Introduction
============

Telepractice is rapidly gaining nationwide interest for the provision of intervention, diagnostic and consultation services in response to the chronic shortage of school-based speech-language pathologists (SLPs) in the United States ([@b2-v4n2-art-10.5195-ijt.2012.6104]; [@b32-v4n2-art-10.5195-ijt.2012.6104]). The shortage of SLP personnel creates the opportunity for researchers and clinicians alike to determine if telepractice can become a practical, cost-effective and valid form of delivery for services. Access to high-speed Internet and video conferencing systems facilitates this method by enabling public schools, clinics and hospitals, and other end-users to connect to professionals and specialists regardless of their geographical location.

Traditional models of service delivery have involved, and in some cases required on-site, face-to-face interactions between the clients ([@b3-v4n2-art-10.5195-ijt.2012.6104], [@b4-v4n2-art-10.5195-ijt.2012.6104]), students in training and/or SLP specialists, and include tangible written or visual materials and stimuli. The advancement of technologies and high speed Internet enable SLPs to simulate therapeutic sessions in virtual environments. SLPs utilize the power and flexibility of the Internet to conduct screenings and diagnostic evaluations; and provide intervention, consultation, and follow-up services utilizing telepractice methodologies.

Telepractice has the potential to revolutionize how SLP services are delivered, particularly with respect to individuals with autism. The number of individuals in the U.S. diagnosed with autism continues to grow annually. Recent estimates suggest that autism affects approximately 1 in every 88 children ([@b7-v4n2-art-10.5195-ijt.2012.6104]) and as many as 61% of children with autism initially present with little to no functional speech ([@b16-v4n2-art-10.5195-ijt.2012.6104]; [@b28-v4n2-art-10.5195-ijt.2012.6104]; [@b21-v4n2-art-10.5195-ijt.2012.6104]). It is estimated that approximately 40% of children with ASD remain non-verbal ([@b19-v4n2-art-10.5195-ijt.2012.6104]) with a significant proportion of this population requiring alternative communication modes for expressive communication ([@b18-v4n2-art-10.5195-ijt.2012.6104]). Many of these children reside in areas where public resources are scarce and have limited access to qualified SLP professionals. Gaining access to services via telepractice allows for the potential to improve long-term outcomes for this population as it enables the implementation of evidence-based interventions. The [@b20-v4n2-art-10.5195-ijt.2012.6104] has identified approximately 24 evidence-based interventions for individuals with autism. Interventions such as functional communication training and behavioural assessment, computer aided instruction, parent implemented intervention, video modeling, peer-mediated intervention, the use of speech generating devices, pivotal response training and social narratives may be appropriate for a telepractice delivery method based upon the intended communication skill targeted with these approaches.

Telepractice is emerging as a viable method not only for delivery of SLP services to clients in remote regions, but also for related services ([@b6-v4n2-art-10.5195-ijt.2012.6104]). To date, several published studies support the use of telepractice applications for the delivery of health care services. The results of these studies show that telepractice has significant benefits for the provision of health-related services ([@b17-v4n2-art-10.5195-ijt.2012.6104]). The purpose of this paper is to introduce a telepractice service delivery continuum as it relates to direct and indirect SLP services. In addition, this paper presents two case studies that provide evidence regarding the potential and efficacy of telepractice as a remote service delivery model.

Clinical Model for a Telepractice Service Delivery program
----------------------------------------------------------

To date, a small number of published studies supports the use of telepractice for the provision of both direct and indirect speech and language services. Direct telepractice services, also known as synchronous services, can be used to provide real-time services to individuals in need of treatment. These services are consistent with traditional in-person sessions; however, the mode of delivery incorporates the use of videoconferencing and screen-sharing software. By using these technologies, the off-site SLP is able to communicate and interact with the client and present stimuli and activities that target specific intervention goals and objectives. Moreover, the procedures followed utilizing telepractice service delivery methodologies must ensure that the quality of services received through telepractice are equivalent to that of traditional on-site services.

Telepractice facilitates Active Consultation practices, an indirect service delivery strategy. Active Consultation implements a combination of Bluetooth^™^ technology and videoconferencing software to inconspicuously provide real-time feedback to an on-site professional. Active Consultation services are employed to facilitate guided training to individuals at an on-site location while they are working with the client. The off-site supervising professional or clinician is able to observe all interactions through videoconferencing software and provide scaffolded instruction. Through Active Consultation, off-site professionals provide directions, recommendations and strategies that target specific skills within the context of services.

The strategic use of these technologies and telepractice methodologies enable a continuum of direct and indirect services regardless of locale and issues related to personnel shortages. In the sections that follow, guidance for providing services through telepractice and Active Consultation is provided, including an outline to help troubleshoot various decision-making processes, technical logistics and clinical strategies needed to support an evidence-based telepractice service delivery program.

Identifying the Need
--------------------

Prior to implementing any technologies to provide SLP clinical services, a thorough needs assessment is essential for the successful implementation of a telepractice program. The on- and off-site telepractice team need to develop a plan that addresses the following components detailed by the [@b4-v4n2-art-10.5195-ijt.2012.6104]: a) current student/school need; b) current resources and infrastructure; c) required technology/equipment; d) tools used for student assessment and treatment; e) strategies for documentation and reporting; f) schedule for professional and caregiver education; g) schedule for student/client services; and h) general communication strategies. The needs assessment identifies the specific goals, practices and problems that the technology will support and clearly describes the benefits and limitations of the technology, including various strategies to integrate new technologies. Establishing an ongoing program evaluation of the quality of services and clinical outcomes helps validate the use of telepractice and thus, improves the overall program.

Student Data, Privacy and Confidentiality Protocols
---------------------------------------------------

It is of the utmost importance for telepractice programs to be implemented and administered to adhere to procedures that ensure confidentiality, student privacy and data security. The Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA) are federal mandates that ensure the protection of student, client data, privacy, and confidentiality.

FERPA applies to elementary, secondary, and adult students in public and private institutions that receive federal funds ([@b9-v4n2-art-10.5195-ijt.2012.6104]). This mandate provides explicit regulations regarding the privacy and release of students' educational records ([@b33-v4n2-art-10.5195-ijt.2012.6104]; [@b31-v4n2-art-10.5195-ijt.2012.6104]). Educational institutions subject to FERPA are prohibited from disclosing the educational records of students or personally identifiable information, without a guardian's or eligible student's written consent. When initiating a telepractice program, obtaining the caregiver's informed consent fosters student safety and privacy. Ethical guidelines require professionals and clinicians to fully inform all parties of the nature and possible effects of the services rendered ([@b8-v4n2-art-10.5195-ijt.2012.6104]; [@b4-v4n2-art-10.5195-ijt.2012.6104]). The process of obtaining consent includes providing a detailed description of the technology to be used and services to be delivered. A description must be furnished to all relevant parties regarding the differences between telepractice services compared to traditional on-site services. Moreover, the positive and negative consequences must be outlined with respect to the potential outcomes and necessary steps and procedures that might result with telepractice services ([@b8-v4n2-art-10.5195-ijt.2012.6104]).

HIPAA addresses the security and privacy of protected health information ([@b11-v4n2-art-10.5195-ijt.2012.6104]). There are several methods to meet HIPAA requirements when providing telepractice, such as the use of data encryption, security certificates and virtual private networks ([@b4-v4n2-art-10.5195-ijt.2012.6104]). All computers and laptops used for telepractice should have a secure firewall and up-to-date anti-virus software. These security measures help to reduce the likelihood that a virus will attack the computer and facilitate the protection and privacy of student/client/patient information. All SLP professionals must be trained in security protocols that include password management and computer monitor placement. All electronic data that passes between participants must have a 256-bit Secure Socket Layer encryption.

Technical Requirements and Quality Standards
--------------------------------------------

Technological competence is pivotal in the successful delivery of telepractice. An established standardized protocol maximizes the reliability and effectiveness of remote service delivery. There are essential items that must be available at both the provider's and client's locations. These items include a computer/laptop with a large monitor, high-speed Internet access, webcam, a video conferencing system, and a screen-sharing program. A number of additional factors must be considered when administering intervention services via telepractice. These include technical requirements (such as bandwidth connection), Internet usage policies, especially when multiple users occupy the Internet concurrently, collaboration with on-site information technology (IT) technicians or technical support/administrators, and the need for supplementary equipment.

Supplementary Equipment and Resources
-------------------------------------

Supplementary equipment can enhance the overall quality of direct/indirect services provided via telepractice. Additional tools, devices and equipment vary according to the application of services and the desired outcomes. For example, additional monitors, web and document cameras, headphones, cell phones, Bluetooth^™^ earpieces, and back-up storage devices may be needed for telepractice services. For direct services, a large monitor (over 20 inches) or dual monitors support the dynamic exchanges that occur when providing telepractice for clinical services. The visual infrastructure of the equipment must support the clinician's ability to provide visual cues and models, as well as use non-verbal body language (such as gestures and facial expressions) via video conferencing. External webcams (versus a built-in webcam) often provide a wider visual field of the remote environment and provide freedom of movement as the camera can be repositioned in any direction. The use of motorized pan and tilt webcams enable the off-site SLP to remotely control the movement and zoom of the camera to obtain different vantage points of the on-site environment. External speakers for sound, headsets, and microphones enhance the audio quality transmitted and received between the participants.

