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Volume 58, October 2018 CNS DC E-Newsletter
Congress Urges CMS to Take Action on Prior Authorization
Restricting abusive prior authorization tactics is a top issue for organized neurosurgery, as such the AANS and CNS are leading an advocacy effort to reduce the burdens of prior authorization practices for Medicare Advantage (MA) and other health plans. Due to neurosurgery's advocacy, Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) spearheaded a letter among their colleagues in the U.S. House of Representatives urging the Centers for Medicare & Medicaid Services (CMS) to improve how prior authorization works under MA. Signed by 103 bipartisan House members, the letter to CMS Administrator Seema Verma notes, "patients may be encountering barriers to timely access to care that are caused by onerous and often unnecessary prior authorization requirements." It goes on to urge CMS do the following:
Issue guidance to MA plans to dissuade the widespread use of prior authorization and to provide direction to the health plans to increase transparency, streamline prior authorization and minimize the impact on patients;
Ensure that these requirements do not create inappropriate barriers to care for Medicare patients; and
Collect data on the scope of prior authorization practices — including denial, delay and approval rates.
The AANS and CNS issued a press release thanking these lawmakers for asking CMS to take action on prior authorization. The statement was picked up by Inside Health Policy, which ran a story noting that the AANS and CNS were pleased with the letter because neurosurgeons often run into prior authorization hurdles before their patients can receive care. Quoting Ann R. Stroink, MD, chair of the AANS/CNS Washington Committee, the piece stated, "Prior authorization — a tool insurance companies use to limit the medical services they cover — is a cumbersome process that we believe is being inappropriately used by Medicare Advantage plans."
House Ways and Means Committee Sends Letters to CMS Asking for Burden Reduction
On Sept. 4, House Ways and Means Committee chair, Kevin Brady (R-Texas), and health subcommittee chair, Peter Roskam (R-Ill.), released three letters to CMS as part of the committee's Red Tape Relief Project. The letters addressed issues related to physicians, hospitals and post-acute care providers. The physician letter reflects the input that the AANS and CNS provided to the committee throughout the past year, incorporating many of the recommendations that neurosurgery made regarding prior authorization, appropriate use criteria for diagnostic imaging and the Medicare physician fee schedule. The letter acknowledges the fact that physicians are spending nearly two out of every three hours on additional paperwork and relief from these unnecessary regulatory burdens must be provided.
Neurosurgery Submits Comments to Senate Regarding Surprise Billing Legislation
On Sept. 18, Sen. Bill Cassidy (R-La.), along with five of his colleagues — Sens. Michael Bennet (D-Colo.), Chuck Grassley (R-Iowa), Tom Carper (D-Del.), Todd Young (R-Ind.) and Claire McCaskill (D-Mo.) — released draft legislation to end surprise medical bills. The draft bill is intended to jumpstart discussions in Congress about how to best stop the use of balance billing to charge patients for emergency treatment or treatment provided by an out-of-network provider at an in-network facility. On Oct. 10, the AANS and CNS submitted a comment letter — prepared with the assistance of neurosurgeons Luis M. Tumialán, MD; Michael H. Brisman, MD; and Jay Nathan, MD — recognizing that while Americans continue to struggle with rising health care costs, including high deductibles and other out-of-pocket expenses, a balanced solution for cost-sharing between patients, physicians and health plans is necessary. The letter concurs that legislation should protect patients from "surprise" bills, but points out that the practice of narrowing networks by commercial payers is a central reason physicians practice out-of-network and the root cause of many of these "surprise" bills. The AANS and CNS urged the senators to make a number of changes to the draft proposal to:
Ensure network adequacy;
Establish fair and transparent out-of-network payment rates based on the FAIR Health, Inc., database; and
Allow balance billing in certain limited circumstances.
Senator Cassidy and his colleagues plan to introduce this legislation before the end of the year and neurosurgery will continue to stay engaged on the issue.
Congress Passes Comprehensive Opioid Legislation
On Oct. 3, by a vote of 98-1, the U.S. Senate passed H.R. 6, the "Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act," bipartisan legislation aimed at combatting the opioid epidemic. The House approved the package on Sept. 28 by a vote of 398-8. The legislation reflects organized neurosurgery's priorities, including:
No opioid prescribing limits;
Improved e-prescribing of opioids;
Enhanced prescription drug monitoring program (PDMP) interoperability; and
Improved payment for opioid alternatives and surgical pain therapies, such as neuromodulation.
President Trump is expected to sign the legislation into law.
