text:
COCATS 4 Task Force 14: Training in the Care of Adult Patients With Congenital Heart Disease
Author + information
- Published online May 5, 2015.
Author Information
- Carole A. Warnes, MD, FACC, Chair,
- Ami B. Bhatt, MD, FACC,
- Curtis J. Daniels, MD, FACC,
- Linda D. Gillam, MD, MPH, FACC and
- Karen K. Stout, MD, FACC
1 Introduction
1.1 Document Development Process
1.1.1 Writing Committee Organization
The Writing Committee was selected to represent the American College of Cardiology (ACC) and included a cardiovascular training program director, a training director specializing in the care of adults with congenital heart disease (i.e., adult congenital heart disease [ACHD]), early-career ACHD cardiologists, highly experienced specialists representing both the academic and community-based practice settings, and physicians experienced in defining and applying training standards according to the 6 general competency domains promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) and endorsed by the American Board of Internal Medicine (ABIM). The ACC determined that relationships with industry or other entities were not relevant to the creation of this cardiovascular training statement. Employment and affiliation details for authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document.
1.1.2 Document Development and Approval
The Writing Committee developed the document, approved it for review by individuals selected by the ACC, and then addressed the reviewers' comments. The document was revised and posted for public comment from December 20, 2014, to January 6, 2015. Authors addressed these additional comments from the public to complete the document. The final document was approved by the Task Force and ACC Competency Management Committee and ratified by the ACC Board of Trustees in March, 2015. This document is considered current until the ACC Competency Management Committee revises or withdraws it.
1.2 Background and Scope
Remarkable advances in surgical management of congenital heart disease (CHD) over the last half century have allowed more than 90% of children with CHD to survive to adulthood (1). This has led to a shift in the prevalence of CHD, such that adults comprise two-thirds of the overall CHD population, with an estimated 1.5 million adult survivors in the United States alone. This population includes not only those with mild and moderate forms of CHD, but also, importantly, those with severe forms of CHD. Indeed, approximately 60% of those with severe CHD are now adults (2,3). The rise in incidence and prevalence is expected to continue, so healthcare delivery for CHD, including the training of cardiologists, must evolve as well to meet this demand. ACHD patients have special healthcare needs and often present complex combinations of problems that are generally unrecognized by those in a traditional, internal medicine–based cardiovascular training program (4). Adult cardiologists are experts in the care of acquired diseases that affect the heart and circulation, but currently most have little or no training in CHD, particularly in complex disorders. Exposure to ACHD patients and clinical experiences for cardiovascular fellows varies widely (3). Many ACHD patients continue to be cared for by pediatric cardiologists for many reasons, including the fact that there are few internal medicine cardiologists specializing in this complicated field and access is, therefore, limited (5,6). This report recommends an approach to more systematic training of internal medicine cardiologists in the recognition and care of ACHD patients on the basis of previous Bethesda Conference descriptions of workforce needs and educational requirements (5). Similar recommendations are made for ACHD training for pediatric cardiovascular trainees, with an emphasis on the importance of ACHD training for all cardiologists who may care for these patients, regardless of specialty (7). In addition, this report addresses the evolving framework of competency-based medical education described by the ACGME Outcomes Project and the 6 general competencies endorsed by ACGME and ABMS. The background and overarching principles governing fellowship training are provided in the COCATS 4 Introduction, and readers should become familiar with this foundation before considering the details of training in a subdiscipline like ACHD. The Steering Committee and Task Force recognize that implementation of these changes in training requirements will occur incrementally over time.
For most areas of cardiovascular medicine, 3 levels of training are delineated:
▪ Level I training is the basic training required to become a competent cardiovascular consultant, is required of all cardiovascular fellows, and can be accomplished as part of a standard 3-year training program in cardiovascular medicine. This level of training should allow the trainee to develop sufficient knowledge to review and understand consensus-based ACHD care guidelines to determine which ACHD patients can be managed by a clinician and which patients are best cared for in collaboration with an ACHD specialist. Along with guideline-based care, this level of training should also enable the cardiologist to recognize when direct consultation and referral to an ACHD specialist are necessary. In some circumstances, Level I–trained physicians may participate in the care of patients with moderately or severely complex disease in close collaboration with an ACHD specialist.