The Internet provides a significant amount of web-based materials and activities that lend themselves to telepractice. When a SLP is determining what digital information to present through screen-sharing software, the visual layout of the screen must be taken into account. "Visual clutter" refers to external visual stimuli, such as advertisements, chat boxes, and tool/navigation bars on a webpage that might distract the client from the content or intended purpose of the activity. To address this issue, the clinician must be able to remove or hide the visual distraction on the page. Presenting material in full screen or using the screen's zoom feature allows clinicians to enlarge the material or activity, thereby eliminating unwanted items from view.

Collaborating with On-site Personnel and Liaisons
-------------------------------------------------

On-site personnel and liaisons are an essential component of a successful telepractice program. Support personnel can include caregivers/parents, general and special educators and assistants, paraprofessionals, e-helpers, and speech language pathology assistants (SLP-As). The support personnel's role must be clearly identified. There must not be any misrepresentation of the credentials of the on-site support personnel. It is essential to distinguish between an on-site helper and a SLP-A. If the support personnel assumes an active role and is involved in the provision of services (i.e., provides and plans additional on-site interventions), then the support personnel's role may be considered a SLP-A. If the person providing therapy is, indeed acting as a SLP-A, the required credentials and requirements must be obtained to legally practice in the state where services are rendered. Likewise, the SLP providing services must adhere to the supervisory guidelines mandated by the state in which the services are being provided.

Monitoring Student Progress and Quality Assurance
-------------------------------------------------

Regardless of the equipment, tools and/or services being implemented, assessment and intervention services provided through telepractice should be evaluated for clinical effectiveness and must include client, caregiver, and provider satisfaction surveys to obtain quality assurance outcome measures ([@b4-v4n2-art-10.5195-ijt.2012.6104]). Ongoing documentation and progress monitoring should occur using a safe, secure caseload management program. For the purpose of telepractice, web-based systems are ideal as they support universal access and the collaboration of all team members regardless of geographical location. The documentation for telepractice is comparable to traditional on-site services in that the following information should be included: 1) date of the session; 2) length of service; 3) technical issues encountered; 4) intervention goals addressed; and 5) data collected for each target objective. Clinicians must document student progress and outcomes toward each goal addressed, as well as any additional referrals and/or recommendations.

The assessment of service quality is an ongoing process. Well established communication processes among the relevant parties and participants directly enhance the overall quality of the intervention and/or consultation services provided via telepractice and Active Consultation. Both on-site and off-site staff must have an organized and effective method implemented through which concerns, questions and information can be shared among all relevant parties and participants.

IT Support
----------

Consultation of on-site Information Technology (IT) support is required when initiating a telepractice program, given the IT professional's knowledge of the technical infrastructure and usage at an on-site location. The collaboration between the off-site SLP and on-site IT personnel will ease the technology selection process and help with troubleshooting when issues arise ([@b14-v4n2-art-10.5195-ijt.2012.6104]). The on-site IT personnel should be made aware of the times and dates that telepractice services are being provided and may require IT support. The on-site IT personnel facilitate ongoing quality assessments, manage firewalls and ensure sufficient bandwidth to prevent interruption or degradation of the Internet connection ([@b4-v4n2-art-10.5195-ijt.2012.6104]). Moreover, IT personnel assist in identifying any breakdowns (i.e., Internet bandwidth or firewall settings) and work with the off-site SLP to find a viable solution.

Clinical Training
-----------------

Initial and ongoing training of personnel ensures that providers are kept abreast of advancements and best practices in telepractice methodologies. Training should include many of the following items previously discussed to ensure fidelity and successful implementation and use of telepractice. These items include: 1) an overview of the feasibility, standards, benefits and limitations of telepractice; 2) the necessity to obtain outcome data using standardized procedures and processes; 3) evidence of professional certification and licensure; 4) regularly scheduled meetings; 5) intervention planning; 6) data collection and documentation; 7) data security and privacy; 8) clinical techniques and behavioral management strategies; 9) a review of assessment and screening protocols for use with telepractice; 10) consultation with parents/guardians, general and special educators and other personnel (i.e., specialists, physicians, clinicians, etc.); 11) resources and materials to be used for telepractice; and 12) the critical collaboration with on-site personnel.

Direct Telepractice Services
============================

Objective of Case Study 1
-------------------------

The objective of this single subject clinical case study was to demonstrate the effects of telepractice as a service delivery method for providing direct SLP intervention services to an individual with autism.

Methodology
-----------

This single subject case study utilized a changing condition (ABC), repeated measures research design ([@b24-v4n2-art-10.5195-ijt.2012.6104]), whereby the participant's progress on use of transition words in narratives was systematically measured while receiving direct services through a telepractice condition followed by an on-site condition. The participant received six telepractice and five on-site intervention sessions that targeted the IEP objective. Six pairs of probes were administered during the telepractice condition and five were administered during on-site condition.

The specific treatment objectives included retelling an event or narrative using a variety of transition words to sequence the actions and/or steps. The Individualized Education Plan (IEP) objectives, intervention and task frequency, treating graduate clinician, and the location of services remained constant throughout the study.

Baseline data were collected by the treating graduate clinician (who was not blind to the purpose of the study) over the course of two weeks prior to the implementation of the first intervention. Within this time frame, no technology, equipment or approaches were introduced for use via telepractice. Five data points were recorded prior to the initiation of the first condition and a stability of target behavior was achieved. During the intervention phases, repeated measurements were performed throughout the on-site and telepractice conditions to establish a clear pattern of the participant's performance on the target objectives.

Two treatment probes were incorporated into the beginning and end of each session. The beginning (Probe 1) and end probe (Probe 2) targeted the same IEP objective; however, different stimuli were utilized to assess the participant's skill level. The two probes were matched in terms of task difficulty and the probe stimuli were different during each intervention session and varied from the therapy stimuli.

Participants and Setting
------------------------

The student participant was an 11-year-old, non-Latino white male diagnosed with autism at age ten. At the time of this study, this participant received services in the areas of speech and language, social skills, English language arts, occupational therapy and mathematics.

This study included the participation of one first-year graduate clinician enrolled in the University of Massachusetts - Amherst's Master's program in Speech Language Pathology. The treating graduate clinician was informed of the purpose of the study and initially received two hours of clinical training on the technology, methods, software, and the documentation used to provide services. Thereafter, the graduate clinician received further training each week with a focus on methods and procedures for the implementation of evidence-based intervention for both on-site and off-site services, materials for treatment, and other responsibilities associated with the study. The treating graduate clinician was supervised at all times by a certified and licensed SLP for both treatment conditions.

The student participant attended a rural school in Western Massachusetts. Administrators at the participating school confirmed their interest and support for this study and the participant's caregiver signed a detailed informed consent document confirming voluntary participation.

Materials and Equipment
-----------------------

Web-based materials and stimuli were used during each intervention session for both the on-site and off-site telepractice conditions. Teaching activities were conducted and developed using SMART Notebook^™^ software, the PresenceLearning platform, and Big Universe, all of which offer Internet-based intervention materials. During the telepractice condition, screen-sharing was conducted through Adobe®, ConnectNow^™^, or PresenceLearning.

Skype^™^, a videoconferencing application with 256 bit Advanced Encryption Standard (AES) encryption, was used for the video and audio communication component ([@b29-v4n2-art-10.5195-ijt.2012.6104]). Adobe® ConnectNow^™^, a web-based conferencing system, and PresenceLearning, a web-based platform, were used for screen-sharing. While PresenceLearning is a feefor-service system, the company donated a copy for the purpose of this research. iSchoolWare, ([@b35-v4n2-art-10.5195-ijt.2012.6104]) a secure web-based program with 256-bit encryption, was used for all data collection, management and personnel collaboration.

The equipment used for the telepractice and traditional on-site conditions included an e-Machine computer with a 22" monitor, external speakers for sound and an external Microsoft HD webcam with an embedded microphone. The e-Machine computer ran with a Microsoft Windows 7 operating system and had a 3.1GHz processor and 3GB memory. The Microsoft webcam had an auto-focus lens and captured 720p HD video with 30 fps.

Data Analysis
-------------

Data on the use of transition words during narratives were collected at baseline, and throughout the on-site and telepractice treatment phases. The baseline data were compared to treatment data from the first telepractice condition using the Improved Rate Difference (IRD). To compare the telepractice vs. the on-site treatment conditions, the Tau-U method was conducted. Data entered for Tau-U was obtained through the combined score for Probe 1 and Probe 2 for each intervention session. The Tau-U analysis determined if the participant's documented progress resulted in a statistically significant trend between the two treatment phases ([@b25-v4n2-art-10.5195-ijt.2012.6104]). For all statistical analyses, the level for non-directional, statistical significance was set at .05.

Findings
--------

This participant's documented outcomes yielded a statistically significant correlation between progress made during telepractice services versus progress made during on-site services for the narrative skills targeted. A comparison of the mean of the combined probe data suggests that the participant responded more favorably to telepractice services.

