The January blues hit us all. Christmas has been and gone, Easter is still a few months away, and maybe the only festivity you've got coming up this month is your brother's birthday. It's a quiet and slow time, and it's a time that you're probably feeling a bit bored over.
But you can always make changes to combat feelings like these, seeing as January is a great time to do a bit of retail therapy… there's sales everywhere, and shops are opening up earlier and longer to try and make a bit more money. So why not take advantage of this? Here's a couple of gifts out there that are going to do the most legwork for making you feel better this wintery season.
It's not just you feeling bored this season, there's a very good chance the rest of your family is as well! And if you've got a young family around you, especially toddlers or kids in their early teens, let's make sure they've got something to look forward to over the next couple of weeks! Hey, the more time you spend with the people you love most in the world means the better distracted you'll be from the blue feelings flowing through you right now.
Maybe it's time to go to Disneyland? Maybe it's time to head over to central or greater London and spend a couple of nights in a hotel to make sure you take in all the touristy sites whilst you're there? Maybe you need to take a city break in paris, to introduce your kids to fine dining and foods they would never see on their school lunch menus?
Jewellery is something everyone out there loves, whether you're a casual wearer at formal events only, or someone who's always decked out in their finest pearls, and love to colour coordinate their accessories and their outfits. Not to mention, jewellery can be a great investment, and if you know how to pick them, there's always some expensive pieces out there going cheap in antique stores.
Maybe you could even have a search through your own collection, to see if you can make any extra money right now? Or you can head online, if you don't fancy leaving your comfy armchair right now. Companies like Opals Australia have some great gifts for anyone who loves having their necks, ears, and fingers sparkle.
There's lots of good books out there, and if you're someone who loves reading, it's time to pad out your bookshelf just a little bit more. You're always hungry for more and more words, and you've got some downtime right about now, so let's make sure you've got a good fantasy world to get stuck into!
For January, make sure you're making investments that will keep paying you back for the rest of the year. You've got some time and money right now!
My youngest has been getting fed up this weekend because we've been stuck indoors due to the weather. I'm hoping to do something fun with them next weekend to make up for it. God knows we all need it!!
So much agree! Can't wait for spring!


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Home Tag "featured"
World War II Vet From Ann Arbor Receives Purple Heart 75 Years After Combat Injury
During World War II, Tony Procassini was pinned down with fellow soldiers, praying the Japanese shelling would miss. It did, but not by much.
Space Force: What Is It Good For?
Some Space Force advocates see a future where space power is the central means of enforcing peace on the planet and within the galaxy.
Special Public Health Services for the Elderly, Prisoners and Refugees
Expert: Older adults, prisoners, and refugees are considered special given the unique elements of their health and well-being.
Man Faces Second Sentence In Charlottesville Car Attack
A man sentenced to life in prison on federal hate crime charges in Virginia is set to face a state judge who could add another life sentence, plus 419 years.
As Neighborhood Brigades Patrol the Streets, No Signs Of ICE Raids In Chicago
Immigration advocates in Chicago, who had braced for raids by ICE this weekend, said all was quiet for now.
Sudan Military Council Says It Foils Attempted Military Coup
Sudan's ruling military council said it foiled an attempted military coup, just days after the military and a pro-democracy coalition agreed on a joint sovereign council to rule the country during a transition period until elections are held.
Boris Johnson Says He's Not To Blame For Ambassador's Ouster
Boris Johnson denied playing a role in the departure of Britain's ambassador to Washington, who quit after coming under attack from President Donald Trump.
Joe Biden promised to end "forever wars" and reassert American leadership to combat authoritarianism and global instability, which he says are proliferating under President Donald Trump.
Otto Warmbier's Parents Sue For North Korean Cargo Ship To Pay Down $500M Court Judgment
The parents of Otto Warmbier have filed a claim for a North Korean cargo ship that was seized by the US in May, saying it could be used to pay off some of the $500 million owed to them for their son's death.
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Secwépemc land defenders convicted for protecting ancestral lands
BC's courts continue enforcing injunctions to suppress resistance to the Trans Mountain Pipeline, advocates say
Fernando Arce
At 46-years-old, April Thomas isn't worried about facing jail time simply for defending her right to hold ceremony on her unceded ancestral lands.
"I could probably get all the reading done that I wanted to get done," said the Secwépemc matriarch and grandmother who – along with three others – was convicted on December 7, 2022, of criminal contempt for breaching a Trans Mountain Pipeline Expansion (TMX) injunction in Kamloops' Supreme Court, in British Columbia. Four others – including non-Indigenous allies – faced trial from December 12 to 16.
"A lot of good things could happen … even if I am incarcerated. I just think that whatever happens, I got put on this path for a reason."
If anything, she told the Media Co-op from her residence in Kamloops, this will help spread more awareness among Indigenous peoples and settlers of how Canada's government, via the courts, uses injunctions at the behest of corporations like TMX to suppress resistance.
"People are starting to understand the effect that these [Mutual Benefit Agreements signed between certain reserve leaders and TMX] and the selling of our land and resources – the impacts they have, not just on me, but on our land and our Title," she said.
Original arrest
Thomas and the others were first arrested two years ago, on October 15 and 17, 2020, in the middle of water and hair-cutting ceremonies, respectively, at Sqeq'petsin, near the Thompson River and within the area covered by TMX's injunction.
A December 5 press release from grassroots group "We, the Secwepemc: Virtual Unity Camp to stop Transmountain Pipeline" states that on Oct. 15, RCMP officers attended the ceremony "despite having no clear jurisdiction in Secwepemc Nation … and immediately began threatening arrest without making any attendees aware of the injunction."
A similar scene is described on October 17, when a "team of all male" RCMP officers arrested the women performing the hair-cutting ceremony.
Secwépemc Matriarch Miranda Dick and her sister in a hair cutting ceremony at the TMX drill site, in October 2020. Photo: We, the Secwepemc (Facebook)
A day after Thomas' conviction, Kamloops Weekly reported that Justice Shelly Fitzpatrick found the four had knowledge of the injunction ahead of time and had gone with the intention of violating it.
Citing evidence given by the Crown, the report says Fitzpatrick found one of the defendants had intentionally zap-strapped herself to a bulldozer during working hours to "disrupt the activities as much as possible."
The report goes on to say Thomas had also been taken into custody after sitting on bulldozers across the road.
Convicted in absence
Thomas, who was the designated court support person for the rest of the defendants, never had the chance to voice her closing arguments – she was absent when the trial concluded due to the death of her sister a few days prior. On the first day of the trial, December 5, Thomas was still cleaning her sister's house and burning her belongings as part of a Secwépemc tradition.
By December 7, the day of their conviction, a bench warrant was issued for Thomas despite the rest of her co-accused – all of whom were self-representing – asking for a few days' adjournment time.
"To me, the whole situation was odd (because) I couldn't be there because of my mental, physical and spiritual state at that time – we had just buried my sister," she says.
"And the judge just had zero compassion for what I was going through and…proceeded without me and, in the end, found me guilty even though I wasn't there to represent myself. ... But at that point, I was just so distraught that I didn't even care if they did come and arrest me and put me in jail."
The trial, which had begun back in October, had been adjourned after Thomas collapsed during court due to what doctors later diagnosed as a non-cardiac arrest.
Thomas and her co-accused – Secwépemc Hereditary Chief Saw-ses, Billie Pierre of the Nlaka'pamux Nation and Romilly Cavanaugh, a former Trans Mountain environmental engineer – are set to be sentenced in February 2023.
The Crown is asking for three to six months in jail for Pierre and two to four for Thomas. Chief Saw-ses could be sentenced to one to three months.
No jurisdiction
Thomas says the intention was never to protest anything but to hold their ceremonies within their unceded territory.
She says no one was working when they got there, though she admits that unbeknownst to her, some of the others began zap-strapping themselves to work equipment.
She says when she decided to sit on the bulldozer, it was after the others had already begun the unexpected protest and was done to protect her friend, because the operator was starting the bulldozer while one of them was strapped to it.
Nevertheless, she says, everything they were doing was within their legal rights as Indigenous Title Holders of the territory.
"We have Aboriginal rights and even under Canadian laws, we also have a right to protest," she said.
According to the Kamloops Weekly article, Fitzpatrick said the fact the lands are unceded are not a defense against criminal contempt charges.
But that's not cutting it for Thomas, who says the government lacks "proper authority and jurisdiction to … impose an injunction on our territory without consulting and getting the collective consent of the proper and rightful Title Holders."
"It is us who write our own laws, and us who make laws on our own territory, and we're the ones who determine it," she said.
"Our laws supersede (Canada's) laws, and that's been upheld right up to the United Nations level. But it's Canada who is not upholding it."
Billie Pierre being arrested on October 15, 2020. Photo: We, the Secwepemc (Facebook)
A co-opted tool
According to First Peoples Law, a law firm dedicated to advancing Indigenous Peoples rights, "courts are increasingly reluctant to grant injunctions to Indigenous groups where the result would be to halt or delay a proposed project."
"The result is to transform the injunction from a tool used by Indigenous people to protect their lands and rights to one which suppresses Indigenous opposition and denies the exercise of Indigenous law."
Since the injunction was granted in 2018, until February 2022, there were more than 248 people arrested for contempt while protesting the TMX, according to advocacy group Protect the Planet StopTMX. Nine-six people have been handed varying jail sentences, including three on house arrest. There has been one acquittal.
In a very similar case to Thomas', in December 2020 Fitzpatrick found Indigenous Elder Jim Leyden guilty of breaching the injunction. It was Leyden's second conviction. And in May of this year, Fitzpatrick sentenced Tsleil-Waututh Nation member and Burrard Inlet protector William George to 28 days in jail for violating an injunction from 2021, the Toronto Star reported.
Freelance journalist and activist Kris Hermes has previously provided legal support to Indigenous land defenders fighting TMX and helped compile the data cited by Protect the Planet. In a piece published in Briarpatch magazine in 2021, Hermes wrote that Leyden's conviction and the "most recent verdicts from Fitzpatrick set a chilling precedent on how the Crown can handle these contempt cases, without even the presence of police or an order to disperse."
"Leyden's conviction represents a new strategy by TMX and the Crown that skirts established Crown policy on civil disobedience and ruthlessly targets Indigenous land defenders," he wrote.
Thomas, who was attending university to prepare for law school, says she feels the government is targeting her to suppress both her activism and education.
"Why would I get arrested and jeopardize all that?" she said. "I know that I was targeted, that their intent was to criminalize me so I can't go to law school."
Sowing division
In his piece, Hermes bluntly noted that BC's government – "in the robes of Crown Counsel – is working at the behest of TMX" by indiscriminately enforcing the injunction.
Liberal Prime Minister Justin Trudeau bought the pipeline in 2018 for $4.5 billion, after its original owner (Kinder Morgan Inc.) withdrew funding due to the mounting resistance in spite of the injunction orders.
Trudeau has said the government is open to Indigenous participation/ownership of the pipeline once completed. Several for-profit and nonprofit Indigenous-led groups have expressed interest, some even despite the fact that construction costs have ballooned upwards of 70 per cent, to $21.4 billion, the CBC reported in March.
Nesika Services, an Indigenous non-profit organization seeking ownership stake in the pipeline, said 14 Indigenous communities who would be affected in Alberta and BC have already signed on.
The government has identified 129 communities that will be affected, and Nesika chair and founding director, Chief Tony Alexis of the Alexis Nakota Sioux Nation in Alberta, said the organization is in the process of contacting them all.
But Thomas says the NDAs signed by a few band leaders in exchange of "contracts" and "fringe benefits," have sowed division between them and the larger off-reserve grassroots opposition to it.
"They're taking all this money for governance and claiming that they're doing it under traditional authority. And the way they're doing that is paying off a lot of people who claim to be spiritual and claim to be hereditary in nature, and they're further dividing our people and misrepresenting us," she said.
According to Statistics Canada, in 2016 there were 820,120 Status First Nations people in Canada. Of those, only 40 per cent (331,025) lived on reserve.
Struggling together
Thomas is prepared to do her time, knowing the fight against the TMX will continue regardless of where she is, and that she will rejoin it as soon as she's out.
She says despite the struggles, she is counting on the mounting and growing support for the resistance, even from settlers.
"They just want to help because they're women, they're mothers, people of colour – they're all kinds of people who are being systematically oppressed by these patriarchal systems," she said.
"So, I think a lot of people are starting to wake up … because a lot of people are struggling and suffering, and the only way we're surviving is helping each other. And the more people realize that, the better we'll be."