▪ Level II training refers to the additional training in 1 or more areas that enables some cardiovascular specialists to perform or interpret specific diagnostic tests and procedures or render more specialized care for patients and conditions. This level of training is recognized for those areas in which an accepted instrument or benchmark, such as a qualifying examination, is available to measure specific knowledge, skills, or competence. Level II training in selected areas may be achieved by some trainees during the standard 3-year cardiovascular fellowship, depending on the trainee's career goals and use of elective rotations. It is anticipated that during a standard 3-year cardiovascular fellowship training program, sufficient time will be available to receive Level II training in a specific subspecialty. Recognizing the special needs of this complex patient population, the ABMS approved ACHD subspecialty certification in December 2012 (see specific criteria under Level III training). There is no Level II training curriculum or qualifying examination in ACHD. Thus, only Level I and III training apply to ACHD.
▪ Level III training requires additional training and experience beyond the cardiovascular fellowship for the trainee to acquire specialized knowledge and experience in performing, interpreting, and training others to perform specific procedures or render advanced specialized care for specific conditions at a high level of skill. In the case of ACHD, Level III training provides the knowledge needed by graduates wishing to make an advanced clinical and/or academic/research commitment to this field and to not only become competent in the care of the entire spectrum of ACHD patients, but also participate in teaching about ACHD (6). Level III competency requires specific time dedicated to training in pediatric cardiology (as outlined by the ACGME) for those with a background in adult cardiovascular medicine, and requires dedicated time in adult internal medicine and cardiology for those with a background in pediatric cardiology. Level III requires training beyond the 3 years of fellowship (in either pediatric or adult cardiovascular medicine). Such Level III training would be sufficient to clinically manage complex ACHD in a regional or tertiary center, pursue an academic career, train others in the field, and/or direct an ACHD program. ACHD subspecialty certification was approved through the ABMS in December 2012. The first examination in 2015 is available for those who qualify by meeting the practice pathway criteria and is administered by the ABIM in collaboration with the American Board of Pediatrics. Once the practice pathway closes, only those completing an ACGME-approved advanced ACHD fellowship (beyond adult or pediatric cardiovascular fellowship) will qualify for ACHD subspecialty certification. Level III training is described here only in broad terms to provide context for trainees and clarify that these advanced competencies are not covered during the cardiovascular fellowship. The additional exposure and requirements for Level III training will be addressed in a subsequent, separately published Advanced Training Statement.
2 General Standards
The ACC and American Heart Association have produced guidelines for ACHD (8) and educational objectives for fellowship training in ACHD (9). The recommendations are congruent and address faculty, facility requirements, emerging technologies, and practice. We recommend strongly that candidates for the ABIM examination for certification in cardiovascular diseases, as well as those seeking certification of added qualifications in ACHD, review the specific requirements of the ABIM. With recent ABMS approval for ACHD subspecialty certification, it is expected that the ACGME will standardize fellowship programs with specific guidelines for faculty, facilities, and curriculum, and that these guidelines will apply to advanced fellowship trainees with either pediatric or adult cardiovascular training.
2.1 Faculty
Ideally, to ensure adequate Level I training, a program should have at least 1 faculty member with expertise and commitment to the care of adults with CHD. This faculty member should have achieved the skills equivalent to Level III training by lifelong experience and/or specific training. In recognition that not all programs have ACHD expert faculty available, Level 1 training may be achieved without ACHD faculty on site, but in such cases other resources, such as online learning modules, visiting professors, "away" rotations, and print or electronic curricula, should be utilized. Affiliation with a pediatric cardiovascular program is an invaluable resource for congenital heart disease education. Advanced training (Level III) requires a critical mass of faculty dedicated to the care of adult patients with CHD and a program that provides comprehensive diagnostic and management services to patients with a broad array of congenital cardiac disorders. Affiliation with a pediatric cardiovascular program is ideal and will further ensure that the trainee in advanced ACHD is exposed to patients across the entire lifespan. This comprehensive ACHD education includes congenital interventional procedures; congenital electrophysiological consultation and procedures; congenital cardiac surgery; and training in ACHD echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). Organized, deliberate, and developmentally appropriate transition and transfer of patients from pediatric to ACHD programs are necessary, and comprehensive ACHD education should include participation in transition programs. Further training in intervention, electrophysiology, and in some cases, imaging, will be necessary for independent practice of these disciplines. Programs that have interdisciplinary involvement, including with obstetrics, pulmonary hypertension specialists, hematologists, hepatologists, and others, are forming a robust network of interdisciplinary clinicians with experience in caring for the entirety of the ACHD patient experience and are ideal in providing comprehensive training. This level of expertise may still be evolving at some institutions, but ACHD training should accord with ABIM– and ACGME–recommended guidelines.