As seen in [Table 2](#t2-v4n2-art-10.5195-ijt.2012.6104){ref-type="table"}, the data suggest that the participant's appropriate use of transition words at baseline was a mean of 24% (SD = 21.9). During the intervention phase the participant's skill level for the same target objectives increased. The participant demonstrated a mean of 91% (SD = 10.1) during the first condition, which was delivered via telepractice. The IRD for baseline compared to the successive on-site phase was 100%, which suggests that 100% of the data collected in the on-site intervention phase exceeded data collected in the baseline phase.

When the treatment conditions were alternated and services were conducted on-site, the participant demonstrated a reduction in the observed skill level on the use of transition words. A mean of 68% (SD = 26.6) was observed during the on-site condition for the same skills that were targeted during the telepractice setting. It was anecdotally noted that the participant appeared attentive and actively participated in telepractice intervention sessions with little to no redirection. However, when the intervention conditions changed to on-site services, the participant exhibited difficulty adjusting to the change and the number of behavioral issues increased. This finding is consistent with other studies that examine the use of technology (i.e., video modeling and computer aided instruction) to provide interventions. The use of technology may provide a more predictable social environment ([@b34-v4n2-art-10.5195-ijt.2012.6104]) therefore reducing the amount of anxiety and adverse behaviors demonstrated by students with an ASD.

For this participant, the correlated relationship between the two treatment conditions were statistically significant, z = −2.05, p \< 0.05.

A visual analysis of the data represented in [Figure 1](#f1-v4n2-art-10.5195-ijt.2012.6104){ref-type="fig"} indicated a positive mean shift when comparing baseline data to telepractice data. The level of performance resulted in negative shift once the services alternated to an on-site setting. A reduction in variability was noted when comparing baseline to telepractice data. An increase in variability was noted when comparing the telepractice to on-site data (see [Table 3](#t3-v4n2-art-10.5195-ijt.2012.6104){ref-type="table"}).

The inter-observer agreement conducted on a random 20% of the participant's probe responses, was 93%. To determine the inter-observer agreement a calculation of the percentile correct for each task was conducted by converting the raw data per goal into percentage data and compared to an independent doctoral level SLP observer's rating.

Active Consultation through Telepractice
========================================

Objective of Case Study 2
-------------------------

The objective of this second single subject study was to supervise a pre-professional graduate clinician through Active Consultation to support implementation of a participant's speech generating device (SGD) within the context of speech and language intervention. An additional objective was to evaluate the impact of Active Consultation on the client and clinician's use of an evidence-based intervention strategy known as aided language stimulation/modeling.

Methodology
-----------

A single-subject, AB design was used to empirically demonstrate the outcomes that Active Consultation had on a preprofessional graduate clinician use of aided language stimulation/modeling in the context of intervention involving the client's speech generating device (SGD). To date, there is no prior literature available describing the use of such training for such purposes. As such, this initial single subject study followed a quasi-experimental design to examine the feasibility and impact of this real-time guidance.

Baseline data were collected over two, one-hour sessions over the course of two weeks prior to implementing Active Consultation intervention. The researcher observed the speech and language intervention sessions and generated language samples for the client and the preprofessional clinician's use of the device. During the baseline phase, the treating clinician did not wear a Bluetooth^™^ earpiece, nor receive Active Consultation.

Following the two-week observation period, the Active Consultation intervention stage was implemented. This training period was defined as systematic coaching of the treating pre-professional clinician on how to implement the use of the participant's device within the intervention session. The treating pre-professional clinician was given instructions with respect to specific symbols to select/point to on the client's device, consistent with the underlying theories of aided language stimulation ([@b10-v4n2-art-10.5195-ijt.2012.6104]) and AAC modeling ([@b5-v4n2-art-10.5195-ijt.2012.6104]). During the intervention stage, the supervising clinician observed the session via surveillance cameras and provided real-time guidance regarding the use of the device to the pre-professional clinician via the Bluetooth^™^ earpiece. While supervisory guidance was provided via a cellular network directly to the treating clinician, the directions were inaudible to the client. The preprofessional clinician was given instructions with respect to: 1) where to locate a target word/symbol; 2) what target phrase to model; or 3) how to prompt the participant to use his device.

Participants and Setting
------------------------

One supervising clinician, one graduate student clinician and one student client participated in this investigation. The pre-professional clinician was a first-year graduate student who self-reported no prior experience working with or using a SGD. The graduate clinician was provided information regarding the objectives of this investigation and informed consent was obtained. The student participant was an 11-year-old non-Latino white male diagnosed with autism and exhibited significant expressive language deficits warranting the use of augmentative and alternative communication (an iPad with a voice output application which converted it into an SGD). The supervising clinician was a licensed speech-language pathologist specializing in the use of SGDs.

The student participant and graduate clinician engaged in biweekly, one hour-long intervention sessions in treatment rooms located at the University of Massachusetts Center for Language, Speech and Hearing. The treatment room format remained constant throughout the duration of the 10-week study.

Materials and Equipment
-----------------------

The treatment rooms were equipped with cameras that were linked to a Marshall 8.4" high resolution LCD monitor. The supervising clinician viewed the sessions in real-time on the monitor in a separate location. The pre-professional graduate clinician was fitted with a Bluetooth^™^ headset that was wirelessly connected to a cellular phone. The supervising clinician offered instruction and guidance to the pre-professional clinician via a cellular phone to support implementation of the student participant's SGD to deliver and address his intervention goals and objectives. All sessions were recorded using a separate, stand-alone Sony Cybershot standard definition digital camcorder with a built-in microphone.

Data Analysis
-------------

Throughout the sessions, the following variables were measured during the baseline conditions and compared to the intervention sessions: 1) the number of phrases produced by the treating pre-professional clinician; 2) the number of varied phrases produced by the treating pre-professional clinician; 3) the number of phrases produced by the student participant; and 4) the number of varied phrases produced by the student participant. For the purposes of this investigation a "phrase" was defined as one or more sequential symbol selections (not including navigating between pages on the device), where each symbol represented only one word. A frequency count was conducted to compare the variables (i.e. number of phrases generated) across the two conditions, and the mean and standard deviation were calculated. In addition, time series analysis was used to determine the significance of changes in the data. Time series analysis calculates a C statistic and p-value. The C statistic identifies whether a trend is present in a given data set ([@b13-v4n2-art-10.5195-ijt.2012.6104]) and the p-value determines the statistical significance of the data. For the purpose of this case study, alpha was set at .05.

To ensure the feasibility and social validity of the Active Consultation process as a mechanism to supervise and/or train, the pre-professional clinician completed satisfaction surveys after each session in which she received Active Consultation. The surveys were devised using a Likert scale with 6 questions with space for comments.

Findings
--------

Data gathered from baseline and intervention sessions revealed a dramatic increase in the number of phrases generated by the pre-professional graduate clinician and the participant, as well as the participant's progress toward meeting his specific intervention goals. As seen in [Figures 2](#f2-v4n2-art-10.5195-ijt.2012.6104){ref-type="fig"} and [3](#f3-v4n2-art-10.5195-ijt.2012.6104){ref-type="fig"} and [Table 4](#t4-v4n2-art-10.5195-ijt.2012.6104){ref-type="table"}, during the baseline stage of the investigation neither the student participant nor the pre-professional graduate clinician used the SGD. Upon receiving the Active Consultation supervision and instruction, the graduate student clinician produced an average of 42.25 phrases (ranging from 19--85 phrases per session). Moreover, during the Active Consultation phase, the student participant produced an average of 73.37 phrases (ranging from 44--105 phrases per session) and mastered intervention goals that included using two-symbol utterances, requesting, and making comments using his SGD. In addition, the student participant produced a greater variety of phrases and the variety of phrases the client produced during the Active Consultation phase ranged from 12--28 different phrases.

A time series analysis of the data yielded a statistically significant trend in the data gathered regarding the clinician and the client's device use when comparing Baseline and Active Consultation Phases of the investigation (please see [Table 4](#t4-v4n2-art-10.5195-ijt.2012.6104){ref-type="table"}). Furthermore, review of the satisfaction surveys revealed the pre-professional clinician's satisfaction with supervision and guidance provided via Active Consultation (please see [Table 5](#t5-v4n2-art-10.5195-ijt.2012.6104){ref-type="table"}).

Conclusions
===========

Due to the critical shortage of SLPs, professionals should consider more innovative, technology-driven methods for service delivery. The primary goal of these studies was to describe a clinical model and provide guidelines that support services through telepractice and Active Consultation. As technology continues to improve and evolve, these protocols and service delivery models help facilitate and provide a standard for the implementation of high-quality telepractice services.

The two single subject case studies provide data that support telepractice and Active Consultation as effective methods of service delivery for direct and indirect intervention. The student participant with autism in Case Study 1 received direct telepractice services and made advancement towards his IEP goals. Similarly, in Case Study 2 the pre-professional graduate student clinician receiving Active Consultation supervision and guidance, and the student participant with autism, demonstrated beneficial outcomes in language production as expressed using a SGD. These two clinical case studies demonstrate that direct and indirect services via telepractice are feasible forms of service delivery for individuals with ASD and the professionals serving such individuals; and contribute to a growing body of literature establishing the use and benefits of a telepractice service delivery method for speech and language services.

Limitations of the Study
------------------------

There are several limitations associated with the two case studies presented in this article. First and foremost, the treatment conditions were not alternated and as a result, the findings obtained from both intervention settings were not replicated within this study. Moreover, these studies were case examples involving a small number of participants and the ability to generalize the results to other students with ASD and/or other individuals with communication disabilities is limited. The treating clinicians were aware of the aims targeted in the studies and were therefore not blind to the purpose of the research.