Start-up businesses aren't the only ones who need individuals with new ideas, the passion to act on them, and the drive to follow through to realization. Established companies—especially the largest and most established out there—are always looking for a transfusion of this type of vibrant, vigorous blood in any new hire.
Especially in recent years, the most forward-thinking companies are working to create an environment where employees are free to explore their own ideas. There are many reasons for this: a company may want to prevent growth from leveling off on a plateau, or give it a boost if it's already on the decline. Another reason is to keep pace and compete with nimble, innovative startup companies that thrive on new ideas and can capitalize on them quickly.
Which means that ESTEEM is not just for entrepreneurs looking to strike out on their own—rather, skills in identifying and outlining the commercial possibilities of scientific ingenuity are highly valued by any prospective employer. Whether you're looking for the next stage in your career, or hoping to break in to the tech workforce, business skills and experience with innovation will be the advantage that makes all the difference, be you entre- or intrapreneur.


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Hidden History of Kansas
By Adrian Zink
Kansas' storied past is filled with fascinating firsts, humorous coincidences and intriguing characters. A man who had survived a murderous proslavery massacre in 1858 hanged his would-be executioner five years later. A wealthy Frenchman utilized his utopian ideals to create an award-winning silk-producing commune in Franklin County. A young boy's amputated arm led to the rise of Sprint Corporation. The first victim of the doomed Donner Party met her end in Kansas. In 1947, a housewife in Johnson County, indignant at the poor condition of the local school for black children, sparked school desegregation nationwide. Author and historian Adrian Zink digs deep into the Sunflower State's history to reveal these hidden and overlooked stories.
Hidden History
Adrian Zink is a native Kansan who has worked in the history profession for over fifteen years at a variety of museums, universities, archives and historic sites. Born and raised in Larned, he holds bachelor of arts degrees in history and political science from the University of Kansas, a master's of library science from the University of Maryland and a master's in history from the University of Wisconsin–Milwaukee. He currently works at the National Archives–Kansas City. He has previously worked at the Kansas Historical Society, UW–Milwaukee Archives, the National Press Club Library and Archives in Washington, D.C., and at the University of Kansas Natural History Museum. Adrian and his wife, Toni, have two children and live in Overland Park, Kansas. This is his first book.


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Senate Committee Unanimously Passes Bill to Stop Online Sex Trafficking
Washington, DC – Today the Senate Commerce Committee voted unanimously in support of the Stop Enabling Sex Traffickers Act (S. 1693). This legislation would amend Section 230 of the Communications Decency Act (CDA) to protect victims of online sex trafficking and empower state law enforcement officials. The National Center on Sexual Exploitation applauds the action of the Commerce Committee and calls on the full Senate to move swiftly to pass the bill.
"With today's unanimous vote of the Senate Commerce Committee, Congress is one step closer to passing the most important anti-trafficking legislation in nearly twenty years, said Lisa L. Thompson, Vice President of Research and Education at the National Center on Sexual Exploitation. "There is no change to federal law more urgent and necessary to fighting sex trafficking than a strong, but narrowly crafted, amendment to the Communications Decency Act."
"We join with victims, judges, U.S. Attorneys General from 48 states, anti-trafficking advocates, and Oracle in calling on the U.S. Congress to act without delay to pass meaningful reform to the CDA," Thompson added.
To learn more about the Communications Decency Act visit endsexualexploitation.org/cda.
BREAKING: Credit Card Companies Still Funding Pornhub via MindGeek's TrafficJunky
No, Pornhub Cannot Be Improved or Reformed
NGOs Urge Congress to Provide COVID-19 Relief to Trafficking Survivors
CDA | Communications | online sex trafficking | SESTA | sex trafficking | Stop Enabling Sex Traffickers Act
Please direct press inquiries to press@ncose.com or 202-393-7245.
You can download our 2017 Press Kit here.
Speaker / Interview
Need expert testimony on the dangers of sexual exploitation? Request NCSE for an interview or presentation, here.


If you are living with a disability, or a chronic illness like multiple sclerosis, how do you choose to approach life?
Some people will say "You must" or "You must not" do this, that, or the other. But, in my opinion, they are wrong. I will only urge you to do certain things, no more. No, 'you must' or 'you should'. Not from me.
We are all individuals and need to form our own opinions and make our own decisions. The human race is not an actual race, not a contest. We are each unique and do not benefit from comparison to other people.
Therefore, what follows is not a list of rules to follow. They are just things that I do, that I would urge you to consider.
Focus on what you can do – and do it. I put what I can no longer do where it belongs. By that, I mean as a happy memory from my past.
Keep calm. By that I mean, when faced with a problem or difficulty, I think about how to overcome it. It's important not to panic, I take my time and think my way through it.
Don't worry too much about the future. Sure, if there is anything that can be done to make life better, then by all means I'll do it. However, in the words of an old song, "Whatever will be, will be, The future's not ours to see", so there is little point worrying about it. Perhaps it would be better to consider what we do with our lives now, rather than what might, or might not, happen in years to come.
Live life to the full. I grasp every opportunity that presents itself. In the past six years, I have divorced and remarried; gone to the most northern point of mainland Europe; visited Hawaii, New York, and Moscow; crossed the Atlantic by cruise ship; and moved to live in Spain. There's an adage in the business world that is perfect for us. And that is not to see problems as insurmountable obstacles but as opportunities to be taken. In other words, turn a negative into a positive.
Live your life as you want to live. While I urge you to live positively, ultimately how you live your life is your own decision.
Accept the love of those nearest and dearest to you, and make sure you show your love for them in return. Think about it for a moment, where would we be without their support?
No man is an island, so the saying goes, and that is true. Whether or not you have a disability, isolation is not an easy choice. While I prize my independence, as I am sure you do, sometimes I do need help. You will too. At such times, we don't need to be too independent or proud to accept assistance – or even ask for it.
Live your life, speak your truth. While speaking out will come easer to some than others, it is important that we speak for ourselves. We need to be our own advocates; no one else can do it as well as ourselves.
← New Year resolutions: Do we want or need them?
Well said. You must be a journalist! Happy New Year to you too.!