2.2 Facilities, Equipment, Ancillary Support, and Program Requirements
To train cardiac fellows to achieve Level III competency, institutions that care for ACHD patients should meet certain program requirements and have essential ancillary support capabilities. Two basic requirements are indicated for a program to train fellows effectively at Level III: 1) the presence of associated formal programs in pediatric cardiology and cardiovascular CHD surgery; and 2) a critical mass of faculty who are board eligible/certified in ACHD. Relationships should also be cultivated in obstetrics, general surgery, cardiac anesthesia, hematology, hepatology, nephrology, and other subspecialties as feasible at a given institution. Because ACHD patients will use noncardiac hospital resources as well, appropriate monitoring should be available and specialty care should be coordinated with the ACHD team.
For comprehensive imaging assessment at a Level III training program, echocardiography laboratories with sonographers with training and expertise in assessing congenital heart lesions as well as echocardiographers who are expert in and experienced with reading ACHD echocardiograms must be available. Advanced imaging facilities, ACHD–specific MRI and CT protocols, and cardiologists or radiologists with experience in CHD are essential for comprehensive imaging at a Level III training program and, if available, should be leveraged for training and exposure at non-Level III programs.
At training institutions that perform adult congenital procedures, including but not limited to hemodynamic assessment and potential catheter-based or electrophysiological interventions, ancillary support is essential to ensure patient safety. This should include laboratories with fluoroscopy and specialized equipment for the safe performance of diagnostic procedures and congenital cardiac interventions or electrophysiological interventions in an adult. Institutions that intervene on ACHD patients must have cardiologists with the expertise to perform coronary interventions. The ability to perform detailed hemodynamic assessments, including the evaluation of pulmonary vascular disease and the reversibility of pulmonary hypertension, is also important. When available, a biplane room may benefit the ACHD patient. For institutions performing interventions on moderate-to-complex ACHD, cardiac anesthesia and a clear process for rapid availability of urgent or emergent cardiac surgery should be established. Operating rooms should be fully staffed and should have dedicated cardiac anesthesiologists and the resources necessary for ACHD operations as well as the capability for imaging and percutaneous interventions, as previously discussed.
3 Training Components
3.1 Didactic Program
Didactic instruction may take place in a variety of formats, including but not limited to lectures, conferences, journal clubs, grand rounds, clinical case presentations, and online learning. Such instruction can occur as a part of the fellow's core curriculum teaching or rotation-specific lectures, or may be incorporated into other subspecialty curricula such as electrophysiology, pulmonary hypertension, cardiac surgery, echocardiography, or noncardiac care (e.g., obstetrics, palliative care). Opportunities such as online learning from approved cardiac educational sites with continuing medical education credit should also be encouraged and included as supplements to hospital-based didactics. Whereas Level I competency can be achieved without an ACHD expert faculty member or substantial ACHD patient volume, Level III training requires both faculty expertise and patient volume that allow direct clinical care in addition to robust didactic education. A comprehensive curriculum is currently being developed by the ACC. Bedside physical examination, whether inpatient or outpatient, is an essential component of Level I training.
3.2 Clinical Experience
Rotation on an ACHD service is an essential component of all levels of ACHD training. For programs with an ACHD service, a rotation is mandatory. Ideally, Level I trainees should gain first-hand experience in both inpatient and outpatient consultation and management of ACHD. Ideally, the ACHD service will have a robust patient mix (including low, moderate, and high complexity) in both inpatient and outpatient settings. The ACHD service should expose trainees to a wide array of ACHD patients and procedures, and should, at a minimum for the Level I trainee, include exposure to ACHD management within the cardiac subspecialties (e.g., arrhythmia, heart failure, pulmonary hypertension, transplant, intervention, and surgery).
If a program lacks the necessary expertise and patient volume, patient-based education can be achieved through alternative approaches, such as didactic education, with a focus on case-based education. The interpretation of clinical cases should always include the interpretation of testing ranging from electrocardiography to echocardiography or advanced imaging, as well as any interventional procedures. Achievement of Level I training must be accomplished with a focused educational experience, as either a dedicated block or a discrete ACHD clinical experience through the course of other rotations (i.e., regular longitudinal participation in an ACHD outpatient clinic, as either a continuity clinic or component of other rotations).