Future Research
---------------

Given these successful results in providing intervention services via telepractice to students diagnosed with ASD in these case examples, and considering the critical national shortage of school-based speech-language pathologists, it is essential that this research strand continue to be investigated. Future research should explore the use of telepractice with a greater number of students with ASD and with a greater variety of target skills in an alternating treatment design or other experimental designs that better control for threats to internal and external validity.

In the first case study, the treating clinicians reported that the level of attention demonstrated by the student participant seemed to be greater when services were rendered through telepractice. This observation is consistent with other research that has been conducted on the use of technology such as video modeling and computer aided programs to provide intervention in the development of communication skills to students with an ASD. It would be beneficial for the future of telepractice to determine if and what similarities exist between telepractice interventions and use of other innovative technologies to deliver services. An important research strand would be to determine if these innovative technological approaches could be facilitated via telepractice.

Future research should also examine if telepractice can be used for the delivery of other evidence-based interventions such as functional communication training and behavioural assessments, parent implemented interventions, peer-mediated interventions, the use of speech generating devices, pivotal response training and social narratives. A determination on the appropriateness of telepractice to deliver these interventions will strengthen the wide-spread acceptance of telepractice.

Telepractice has the potential to significantly improve access to services for individuals with special needs as well as to assist speech and language professionals in working more effectively with these individuals. The continuation of this research must further define best practice or evidence-based approaches within this framework and clinical service delivery models. There is a vital need to demonstrate evidence-based practices and methodologies for all assessment and intervention services provided to clients with communicative disabilities and in particular, services provided through telepractice. The impact of telepractice technology will undoubtedly increase the quantity, quality and accessibility of services and support provided to individuals in need of services, including graduate students, speech/language assistants, general and special educators and paraprofessionals.

At the time of these investigations, Michelle Boisvert and Nerissa Hall were funded by a grant awarded to Dr. Mary Andrianopoulos by the U.S. Department of Education, Office of Special Education and Rehabilitative Services (CFDA 84.325D, H325D080042).

![**Student Participant's Documented Progress across the Study**](v4n2-art-10.5195-ijt.2012.6104f1){#f1-v4n2-art-10.5195-ijt.2012.6104}

![Total Number of Phrases and Varied Phrases Produced by the Clinician](v4n2-art-10.5195-ijt.2012.6104f2){#f2-v4n2-art-10.5195-ijt.2012.6104}

![Total Number of Phrases and Varied Phrases Produced by the Client](v4n2-art-10.5195-ijt.2012.6104f3){#f3-v4n2-art-10.5195-ijt.2012.6104}

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Telepractice Implementation Plan

  -------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Needs Assessment**                                                       Assess client/facility needs and goalsIdentify implementation team and resourcesAssess infrastructure and supportDevelop policies/proceduresInitial training on technology and approaches
  **Hardware**                                                               **Clinician Side** Computer with 3.0 GHZ or higherMonitor (20" or larger)Webcam (external if possible)SpeakersMicrophone                                                                                **Client Side** Computer with 3.0 GHZ or higherMonitor (20" or larger)Webcam (external if possible)SpeakersMicrophone
  **Software**                                                               Videoconferencing accountWeb conferencing account                                                                                Videoconferencing accountWeb conferencing link or plugin
  **Internet**                                                               High Speed Connection Incoming signal of at least 150kpsOutgoing signal of at least 150kpsDelay of 200ms (less is better)                                                                                High Speed Connection Incoming signal of at least 150kpsOutgoing signal of at least 150kpsDelay of 200ms (less is better)
  **Best Practice Approaches and Requirements for Clinic Confidentiality**   ASHA Code of EthicsASHA Scope of PracticeAppropriate licensureDocumentation of student progressMonitoring of quality assuranceIT collaborationCollaborative teaming with onsite personnelSupplementary equipment and resourcesVisual display strategiesConsultation with on-site staffCarryover programsBehavior management plansClinical training   HIPAA Secure firewallData encryptionUp-to-date antivirus softwarePersonnel trained in security protocolsPassword managementMonitor placementFERPA Consent formDescription of differences in service deliveries
  -------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

######

Participant Baseline, On-site and Telepractice Probe Data (reported in combined r aw data and percentages)

  **Session**         **Baseline**        **Telepractice**    **On-Site**
  ------------------- ------------------- ------------------- -------------------
  **1.**              0/5 (0%)
  **2.**              0/5 (0%)
  **3.**              2/6 (33%)
  **4.**              2/5 (40%)
  **5.**              5/11 (45%)
  **6.**                                  6/7 (85%)
  **7.**                                  15/16 (94%)
  **8.**                                  15/18 (83%)
  **9.**                                  14/15 (96%)
  **10.**                                 12/13 (92%)
  **11.**                                                      13/15 (87%)
  **12.**                                                      12/14 (86%)
  **13.**                                                     11/23 (49%)
  **14.**                                                     7/11 (64%)
  **15.**                                                     7/12 (58%)
  **Mean and S.D.**   24% (S.D. = 21.9)   91% (S.D. = 10.1)   68% (S.D. = 26.6)

Data is derived from the combined raw score of Probe 1 and Probe 2 for each intervention session.

######

**Visual Analysis of Baseline, On-site and Telepractice Data**

                **Baseline**   **Telepractice**   **On-Site**   **Change**
  ------------- -------------- ------------------ ------------- ------------
  Mean Shift    \-             2.8                −.33          \-
  Variability   21.9           10.1               \-            −11.8
                               10.1               26.6          16.5

Participant received services in an ABC design (baseline, telepractice, on-site)

######

Clinician & Client Baseline and Active Consultation Data (frequency count)

  **Session**          **Baseline**   **Active Consultation**
  -------------------- -------------- ------------------------- ------- ------ ------- -------
  1\.                  0              0
  2\.                  0              0
  3\.                                                           85      2      44      2
  4\.                                                           42      8      54      15
  5\.                                                           32      4      52      8
  6\.                                                           40      8      63      16
  7\.                                                           54      13     105     25
  8\.                                                           42      15     96      37
  9\.                                                           24      10     68      24
  10\.                                                          19      13     105     41
  Mean                 0              0                         42.25   9.12   73.38   21.0
  Standard Deviation                                            20.53   4.55   24.91   13.48
  C statistic                                                   .541    .547   .513    .620
  p (0.05)                                                      .039    .038   .048    .022

Data is derived from the averaging the Number of Phrases and the Number of Varied Phrases produced by the clinician and the client for each session of the Baseline and Active Consultation Phases of the investigation.

######

Pre-professional Clinician Satisfaction Survey Responses

  **Session**                                                             **Delivery of AAC Consultation using telepractice**   **Student participant's progress over the course of the study**   **Your ability to communicate with the clinician over the course of the study**   **Your attitude about AAC consultation via telepractice**   **How do you think telepractice compares to face-to-face consultation?**   **What is the likelihood you would recommend Active Consultation to your colleagues?**
  ----------------------------------------------------------------------- ----------------------------------------------------- ----------------------------------------------------------------- --------------------------------------------------------------------------------- ----------------------------------------------------------- -------------------------------------------------------------------------- ----------------------------------------------------------------------------------------
  1\. [^\*^](#tfn5-v4n2-art-10.5195-ijt.2012.6104){ref-type="table-fn"}
  2\. [^\*^](#tfn5-v4n2-art-10.5195-ijt.2012.6104){ref-type="table-fn"}
  3\.                                                                     3                                                     4                                                                 4                                                                                3                                                           4                                                                          4
  4\.                                                                     4                                                     5                                                                 5                                                                                5                                                           5                                                                          5
  5\.                                                                     5                                                     5                                                                 5                                                                                5                                                           5                                                                          5
  6\.                                                                     5                                                     5                                                                 5                                                                                5                                                           5                                                                          5
  7\.                                                                     5                                                     5                                                                 5                                                                                5                                                           5                                                                          5
  8\.                                                                     5                                                     5                                                                 5                                                                                5                                                           5                                                                          5
  9\.                                                                     5                                                     5                                                                 5                                                                                5                                                           5                                                                          5
  10\.                                                                    5                                                     5                                                                 5                                                                                5                                                           5                                                                          5
  Mean                                                                    4.625                                                 4.875                                                             4.875                                                                             4.75                                                        4.875                                                                      4.875

Data is derived from satisfaction surveys that used a 5-point Likert scale with 1 = Not Very Good, 2 = Below Average, 3 = Average, 4 = Above Average, and 5 = Very Good. Averages were calculated for each question over the course of the Active Consultation Phase.