Two boxers square up in the ring in front of the arcade machine.
A top boxing coach has turned to technology to improve his fighters' performances by making them play computer games.
Champion boxing manager John Rooney Jr took the unusual step of installing arcade machines in his gym to improve the reactions of his fighters.
John, who coached Steve Collins to WBO Super Middleweight championship glory, encourages his fighters to play violent 'beat 'em up' Tekken Tag Tournament 2 at Rooney's Gym in London.
He reckons playing the fast-paced fighting game improves reflexes and hand-eye coordination – two key boxing skills.
John said: "It's one thing to get your body fit but it's equally important to train the mind as well.
"I know a number of boxers who play fighting games like Tekken and I was surprised to see a noticeable improvement in their reflexes and hand-eye coordination.
"We've installed the arcade machine in Rooney's gym as I am a firm believer in video games and the benefits they have for fighters' reflexes and reaction times.
Computer games and athletes have a chequered relationship.
Usain Bolt unwinds by playing Call of Duty online with his cousins, while former England keeper David James once blamed a spate of poor performances on playing too much Playstation.
Tekken Tag Tournament 2 is out on now.


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Throughout your working years, you built your pension as you and your employer contributed to the CAAT Pension Plan. Now is the time to enjoy your retirement, secure that you have a reliable stream of pension income that will be paid to you for the rest of your life.
Less than 40% of Canada's working population is fortunate enough to belong to an employer-sponsored pension plan. As a retired member of the CAAT Plan you have access to a stable source of income from the time you retire until your death. It comes with annual increases to offset the inflation and includes survivor benefits to continue payments to your spouse when you die.
Today's seniors are spending more time in retirement than previous generations. This can be attributed to a number of factors, including a decrease in the average retirement age, and the steady increase in life expectancy. For some, it is now possible to spend the same amount of time in retirement as in the workforce, and your CAAT Plan pension can help make that time comfortable.
Your monthly pension is paid by convenient and secure direct deposit into your bank account on the first day of each month, for that month. If you retired before age 65 and are receiving a bridge benefit, the bridge benefit payment is included with your lifetime pension in one payment.
Your pension payments start in the month following your retirement, providing all of the necessary forms and documents are accurately completed and promptly submitted.
Income tax will be deducted from your monthly pension payment if it applies.
If you are applying for your pension, you will be required to provide proof of age. Acceptable proof of age includes any government issued identification (federal or provincial) that clearly shows the card holder's date of birth, excluding health cards, (e.g. passport, birth certificate, citizenship card, driver's license). Please note that payment will not be made unless proof of age is provided.
Those of you who spend the winter months, or have retired permanently outside of Canada, will want to ensure the uninterrupted delivery of your monthly pension. Regardless of your country of residence, you should have no problems collecting your pension benefit.
If you're among the "snowbirds" who winter abroad your pension payment will continue to be deposited into your Canadian bank account. Even if you relocate to another country permanently, you can benefit from the convenient direct deposit service to a Canadian bank - or you can choose to have your cheque in Canadian funds mailed to your foreign address.
It's worth noting that the income tax deducted from your employment and government pensions may be affected by your new country of residence. The Canada Revenue Agency offers a variety of information that you should investigate before you leave.


I haven't posted in a few weeks. July 3rd, I was finally able to visit the Mütter Museum after wanting to go for years. I went with my cousins. We took the train down to 30th Street and walked about 3 blocks or so down to 22nd Street where the Museum is located. Definitely better than driving in downtown Philadelphia traffic or looking for parking! I wish I had pictures, but photography is not allowed inside the museum. It is a medical oddities museum. They had Siamese twin skeletons, babies with birth defects in jars from the 1800 & 1900's. A full wall of skulls from people that passed from different diseases. They had animal brains in jars, rats, ferrets, cats, dogs, etc. Any organ you can imagine. The world's tallest man skeleton, a dwarf skeleton. Human leather... some of the stuff makes you go "Ew!" or "Wow!" but it's a really interesting museum. My mom & brother want to go some time so I will definitely be going back!
About 4 more months until I am off to the Philippines. I can't believe it's already July! In September I have to apply for my visitor's visa from the Philippine Consulate in New York. I am still making copies of everything for our immigration process next year. It's slow but I'm getting there!
Sugar's two tumors are growing very large. She has one under her right armpit and another near her right back leg on her tummy. She is still able to get around but I've had to learn to pick her up differently now by supporting her bottom in my hand when holding her instead of picking her up around her waist. A few years ago I bought a carrot shaped calcium chew for the rats but no one would touch it. Then Spice developed a mammary tumor and she would chew and chew on the calcium chew. After Spice passed no one touched it again. Until Sugar developed her tumors... I am thinking with the tumors sucking nutrients from her body she needs the extra calcium and vitamins. I've been buying her calcium chews at the pet store. (Never salt chews! Salt is bad for rats as it can dehydrate them quickly.) She really loves these ice cream shaped ones.
I discovered Pet Discounters through a Yahoo Search. Their prices are unbelievable! I pay $5.99 at Petco for Sugar's calcium chews. For some of my girls other treats I pay $3.99-$4.99 each. I bought 9 items at Pet Discounters and only paid $30 including shipping! I would have spent $50+ for the those same items at the regular pet store. Fast shipping too! Everything arrived this morning and I ordered on Monday!
What else have I been up too? I finally caved and purchased The Sims 3 during my mini vacation from work. (Love The Sims!) Thought it might be a bit much for my 3 year old PC. But it runs really well actually on my 2.0GHz Duel Core Duo processor, 2GB of RAM, 256MB video card PC. (Even with the graphics set to medium & high on some options!) The biggest issue I have with my laptop is space. I only have a 87GB or so hard drive. (Originally 100GB but system hardware & Windows XP take up some of that space.) I have about 23GB left. I uninstalled some other programs, but I do still have The Sims 2 and all it's expansions, plus 2 stuff packs installed. I want to get an external hard drive at some point.
Actually, at some point down the road I want a whole new laptop from Dell. I asked F.B. when we're married if we get a new laptop can I have it and I'll give him this one, haha! He said since he likes older games my laptop would run his games perfectly with my specs so he would love mine. I really want a higher 2.0GHz processor. Probably Core Duo 2. (It's the fastest processor for a laptop.) Windows 7, 4GB of RAM would be nice and a 512MB video card! A bigger hard drive too. Anything from 200 to 500GB. Sigh.... Haha!


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São Geraldo est un quartier de la ville de Porto Alegre, capitale de l'État du Rio Grande do Sul.

Il a été créé par la Loi 2022 du 07/12/1959.

Données générales
Population (2000) : 8.692 habitants
Hommes : 3.873
Femmes : 4.819
Superficie : 144 ha
Densité :

Limites actuelles
De la rue Voluntários da Pátria, angle de la rue du Parque, jusqu'à l'avenue Brasil, puis jusqu'à l'avenue Benjamin Constant ; de là, jusqu'à l'avenue Olinda, et, sur toute sa longueur, jusqu'à la rue Guimarães ; de cette dernière jusqu'à la rue Conde de Porto Alegre et la rue du Parque jusqu'à sa jonction avec la rue Voluntários da Pátria.

Localisation
São Geraldo est localisé dans la zone Nord de la ville, faisant limite avec les quartiers de  Navegantes et Floresta.

Histoire
L'occupation du quartier a commencé à la fin du , mais est devenue effective en 1895, quand la Compagnie Territoriale Porto-alegrense a commencé à lotir les terrains et construire de nouvelles routes dans la région et toujours existantes à ce jour, telles que les avenues Amazonas, Bahia, Brasil, Pará, Paraná, Pernambuco, Maranhão et une partie de l'avenue Ceará. La même année, un autre facteur a contribué pour améliorer l'occupation : ce fut la mise en service de la ligne de tramway de São João, par la Compagnie Carris.

Parmi les habitants du quartier se trouvent un nombre important de descendants d'immigrants italiens et d'allemands. À la fin du , ceux-ci descendaient du train qui continuait ensuite pour Novo Hamburgo à la gare des Navegantes, et sont restés sur place. De l'actuel quartier de Navegantes, certains allèrent s'établir sur le territoire de l'actuel São Geraldo, participant à l'occupation et au développement de la zone. Cette présence devint plus visible dans les manifestations socio-culturelles du quartier comme à travers la Société de danse et de loisir des Gondoliers, fondée en 1915, et dont le nom est une référence aux gondoles vénitiennes.

Avec le développement du plan urbain de la ville, à partir des années 1940, la capitale subit de grands projets de réagencement, principalement par l'ouverture de grandes voies de communication. Les travaux d'extension et d'asphaltage de l'avenue Farrapos donnèrent à São Geraldo l'occasion d'un développement plus accéléré. Cette avenue est, jusqu'à aujourd'hui, une des plus importantes artères d'entrée, dégageant une importante liaison entre son centre et sa périphérie industrielle.

En 1949, une pétition est envoyée au Conseil municipal de Porto Alegre par les habitants pour officialiser la délimitation de São Geraldo, avec pour base la circonscription territoriale de la paroisse ecclésiastique du même nom. São Geraldo ne sera établi comme quartier qu'en 1959.

Aujourd'hui
Coupé par l'avenue Farrapos, c'est un quartier qui mélange les caractéristiques résidentielles et commerciales.

Lien externe
  Site de la Mairie de Porto Alegre.