President Trump Signs Bipartisan Children's Hospital GME Bill into Law
On Sept. 18, President Trump signed , the "Dr. Benjy Frances Brooks Children's Hospital GME Support Reauthorization Act of 2018," into law (P.L.115-241), officially extending the Children's Hospitals Graduate Medical Education (CHGME) program for five years. Rep. Gene Green (D-Texas) originally introduced the bill, which increases funding for the program at $325 million per year until 2023. Hospitals that receive the funding represent less than one percent of all hospitals, but train half the country's pediatricians and pediatric specialists. The program will ensure the longevity of a strong pediatric health care workforce for our nation's freestanding children's hospitals.
President Trump Signs Health Appropriations Legislation
On Sept. 28, President Trump signed H.R. 6157 (P.L. 115-245) into law, funding the U.S. Departments of Labor, Health and Human Services (HHS) and Education for FY 2019. Of interest to neurosurgery, the law provides a total of $39.1 billion for the National Institutes of Health (NIH) — an increase of $2 billion above FY 2018 funding. It also increases support for several neurologic research initiatives, including a $425 million increase for Alzheimer's disease research and a $29 million increase for the Brain Research through Application of Innovative Neurotechnologies (BRAIN) initiative. Additionally, the legislation includes a total of $7.9 billion for the Centers for Disease Control and Prevention (CDC), with $475 million going to fund Opioid Overdose Prevention and Surveillance and $6.75 million going to fund traumatic brain injury (TBI). In a letter to appropriations negotiators, the AANS and CNS expressed support for increased NIH and CDC funding.
House Passes the Local Coverage Determination Clarification Act
On Sept. 12, the House of Representatives passed the Local Coverage Determination (LCD) Clarification Act, H.R. 3635, by voice vote, which aims to improve accountability and transparency in the process Medicare contractors use to make local coverage decisions. The AANS and CNS joined the Alliance of Specialty Medicine and others in advocating for passage of this bill. Following the House action, CMS announced its own plans to accelerate innovation and promote patient access to medical technology by reforming Medicare's Local Coverage Determination process. The agency is taking the following steps to increase transparency and patient engagement:
Requiring a consistent, standardized summary of the clinical evidence supporting LCD decisions;
Including a beneficiary representative and other healthcare professionals in addition to physicians on Contactor Advisory Committees that inform LCDs; and
Ensuring that the Contractor Advisory Committee (CAC) meetings are open to the public.
Congress Asks HHS to Improve EHR Interoperability and Stop Data Blocking
During September, the AANS and CNS joined our colleagues from the American Academy of Dermatology and others to help gather signatures on a letter to HHS Secretary Alex Azar, regarding electronic health records and data blocking. Led by Reps. Mike Kelly (R-Fla.) and Mike Thompson (D-Calif.), more than 20 bipartisan members of the House signed this letter calling on HHS to address barriers to data sharing between qualified clinical data registries (QCDRs) and electronic health record (EHR) systems. The letter raises concerns about EHR vendor practices that are blocking the transfer of data between EHRs and clinical data registries and urges reforms, so neurosurgeons can better participate in Medicare's Quality Payment Program (QPP).
Coding and Reimbursement
Neurosurgery Comments on Payment-related Provisions of the Proposed 2019 Medicare Physician Fee Schedule
On Sept. 10, neurosurgery submitted a letter to CMS expressing concerns about several reimbursement-related provisions of interest to neurosurgeons contained in the 2019 Medicare Physician Fee Schedule proposed rule. In the letter, the AANS and CNS:
Opposed the agency's proposal to collapse the evaluation and management (E/M) office visit codes from five to two payment levels and recommended that CMS take more time to consult with stakeholders;
Agreed that preliminary results of global surgical data collection are incomplete and cannot be used to change the value of existing codes.
Encouraged CMS to cover evidence-based, opioid-sparing surgical therapies as an effective strategy to reduce opioid prescribing and abuse; and
Opposed CMS' plan to reduce the AMA/Specialty Society Relative Value Scale Update Committee (RUC)-passed values for five neurostimulator programming codes.
Click here to view a CMS fact sheet on the proposed rule. Click here to review a summary prepared by the American Medical Association (AMA) and annotated by AANS/CNS Washington Office staff. In addition to the neurosurgery-specific letter, the AANS and CNS joined the AMA and 160 other national and state medical societies in a letter regarding the proposed E/M changes. Neurosurgery also joined the Alliance of Specialty Medicine in a letter addressing issues of concern to specialty medicine. CMS is expected to issue the final 2019 MPFS final rule by early November.