Satisfaction surveys were not administered during the Baseline Phase.


package haproxy

import (
	"fmt"
	"io/ioutil"
	"net/http"
	"net/url"
	"strings"
	"time"

	"github.com/github/freno/pkg/base"

	"github.com/patrickmn/go-cache"
)

var csvCache = cache.New(time.Second, time.Second)

var HAProxyEmptyBody error = fmt.Errorf("Haproxy GET error: empty body")
var HAProxyEmptyStatus error = fmt.Errorf("Haproxy CSV parsing error: no lines found")
var HAProxyPartialStatus error = fmt.Errorf("Haproxy CSV parsing error: only got partial file")
var HAProxyMissingPool error = fmt.Errorf("Haproxy CSV parsing: pool not found")
var HAProxyAllUpHostsTransitioning error = fmt.Errorf("Haproxy: all host marked as UP are in transition. HAProxy is likely reloading")
var HAProxyAllHostsTransitioning error = fmt.Errorf("Haproxy: all hosts are in transition. HAProxy is likely reloading")

var MaxHTTPGetConcurrency = 2
var httpGetConcurrencyChan = make(chan bool, MaxHTTPGetConcurrency)

var httpClient *http.Client

func init() {
	httpClient = base.SetupHttpClient(0)
}

// parseHeader parses the HAPRoxy CSV header, which lists column names.
// Returned is a header-to-index map
func parseHeader(header string) (tokensMap map[string]int) {
	tokensMap = map[string]int{}
	header = strings.TrimLeft(header, "#")
	header = strings.TrimSpace(header)
	tokens := strings.Split(header, ",")

	for i, token := range tokens {
		tokensMap[token] = i
	}
	return tokensMap
}

// Simple utility function to split CSV lines
func parseLines(csv string) []string {
	return strings.Split(csv, "\n")
}

func ParseStatus(fullStatus string) (status BackendHostStatus, isTransitioning bool) {
	// status can show up as:
	// `UP`
	// `UP 1/2` (transitioning)
	// `NOLB`
	// `DOWN`
	// `DOWN (agent)`
	// `no check`
	// etc. See https://github.com/haproxy/haproxy/blob/a5de024d42c4113fc6e189ea1d0ba6335219e151/src/dumpstats.c#L4117-L4129
	if ToBackendHostStatus(fullStatus) == StatusNoCheck {
		return StatusNoCheck, isTransitioning
	}

	statusTokens := strings.Split(fullStatus, " ")
	isTransitioning = (len(statusTokens) > 1 && strings.Contains(statusTokens[1], "/"))
	return ToBackendHostStatus(statusTokens[0]), isTransitioning
}

// ParseHosts reads HAProxy CSV lines and returns lists of hosts participating in the given pool (backend)
// Returned are all non-disabled hosts in given backend. Thus, a NOLB is skipped; any UP or DOWN hosts are returned.
// Such list indicates the hosts which can be expected to be active, which is then the list freno will probe.
func ParseHosts(csvLines []string, poolName string) (backendHosts [](*BackendHost), err error) {
	if len(csvLines) < 1 {
		return backendHosts, HAProxyEmptyStatus
	}
	if len(csvLines) == 1 {
		return backendHosts, HAProxyPartialStatus
	}
	var tokensMap map[string]int
	poolFound := false
	countHosts := 0
	countUpHosts := 0
	countTransitioningHosts := 0
	countTransitioningUpHosts := 0
	for i, line := range csvLines {
		if i == 0 {
			tokensMap = parseHeader(csvLines[0])
			continue
		}
		tokens := strings.Split(line, ",")
		if tokens[tokensMap["pxname"]] == poolName {
			poolFound = true
			if host := tokens[tokensMap["svname"]]; host != "BACKEND" && host != "FRONTEND" {
				countHosts++

				status, isTransitioning := ParseStatus(tokens[tokensMap["status"]])

				backendHosts = append(backendHosts, NewBackendHost(host, status, isTransitioning))
				if isTransitioning {
					countTransitioningHosts++
				}
				if status == StatusUp {
					countUpHosts++
					if isTransitioning {
						countTransitioningUpHosts++
					}
				}
			}
		}
	}
	if !poolFound {
		return backendHosts, HAProxyMissingPool
	}
	if countTransitioningHosts == countHosts && countHosts > 0 {
		return backendHosts, HAProxyAllHostsTransitioning
	}
	if countTransitioningUpHosts == countUpHosts && countUpHosts > 0 {
		return backendHosts, HAProxyAllUpHostsTransitioning
	}
	return backendHosts, nil
}

// ParseCsvHosts reads HAProxy CSV text and returns lists of hosts participating in the given pool (backend).
// See comment for ParseHosts
func ParseCsvHosts(csv string, poolName string) (backendHosts [](*BackendHost), err error) {
	csvLines := parseLines(csv)
	return ParseHosts(csvLines, poolName)
}

func toCSVUrl(u url.URL) *url.URL {
	u.Path = fmt.Sprintf("%s;csv;norefresh", u.Path)
	return &u
}

// Read will read HAProxy URI and return with the CSV text
func Read(u *url.URL) (csv string, err error) {
	httpGetConcurrencyChan <- true
	defer func() { <-httpGetConcurrencyChan }()

	haproxyUrl := toCSVUrl(*u).String()

	if cachedCSV, found := csvCache.Get(haproxyUrl); found {
		return cachedCSV.(string), nil
	}

	resp, err := httpClient.Get(haproxyUrl)
	if resp != nil {
		defer resp.Body.Close()
	}
	if err != nil {
		return "", err
	}
	body, err := ioutil.ReadAll(resp.Body)
	if err != nil {
		return "", err
	}

	csv = string(body)
	if csv == "" {
		return "", HAProxyEmptyBody
	}
	csvCache.Set(haproxyUrl, csv, cache.DefaultExpiration)
	return csv, nil
}


In Patent Literature 1, there is disclosed a system in which a storage unit called a pallet is conveyed by a conveyor from a warehouse to a picking zone (picking work position). At the picking zone, a worker picks up an objective article of goods from the storage unit, and the storage unit is then returned to the warehouse by the conveyor.


BJÖRN DIXGÅRD

.

SOMETHING TO DIE FOR (B.D. & THE SOUNDS, 2019)

Working for another hour tonightStaring at the wall and let the time just pass me byYou might think you know me, but it's all just a faceTrying
to ignore when people screaming my name(Screaming my name)

Walking by a house with colorful lightsThere's a sign, an invitation from the woman insideTalk about your boyfriend, talk about your wifeIt's just a different way
of living your life

When something's right, then something is worth to die forWhen I feel that something is wrong, then something is worth to fight for

Don't say goodbye, just leave an open doorI wanna hear you say, you give
me something to die for

Searching for another reason to staySlowly my regrets are fading awayYou leave me on my own to find out what's realYou
say you want your freedom, but it's not how I feel

When something's right, then something is worth to die forWhen I feel that something is wrong, then
something is worth to fight for

Don't say goodbye, just leave an open doorI wanna hear you say, you give me something to die for

When I feel that something is rightYou give me something to die for

When something's right, then something is worth to die forWhen I feel that
something is wrong, then something is worth to fight forWhen something's right, then something is worth to die forWhen I feel that something is wrong, then something is worth to fight for


Q:

How to make the text of list horizontally in beamer

The MWE is
\documentclass[14pt]{beamer}% http://ctan.org/pkg/beamer
\let\Tiny\tiny% http://tex.stackexchange.com/q/58087/5764
\usetheme{Berkeley}
\makeatletter
\beamer@headheight=1.5\baselineskip
\makeatother
\setbeamercolor{normal text}{bg=black!10}
\begin{document}
\title[Title]{My title}
\subtitle{Subtitle}
\author{Author}
\institute[Institute]{My institute}
\date[Date]{My date}
\logo{\color{blue!50}\scalebox{2}{\TeX}} % you can % it
\begin{frame}
  \titlepage
\end{frame}

\section{A section}
\subsection{A subsection}
\begin{frame}
  \frametitle{Frame title}
  \framesubtitle{frame subtitle}

     \begin{center}
       \begin{enumerate}
        \item A1
        \item A1
        \begin{itemize}
        \item A1
        \item A1
        \item A1
        \end{itemize}
       \end{enumerate}
     \end{center}

\end{frame}

\end{document}

I want to put the text into the center as shown on the screenshot below. I tried using a center environment, but that didn't produce the expected output. Then I tried using vspace, but I need to adjust again and again. Is there any package I can use for this?

A:

There's no easy way to automatically centre a list, since the degree of centring required will depend on the length of the longest line in the list.  However, it's not to difficult to set one value per frame that you need to do this on, as in the following example:
\documentclass{beamer}
\usetheme{Berkeley}

\begin{document}
\begin{frame}
\setlength{\leftmargini}{12em}
  \frametitle{Frame title}
  \framesubtitle{frame subtitle}
       \begin{enumerate}
        \item A1
        \item A1
        \begin{itemize}
        \item A1
        \item A1
        \item A1
        \end{itemize}
       \end{enumerate}
\end{frame}

\end{document}


Geospatial Image To Learn (GeoLearn)

The motivation for developing Geospatial Image To Learn (GeoLearn) comes from hydroclimatology and terrestrial
hydrology. The research and development in this area addresses the scientific questions
about causes and consequences of hydrologic variables through phenomenology,
modeling, and synthesis.

GeoLearn has been prototyped as a novel simulation and exploratory environment for prediction modeling from remote
sensing imagery, and large size geospatial raster and vector data. The GeoLearn framework has the functionality to read
data sets from local and remote sites; extract features like slope from elevation; mosaic tiles; perform quality
assurance of remotely sensed images; integrate images; spatially
select pixels by masking with boundaries, geo-points, maps with categorical variables, thresholded maps with continuous
variables or painted regions using primitives; extract pixels over a mask, perform data-driven modeling using
machine learning techniques, provide interpretation
of models in terms of variable relevance and visualize a variety of input, output and intermediate data.