Quartier de Porto Alegre

redpajama_set_name: RedPajamaWikipedia


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New partnership with Jonathan Hivernat, captain of the French Wheelchair Rugby Team
Societe Generale has entered a partnership contract that will see it sponsor Jonathan Hivernat's professional sports activities until the end of 2019 and oversee initiatives to help raise awareness around disabled sport.
Jonathan Hivernat's team came 7th in the 2016 Rio Paralympic Games. In 2017, they came 9th in the World Wheelchair Rugby Championships and 3rd in the European Championship. With his club, Stade Toulousain Rugby Handisport, he has won the French National Wheelchair Rugby Championship seven times.
Jonathan is on the team currently competing in the Wheelchair Rugby World Championship in Sydney between 5 and 10 August 2018.
He joins the seven other professional rugby players sponsored by Societe Generale: Jonny Wilkinson, Thierry Dusautoir, Sylvain Marconnet, Guilhem Guirado, Matt Giteau, Christian Califano and Shannon Izar. Alongside the Bank, these players are engaged in promoting the values of commitment and team spirit that Societe Generale shares with the sport of rugby. We will benefit from their expertise and professional insight during the 2019 Rugby World Cup.
Societe Generale, preferred partner in rugby and disabled sport
For more than 30 years, the Bank has been a partner at all levels of rugby.
In France, it has been a partner of the French Rugby Federation (FFR) and the French teams since 1987, and the French National Rugby League (LNR) since 1998. Societe Generale provides year-round sponsorship for the 13 regional rugby leagues and nearly 500 amateur clubs.
The 2019 Rugby World Cup in Japan will be the sixth time it acts as a major partner of this tournament.
It has been a partner of the French Disabled Sports Federation (FFH) since 2003 as well as the French paralympic teams. Societe Generale also sponsors para alpine ski champion Marie Bochet and disabled rower and silver medal paralympic champion Perle Bouge.
Biography of Jonathan
Jonathan, 27, was born in Figeac in 1991 and as a child was diagnosed with the hereditary motor disease Charcot-Marie-Tooth. He completed mainstream schooling in Figeac. He loved sports and excelled in disabled table tennis and horse-riding. The disease progressed and he entered a special facility in 2007. It was there, in 2010, that he discovered wheelchair rugby: "I was in Toulouse at a centre for disabled people when a wheelchair rugby team came to give a demonstration," remembers Jonathan. "The players moved around in light wheelchairs with such vibrancy and energy.... That same day, I tried out for the coach and was selected!" Jonathan joined the Stade Toulousain Rugby Handisport club where he met three people that were pivotal to his sports career: Nicolas Costes, coach, Pablo Neumann, player and club chairman, and Olivier Cusin, his coach on the French team.
Today, Jonathan is captain of the Stade Toulousain and the French National Wheelchair Rugby teams.
Wheelchair rugby, also known as quad rugby, is a mixed gender team sport that originated in Canada in 1977. It is played in teams of four on a hardwood court of the same measurements as a regulation basketball court, with a round ball. "We go into Mad Max mode" jokes Jonathan: the wheelchairs are streamlined specifically for the game, with defensive wheelchairs fitted with a bumper to help hold opposing wheelchairs. The wheelchairs of attacking players are designed specifically to help strike. This has been a paralympic sport since the 2000 Sydney Olympic Games. Today there are more than 260 qualified players in France and 16 affiliated clubs.
Laure Bencheikh – +33 1 57 29 39 38 – laure.bencheikh@socgen.com - @SG_presse