Fellows seeking more detailed ACHD training than prescribed by the Level I minimum recommendations during the clinical cardiovascular fellowship should obtain robust clinical experiences in the outpatient and inpatient consultation settings, as well as experience in cardiac catheterization, arrhythmia and heart failure management, ICU care, appropriate indications for surgical or catheter-based intervention; exposure to operations; and, importantly, perioperative and postoperative intensive care. Management of ACHD patients admitted for noncardiac diagnoses with a special focus on pregnancy, labor, and delivery must also be a component of this extra training. In each of these clinical settings, trainees should assist in patient care in a supervised setting that provides for patient-centered education in all aspects of ACHD management.
3.3 Hands-On Experience
Hands-on experience is important for training in ACHD management. Cardiovascular trainees should have a hands-on clinical experience to acquire the core competencies for Level I training. During this period, and during rotations on the other cardiac services, trainees should review case histories, physical findings, and electrocardiograms, and log echocardiogram reading, arrhythmia management, and percutaneous and surgical cases involving ACHD patients. Interaction with the ACHD team should not be limited to "on-rotation" time, because exposure to the ACHD patient is likely to become pervasive in all cardiac subdisciplines.
4 Summary of Training Requirements
4.1 Development and Evaluation of Core Competencies
Training and requirements in ACHD address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.
Tables 1 and 2 delineate each of the 6 competency domains as well as their associated curricular milestones for training in adult congenital heart disease. The milestones are categorized into Level I and III training (as previously defined in this document) and indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular trainee should achieve the designated level. Given that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may also vary. Level I competencies may be achieved at earlier or later time points. Acquisition of Level III skills requires training in a dedicated ACHD program. The tables also describe examples of evaluation tools suitable for assessing competence in each domain.
4.2 Structure and Duration of Training
Because relatively few centers in the United States have amassed a sufficient number of ACHD patients who have been followed in an organized manner, regionalization of training in the care of the complex CHD patients is necessary (6). In addition to meeting requirements for training duration and numbers of procedures performed and/or interpreted, the trainee must demonstrate achievement of specific competencies. A brief discussion of the competencies and training requirements for ACHD follows.
The specific competencies for Levels I and III are delineated in Table 1. Level I competencies must be obtained by all fellows during the 3-year cardiovascular disease fellowship training program. There is no Level II training in ACHD. Level III competencies are noted so that fellows are aware of the competencies for which additional, advanced training beyond the standard 3-year fellowship is required. A brief discussion of the competencies and training requirements for Levels I and III follows. Although these minimum training duration and numbers of procedures are typically required to obtain competency, there must also be demonstration of achievement of the competencies as assessed by the outcomes evaluation measures.
4.2.1 Level I Training Requirements
All cardiovascular trainees should be exposed to a core of information regarding adults with CHD. The goal of Level I training is to have the ability to recognize and evaluate common, simple congenital heart lesions and the sequelae of the more commonly repaired congenital heart defects. These graduates should consult and collaborate with a Level III–trained ACHD specialist when major management decisions are made for adults with CHD and for periodic discussions of ongoing care.
We suggest that at least 6 hours of formal lectures within the core curriculum of the training program be devoted to CHD in adults. Table 1 indicates the content suggested for these 6 hours, covering key basic and clinical aspects of these disorders. With the acknowledgment that there are many teaching styles and organizational strategies to teach the necessary concepts, a proposed curriculum is as follows: Hour 1 = basic anatomy, pathology, physiology, hemodynamics, and known genetics of common lesions and conditions; Hour 2 = clinical diagnosis (history, clinical examination, electrocardiogram, and x-ray) and management of the most common lesions expected to be encountered in adults, operated or not; Hour 3 = specific issues relevant to cyanotic CHD and Eisenmenger syndrome; Hour 4 = a description of the most commonly performed surgical procedures involved in repair and palliation of CHD and a review of the common residua and sequelae encountered in clinical practice; Hour 5 = common echocardiographic features in operated and unoperated adult CHD; and Hour 6 = various topics, which could include management during pregnancy, endocarditis prophylaxis, and basic counseling on genetics and contraception, employment, and exercise. Within those 6 hours of core curriculum, the trainees should be taught the major outpatient management issues in ACHD and when to consult or refer for more specialized advice. Currently available modes of supplementing this education include readily available ACC educational products (ACHD section of the Adult Clinical Cardiology Self-Assessment Program [ACCSAP] and the Echocardiography Self-Assessment Program) and web-based sites specific to CHD. Additional content could include areas such as preoperative noncardiac surgery assessment, evaluation and management of heart failure, and CHD–related pulmonary hypertension.