Geospatial Image To Learn can be viewed as an encapsulated workflow for:

loading multiple raster files (images) from local or remote locations,

pre-processing the files based on quality control requirements and performing feature extractions from them if necessary,

integrating and mosaicking all raster data sets to form a stack with consistent spatial
and temporal resolution as well as geographic projection,

loading other files (boundaries, points or images) to create a mask for pixel selection purposes,

integrating the existing stack of raster images with other masking information,

selecting boundaries or image regions of interest and extracting variables from the stack of images,

analyzing data-driven model to assign a relevance coefficient to input variables, and

mapping the data-driven model at a pixel level to spatial domain.

All aforementioned steps are supported by visualizations (gray-scale or pseudo-color) of
input, intermediate, and output data sets, as well as the data models. An overview of the
functionality is provided in Figure 1.

GeoLearn is a java-based, open source, desktop application given the fact that
the primary users of
the GeoLearn exploratory framework are scientists without access to high performance computing resources.
This allows users to run the code on any platform and perhaps modify and extend the framework.
However, this approach could be effective only for those components that were developed by the authors
or were leveraged as open source codes. The tradeoffs between resources and functionality led to
the use of the third party software.

The majority of the code is based on our own
Image to Learn (Im2Learn) software to perform an
out-of-core image
representation, data integration, image manipulation and visualization, with additional calls to:

Data To Knowledge (D2K, Version 4.1.2) developed by
NCSA to perform decision tree modeling.

Figure 2 shows GeoLearn workflow interface that guides a user through the five major steps, such as
Load Raster, Create Mask, Attribute Selection, Modeling and Visualization.
Multiple file formats (HDF, netCDF, GeoTiff, DEM, SRTM) can be loaded. Additionaly the files can be retrieve not only
from a desktop disk or a networked disk but also from a remote site using OPeNDAP protocol (e.g., NASA DACC). Software also
performs feature extraction (from elevation to slope, aspect, flow direction and cumulative flow) and quality assurance
and quality control (QA/QC).

Figure 2: GeoLearn workflow interface. The ellipsoid highlights the total memory footprint (around 30MB)
for a large number of ingested files using the out-of-core data representation approach.
Large input files are represented as multiple tiles (data chunks) that are paged in and out of
a desktop computer RAM. Thus, even if the files could not fit into RAM they still could be processed
on a desktop computer by keeping only a small portion of
the data in RAM at any time.

GeoLearn enables several tradeoff studies related to data integration in terms of projection and spatial resolution
parameters of integrated data sets. Different temporal integration schemes have been implemented. Similarly,
spatial integration uses different interpolation schemes. Examples of two types of
spatial data integrations are shown in Figure 3

GeoLearn provides five masking methods for pixel subset selection,
such as boundary-based (Shapefile), point-based (Table), categorical map-based (Categorical), continuous
map-based (Threshold), user-defined (User defined) or any Boolean combination of already created masks.
Using the masking functionality, one can explore and compare region-based models or point-based models
with or without constraints (land cover label or an elevation range).

It is not known many times how earth observations are related and how those relationships vary over space and time.
Similarly, in terms of modeling, there is no superior machine learning technique. GeoLearn enables to compare
data-driven modeling results obtained by exploring multiple
possible relationships among variables and by investigating regression tree, support vector machine and k-nearest
neighbor machine learning algorithms.
In addition, we designed a methodology and an algorithm for ranking input variables based on their relevance for predicting
output variables. Figure 5 illustrates not only the process of data-driven modeling and visualization
but also the assistance in interpreting the relevance as a function of space (Fig.5 - bottom right). In this case,
vegetation greenness (NDVI index) is predicted with the leaf area index (LAI), fraction of photo-synthetically active
radiation (FPAR) absorbed by the plant canopy and snow cover. As expected, LAI is ranked with the highest relevance
at the majority of pixels and snow cover is never ranked with the highest relevance. This type of analysis was used to
validate the correctness of relevance assignment based on our prior knowledge.

Projects using GeoLearn software:

Geospatial Image To Learn was created as a joint collaboration between the
Civil and Environmental Engineering Department
(CEE) at the University of Illinois at Urbana-Champaign
(UIUC) and the National Center for Supercomputing Applications (NCSA) at UIUC.

Additional help with the software requirement specifications and code release came from
Amanda White (CEE), Ben Ruddel (CEE), and Tim Nee (NCSA).

Acknowledgments

Funding support was provided by National Aeronautics and Space Administration (NASA),
National Archive and Record Administration (NARA), and National Science Foundation (NSF).
The NASA project was led by the principal investigators Praveen Kumar and Peter Bajcsy. Praveen Kumar
served as the principal investigator for the NSF project.
The NARA project was led by the principal investigator Peter Bajcsy.


This week's Patch Tuesday release from Microsoft was epic.

The list of 14 security-related updates was far more than normal, but that was just the appetizer. There were more than a dozen non-security-related updates for Windows 8.1 (these appear in Windows Update under the Recommended heading), and this month's batch of Microsoft Office updates, which are also released on Patch Tuesday, included another long list.

Between Windows and Office, that's an awful lot of updates. A colleague sent me a screenshot that showed 50 updates installed on Patch Tuesday for a system with Windows 8.1 and the perpetual license version of Office 2013 installed.

If you have an Office 365 subscription, updates arrive via the Click-to-Run installer and are much less intrusive. But even with Office out of the picture that was a lot of updates.

And no, that's not normal.

For comparison's sake, I checked a Surface Pro 3 that has been running Windows 8.1 and Office 365 since last September. Here's how many updates it received in each of the past six months.

So why the big uptick this month? Besides the 14 security related updates, there were another 16 Recommended updates, with bug fixes and reliability improvements. In addition, some systems, including this Surface Pro 3, picked up driver updates.

Here's a rundown on what was in those non-security updates for Windows 8.1.

The most universally applicable update is the March 2015 system rollup, which contains unspecified Reliability improvements for Windows 8.1 (3027209).

Update 3036612 fixes an annoying issue that causes Windows Store apps to crash in Windows 8.1. Update 3029803 addresses a pair of STOP errors that occur when Windows 8.1 PCs resume from sleep mode: hopefully you've seen the last of 0x0000009F (DRIVER_POWER_STATE_FAILURE) and 0x14F_WCM (PDC_WATCHDOG_TIMEOUT) errors.

The remainder of the updates cover some fairly obscure bugs:

A few updates were installed on my test systems even though the associated Knowledge Base (KB) articles said they shouldn't apply. Update 3036228, for example, is intended to prevent a specific Blue Screen of Death, a 0x00000119 Stop error (VIDEO_SCHEDULER_INTERNAL_ERROR). According to the associated Knowledge Base article, "The issue occurs when an application is used that displays DirectX content and captures screen shots continuously on an ARM-based device." That sounds like it should apply only to Windows RT devices, but you'll find it on Intel-based PCs as well.

Another update, 3024751, is intended to fix a specific issue involving the use of the Tab key in Wi-Fi connection dialog boxes on a Surface Pro 3. For some reason, that update was installed on an HP Stream desktop device in my office.

And I'm honestly not sure how many Windows 8.x devices really need updated APN database entries for Y!Mobile and Truphone. Hundreds? But if you happen to be one of them, then update 3036562 is for you.

For a full accounting of what the Office team released, see the lengthy post from the Office Sustained Engineering team.

Over the past year or so, Microsoft has had a checkered history with updates, having to pull several after they caused widespread problems with some configurations. So far, more than 24 hours after the Patch Tuesday release, I haven't heard of any widespread problems with this month's batch, aside from a problem with the StartIsBack Start menu replacement and a temporary glitch (since fixed) with a driver update for DisplayLink video adapters.


Former Attorney General Eric Holder on Tuesday called for eliminating the Electoral College, saying that it is "undemocratic" and "forces candidates to ignore" the majority of voters.

"Time to make Electoral College a vestige of the past. It’s undemocratic, forces candidates to ignore majority of the voters and campaign in a small number of states. The presidency is our one national office and should be decided - directly - by the voters," Holder wrote in a tweet.

Holder's comments comes as several states have moved to circumvent the Electoral College.

ADVERTISEMENT

Earlier this week, Colorado Gov. Jared Polis (D) told The Hill that he plans to sign a measure that would award the state’s electoral votes to the winner of the national popular vote.

Eleven other states and Washington, D.C., have joined the National Popular Vote Interstate Compact, which would guarantee that the candidate who wins the popular vote is elected president. It would only go into effect if the coalition is expanded to include states representing at least 270 electoral college votes.

With Colorado on board, the coalition would include states and the District, which account for 181 electoral college votes, 89 votes shy of the 270 needed by a presidential candidate to secure the White House.

The push to get rid of the Electoral College comes after 2016 Democratic presidential nominee Hillary Clinton Hillary Diane Rodham ClintonButtigieg stands in as Pence for Harris's debate practice Senate GOP sees early Supreme Court vote as political booster shot Poll: 51 percent of voters want to abolish the electoral college MORE won the popular vote but lost the election to President Trump Donald John TrumpOmar fires back at Trump over rally remarks: 'This is my country' Pelosi: Trump hurrying to fill SCOTUS seat so he can repeal ObamaCare Trump mocks Biden appearance, mask use ahead of first debate MORE, who received more Electoral College votes.