CMS plans to release its Request for Applications ("RFA") to solicit participation in the ET3 Model from Medicare-enrolled ambulance providers and suppliers in the summer of 2019. The ET3 Model start date is anticipated for January 2020 for those selected to participate under the RFA. It will have a five-year performance period.
Currently, Medicare will reimburse for emergency ground ambulance services when individuals are transported to certain covered destinations, such as an emergency department ("ED") in a hospital. The current reimbursement model, according to CMS, incentivizes ambulance crews to transport most Medicare beneficiaries who call 911 to a hospital ED—even when a lower "acuity" health care destination may be more appropriate for the patient and for costs.
This incentive to transport most Medicare patients to hospital EDs can result in two issues. First, hospitals are expensive destinations; health care costs (for both patients and the government/taxpayers) are much higher for hospital ED visits than for visits to other health care destinations. In fact, CMS notes that "an earlier White Paper by the U.S. Departments of Health and Human Services and Transportation found" savings potential of $560 million per year by transporting Medicare beneficiaries to "doctors' offices" when appropriate instead of hospital EDs. Second, hospital EDs are clogged with patient cases that can divert important resources necessary to efficiently treat higher-acuity cases.
providing treatment to the beneficiary with a qualified health care practitioner either on the scene (e.g., a nurse practitioner as part of the EMS crew) or via telehealth, will be paid to participating providers and suppliers as a telehealth originating site.
As a result of these reimbursement options, the ET3 Model targets the reduction of avoidable transports to hospital EDs (or transports to any destination, since on-scene or telehealth-delivered care may be reimbursed), which would in turn decrease unnecessary hospitalizations following those transports.
The ET3 Model also encourages a medical triage component delivered by a "health care professional" for low acuity 911 calls. Under the ET3 Model, after a 911 call is received, the dispatcher either (1) initiates an ambulance service immediately or (2) routes the caller to a health care professional, who discusses health concerns with the individual and determines whether an ambulance should even be initiated (e.g., or whether the problem may be treated using telehealth). By triaging these calls, the ET3 Model seeks to improve efficiency in the EMS system so that professionals are able to more readily respond to and focus on higher-acuity cases, such as strokes, heart attacks, and serious physical trauma. By implementing these medical triage lines, applying local governments and other entities that operate or have authority over 911 dispatches in geographic regions where ambulance providers and suppliers have been selected to participate in the ET3 Model may receive "cooperative agreement funding" from CMS.
As discussed above, the ET3 Model will be open to Medicare-enrolled ambulance providers and suppliers. Although the ET3 Model proposes to pay for telehealth and in-person treatment performed by participating ambulance providers and suppliers, the question of who will be coordinating these services is not yet contemplated. CMS has noted that ambulance providers and suppliers without qualified telehealth practitioners may wish to "seek opportunities for partnership" in preparation for the RFA release in the summer of 2019.
 "Acuity" is essentially the level or intensity of care required to treat a patient.
 Centers for Medicare & Medicaid Services, Webinar: Emergency Triage, Treat, and Transport (ET3) Model – Overview, Slide 7 (Last updated March 21, 2019), available at https://innovation.cms.gov/resources/et3-overview.html.
 Participating EMS companies should be prepared to adhere to documentation rules if providing reimbursable treatment on scene or via telehealth.
 Centers for Medicare & Medicaid Services, Webinar: Emergency Triage, Treat, and Transport (ET3) Model – Overview, Slide 10 (Last updated March 21, 2019), available at https://innovation.cms.gov/resources/et3-overview.html.
 In Fall 2019 after ET3 Model participants have been selected and announced, CMS "anticipates issuing a Notice of Funding Opportunity (NOFO) . . . for up to 40 two-year cooperative agreements" for local governments and other entities to implement medical triage lines. See Centers for Medicare & Medicaid Services, Emergency Triage, Treat, and Transport (ET3) Model (Last updated March 21, 2019), available at https://innovation.cms.gov/initiatives/et3/.
 Centers for Medicare & Medicaid Services, Webinar: Emergency Triage, Treat, and Transport (ET3) Model – Overview, Slide 22 (Last updated March 21, 2019), available at https://innovation.cms.gov/resources/et3-overview.html.
A key aspect of the Act is the expanded Medicare coverage of telehealth services to beneficiaries in their home (see Section 2001 of the Act). Currently, and historically, Medicare has restricted coverage of telehealth services to beneficiaries who reside within certain geographic rural areas and who seek such services at specific "originating sites" (patient beneficiary's home is not included in the current Medicare definition for "originating site"). The Act amends 42 U.S.C. § 1395m(m) to eliminate these coverage restrictions for "an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder, as determined by the Secretary [of Health and Human Services]." With this amendment in place, health care providers may now be reimbursed for providing eligible substance use disorder services to Medicare beneficiaries in their homes via telehealth. Although the Act does not provide for any "facility fee" reimbursement for telehealth services provided to beneficiaries in their homes, the Act requires reimbursement be provided to physicians and other health care practitioners furnishing these services at the same rate as they would otherwise receive if providing the same services in-person.
It is important to note that while Section 2001 of the Act takes effect on July 1, 2019, it authorizes the Secretary of the U.S. Department of Health & Human Services ("Secretary") to implement these amendments immediately by creating a final interim rule. The Act also mandates that the Secretary report on the impact of this legislation on: (1) the health care utilization (and in particular, emergency department visits) related to substance use, and (2) "health outcomes related to substance use disorders," including opioid overdose deaths. The Act provides $3 million to the Centers for Medicare & Medicaid Program Management Account in order to carry out these reporting requirements, which must be completed within five years.
Another key aspect of the Act mandates that the U.S. Attorney General ("Attorney General") promulgate final regulations that specify (1) "the limited circumstances in which a special registration under this subsection may be issued" and (2) "the procedure for obtaining a special registration." Under 21 U.S.C. 831(h), as amended by The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 ("Ryan Haight Act"), this special registration would allow health care providers to prescribe controlled substances via telemedicine when legitimately necessary, including when an in-person evaluation is not possible. As discussed in one of our recent TechHealth Perspectives blog posts, despite the statutory mandate in the Ryan Haight Act passed more than eight years ago, the Attorney General has not yet issued any regulations or guidance on how to obtain this special registration. The Drug Enforcement Administration ("DEA"), the federal agency delegated authority to promulgate these regulations by the Attorney General, has also not promulgated any regulation or other guidance addressing special registration. The SUPPORT Act gives the Attorney General until October 24, 2019, to promulgate its final regulations on this matter.
Epstein Becker & Green plans to discuss the Act's numerous provisions in greater detail in future Client Alerts.
The Ryan Haight Act Online Pharmacy Consumer Protection Act of 2008 (21 U.S.C. § 802(54)) (the "Ryan Haight Act" or "Act") expanded the federal Controlled Substances Act to define appropriate internet usage in the dispensing and prescribing of schedule drugs, and in doing so effectively banned the issuance of prescriptions via telemedicine services for any controlled substances unless the ordering physician has conducted at least one in-person evaluation of the patient. The Act includes multiple exceptions that permit prescribing of controlled substances without conducting an in-person evaluation, the most relevant to the practice of telemedicine being the mandate that the Drug Enforcement Administration ("DEA") or other federal agency establish rules for a "Special Registration" to be utilized by health care providers. However, despite the statutory mandate, since the 2008 passing of the Act neither the DEA nor any other federal agency has promulgated any regulation or other guidance regarding the development and implementation of such a Special Registration process.
Several previous TechHealth Perspectives blog posts have highlighted the pressures imposed from Congress on the DEA to promulgate the Special Registration process in the wake of the opioid crisis and the recent passage of House Bill 5483, entitled the "Special Registration for Telemedicine Clarification Act of 2018" (the "Bill"), which seeks to address the lack of regulatory guidance regarding the Special Registration exception to the Ryan Haight Act. Ironically, the Bill would require the DEA to promulgate rules that are already required under the Ryan Haight Act to allow health care providers to apply for a Special Registration.
Category I—Remote Prescribing is Allowed. Many states have not regulated the remote prescribing of controlled substances any differently than how the state has regulated in-person prescribing practices, or states have placed very minimal, added responsibilities on telemedicine providers seeking to do remote prescribing of controlled substances, which primarily are intended to ensure that the standard of care provided in the telemedicine delivery setting sufficiently mirrors the standard of care provided in the traditional in-person delivery setting. Examples of states that have taken this route include Arizona, Kentucky, Maine, Minnesota, Missouri, Tennessee, and Vermont.
Category II—Remote Prescribing is Prohibited. A handful of states have completely prohibited the remote prescribing of controlled substances or only permit it to occur in rare instances. Connecticut and Georgia (citation available just past verification page) are examples of two states that have adopted this approach.
Category III—Remote Prescribing is Allowed, But Additional Burdens and Barriers Are Placed on Prescribing Providers. Several states, including New Jersey, North Dakota, Oklahoma, and South Carolina, require at least one in-person appointment before a health care provider can remotely prescribe controlled substances or scheduled narcotics / medications to their patients. While these states may allow for the remote prescribing of controlled substances, there may be limits on prescribing activities, including limits on the types of controlled substances that can be remotely prescribed (and expressly prohibiting the prescribing of certain controlled substances entirely, such as opioids and certain schedule narcotics).
Regardless of which category a state may fall into, many of these states' laws would be in direct conflict with the Special Registration exception under the Act, if it is ever formulated. That is, many states either prohibit the remote prescribing of controlled substances without an initial in-person consult, or impose more stringent conditions on remote prescribing than what is mandated under current federal law. The question is whether federal law would preempt any state law that is inconsistent with the Special Registration exception and would prohibit remote prescribing without an in-person examination even if the health care provider holds a Special Registration from the federal government.
Congress expressly retained supremacy and preemption through provisions of the Controlled Substances Act (21 U.S.C. § 903): "[n]o provision of this subchapter shall be construed as indicating an intent on the part of the Congress to occupy the field in which that provision operates, including criminal penalties, to the exclusion of any State law on the same subject matter which would otherwise be within the authority of the State, unless there is a positive conflict between that provision of this subchapter and that State law so that the two cannot consistently stand together." The legislative intent is clear that upon the passing of the Controlled Substances Act, Congress anticipated federal and state conflicts of law and expressly directed that federal law would control. However, the drafting yields some authority to the states and is somewhat ambiguous on relevant points.
Thus, states may also regulate remote prescribing and many have taken the opportunity to do so. If the DEA or any other federal agency promulgate rules that potentially could affect any of the existing state laws pertaining to remote prescribing, the supremacy provision in the Controlled Substances Act is sufficiently vague such that states could craft creative legal arguments providing that the federal and the state laws can consistently stand together. Currently, no entity (federal or state) has challenged any of the existing state laws as conflicting with the Ryan Haight Act or the exceptions for remote prescribing without an initial in-person examination. However, should such an action be filed, federal preemption could overrule any inconsistent state laws, rules, or regulations.
Recently, we have seen some indicia of federal preemption in the telehealth arena with the Department of Veterans Affairs asserting dominance over any state regulation and oversight of telemedicine services with the promulgation of recent regulation (38 C.F.R. § 17.417) which states in no uncertain terms that the federal rule overrides any conflicting state laws. Moreover, the notice and comments from the Department of Veterans Affairs strongly invoke federalism in this area.
Ultimately, federal law could preempt the various state laws that completely prohibit telehealth prescribing, as well as those state laws that have put in place barriers to remote prescribing that are inconsistent with the Ryan Haight Act. Upon the promulgation of the Special Registration process, if and when it may occur, each state will have to assess and address any inconsistencies with federal law in the area of remote prescribing. Of course, while the provisions in the Ryan Haight Act addressing Special Registration do not have limitations on what kind of controlled substances could be remotely prescribed without an in-person examination under the exception, the Special Registration could incorporate limitations on the type of controlled substances that can be remotely prescribed without an in-person examination (similar to current requirements in a number of states).
Rebecca Francis, a Summer Associate (not admitted to the practice of law) in the firm's Houston Office, contributed significantly to the preparation of this post.
At first blush, the passage of House Bill 5483, entitled the "Special Registration for Telemedicine Clarification Act of 2018" (the "Bill"), appears to address the issue concerning the lack of regulatory guidance regarding the "Special Registration" exception to the Ryan Haight Act of 2008; however, a deeper and more careful analysis reveals that the Bill may not be as effective as most health care practitioners may hope. The Bill, sponsored by Rep. Carter (R-Georgia), a pharmacist, Rep. Bustos (D-Illinois), and nine others, cleared the House on June 12, 2018 without objection. The Bill would require the federal Drug Enforcement Agency ("DEA") to promulgate rules that would allow health care providers to apply for a "Special Registration" that would allow a provider to prescribe controlled substances via telehealth without first conducting an initial in-person examination of the patient. A transcript of the testimony in support of the Bill ("Transcript") reveals enthusiasm by the sponsors of the Bill, as well as by Representatives Pallone (D-New Jersey) and Walden (R-Oregon), who called the Bill "a commonsense measure that cuts through the red tape to provide more treatment options to underserved communities through the use of telemedicine." While Section 413 of the current version of S.B. 2680 would only give the DEA six months to promulgate such rules, the two bills are very similar and almost guarantee that a law will be signed in the coming months that will require DEA to promulgate rules that will finally create a Special Registration exception to the Ryan Haight Act. While the prospect of rules implementing the Special Registration may be exciting for many practitioners, it should be noted that the DEA has been obligated to create these regulations, and has ignored this obligation, for a decade.
Once enacted, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (the "Act") effectively banned the prescription of controlled substances via telehealth without an in-person examination of the patient. While there are exceptions to the Act, these exceptions are very technical and do not apply to the majority of treatment settings for which a controlled substance could be prescribed by a treating physician to a patient in his or her home. When the Act was passed, Congress appeared to have the foresight to know that the Act was restrictive and that the Act should have some mechanism by which its prohibitions could be relaxed, because the Act also created 21 U.S.C. § 831(h)(2), which orders the Attorney General of the United States and the DEA to "promulgate regulations specifying the limited circumstances in which a special registration under this subsection may be issued and the procedures for obtaining such a special registration." However, as we have previously discussed, the only related action the DEA has taken in the decade between the passage of the Act and today was, in 2016, to mark the creation of these rules a "Long-Term Action" that has not substantively been addressed. By suggesting that the DEA "understand[s] the need to implement this provision of law" Rep. Walden appears to be incognizant of the historical lack of the DEA's movement to promulgate the Special Registration rules, despite the DEA having the authority to do so since the Act originally was passed in 2008. Mr. Walden also seems to advocate for the DEA, as he supports revising the Bill's original 90-day deadline for the promulgation of rules to implement a one-year deadline on account of the DEA's position it would be burdensome. As such, the question remains whether the DEA, who has avoided this exact obligation for nearly a decade, will at last take action within the year if the Bill becomes law.
If the DEA takes its cues from the recent House testimony supporting the Bill, the agency may decide the Special Registration should be limited to certain declarations of emergencies, such as the declaration of the opioid crisis as a Public Health Emergency. Such a narrow definition may be fruitful in the fight against opioid use disorder, but may ultimately fall short of expectations held by telehealth practitioners interested in providing services to patients via telehealth that involve prescribing controlled substances.
24 claims were unallowable because beneficiaries received services at non-rural originating sites that did not fall under the demonstration program exception. For proper telehealth Medicare reimbursement, beneficiaries must be located in either: (1) an HPSA that is outside of an MSA or within a rural census tract of an MSA, as of December 31 of the preceding year, or (2) a county that is not included in an MSA as of December 31 of the preceding year. Providers should check whether their patients' location qualify as an originating site via the Medicare Telehealth Payment Eligibility Analyzer.
7 claims were billed by ineligible institutional providers. Institutional facilities at a distant site may bill Medicare only if: (1) the facility is a CAH that elected the Method II payment option and the practitioner reassigned his or her benefits to the critical access hospital (CAH) or (2) the facility provided medical nutrition therapy (MNT) services.
3 claims were for services provided to beneficiaries at unauthorized originating sites. Telehealth services must be furnished to a beneficiary that is located in one of the following sites: the office of a practitioner, a hospital, a CAH, a rural health clinic, a federally qualified health center, a hospital-based or CAH-based renal dialysis center, a skilled nursing facility, or a community mental health center.
2 claims were for services provided by an unallowable means of communication. Under the Federal regulations, telehealth practitioners must provide telehealth services using an interactive telecommunications system, which excludes telephone, fax, or email. However, CMS provides a carve-out for asynchronous store and forward technology for Federal telemedicine demonstration programs in Alaska and Hawaii.
1 claim was for a non-covered service. Practitioners should refer to the CMS website for the list of telehealth services payable under the Medicare physician fee schedule. Changes to the list are made annually.
1 claim was for services provided by a physician located outside the U.S. Telehealth services are only covered if those services are provided within the U.S.
The OIG largely cited that many of these claims should not have been approved and reimbursed in the first place. For example, the majority of claims related to unallowable geographical locations of the originating sites. Presently, Medicare Administrative Contractors (MACs) do not have a process of editing these types of errors because claim forms do not have designated field for the originating-site location. The claim forms also do not have a field determining the form of communication used by the practitioner. CMS officials stated that it would be unlikely that the forms would include such designations because those designations would not be applicable to non-telehealth practitioners who use the same claim forms.
To date, there have not been any reported cases of enforcement actions taken against telehealth practitioners and stakeholders. However, practitioners and stakeholders should be aware that qui tam actions under the False Claims Act (FCA) may be brought by whistleblowers. The first FCA case was brought in 2016 where a Connecticut mental health practice allegedly submitted false claims to Medicare for telehealth service provided to patients. The complaint alleged that the physician and mental health practice did not use interactive audio and video communications, but simply treated Medicare beneficiaries over the telephone. Although that settlement only amounted to $36,704, the recent OIG report should signal to telehealth practitioners and stakeholders that OIG is now aware and will most likely hold telehealth service providers more accountable for complying with both Federal and state telehealth laws and regulations.
Therefore, practitioners and stakeholders should familiarize themselves with Medicare telehealth requirements as they will most likely change in the next several months, seen most recently with the passage of the Bipartisan Budget Act of 2018, which expanded coverage of telehealth services under Medicare related to telestroke care, Medicare Advantage, and accountable care organizations.
In March 2018, the Medicaid and CHIP Payment and Access Commission (MACPAC) made its 2018 report to Congress, which included the Commission's evaluation of telehealth services provided through the Medicaid program. Chapter 2 of MACPAC's report had a positive outlook on telehealth's contribution toward better accessibility of health care services to underserved individuals as well as individuals with disabilities.
Unlike its larger counterpart, Medicare, federal policy has not placed many restrictions on state Medicaid programs in terms of adopting or designing telehealth coverage policies. For example, there is limited reimbursement coverage of telehealth services provided through the Medicare Fee-For-Service (FFS) program (e.g., geographical restrictions). However, there is little federal guidance or information regarding the implementation of telehealth services in state Medicaid programs or coverage for these services. As a result, state Medicaid coverage of telehealth services is highly variable across state lines, in terms of telehealth modalities, specialties and services, provider types, and even permissible site locations where telehealth services may be rendered. This high degree of variability stems, at least in part, from the unique federal-state partnership that provides the foundation for all state Medicaid programs.
Federal Medicaid Program Requirements. Although the federal requirements for coverage of telehealth services provided through the Medicaid program are few, in comparison to comparable requirements under the Medicare FFS program, some broad CMS guidelines do require Medicaid providers to practice within the scope of their state practice laws and to comply with all applicable state professional licensing laws and regulations. Additionally, any payments made by state Medicaid programs for telehealth services must satisfy the federal Medicaid program requirements for efficiency, economy, and quality of care. Furthermore, although Medicaid program requirements for comparability, state-wideness, and freedom of choice do not apply to telehealth services, states choosing to limit access to telehealth services (e.g., limited to particular providers or regions) must ensure access to and cover face-to-face visits in areas where such services are not available. Moreover, states are not required to submit a Medicaid state plan amendment to cover and pay for telehealth services as long as the program is in a state where telehealth parity laws are in effect, which are intended to ensure same coverage and payment of telehealth services as those provided in-person.
State-to-State Variations in Medicaid Coverage of Telehealth Services. A big focus of the MACPAC report was the impact that state-by-state variations may have on providing access to telehealth services through state Medicaid programs. As previously noted, because of the lack of any unified federal telehealth policy, state Medicaid program coverage of telehealth services is inconsistent. Some states, like West Virginia, mirror their Medicaid policies and regulations after the Medicare program, meaning that telehealth services are covered only if the originating site is in a rural location that either meets the definition of a non-metropolitan statistical area or a rural health professional shortage area, or originating site must be at hospitals, critical access hospitals, physician offices, federally qualified health centers, etc. In other words, in these states, Medicaid recipients would be required to travel to particular qualified locations for their telehealth service to be covered under Medicaid. Interestingly, MACPAC reported that some states that initially adopted these Medicare-like standards have changed their policies over time, as the state Medicaid programs have gained experience and understanding of the implications for access, cost, and quality. Other states are increasingly allowing homes, workplaces, and schools to serve as originating sites for telehealth services, while some states do not explicitly require patients to be at any specific sites in order to receive telehealth services. For example, while West Virginia's Medicaid program specifies that originating sites must be a physician's or other health care practitioner's office, hospitals, rural health centers, skilled nursing facilities, etc., Medicaid recipients in Washington state may choose the location they would like to receive telehealth services, without these types of restrictions.
Similarly, the types of telehealth services that are covered vary greatly from state-to-state. For example, Idaho's Medicaid program covers live video telehealth for mental health services, developmental disabilities services, primary care services, physical therapy services, occupational therapy services, and speech therapy services. In contrast, Arizona's Medicaid program covers live video telehealth for a variety of specialty services including cardiology, dermatology, endocrinology, pediatric subspecialties, hematology-oncology, home health, infectious diseases, neurology, obstetrics and gynecology, oncology and radiation, ophthalmology, orthopedics, pain clinic, pathology, pediatrics, radiology, rheumatology, and surgery follow-up and consultation.
Across state Medicaid programs there also is wide variation regarding the types of health care practitioners who may provide telehealth services to Medicaid program recipients. Nineteen states (e.g., Connecticut, Florida, Hawaii, Iowa, Kansas, Louisiana, Maine, Massachusetts, Mississippi, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Tennessee, Utah, and Vermont) do not specify the type of providers that may provide health care services via telehealth and therefore are presumed to have the most inclusive provider policies. There also is variation with respect to professional licensure requirements for these providers, with some state policies allowing out-of-state practitioners to provide telehealth services as long as they are licensed in the state from which they are providing the service and are registered with the state's Medicaid program (e.g., Arizona) while other state policies require practitioners to be licensed or certified to practice in the state unless only providing episodic consultation services (e.g., Arkansas).
States set their own payment levels for telehealth services provided to Medicaid recipients. Some payment rates for telehealth services may be lower than payment rates for the same services provided in-person. State Medicaid programs also vary in terms of payments for facility fees and transmission fees, which assist providers with covering associated telecommunications costs. Additionally, state Medicaid policies for telehealth services may differ between managed care and FFS plans. Some states do not require Medicaid managed care plans to provide services via telehealth at all. For example, Florida's live video telehealth is covered under Medicaid FFS but is optional for Medicaid managed care plans, while in Massachusetts telehealth services are not covered under Medicaid FFS but there is some coverage under at least one of the state's Medicaid managed care plans.
Behavioral Health. MACPAC reported that non-institutionalized adult, children, and adolescents covered by Medicaid have a higher rate of behavioral health disorders compared to their privately insured counterparts. Barriers to care include fragmented delivery systems, lack of accessibility to provider and resources, and patients' concerns regarding confidentiality and fear of stigma attached to seeking mental treatment. MACPAC reported that there is increasing evidence that telehealth has the potential to improve access to evidence-based care for mental health and substance use disorders for individuals located in underserved areas. As of now, all state Medicaid programs that cover telehealth services include as part of that coverage access to behavioral health services via videoconferencing, although the scope of coverage varies state-to-state. Generally, most commonly covered services include mental health assessments, individual therapy, psychiatric diagnostic interview exams, and medication management. Although most state Medicaid programs will cover behavioral health services via telehealth if provided by licensed or certified psychiatrists, advanced practice nurses, and psychologists, some states also will cover those services if treatment is delivered by social workers and/or counselors. MACPAC reported that there is a growing number of studies showing that behavioral health care services provided via telehealth is effective, particularly for assessment and treatment of conditions such as depression, post-traumatic stress disorder, substance use disorder, and developmental disabilities. MACPAC reported high patient satisfaction with behavioral health care services via telehealth was on par with non-Medicaid payor populations, although MACPAC indicated that more research is needed.
Oral Health. Oral health services among Medicaid participants are relatively low. Barriers to oral health care include cost, difficulty of finding dentists who accept Medicaid, and inconvenience of location and time. MACPAC reported that the use of telehealth in dentistry has been recognized for its potential in improving access to primary and specialty oral health care services in communities that either lack or have limited provider capacity. Typically a patient is joined by an oral health professional at the originating site during a real-time video consultation with a dentists or specialty dentists for diagnosis and development of a treatment plan. Store-and-forward modality allows the provider at the originating site to send images (i.e., x-rays, photographs, lab results) to the dentist for review. As of 2017, 11 states were identified for including some Medicaid coverage for teledentistry (e.g., Arizona, California, Colorado, Florida, Hawaii, Minnesota, Missouri, Montana, New Mexico, New York, and Washington). Studies have shown that certain teledentistry services such as screening of childhood dental caries and orthodontic referrals appear to be as effective as in-person visits. MACPAC reported that patients expressed satisfaction of these dental health care services provided via telehealth because of greater convenience and improved access to care.
Maternity Care. In 2010, although state Medicaid programs covered nearly half of all births in the U.S., nearly 50 percent of U.S. counties had no obstetrician-gynecologists providing direct patient care. Telehealth can be used to manage pregnancies in several ways including the use of videoconferencing between a patient and her regular maternity care provider or between two providers during labor and delivery. Live videoconferencing could also be utilized during genetic counseling or even neonatal resuscitation. MACPAC reported that pilot studies have tried videoconferencing for prenatal care visits, group prenatal care, and breastfeeding support, which include women with both high-risk and low-risk pregnancies. MACPAC also reported that an emerging practice is the use of telehealth to diagnose congenital heart defects via live videoconferencing between the radiographer and fetal cardiologists, or the use of store-and-forward technology to allow a specialist to review echocardiograms post hoc.
MACPAC Recommendations. Before integrating or expanding telehealth services in their respective Medicaid programs, MACPAC recommended that states weigh the costs and the resource requirements associated with using or implementing telehealth against their goals of improving access for Medicaid recipients to needed health care services. One of the primary concerns voiced against greater use of telehealth services is the inappropriate use or overuse of those services. For example, MACPAC asked the states to consider whether inclusion of facility or transmission fees would increase the overall costs to their Medicaid programs if telehealth services replaced in-person services. MACPAC also asked states to consider whether telehealth services had the potential to increase fragmentation of care if services were provided by different telehealth providers or providers were unable to obtain updated patient medical records. MACPAC emphasized that while there appeared to be growing number of studies showing the effectiveness of telehealth services, there are still very few published studies addressing the effect of telehealth in Medicaid populations.
MACPAC also noted several factors that contributed to limited adoption of telehealth in Medicaid. The combination of lower payment rates for Medicaid and yet potential high costs for licensing across different state lines may deter providers from using telehealth for Medicaid services. Telehealth technology is dependent on reliable and affordable broadband connectivity. Unfortunately many rural areas and Native American reservations still lack such connectivity. An estimated 53 percent of individuals living in rural areas lack access to broadband speeds needed to support telehealth. Furthermore, costs of broadband can be almost three times that in urban areas. Costs associated with the acquisition, installation, and maintenance can be quite cost-prohibitive to providers and affect their ability or willingness to adopt telehealth. Additionally, telehealth-focused remote prescribing laws vary from state-to-state while prescribing of controlled substances are limited by the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. The law generally prohibits prescribing of controlled substances through the internet without a valid prescription, which requires the prescriber to have conducted at least one in-person medical examination of the patient. Although the law includes a telehealth exemption, the exemption requires the originating site to be located at Drug Enforcement Administration (DEA)-registered clinic or hospital. In addition, state medical licensing boards may also limit the circumstances in which providers can prescribe controlled substances via telehealth. As illustrated above, the varying length and degree of Federal and state laws and regulations governing telehealth services is complex and may deter providers from entering into the telehealth service market.
Overall, the MACPAC report illustrates a positive outlook on telehealth's integration into state Medicaid programs. However, in its recommendation to Congress, MACPAC did not outright push states to adopt telehealth into their Medicaid programs. Rather, the Commission continues to seek more research and collaborative studies among states to gain better insight and understanding of the effects of telehealth on access to care, quality, and cost of care of the Medicaid program.