AANS and CNS Comment on the Payment-related Provisions of the Medicare Outpatient Facility Proposed Payment Rule
On Sept. 24, the AANS and CNS submitted a letter to CMS expressing concerns about several reimbursement-related provisions of interest to neurosurgeons included in the 2019 Medicare Hospital Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) proposed rule. In the letter, the AANS and CNS:
Supported a proposal to lower the threshold for device-intensive procedures from 40 percent of the total cost of the surgery to 30 percent, allowing more appropriate facility reimbursement for innovative procedures;
Urged CMS to study available data and consult appropriate stakeholders regarding the safety of performing surgery in the ASC setting, emphasizing that the site of service should be determined by the operating surgeon in consultation with the patient; and
Agreed with CMS that, in the ASC setting, separately paying for non-opioid pain management is an effective way to increase the use of non-opioid treatments for improved pain treatment.
Aetna Updates Policy on Expandable Spinal Cage Devices for Lumbar Fusions
Aetna recently updated their policy to extend coverage for expandable spinal cage devices from L2 to S1, consistent with the FDA labeling of the Elevate device (the previous version of the policy limited coverage to L5-S1). The AANS and CNS had requested this change in a letter drafted by Kurt M. Eichholz, MD, Stephen L. Reintjes, MD and other members of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves, sent to Aetna on July 25.
MedPAC Releases Updated 2018 Payment Basics Series
On Oct. 12, the Medicare Payment Advisory Commission (MedPAC) announced the release of the updated 2018 Medicare Payment Basics series. Neurosurgeons may view the documents in the series, which provide an overview of 20 payment systems, by clicking here.
Neurosurgery Comments on Quality-related Provisions of the Proposed 2019 Medicare Physician Fee Schedule
On Sept. 10, neurosurgery submitted a letter to CMS expressing concerns about several quality-related provisions in the 2019 Medicare Physician Fee Schedule proposed rule, of interest to neurosurgeons. In the letter the AANS and CNS:
Supported several policies meant to reduce the complexity of the Merit-Based Incentive Payment System (MIPS), including facility-based scoring and simplifications to the Promoting Interoperability category;
Urged CMS to move more aggressively toward a more simplified scoring methodology to further reduce reporting, including providing credit across performance categories burden; and
Opposed multiple proposals that would make the program more challenging and confusing, including shifting more weight to the Cost category, mandating the use of 2015 Edition Certified EHR Technology, scaling back on the use of claims-based reporting for quality measures and doubling the MIPS scoring threshold to avoid a penalty.
Click here, to view a CMS fact sheet on the proposed rule. Click here, to review a summary prepared by the AMA and annotated by AANS/CNS Washington Office staff. Neurosurgery also joined the Alliance of Specialty Medicine in a letter addressing issues of concern to specialty medicine. CMS is expected to issue the 2019 MPFS final rule by early November.
The AANS and CNS Comment on the Quality-related Provisions of the Medicare Outpatient Facility Proposed Payment Rule
On Sept. 24, the AANS and CNS submitted a letter to CMS expressing concerns about several quality-related provisions of interest to neurosurgeons included in the 2019 Medicare Hospital OPPS/ASC proposed rule. In the letter, the AANS and CNS:
Opposed the removal of quality measures based solely on "topped-out" status;
Urged CMS to maintain ASC claims-based data collection and tracking for wrong side, wrong patient, wrong implant surgery and to continue to track the rate of ACS admissions requiring transfer to a hospital; and
Supported the removal of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) pain questions, given their tenuous link to higher quality.
CMS will publish the final rule in early November 2018.
Neurosurgical Resident Picked for White House Fellow Program
Jeremy Hosein, MD, a neurosurgical resident at University of Colorado School of Medicine, has been named to the 2018-2019 White House Fellows class. The White House Fellows Program was created in 1964 by President Lyndon B. Johnson to give promising American leaders "first hand, high-level experience with the workings of the Federal government, and to increase their sense of participation in national affairs." He joins 13 other individuals selected to participate in this prestigious program and follows in the footsteps of neurosurgeons Lindsey B. Ross, MD; Anand Veeravagu, MD; and Sanjay K. Gupta, MD, who also served as White House Fellows in the Obama/Trump Administrations (2016-2017), Obama Administration (2012-13) and Clinton Administration (1997-98), respectively.
Neurosurgeon Appointed to Medicare Advisory Committee
Ahmed M. Raslan, MD, has been appointed to the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). He joins Joseph S. Cheng, MD, in representing neurosurgery on this CMS panel. The AANS and CNS nominated Dr. Raslan at the end of last year. MEDCAC is a group of 100 appointed individuals — including physicians, patients and industry representatives. CMS calls on MEDCAC members when it is considering National Coverage Determinations (NCDs).
