level SCI. This study demonstrates that an implanted neuroprosthesis utilizing MES-controlled stimulation allows considerable flexibility in the control algorithms that can be utilized. Improved active range of motion, grip strength, and the ability to pick up and release objects were improved in all arms tested. Adverse events were few and were consistent with the experience with similar active implantable devices. For individuals with cervical SCI who are highly motivated, implanted neuroprostheses provide the opportunity to gain grasp function that cannot be gained through the use of orthotics or surgical intervention alone.
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This work was supported by National Institutes of Health National Institute for Neurological Diseases and Stroke (NINDS) R01-NS-29549 and N01-NS-5-2365; by the Department of Veterans Affairs Rehabilitation Research and Development Service Merit Review A6027R and A3707R; and by the US Food and Drug Administration Orphan Products Division FD-R-002389.
Supplementary material: The online version of this article contains the eTable.
© 2018 Thomas Land Publishers, Inc.
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Exercises With Optimal Scapulothoracic Muscle Activation for Individuals With Paraplegia
Linda M. Riek, PT, DPT, PhD, Amy Aronson, DPT, Kacie Giust, DPT, Samantha Putnam, DPT, Hannah Froese, DPT, Sean Rutherford, DPT, Mary Kathryn White, DPT
Transcutaneous Spinal Stimulation From Adults to Children: A Review
Goutam Singh, PT, PhD, Kathryn Lucas, PhD, PT, Anastasia Keller, PhD, Rebecca Martin, OTR/L, OTD, CPAM, Andrea Behrman, PhD, PT, Sergey Vissarionov, PhD, Yury P. Gerasimenko, PhD
Identifying Body Awareness-Related Brain Network Changes After Cognitive Multisensory Rehabilitation for Neuropathic Pain Relief in Adults With Spinal Cord Injury: Protocol of a Phase I Randomized Controlled Trial
Ann Van de Winckel, PhD, MSPT, PT, Sydney Carpentier, BA, Wei Deng, BS, MS, Sara Bottale, PT, Timothy Hendrickson, MS, Lin Zhang, PhD, Rob Wudlick, BS, Clas Linnman, PhD, Ricardo Battaglino, PhD, Leslie Morse, DO
Telepsychology for Individuals With Spinal Cord Injury: Protocol for a Randomized Control Study of Video-Based Cognitive Behavioral Therapy
Elizabeth Pasipanodya, PhD, Cria-May Khong, BS, Benjamin Dirlikov, MA, Michael Prutton, BS, Mark Held, PhD, Kazuko Shem, MD
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We have an exciting opportunity to join our well established teacher training programme. KGS Drama department is committed to ensuring our trainees become the best teacher they can be.
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Nestled amongst the quiet foothills of Mount Kinabalu about 2 hours drive from Kota Kinabalu is the Dusun village of Sayap. Since 2015 Sticky Rice Travel has been assisting Sayap Village in establishing community based tourism as an alternative livelihood for local community members. The result of this so far is the establishment of 7 homestay families who are now able to provide lodging for tourists wanting experience what life is like in a rural Dusun community.
Few places in Sabah offer the raw cultural immersion that the Sayap Village Homestay program is able to provide. The concept of tourism is still quite a novelty for the local community, whilst the majority of people lack english speaking skills their friendliness and hospitality is incredibly humbling and they always find a way to make do.
Simple, clean private rooms with single and/or queen bed(s) with linen and blankets. Ceiling and/or stand fan are available in each room – no air conditioning needed as temperature is pleasantly cool at night. All communal toilet & shower.
Your host family will provide delicious but simple meals cooked with fresh produce supplied direct from the village – vegetarians and special diets catered for.
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The village is located about 1-1.5 hours drive from Kota Belud town nestled amongst the foothills of Mount Kinabalu and is surrounded by agricultural land and forested hillsides.
Pick-up at your hotel at 9.30am and drive for 2 hours to Sayap Village, stopping at points of interests along the way. Meet your host and check-in upon arrival and enjoy lunch at the local homestay with your host family. After lunch, your guide and host will introduce you to the ways of life in a local Dusun village. The Dusuns are the biggest ethnic group in Sabah, most living subsistence lifestyles in terms of agricultural farming which includes rice, fruit and vegetable plantation. Spend the day exploring the village farmlands and pick your own fruit (coconut, pineapple, tarap and other local seasonal fruit) to enjoy fresh or bring back with you to your homestay where you can learn how to cook a local dish, make fruit jam or ferment it. A traditional Dusun dinner will be served at your host's home in the evening.
Wake up early and join your host family and local villagers in the rubber plantations where you will learn about tapping rubber and see if you can master the skill. Return back to your homestay where you will enjoy breakfast and prepare a day pack for a nature hike to explore the nearby primary montane rainforest.
You will travel a short distance from the village to the Sayap Substation that lies along the boundary of Kinabalu National Park. With an extensive network of trails, this hidden oasis allows you to experience montane forest, an abundance of bird life, and a refreshing swim along the cascading Kemantis Waterfall that flows through the substation area. A picnic lunch will be served along with some spare time to soak up the serenity before returning back to Sayap Village.
Upon your return to your homestay you will learn how to catch locally farmed freshwater fish using the traditional methods of the Dusun people. In the evening, enjoy another scrumptious dinner and farewell ceremony with your host.
Wake up early and enjoy morning breakfast cooked by your host. Depart to Kota Kinabalu at 9.00 am and expect to arrive by 11 am.
Return land transfer form Kota Kinabalu pick up and drop off can also be arranged at Kundasang, accommodation, meals as specified in programme, Sticky Rice Travel nature guide and local host, activities as specified in programme, drinking water, coffee & tea, snacks, and community fee.
Additional meals and beverage not specified in program, and tips or gratuities for guides & homestay owners.
Hat, sunscreen, camera, towel, change of clothes.
Daily based on minimum 2pax.
Perfect for adventurers looking to get off the beaten track to get a taste of what life is like in a rural community in Sabah and experience the heart warming hospitality of Dusun people.