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Volume XVIII | Issue 1
Climatology, Geomorphology
Climate parameters relevant for avalanche triggering in the Făgăraș Mountains (Southern Carpathians)
Narcisa Milian1,*, Sorin Cheval2
Abstract: The climate conditions may contribute significantly to the generation of several hazards in mountain areas, such landslides, wildfires, flash floods and avalanches. This study examines the variation of the main meteorological parameters with impact on avalanche triggering conditions at Bâlea-Lac Meteorological Station. At the best of our knowledge, this is the first overview of the basic climate parameters which are potentially avalanche triggers in the Făgăraș Mountains (Southern Carpathians). The study is based on data from only one weather station (Bâlea-Lac) from the period 1979-2017, assuming it is consistently relevant from climatic point of view for avalanche occurrence in the area. The results demonstrate that the theoretical circumstances for avalanche triggering (e.g. snow pack, fresh snow or wind) can be captured. This paper briefly describes the nivologic monitoring system run by the National Meteorological Administration and emphasises its utility for avalanche forecasting and alerts.
Keywords: avalanche hazards, avalanche triggering factors, mountain climate, Făgăraş Mountains
1 National Meteorological Administration, Romania
2 University of Craiova, Craiova, Romania
* narcisa.milian@gmail.com
Climatology, Environment
A review of recent studies on heat wave definitions, mechanisms, changes, and impact on mortality
Adrian Piticar1,*, Sorin Cheval1, Maria Frighenciu2
Abstract: Heat waves (HWs) represent a major danger to society and natural environment. The increasing occurrence of high magnitude and impact HWs has raised concerns worldwide and has attracted an increasing interest on this issue among climatologists over the past decade. In this review the research from 2007-2018 period on HWs definitions, driving mechanisms, present changes, future changes, and impact on human mortality is summarized. By reviewing the recent literature, it was found that whilst the atmospheric dynamic is considered to be the primary driver in HW occurrence, the sea surface temperature (SST) and land surface conditions are also essential driving components. The vastness of HW-definitions raises difficulties in selecting the appropriate methodology to identify heat episodes and to compare results from studies which used different definitions. However, by analyzing a sample of 109 papers, a preference for percentile-based definitions was observed. Therefore, 71.6% of the analyzed articles used only percentile-based definitions to identify HWs. Despite the wide variety of definitions, the analysis of changes in HWs converged to similar results. Thus, the existing recent literature provided extensive evidence of significant increase in HWs characteristics across large regions of the planet. Available scientific literature indicated that HWs have been responsible for a considerable increase in mortality in many regions of the world. In the future HWs are predicted to increase in their main characteristics leading to a greater impact on human mortality. Nevertheless, the implementation of rigorous adaptation measures can mitigate the negative impact on mortality. In conclusion, it was noted that a substantial progress has been done in the HW research, but there are still important gaps in this issue which need to be addressed.
Keywords: climate change, extreme temperatures, heat wave, excess heat factor
1 Faculty of Aeronautical Management, Henri Coandă" Air Force Academy, 160, Mihai Viteazul Street, Brașov, Romania
2 National Meteorological Administration, 97, București-Ploiești Street, Bucharest, Romania
* adrian.piticar@gmail.com
Acknowledgements: The authors kindly acknowledge Ms Mădălina Timu for the English technical support. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Volume XI | Issue 2
The wind regime of Romania – Characteristics, trends and North Atlantic oscillation influences
Alfred Vespremeanu-Stroe1,*, Sorin Cheval2, Florin Tătui1
Abstract: The present study attempts to develop a comprehensive perspective of the wind regime on the Romanian territory, focusing on the characteristics and tendencies encountered over the past 50 years, as well as on the NAO projection on it, using several data categories gathered from 167 meteorological stations. Based on the recorded multiannual averages and on the strong correlation (r = 0.87) established between altitude and wind speed in wind exposed areas, we created the map of mean (multi)annual wind speed. The highest aeolian potential corresponds to the Carpathians (7-10 m/s on the ridges and 3-7 m/s on the slopes and within valleys) and the Black Sea Shore (5-7 m/s); nevertheless, the two areas develop extreme values of the wind turbulence – maximum in the Carpathians and minimum in the coastal units. Tablelands in Moldova and Dobrogea, as well as the northern part of Bărăgan show ideal conditions for the development of aeolian parks (moderate and strong winds, low turbulences). On a country-size scale, the month with the highest mean wid speed is March, whereas August is the calmest one. For the first time, the map of resultant wind direction (DRV) was designed, expressing both the resultant wind orrientation and its intensity (high intensity = low directional variability). Concerning NAO, a negative correlation is observed between its indices and the wind speed (mean speed, frequency and intensity of the stromic events) at a multiannual and multidecadal scale. The correlation coefficients present high values in the extra-carpathian areas and small or moderate values in the intra-carpathian areas. The positive (negative) NAO associated with low (high) cyclogenesis over the Mediterranean area induce low (high) winds over the Romanian territory due to diminished (enhanced) frequency of cyclones reaching Romanian regions.
Keywords: wind regime, North Atlantic influences, wind direction
Full article 10.5775/fg.2067-4635.2012.003.dDates: Received: 21-08-2012 Accepted: 08-12-2012 Printed: 20-12-2012 Online: 03-01-2013
1 Faculty of Geography, University of Bucharest, N. Bălcesu Blvd, no 1, Bucharest, Romania
2 National Administration of Meteorology, Bucharest-Ploiesti Road, no 97, 71552 Bucharest, Romania
* fredi@geo.unibuc.ro
Acknowledgements: Special thanks are addressed to Florin Iosub for helping us mapping the Resultant Wind Direction values.