Neurosurgeon Selected for National Academies Committee for Opioid Pain Guidelines
Christopher J. Winfree, MD, was selected to serve on the National Academies of Science, Engineering, and Medicine's (National Academies) new study committee titled "Evidence-based Clinical Practice Guidelines for Prescribing Opioids for Acute Pain." Nominated by the AANS and CNS, his clinical, health policy and leadership experience related to pain medicine and opioids make Dr. Winfree ideally suited to serve on this important committee. The FDA is funding this effort, which will help advance the development of evidence-based guidelines for appropriate opioid analgesic prescribing for acute pain resulting from specific conditions or procedures.
Neurosurgeons Elected to Prestigious National Academy of Medicine
On Oct. 15, the prestigious National Academy of Medicine announced the election of two neurosurgeons to its ranks. Linda M. Liau, MD, PhD,, the W. Eugene Stern Professor and chair of the department of neurosurgery at the University of California, Los Angeles, was recognized for her achievements in understanding the immunology of malignant brain tumors and designing clinical trials of dendritic cell-based vaccines for glioblastoma. Robert M. Friedlander, MD, chair of the department of neurological surgery, and Walter E. Dandy Professor at the University of Pittsburgh Medical Center, was recognized for demonstrating the role of caspases in cell-death pathways in neurologic diseases and for groundbreaking discoveries that have led to the development of novel therapies to improve outcomes for patients suffering from stroke, brain and spinal cord injury, Huntington's disease and ALS.
Neurosurgery Issues Press Release on Cutting Red Tape in the Medicare Program
On Sept. 7, the DC office issued a press release highlighting a letter sent to lawmakers on Capitol Hill seeking regulatory relief from a burdensome program that will require clinicians who order advanced diagnostic imaging to consult with appropriate use criteria (AUC) each time they order a test. The letter was sent to the leaders of the Senate Finance and House Ways and Means and Energy and Commerce Committees and was signed by physician organizations representing primary, specialty and surgical care. Following this release, Bloomberg Law wrote an article, "Doctors Lobby Against Medicare Hurdle for Ordering MRIs," which not only highlighted our letter, but also quoted Katie O. Orrico, Esq., director of the AANS/CNS Washington Office, who noted:
It's great that they've acknowledged that the appropriate use program should be folded into MACRA's quality payment program … Unfortunately, we don't see that CMS has the statutory authority to remove the separate requirement for physicians to consult the imaging criteria. We'd like legislation to acknowledge that you don't have to comply with two different programs. Nonetheless, the medical societies will both continue to educate Congress on the issue and to advocate for the CMS to take steps to incorporate the programs.
Neurosurgery Blog's Pediatric Neurosurgery Focus Month a Huge Success!
Throughout September and part of October, Neurosurgery Blog hosted a pediatric neurosurgery focus awareness campaign. To maximize attention on pediatric neurosurgery-related issues, we launched the campaign during the back-to-school months. The goal is to shed important light on pediatric neurosurgery facts, innovations and the role of pediatric neurosurgeons. The first guest post was authored by Nathan R. Selden, MD, PhD, who discussed the changing face of pediatric epilepsy surgery. Our second guest post, which highlighted the newly released CDC evidence-based guideline on mTBI (including concussion) among children, was written by Grant Baldwin, PhD, Director, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. The Neurosurgery Blog team also developed an animation titled, "What's a Pediatric Neurosurgeon?" highlighting the superheroes who care for the littlest neurosurgical patients. Other blogs from the neurosurgical community incorporated into this series include:
Cutting Edge Caring: The Impact of Pediatric Neurosurgeons
Image Gently Alliance and The Think A-Head Campaign
Journal of Neurosurgery Covers All Aspects of #PedsNeurosurgery
Pediatric Scoliosis: Early Detection is Key
We invite all neurosurgeons to continue the conversation using the #PedsNeurosurgery hashtag so we can grow awareness through social media. In the meantime, if you have not already done so, we also encourage you to visit the blog and subscribe to it, as well as connect with us on our various social media platforms. Subscribe to stay informed on this and other important topics facing neurosurgery.
Neurosurgery Blog: More Than Just Brain Surgery
Neurosurgery's Twitter Feed: @Neurosurgery
Neurosurgery's Facebook Page
Neurosurgery's Instagram Page
Neurosurgery's LinkedIn Group
Neurosurgery's YouTube Channel
Neurosurgery's Tumblr Page
For more information on these or other health policy issues, please contact Katie O. Orrico, director of the AANS/CNS Washington Office at korrico@neurosurgery.org.