Pete Buttigieg, the Democratic mayor of South Bend, Ind., and a 2020 presidential candidate, has also called for eliminating the Electoral College.

“We’ve got to repair our democracy. The Electoral College needs to go, because it’s made our society less and less democratic," Buttigieg said last month.


An implantable surgical injection port having an undeployed position, and a deployed position wherein it is attached to tissue. The port includes a housing having a closed distal end, a open proximal end and a fluid reservoir therebetween. The port further includes a needle penetrable septum attached...http://www.google.ca/patents/US20060173424?utm_source=gb-gplus-sharePatent US20060173424 - Surgically implantable injection port having an absorbable fastener

An implantable surgical injection port having an undeployed position, and a deployed position wherein it is attached to tissue. The port includes a housing having a closed distal end, a open proximal end and a fluid reservoir therebetween. The port further includes a needle penetrable septum attached to the housing about the opening. The port even further includes at least one attachment mechanism mounted to the housing for initially attaching the port to tissue wherein the attachment mechanism is made from a bioabsorbable material.

Images(5)

Claims(19)

1. An implantable surgical injection port having an undeployed position, and a deployed position wherein it is attached to tissue, said port comprising:

a. a housing having a closed distal end, a open proximal end and a fluid reservoir therebetween;

b. a needle penetrable septum attached to said housing about said opening; and

c. at least one attachment mechanism mounted to said housing for initially attaching said port to tissue, said attachment mechanism comprising a bioabsorbable material.

2. The injection port of claim 1 wherein said attachment mechanism comprises an arcuate hook pivotable with respect to said housing, said hook having a fixed end attached to said housing and a free end, said arcuate hook having a length extending substantially at least 180° about said pivot point.

3. The injection port of claim 1 wherein said attachment mechanism comprises an arcuate hook pivotable with respect to said housing, said hook having a fixed end attached to said housing and a free end, said arcuate hook having a length extending substantially greater than 90° about said pivot point.

11. An implantable surgical injection port having an undeployed position, and a deployed position wherein it is attached to tissue, said port comprising:

a. a housing having a closed distal end, a open proximal end and a fluid reservoir therebetween;

b. a needle penetrable septum attached to said housing about said opening;

c. at least one attachment mechanism mounted to said housing for initially attaching said port to tissue, said attachment mechanism comprising a bioabsorbable material; and

d. an adjustable gastric band attached to said housing via a catheter connection tube attached to said housing and in fluid communication with said reservoir.

12. The injection port of claim 11 wherein said attachment mechanism comprises an arcuate hook pivotable with respect to said housing, said hook having a fixed end attached to said housing and a free end, said arcuate hook having a length extending substantially at least 180° about said pivot point.

13. The injection port of claim 11 wherein said attachment mechanism comprises an arcuate hook pivotable with respect to said housing, said hook having a fixed end attached to said housing and a free end, said arcuate hook having a length extending substantially greater than 90° about said pivot point.

19. The injection port of claim 1 wherein said septum self seals after being punctured by a needle and the needle is withdrawn.

Description

FIELD OF THE INVENTION

The present invention has application in conventional endoscopic and open surgical instrumentation as well as application in robotic-assisted surgery. The present invention has even further relation to adjustable surgically implantable bands, such as gastric bands for the treatment of obesity.

BACKGROUND OF THE INVENTION

The percentage of the world's population suffering from morbid obesity is steadily increasing. Severely obese persons are susceptible to increased risk of heart disease, stroke, diabetes, pulmonary disease, and accidents. Because of the effect of morbid obesity to the life of the patient, methods of treating morbid obesity are being researched.

Numerous non-operative therapies for morbid obesity have been tried with virtually no permanent success. Dietary counseling, behavior modification, wiring a patient's jaws shut, and pharmacological methods have all been tried, and failed to correct the condition. Mechanical apparatuses for insertion into the body through non-surgical means, such as the use of gastric balloons to fill the stomach have also been employed in the treatment of the condition. Such devices cannot be employed over a long term, however, as they often cause severe irritation, necessitating their periodic removal and hence interruption of treatment. Thus, the medical community has evolved surgical approaches for treatment of morbid obesity.

Most surgical procedures for treatment of morbid obesity may generally be classified as either being directed toward the prevention of absorption of food (malabsorption), or restriction of stomach to make the patient feel full (gastric restriction) The most common malabsorption and gastric restriction technique is the gastric bypass. In variations of this technique, the stomach is horizontally divided into two isolated pouches, with the upper pouch having a small food capacity. The upper pouch is connected to the small intestine, or jejunum, through a small stoma, which restricts the processing of food by the greatly reduced useable stomach. Since food bypass much of the intestines, the amount of absorption of food is greatly reduced.

There are many disadvantages to the above procedure. Typically the above mentioned procedure is performed in an open surgical environment. Current minimally invasive techniques are difficult for surgeons to master, and have many additional drawbacks. Also, there is a high level of patient uneasiness with the idea of such a drastic procedure which is not easily reversible. In addition, all malabsorption techniques carry ongoing risks and side effects to the patient, including malnutrition and dumping syndrome.

Consequently, many patients and physicians prefer to undergo a gastric restriction procedure for the treatment of morbid obesity. One of the most common procedures involves the implantation of an adjustable gastric band. Examples of an adjustable gastric band can be found in U.S. Pat. No. 4,592,339 issued to Kuzmak; U.S. Pat. No. RE 36176 issued to Kuzmak; U.S. Pat. No. 5,226,429 issued to Kuzmak; U.S. Pat. No. 6,102,922 issued to Jacobson and U.S. Pat. No. 5,601,604 issued to Vincent, all of which are hereby incorporated herein by reference. In accordance with current practice, a gastric band is operatively placed to encircle the stomach. This divides the stomach into two parts with a stoma in-between. An upper portion, or a pouch, which is relatively small, and a lower portion which is relatively large. The small partitioned portion of the stomach effectively becomes the patients new stomach, requiring very little food to make the patient feel full.

Once positioned around the stomach, the ends of the gastric band are fastened to one another and the band is held securely in place by folding a portion of the gastric wall over the band and closing the folded tissue with sutures placed therethrough thereby preventing the band from slipping and the encircled stoma from expanding. Gastric bands typically include a flexible substantially non-extensible portion having an expandable, inflatable portion attached thereto. The inflatable portion is in fluid communication with a remote injection site, or port. Injection or removal of an inflation fluid into or from the interior of the inflatable portion is used to adjust the size of the stoma either during or following implantation. By enlarging the stoma, the patient can eat more food without feeling as full, but will not lose weight as fast. By reducing the size of the stoma, the opposite happens. Physicians regularly adjust the size of stoma to adjust the rate of weight loss.

For most fluid injection ports for the above described bands are attached underneath the skin to the fascia of a patient. Such ports are often provided with suture holes and the port is sutured to the tissue. However, alternative means of attaching the port to the patient, such as using integral hooks, can be used as well. Such other means for attaching the port to a patient are described in commonly assigned and copending U.S. patent application Ser. Nos. 10/741,785 filed Dec. 19, 2003; 60/478,763 filed Dec. 19, 2003; 10/741,868 filed Dec. 30, 2003; all of which are hereby incorporated herein by reference.

However, many of the prior art fasteners could cause patient discomfort, including pain. It is well known that once the port is placed a fibrotic capsule begins to grow over the port until it is completely enclapsuled. The rate at which the fibrotic capsule grows varies from patient to patient, but generally surgeons agree that the port is fully encapsulated after 2 months. Once the port has been captured by the fibrotic capsule, there is no longer a need for the port to be fastened with sutures or other types of fasteners. In fact, it would be desirable if these additional fastening means were no longer part of the port system so as to not cause patient discomfort.

SUMMARY OF THE INVENTION

In accordance with the present invention, there is provided an implantable surgical injection port having an undeployed position, and a deployed position wherein it is attached to tissue. The port includes a housing having a closed distal end, a open proximal end and a fluid reservoir therebetween. The port further includes a needle penetrable septum attached to the housing about the opening. The port even further includes at least one attachment mechanism mounted to the housing for initially attaching the port to tissue wherein the attachment mechanism is made from a bioabsorbable material.

DETAILED DESCRIPTION OF THE DRAWINGS

The novel features of the invention are set forth with particularity in the appended claims. The invention itself, however, both as to organization and methods of operation, together with further objects and advantages thereof, may best be understood by reference to the following description, taken in conjunction with the accompanying drawings in which:

FIG. 1 is a perspective view of a surgically implantable fluid port made in accordance with the present invention, showing the port attached to an adjustable gastric band.

FIG. 2 is a perspective view of a surgically implantable fluid port made in accordance with the present invention.

FIG. 3 is a cross section of the port shown in FIGS. 1 and 2, taken along line 3-3 in FIG. 1.

FIG. 4 is a view similar to that of FIG. 3 but showing the fluid port implanted within a patient.