Khan Lai, a resident in Poipet commune, a boom town on the Cambodia-Thailand border, celebrated a housewarming party in early January. There were some 200 guests including his neighbors and former members of the local, now-dissolved opposition party.
But the party was cut short when police spotted the festivities and intervened.
Lai, 44, an opposition activist, and other opposition officials were questioned by the police.
"Police came to my house and asked me about the party and posts on Facebook," he said, adding that some opposition Cambodia National Rescue Party (CNRP) officials took pictures and videos showing their support for exiled CNRP leader Sam Rainsy, the party's former president.
More than 100 local opposition officials lost their posts after the CNRP was dissolved in November 2017.
"They questioned who are the organizers of the videos and gatherings," he said, adding that police questioned him at the police station.
"I told them that I didn't know about filming videos since I was busy inside the house," said Lai, who joined the CNRP in 2012.
Lai said that in the afternoon of the day following the party, the provincial police chief, Ath Khem, lead some 10 police in a raid on his house. The video of the raid went viral on Cambodian social media.
In December last year, at a conference conducted in the United States, Rainsy who previously resigned from the party, was supported by attendees to be the acting president of the party while Kem Sokha, its president, remains under house arrest.
Fear has gripped local opposition officials since the CNRP was dissolved by the Supreme Court in November 2017. For former members of the CNRP, even organizing a private party comes with surveillance and questions from the authorities.
The ruling Cambodian People's Party, led by Prime Minister Hun Sen, bristles with paranoia over the alleged threat of a "color revolution", even as it has stifled almost all dissenting voices and claimed every seat in parliament in last year's general election.
The CNRP was the country's largest political party and the only party to win seats in parliament in the 2013 election. Its president, Sokha, was jailed on treason charges shortly before the party was disbanded. He was later placed under house arrest and is still awaiting trial. The CPP claims that Sokha conspired with the United States to overthrow Hun Sen.
At least five people were called by police for questioning, but no one has been detained or charged, according to Lai.
But fear has stifled their political discussions and plans for further gatherings.
"I am always hiding. I know I am the main target as well," said Chham Sophan, 41, who was a former opposition councilor in Poipet and also attended the housewarming party. "I can't stay home like before," he added.
Former opposition officials like Sophan are now wary of using the telephone to communicate, fearing surveillance. "I don't dare to stay home and now we are even afraid of picking up phone calls," he said.
Mean Sarith, the owner of the house where the party was held and a former opposition party official in that city, said there is "no freedom anymore".
"We can only whisper now," he said. "If they see many people, they will come," he said.
In Poipet, the opposition CNRP won a majority of more than 9,000 at the last election where they were allowed to stand.
But immediately following the party's dissolution, the CPP oversaw a purge of CNRP officials, with more than 5,000 local CNRP representatives losing their positions. The opposition had controlled about 30 percent of local authorities and increased its minority share to 43 percent in local elections in summer 2017.
In other districts, two officials who joined the party were issued with a summons to appear at local police stations.
Tuon Veasna, a former opposition district chief who received a summons, said he was questioned for about three hours. Police forced him to sign a contract, he said.
"They asked me not to hold any gatherings and support for Sam Rainsy and they do not allow us to talk about the CNRP," he said. "It was a pressure on me to sign the contract," he said.
"I thought they will ask me about the housewarming party gathering, but they asked me about a [social media] post on December 17, in which we showed our support to Sam Rainsy," he said.
"Police now drive around my house day and night," he added.
Ath Khem, Banteay Meanchey provincial police chief, could not be reached for comment.
Local opposition now largely keep silent when it comes to political activities.
Public support for the CNRP has become risky and, in some cases, illegal, despite the constitution guaranteeing the right to free assembly and association. Even those with no affiliation with the CNRP say they are wary of openly discussing political ideas under the new regime.
In Kampong Chhnang province, Chou Sam On, the former Kampong Leang district chief, said early this month that local officials wanted to have a meeting together, but they were told: "police threatened and started noting names." The planned meeting was canceled.
"We want to gather and express ideas about supporting Sam Rainsy to lead the party, but we can't do it," he said.
In Battambang province, several former opposition officials were questioned over a meeting held to support Rainsy.
Seng Rathmony, 46, a former commune chief of Chrey in Morng Russei district, was questioned on December 16 when she gathered at her home with over 20 activists to eat noodles and drink soft drinks.
"We haven't met for a long time and we missed each other," said Mony during a recent interview at her home.
"We don't have anything to hide," she said. "They have their own network nearby. If four or five motorbikes enter my house, police officials will call and ask me about it," she added.
In response, Lay Chham, Chrey, the commune police chief, said local authorities have to know about any gatherings taking place in the commune.
"Let me ask you whether it is right or not to do that," he told VOA Khmer in a telephone interview. "What happens in this commune, I have to know as the local authority," he added.
"I don't allege that they are in the wrong, but the court dissolved [the opposition] already; how come they can be the opposition party now. It is for the courts to decide," he said.
For Lai in Poipet, concerns remain that the police will return or call him in for further questioning. But he said he still wants to be involved with the opposition party.
"I don't aim for any position. I don't know how to write. But I joined the opposition because I love the party and their officials," he said.