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'Shared Space' Design: Road Signs Suck. What if We Got Rid of Them All?
Shared space image via the Congress for the New UrbanismClick to enlarge image
It seems counterintuitive, but there's evidence that getting rid of signals, signs and barriers might actually make streets a lot safer. Towns all over Europe are starting to experiment with streets where cars, buses, bikes and pedestrians can travel freely in the same space. 99% Invisible teamed up with Vox to bring you this video story on how "shared space" approaches are challenging road design conventions:
There's a spot in Google street view where you can witness a town undergoing this exact kind of transformation. In Poynton, England there used to be a mess of signs and lights, a few small sidewalks and some haphazard guardrails to keep pedestrians safe.
A few years ago, all of these were removed. The town spent four million pounds to expand sidewalk space and strip the city center of traditional demarcations. Now, the only marker left is this little sign denoting the "Poynton Shared Space Village."
The concept is that the absence of separation will make everyone more cautious — so commuters slow down, make eye contact, and negotiate. And because cars don't spend time waiting at traffic lights, it takes less time on average for them to get through the crossing.
Even when cyclists and pedestrians are absent cars drive slowly due to a something called "edge friction." It's the idea that nearby vertical elements in a driver's peripheral vision (like trees or lamps) create a visual cue for how fast they're going. On a highway, those are often totally absent, so the sidelines blur. In a shared space, those lines play an important mental trick to slow down drivers.
In theory, shared spaces work well for pedestrians, allowing them to follow their desired path while walking. Instead of being limited to a strict path, they can walk exactly in the direction they want to go. In practice, that doesn't always seem to be the case — often, people will still walk where they would expect to see crosswalks. And those pedestrians frequently report that they prefer things the way they used to be — but the "way things used to be" is relative.
If you look at old footage of city streets in the early 1900s (or listen to the episode above), cars mixed freely with pedestrians, bicyclists, and streetcars. Vehicles couldn't go very fast back then, so there wasn't a huge concern about separating them from walkers and bike riders.
With plenty of city streets, that's still the case without any intentional urban planning. But the big question is whether these deliberately stripped-down designs actually make people safer. It seems that in many cases, they do — we know that the number of accidents drops after shared spaces are installed. We also know that shared spaces are more free-flowing based on analysis of "traffic conflicts" (where someone makes an evasive maneuver to avoid an accident). But that doesn't mean these designs work for everyone.
From the beginning, shared space designs have been under fire for providing insufficient protections for disabled pedestrians, especially the visually impaired. A 2015 House of Lords report called for a temporary ban on shared space designs. And in August of 2016, a select committee of the House of Commons launched an inquiry into the accessibility of such environments. Their final report in April of 2017 asked the government to put all shared space schemes on hold until they improved the process of consulting disabled communities.
Preliminary designs by groups like the Danish Building Research Institute hint at what a balanced approach might look like. They include both the mixed traffic of shared spaces but also raised street textures and button-activated crosswalks for pedestrians with disabilities.
Urban Crop Circle: "Ghost Roundabout"…
Urban Crop Circle: "Ghost Roundabout" Designed to Confuse & Slow
Shared spaces can be effective, but for this kind of plan to function well across communities, a lot more research is needed to determine what will work in different places and serve the needs of all the people sharing the streets. This will also require a radical rethinking of how we move through our daily lives, raising questions about signs and infrastructure we see everywhere but take for granted — and it will mean rewriting the rules of what a city can look like.
Civic Superblocks: Barcelona's Urban…
Civic Superblocks: Barcelona's Urban Redesign Returns Streets to…
This video was co-produced by Christophe Haubursin of Vox Media with Roman Mars and Kurt Kohlstedt of 99% Invisible.
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I find these unsigned spaces much more stressful, both as a driver and a pedestrian. Yes everyone slows down as they feel anxious, but conventions that cars won't enter pavements and pedestrians amble down the road benefit both parties.
Compare a spiral laned roundabout with the Arch de Triomphe
One reason I feel like there are so few pedestrian accidents in NYC is that it is one of the few cities where the pedestrians feel like they own the road. They cross streets on a whim and rarely wait for the light cats are physically in the space already. Because of this drivers are much more cautious driving in these congested areas and accidents on a per capita basis are very low.
Shared Space definitely has its place in among others in the road design toolbox. But the only times I have ever seen them be effective is when traffic volumes are extremely low, as in <100 cars an hour. This is when drivers actually respond to the lack of signs and specific markings.
In the UK, shared space has been used mainly without serious attempts to lower traffic volume. So car drivers see other cars in large numbers, feel like they still 'own' the space and therefore do not meaningfully adjust their behaviour to accommodate people walking a cycling.
Ultimately, the way to make shared space suceed is down to other less fashionable factors such as modal filtering and not allowing rat running.
Bikers or cyclists?
All-Purpose Guru
Road signs suck in many places in Europe, but they generally don't suck TOO badly in the US, where there are Federal standards that are, for the most part, pretty reasonable.
I've driven in the US, Europe, Australia, the U.K., Japan, Hong Kong, and China, so I've got some experience with both good and bad signage and road construction. I've seen good designs, bad designs, and what the frood were they thinking designs. Another point of note in my humble opinion is that what SIDE of the road you drive on makes effectively no difference at all.
If you tried the "shared space" model in Texas, traffic and pedestrian deaths would easily triple. In any case, driver stress levels and road rage would increase dramatically.
Oh God NO!!! No No No! I live in Poynton! The traffic is backed up just as much as it ever was when we had the traffic lights. If you are visibly impaired you cannot cross. When we checked with the Dutch designers they said it only would work if we had a bypass (we still don't) and they then said there was better schemes than shared space. The council only did it to spend money because the next village, Handford, got a cash grant to do up their little shopping centre.
The only single good thing was we got a new piece of music composed. Even the way they did it. Months to rip up the roads to lay down blocks to raise the road level with the pavement. Pouring extra tarmac was too cheap and quick to do.
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Peace Lines