DETAILED DESCRIPTION OF THE INVENTION

Referring now to the drawings wherein like numerals indicate the same elements throughout the views, as stated above there is shown in FIG. 1 an adjustable gastric band 1 of the type described in the above mentioned incorporated references. Band 1 is implanted within a body of a patient to surround the stomach 12. The inflatable portion of the band is in fluid communication with injection port 10 via a catheter tube 52. Tube 52 has a proximal end 53 attached to the port 10 and a distal end 55 attached to adjustable gastric band 1. Port 10 can be used for a wide range of devices in the medical field and not only for gastric bands. For example the port can also used for vascular access for drug delivery.

As seen from FIGS. 2 and 3, surgically implantable injection port 10 includes a housing 12. Housing 12 can be made from any number of materials including stainless steel, titanium, or polymeric materials. Housing 12 has a distal back portion or closed distal end 14 and a perimeter wall portion 16 extending proximally from the back portion 14 at an angle. Wall portion 16 defines a proximal opening or open proximal end 18, and a fluid reservoir 20 between opening 18 and back portion 14. The port includes a needle penetrable septum 22 attached to the housing about the opening 18 so as to cover the opening and seal the reservoir 20. Septum 22 can be made from any number of materials including silicone. Septum 22 is preferably placed in a proximal enough position such that the depth of the reservoir 20 is sufficient enough to expose the open tip of a needle, such as a Huber needle, so that fluid transfer can take place. Septum 22 is preferably arranged so that it will self seal after being punctured by a needle and the needle is withdrawn. In one embodiment, the septum is made from silicone which is under compression when attached to the housing. Port 10 further includes a catheter tube connection member 30, in fluid communication with reservoir 20.

Port 10 is implanted into a patient and attached to the fascia just below the skin of the patient, so that fluid can be inserted and withdrawn from the inflatable portion with a syringe. As seen from the figures, port 1 includes one or more attachment mechanisms 70, taking the form of an arcuate hook. However, for purposes of this invention, the attachment mechanism could take the form of alternative means such as using suture. Some of these other means for attaching the port to a patient are described in commonly assigned and copending U.S. patent application Ser. Nos. 10/741,785 filed Dec. 19, 2003; 60/478,763 filed Dec. 19, 2003; 10/741,868 filed Dec. 30, 2003; all of which are hereby incorporated herein by reference.

As seen from the figures, port 1 includes one or more attachment mechanisms 70. The figures herein show three attachment mechanisms all substantially identical and equally spaced from each other. Attachment mechanisms 70 are mounted to the housing 12 at a pivot point 80 along an outer periphery 13 of the housing 12. As seen from the figures, attachment mechanisms 70 are arcuate hooks pivotable with respect to the housing. Attachment mechanisms 70 have an arcuate length L extending substantially greater than 90°, and preferably at least 180° about the pivot point. Implantable surgical injection port 10 has an undeployed position, shown as a solid line in FIG. 3, and a deployed position, shown as the phantom line in FIG. 3 and in FIG. 4, wherein the port is attached to tissue. Attachment mechanisms 70 is preferably made from a bioabsorbable material including, but not limited to, one or more of the following either alone or in combination: iron, polydioxanone, polyglactin and/or poliglecaprone.

Attachment mechanism 70 has a fixed end 72 pivotally attached to the housing 12 at pivot point 80. The design allows a surgeon to use forceps and drive the fastener through the tissue until the free end 74 rests against the flat 75. In this way the patient is protected from the sharp end of the tip. Attachment mechanism 70 also includes a free end 74 which has a sharp or pointed configuration. Housing 12 further includes at least one recessed portion 15 along its distal end 14. Recessed portion 15 is designed to receive the free end 74 of attachment mechanisms 70 when the port 1 is in its deployed position. This design prevents any exposure of the sharp free end to tissue after the port has been implanted.

The above described 180° hook or attachment mechanisms provide advantages over prior 90° or less hooks. As seen from FIG. 4, the above described attachment mechanism allows the hook to engage a greater area of tissue, and allows for two locking points, entry into and then out of the fascia. This provides for better sacrament of the port to the tissue. Further no “sharp” is exposed to the patient. A further advantage of the fastener configuration is that the fastener follows a constant radius when pushing through the tissue. By maintaining a constant radius the fastener never induces a compressive force onto the fascia. This should minimize pain because the fastener is not “compressing or squeezing” nerves.

In practice, the physician would create an incision in the skin 110 of a patient to expose the fascia according to well known surgical techniques. Thereafter, as seen from FIG. 4, the port 1 could be placed against the fascia 100 of the patient with the port in its undeployed position. Thereafter, the physician could rotate, manually or otherwise, the attachment mechanism substantially greater than 90° and preferably at least 180° so that the hook enters and then exits the fascia. The design allows a surgeon to use forceps and drive the fastener through the tissue until the free end 74 rests against the flat 75. In this way the patient is protected from the sharp end of the tip. This could be done for each attachment mechanism on the device. Thereafter, the catheter tube 52 would be connected to connection member 30, and the patient is sewn up.

It will become readily apparent to those skilled in the art that the above invention has equally applicability to other types of implantable bands. For example, bands are used for the treatment of fecal incontinence. One such band is described in U.S. Pat. No. 6,461,292 which is hereby incorporated herein by reference. Bands can also be used to treat urinary incontinence. One such band is described in U.S. Patent Application 2003/0105385 which is hereby incorporated herein by reference. Bands can also be used to treat heartburn and/or acid reflux. One such band is described in U.S. Pat. No. 6,470,892 which is hereby incorporated herein by reference. Bands can also be used to treat impotence. One such band is described in U.S. Patent Application 2003/0114729 which is hereby incorporated herein by reference.

While preferred embodiments of the present invention have been shown and described herein, it will be obvious to those skilled in the art that such embodiments are provided by way of example only. Numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention. For example, as would be apparent to those skilled in the art, the disclosures herein have equal application in robotic-assisted surgery. In addition, it should be understood that every structure described above has a function and such structure can be referred to as a means for performing that function. Accordingly, it is intended that the invention be limited only by the spirit and scope of the appended claims.


Glabridin inhibits dexamethasone-induced muscle atrophy.
Prevention of muscle wasting is known to contribute to improving the quality of life and extending a healthy life. Recently, we have reported that licorice flavonoid oil containing glabridin, which is a prenylated isoflavone, enhances muscle mass in mice. In this study, we investigated the prevention effect of glabridin on dexamethasone-induced muscle atrophy and clarified its mechanism in cultured myotubes and in muscle of mice. Treatment with glabridin to C2C12 myotubes inhibited dexamethasone-induced protein degradation through dexamethasone-induced expression of ubiquitin ligases, MuRF1 and Cbl-b, but not atrogin-1. Mechanistically, glabridin inhibited nuclear translocation of the glucocorticoid receptor. Glabridin directly bound to the glucocorticoid receptor, resulting in the inhibition of binding between dexamethasone and the receptor protein. Glabridin also inhibited dexamethasone-induced phosphorylation of p38 and FoxO3a, as the upstream for the induction of ubiquitin ligases in C2C12 myotubes. Moreover, the glabridin-induced inhibition of protein degradation was eliminated by knockdown of the glucocorticoid receptor, but not by p38 knockdown. These data indicated that the inhibitory mechanism of glabridin against dexamethasone-induced muscle atrophy was mainly mediated by the inhibition of binding between dexamethasone and the glucocorticoid receptor in myotubes. Oral administration of glabridin prevented dexamethasone-induced protein degradation in the tibialis anterior muscle of mice. It was confirmed that glabridin inhibited dexamethasone-induced nuclear translocation of the glucocorticoid receptor and phosphorylation of FoxO3a in the muscle of mice. These findings suggest that glabridin is an effective food ingredient for the prevention of glucocorticoid-induced skeletal muscle atrophy.


Petition 20185831 Details

To the Honorable Wade Keys Chancellor of the Southern Chancery Division of the State of Alabama in the Eleventh Chancery District (KEYES, Wade)

Filing Date:

1858-February-2

Ending Date:

1860-November-8

General Petition Information

Abstract:

Susan E. Walker, a feme sole and widow of James T. Walker, prays that the court will restore her distributive share in her husband's estate. James T. Walker died in 1857 "seized & possessed of a large Estate," worth at least fifteen thousand dollars. The estate included several valuable tracts of land and eighteen slaves. Shortly after her husband's death, Susan was invited to visit the home of William Mount, a relative and heir of her late husband, and his family in Georgia. While enjoying "the apparent hospitality & Kindness" of Mount she was asked if she would be willing to sell her dower's interest in the lands of her late husband for twenty four hundred dollars. She accepted the offer, but now realizes that in the contract she later signed to seal the deal she actually bargained away not only her dower's interest but her distributive interest for the previously agreed upon sale price. Being "unable to read or write, & reposing the utmost confidence in the said Mount as a man of truth, good faith & honesty," she did not suspect that he would be capable of fraud and deceit. If it is necessary to rescind the whole contract in order to effect the restoration of her distributive interest, Susan Walker informs the court, she is prepared to do so. But if not necessary, she would prefer that the contract remain in place as regard her dower's interest provided she is able to recover her rights to her distributive share.

Result:

denied; dismissed

# of Petition Pages:

3

Related Documents:

Copies of Indenture, Susan E. Walker to William Mount, 13 November 1857; Final Decree, 8 November 1860