Leslie Coffey | Living or Dead?
Is Leslie Coffey Living or Dead?
Has Australian sportsperson Leslie Coffey died? Or is he still alive?
Leslie Coffey isn't dead yet!
Leslie Coffey (9 September 1936 – 3 March 2018) was an Australian sports shooter. He competed in the 50 metre pistol event at the 1964 Summer Olympics.


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Home›Air Pollution Causes›New discovery on regulation of organelle contacts — ScienceDaily
New discovery on regulation of organelle contacts — ScienceDaily
A pioneering study has revealed how cellular compartments (organelles) are able to control how much they interact and cooperate.
The study, led by Professor Michael Schrader and Dr Joseph Costello from the University of Exeter, builds on their recent discovery of how two cell organelles — called peroxisomes and the endoplasmic reticulum (ER) — associate with each other and work together.
This cooperation is crucial for the production of specific lipids, which are essential for the function of nerve cells and can protect cells from oxidative damage.
Organelles are the functional units of a cell. Like organs in a body, they perform specialised functions.
To allow survival of the cell and organism, organelles have to interact and cooperate.
How this is mediated and regulated in the cell is an important and challenging question in cell biology.
In a previous study, the researchers discovered that a protein at the peroxisomes called ACBD5 directly interacts with a protein at the ER, called VAPB.
This interaction links both organelles together and allows transfer of lipids between them.
The new study now revealed how this interaction is regulated at the molecular level.
"Organelles are not constantly tethered to each other, this would be disadvantageous," said Professor Schrader.
"They also need to keep distance and change location in the cell to meet other organelles.
"Therefore, membrane contacts between organelles need to be dynamic. How membrane contacts are regulated is, however, not well understood."
"Our findings reveal how regulation of peroxisome-ER contacts in mammalian cells works and also provide one of the first clear examples for a physiological role of phosphorylation of peroxisomal proteins," said Dr Costello.
Phosphorylation reactions are critical for many cellular processes in biology.
The addition (or removal) of a phosphate to a protein can change its properties and thus, its function or activity.
Therefore, protein phosphorylation/dephosphorylation is an important regulatory mechanism in the cell.
It is carried out by enzymes, e.g. kinases, which mediate protein phosphorylation, and phosphatases, which remove the phosphate (dephosphorylation).
The researchers revealed that a binding motif of ACBD5 (called FFAT motif), which is essential for the interaction with a protein domain of VAPB, can be phosphorylated at multiple amino acids.
Remarkably, phosphorylation at only one amino acid in the core region of the FFAT motif blocks binding of ACBD5 to VAPB and inhibits peroxisome-ER membrane contacts.
Moreover, the researchers identified the enzyme, the kinase GSK3?, which phosphorylates ACBD5 within the cell.
In addition, other phosphorylation sites adjacent to the core region were identified, whose phosphorylation is promoting ACBD5-VAPB interaction, revealing a complex regulatory mechanism.
The researchers cooperated with the laboratory of Professor Bettina Warscheid at the University of Freiburg, Germany, who is an expert in phospho-proteomics.
"FFAT motifs are found in many other proteins involved in VAP protein interaction at other locations in the cell," said Professor Schrader.
"Our findings expand the current model of FFAT motifs and point to a general mechanism of their regulation by phosphorylation.
"Understanding how they are regulated, is also disease-relevant."
Patients with a defect in ACBD5 suffer from a peroxisomal disorder with severe damage to the brain and retinas, affecting eyesight, whereas VAPB and GSK3? have been linked to amyotrophic lateral sclerosis (ALS) and fronto-temporal dementia (FTD).
People with severe peroxisomal disorders, also known as Zellweger Spectrum Disorders, often die as children or young adults, and the team cooperates with experts from the Academic Medical Center in Amsterdam and a charity called Zellweger UK to tackle peroxisomal disorders, raise awareness and support families and sufferers.
The research was supported by the Biotechnology and Biological Sciences Research Council, and the EU Marie Sk?odowska-Curie Innovative Training Network PerICo.
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