redpajama_set_name: RedPajamaCommonCrawl


Another spiralized dish! I know, but you have to get one if you don't already. I've talked my mom into it and now I'm going to convince you that you need it as well.
My veggie intake has doubled if not tripled since I bought one. (so has my kids!) And they're so fun! My husband is obsessed with curly fries, has me make them every weekend. Almost all the time, you don't even miss the pasta. If my carb loving husband doesn't mind all the veggie noodles, than I promise you will love it!
I've mentioned before that I'm obsessing over this little machine, and that obsession hasn't dwindled in the slightest. Plus check out this super tasty combo! And these Pancetta & Zucchini noodles make a weekly appearance in my lunches.
These spicy shrimp noodles are just as good cold the next day, as they are right off the stove. And they warm up just as well! There's a whole Serrano pepper in there and some chili paste, so this isn't for the faint of heart, there is definitely a kick to it, but it's awesome. Also, I apparently like spicy shrimp! 🙂 Enjoy!
To make the sauce, combine all the ingredients together and mix well. Add the shrimp. And set aside to sit for 20 minutes while you prep everything else.
In a large skillet heat the sesame oil over medium-high heat. Once shimmering, add the serrano, ginger, and garlic. Saute for 1-2 minutes.
Add the peppers and radishes, and saute for 5-8 minutes, until softened.
Add the sauce that the shrimp is marinating in, but hold the shrimp for now, and stir in the sweet chili sauce. Reduce heat to medium, cover, and cook for about five minutes, tossing once until the sweet potato noodles begin to soften.
Add in the shrimp and cook for 3-5 minutes longer until the shrimp is pink and cooked through.
Serve and top with chopped peanuts and fresh cilantro. Enjoy!


Gorgeous one of a kind piece. The sham measures 18x23inches and is piped with colorful accents Each piece is hand embroidered. Expertly sewn with a hidden zipper closing and professionally lined for easy stuffing. Each piece is one of a kind. NO two are alike.


Need firearms training in California, are Introduction to firearms Class covers California guns laws and federal laws. Our course covers firearm safety and the different types of firearms sold in California. We also cover how to buy firearms, store and handle them in any environment. We cover nomenclature of handguns, shotguns, AR-15 rifle and bolt action rifles. The class will discuss what to do in an emergency situation in your home. When the class is done, every student will have basic knowledge of California gun laws and firearms nomenclature.
Introduction to firearms training is a great way to get into shooting. We give people the knowledge to understand California laws and how every firearm works that someone could buy in California. This class will give students the mindset to buy and be a responsible gun owner.
We can help with purchasing a firearm with are gun store 3 doors down from us at guns N stuff. This allows shooters to pick from a different selection of firearms at a good price.
We will also show the fundamentals of holding different types of firearms, also sight alignment and sight picture. The different types of ammunition for all the firearms that the class will present. We cover the proper handling of every firearm and how to use the safety device.


Heyzap allows you to check in and discover new mobile games with your friends.
Use Heyzap to find and discover new games for your phone. Check-in to your favorite games, see what your friends are playing, share gaming tips and unlock badges the more you play.
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Lenovo has a new feature that will make you wonder why it isn't standard on all touch devices. The new feature is called WRITEit and according to Lenovo it allows users to "write their input directly into virtually any text field that accepts typed input, even if the field is in an app without native pen support." This takes away the need to click a type box and pull up a touch screen keyboard. This streamlines text entry on touch devices and makes it much more natural. As you can see below, WRITEit allows you some leeway when it comes to writing inside boxes.
The new technology works with a variety of inputs including Windows 8 digitizers, active pen, and the very handy AnyPen technology. WRITEit works in areas other than search boxes as well: "WRITEit also works well for emails, social media, online forms and more." The ability to write directly in emails is especially handy because their text boxes give you more room to work with.
Here's a video from Lenovo showing off the new technology.
WRITEit is one of those seemingly small features that we may look back on and wonder why it isn't on every device that has a touch interface. For tablets to leap into more fully functioning everyday devices they need a simple way to enter text. While Windows devices have some options now, none of them flow as naturally as WRITEit.
Edit: This post has been edited to replace the original lead image with a photo of WRITEit. Additionally photos were added with some brief text explaining some of them.


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Бабчинецька сільська громада — об'єднана територіальна громада в Україні, в Могилів-Подільському районі Вінницької області. Адміністративний центр — село Бабчинці.

Утворена 8 вересня 2016 року шляхом об'єднання Бабчинецької та Вило-Ярузької сільських рад Чернівецького району. 17 серпня 2018 року добровільно приєдналася Моївська сільська рада.

12 червня 2020 року Бабчинецька сільська громада утворена у складі Бабчинецької, Вило-Ярузької, Моївської сільських рад Чернівецького району, Бандишівської, Мервинецької сільських рад Могилів-Подільського району та села Вітрівка Тростянецької сільської ради Ямпільського району.

Населені пункти
До складу громади входять 1 селище: Степне та 12 сіл: Бабчинці, Бандишівка, Букатинка, Вазлуївка, Вила-Ярузькі, Вітрівка, Гамулівка, Майорщина, Мервинці, Моївка, Нове Життя, Новомикільськ.

Примітки

Громади Могилів-Подільського району

redpajama_set_name: RedPajamaWikipedia


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text:
Q: Binding com CustomControl não está funcionando Criei um CustomControl porém criando uma BindingProperty não consigo efetuar um binding
Código XAML do Custom Control
<ContentView xmlns="http://xamarin.com/schemas/2014/forms"
         xmlns:x="http://schemas.microsoft.com/winfx/2009/xaml"
         x:Class="CustomControls.Controls.CustomEditor">
    <Editor x:Name="edt" Text="{Binding Text, Mode=TwoWay}" />
</ContentView>

Código CS do CustomControl
[XamlCompilation(XamlCompilationOptions.Compile)]
public partial class CustomEditor : ContentView
{
    public CustomEditor ()
    {
        InitializeComponent ();
        this.BindingContext = this;
    }

    public static readonly BindableProperty TextProperty = BindableProperty.Create(
       propertyName: nameof(Text),
       returnType: typeof(string),
       declaringType: typeof(CustomEditor),
       defaultValue: "",
       defaultBindingMode: BindingMode.TwoWay,
       propertyChanged: (b, o, n) =>
       {
           if (b is CustomEditor view)
               view.edt.Text = n.ToString();
       });

    public string Text
    {
        get => (string)GetValue(TextProperty);
        set
        {
            SetValue(TextProperty, value);
            base.OnPropertyChanged(nameof(Text));
        }
    }
}

MainPage XAML que consome o CustomControl
<ContentPage xmlns="http://xamarin.com/schemas/2014/forms"
         xmlns:x="http://schemas.microsoft.com/winfx/2009/xaml"
         xmlns:local="clr-namespace:CustomControls"
         xmlns:controls="clr-namespace:CustomControls.Controls"
         x:Class="CustomControls.MainPage">
    <StackLayout Padding="10">
        <Label Text="{Binding Email}"/>
        <Editor x:Name="txtTeste" Text="{Binding Email}"/>
        <controls:CustomEditor Text="{Binding Email, Mode=TwoWay}"/>
    </StackLayout>
</ContentPage>

MainPage CS
public partial class MainPage : ContentPage
{
    public MainPage()
    {
        InitializeComponent();
        BindingContext = this;
        this.Email = "lucas@email.com";
    }

    private string _email;

    public string Email
    {
        get { return _email; }
        set { _email = value; base.OnPropertyChanged(nameof(Email)); }
    }
}

Na MainPage no customControl se começo com um HardCode ele já abre o app com Editor preenchido porém qualquer alteração na propriedade Email ele não reflete no Editor e se mudo o valor do Editor ele não reflete na propriedade email, é possível utilizar Binding nessa Situação?

A: Com esse artigo CustomControls Xamarin Forms consegui resolver meu problema, o componente final ficou.
XAML
<?xml version="1.0" encoding="UTF-8"?>
<Grid xmlns="http://xamarin.com/schemas/2014/forms"
        xmlns:x="http://schemas.microsoft.com/winfx/2009/xaml"
        x:Class="Camareira.Controls.FormEntry"
        HorizontalOptions="FillAndExpand">
    <Grid.RowDefinitions>
        <RowDefinition Height="25"/>
        <RowDefinition Height="*"/>
    </Grid.RowDefinitions>
    <Label x:Name="label" Grid.Row="0"/>
    <Entry x:Name="entry" Grid.Row="1"/>
</Grid>

.CS
[XamlCompilation(XamlCompilationOptions.Compile)]
public partial class FormEntry : Grid
{
    public FormEntry ()
    {
        InitializeComponent ();
        entry.TextChanged += (s, e) =>
        {
            Text = e.NewTextValue;
        };
    }

    public static readonly BindableProperty TitleProperty = BindableProperty.Create(
        nameof(Title),
        typeof(string),
        typeof(FormEntry),
        null,
        BindingMode.OneWay);
    public string Title
    {
        get => (string)GetValue(TitleProperty);
        set => SetValue(TitleProperty, value);
    }

    public static readonly BindableProperty TextProperty = BindableProperty.Create(
        nameof(Text),
        typeof(string),
        typeof(FormEntry),
        null,
        BindingMode.TwoWay);
    public string Text
    {
        get => (string)GetValue(TextProperty);
        set => SetValue(TextProperty, value);
    }

    public static readonly BindableProperty PlaceholderProperty = BindableProperty.Create(
        nameof(Placeholder),
        typeof(string),
        typeof(FormEntry),
        null,
        BindingMode.TwoWay);
    public string Placeholder
    {
        get => (string)GetValue(PlaceholderProperty);
        set => SetValue(PlaceholderProperty, value);
    }

    protected override void OnPropertyChanged([CallerMemberName] string propertyName = null)
    {
        base.OnPropertyChanged(propertyName);
        switch (propertyName)
        {
            case nameof(Title):
                label.Text = Title;
                break;
            case nameof(Text):
                entry.Text = Text;
                label.IsVisible = !String.IsNullOrEmpty(Text);
                break;
            case nameof(Placeholder):
                entry.Placeholder = Placeholder;
                break;
        }
    }
}

redpajama_set_name: RedPajamaStackExchange


text:
Sitges Review: Benson & Moorhead's Clever Sci-Fi Film 'Synchronic'
There's nothing like a Benson & Moorhead film. These two indie filmmakers have been working together since 2012, launching with their first feature film Resolution. They followed that up with Spring in 2014, then The Endless in 2017, both excellent features. And now they're ready with another new film - this one titled Synchronic. Out of all of their films, this one is a bit more "commercial" than their others, but still as intricately crafted. At some point we just need to start admitting that Benson & Moorhead are some of the best sci-fi / genre filmmakers cooking up some of the most original projects these days, I mean goddamn these guys rule. Everything they make is outstanding. If you can see Synchronic without knowing anything else about it, go see it that way first. It is always the best way to experience every Benson & Moorhead film.
The only thing I can (or want to) tell you about Synchronic at this point, is that it's a must watch for anyone who enjoys sci-fi, or anyone who loves time travel. The film is about two best friends who work as EMTs in an ambulance down in New Orleans. Jamie Dornan stars as Dennis, and Anthony Mackie stars as Steve. They're both stressed, about life and the job, but that's normal. Things start to get weird when they discover people who have died in very strange ways. When they start to look closer, they notice there's a recreational drug nearby called "Synchronic" that seems to be connected to these strange deaths. When a family member disappears, the two of them end up diving full-on into trying to figure out how to solve this peculiar mystery and make sense of this weird time travel drug. I won't say anything more since I don't want to spoil any of it.
I really, really enjoyed this film - as a sci-fi geek especially, but also as just a movie lover. Justin Benson & Aaron Moorhead's Synchronic is an excellent little time travel film that breaks mold of what's expected, gives us something totally fresh and new, and is an engaging thriller right up to the end. I love all the cosmic hints that make it extra fascinating and mystical. I am seriously impressed by so much of it - the editing especially is incredible, pulls you in even more into the film. It's hard to imagine how anyone can re-invent or try something new with time travel, and while many try, few succeed. Synchronic is one of the few films that succeeds in approaching time travel in a brand new way - breaking some rules of what we expect, how it should work, but also giving us something exciting and fascinating to think about well after the film is over.
Benson & Moorhead's films are all intricately built around raw, realistic emotions and lived-in interpersonal relationships between characters. That's where they start and that's a core strength that is necessary. Then they build up the rest of the story around that, throwing in twists to the usual genre tropes, and challenging viewers by going the opposite way and bringing in fresh ideas that no one has seen before. Synchronic's use of this recreational drug as the time travel mechanism is rather brilliant - simple in concept but intriguing in execution. I just wanted them to push it further. Maybe it was a budgetary limitation, or maybe it was their plan to keep the film minimal. Right when it's getting good, they pull back and streamline the next major developments. I know they can pull off more, this just felt like they were holding back for whatever reason.
Nonetheless, it's still an impressive film - a worthy new addition to the time travel sci-fi subgenre. And it's a captivating film that can be discussed in-depth once you see it, whether that be with friends or with other folks online. There's plenty to dig into here. And hopefully discussions will encourage Benson & Moorhead to keep making more original films, to keep telling stories their way in order to make their mark on cinema.
Alex's Sitges 2019 Rating: 8.5 out of 10
Follow Alex on Twitter - @firstshowing
Find more posts: Review, Sci-Fi, Sitges


text:
struct default_init_tag;

class poi::hssf::record::FormulaRecord_SpecialCachedValue final
    : public ::java::lang::Object
{

public:
    typedef ::java::lang::Object super;

private:
    static constexpr int64_t BIT_MARKER { int64_t(-281474976710656LL) };
    static constexpr int32_t VARIABLE_DATA_LENGTH { int32_t(6) };
    static constexpr int32_t DATA_INDEX { int32_t(2) };

public:
    static constexpr int32_t STRING { int32_t(0) };
    static constexpr int32_t BOOLEAN { int32_t(1) };
    static constexpr int32_t ERROR_CODE { int32_t(2) };
    static constexpr int32_t EMPTY { int32_t(3) };

private:
    ::int8_tArray* _variableData {  };
protected:
    void ctor(::int8_tArray* data);

public:
    int32_t getTypeCode();
    static FormulaRecord_SpecialCachedValue* create(int64_t valueLongBits);
    void serialize(::poi::util::LittleEndianOutput* out);
    ::java::lang::String* formatDebugString();

private:
    ::java::lang::String* formatValue();
    int32_t getDataValue();

public:
    static FormulaRecord_SpecialCachedValue* createCachedEmptyValue();
    static FormulaRecord_SpecialCachedValue* createForString();
    static FormulaRecord_SpecialCachedValue* createCachedBoolean(bool b);
    static FormulaRecord_SpecialCachedValue* createCachedErrorCode(int32_t errorCode);

private:
    static FormulaRecord_SpecialCachedValue* create(int32_t code, int32_t data);

public:
    ::java::lang::String* toString() override;
    int32_t getValueType();
    bool getBooleanValue();
    int32_t getErrorValue();

    // Generated

private:
    FormulaRecord_SpecialCachedValue(::int8_tArray* data);
protected:
    FormulaRecord_SpecialCachedValue(const ::default_init_tag&);

public:
    static ::java::lang::Class *class_();

private:
    virtual ::java::lang::Class* getClass0();
    friend class FormulaRecord;
};

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