In addition to the didactic material in the core curriculum, trainees should be exposed to ACHD patients on a regular basis. This could be done in the context of ongoing weekly case conferences, which may already be part of the cardiovascular training program. In addition, trainees are encouraged to become involved in an ongoing CHD outpatient clinic, to see older children or adolescents with a pediatric cardiology colleague, or both. If not available at the training institution, regional ACHD case conferences may provide an opportunity for fellows to receive exposure to ACHD management at dedicated centers.
Cardiovascular trainees should be exposed to the evaluation of CHD with various diagnostic modalities during the usual clinical rotations (electrocardiography, electrophysiology, transthoracic and transesophageal echocardiography, nuclear cardiology, and the cardiac catheterization laboratory [including invasive transcatheter techniques]). Exposure to other advanced imaging techniques now commonly utilized in CHD (e.g., MRI and CT) as well as cardiopulmonary exercise testing is highly desirable. Didactic material for these rotations should include materials on diagnosis and management of the adult with CHD.
A 4-week rotation is strongly recommended to complete Level I competence if the training program has expertise in ACHD with a board-eligible/board-certified cardiologist on staff (or equivalent experience). If the training program does not have expertise in CHD or have access to CHD locally, partnering with an expert regional ACHD facility for an elective rotation of 4 weeks total duration may be a valuable supplement. A similar recommendation exists for pediatric cardiovascular trainees. Thus, partnership with a pediatric cardiovascular program can facilitate collaboration as well as effective resource utilization.
4.2.2 Level III Training Recommendations
Level III training prepares the cardiologist to specialize in advanced care for the adult with CHD. In order to obtain a comprehensive understanding of all aspects of CHD, a 2-year program (following either internal medicine or pediatric cardiovascular fellowship) is necessary with ongoing participation in clinical practice relating to CHD. The ACGME is currently reviewing the ABIM and ABMS petition and establishing curriculum guidelines; it has defined the essential components of a specialized program for training in ACHD. Level III training should align with the ACGME curriculum as this is planned per the current timeline to be part of fellowship training in July 2016. The ABIM will begin to offer an examination for this additional certification in 2015. Information concerning the eligibility requirements for the examination can be obtained from the ABIM. There will be 2 pathways, with the chosen path depending on whether the trainee's background is in adult or pediatric cardiology. Pediatric cardiologists will devote a portion of their training to areas of adult internal medicine and cardiology to fulfill requirements and competencies necessary to care for adults with CHD. Adult cardiologists will complete additional training in pediatric cardiology for the same purposes.
It is, therefore, expected that trainees should:
1. Participate in a regular outpatient clinic organized for the care of adults with CHD for at least 18 of the 24 months. The Level III trainee should be involved with the care of a minimum of 10 patients per week. Programs that are able to provide Level III training will have clinic more than once a week. The Level III trainee should participate in clinic at least once a week and for much of the training period will need to be in clinic more often to obtain appropriate exposure.
2. Participate in a total block or cumulative equivalent of at least 9 months of inpatient consultative services providing care for ACHD patients. This typically includes consultation for admissions related to heart failure, arrhythmias, preoperative and postoperative care, and noncardiac issues.
3. Participate in at least 3 months of comprehensive imaging methods used in caring for ACHD patients, including direct experience in echocardiography (transthoracic and transesophageal) and advance imaging techniques (MRI and CT).
4. Participate in at least 2 months of cardiac catheterization (diagnostic and interventional) that includes understanding indications for intervention, hemodynamics, diagnostic angiography, and physiological calculations.
5. Participate in at least 1 month of dedicated cardiothoracic intensive care unit and surgical service for the care of ACHD patients. This includes preoperative assessment and intraoperative (including direct observation of surgical repair) and postoperative care.
6. Participate in at least 3 months of formal rotations in pediatric cardiology (for those following the adult cardiovascular pathway) for either a total block or cumulative equivalent months, including exposure to neonates and children with CHD via conferences, outpatient clinics, diagnostic laboratories (e.g., echocardiography, catheterization laboratory), and inpatient services, including consultations and exposure to children with postoperative CHD in the intensive care unit. Given that such fellows will not likely be experienced in the critical care of pediatric patients, all inpatient participation should be observed and supervised by experienced pediatric cardiologists.
7. Participate in at least 3 months of formal rotations in adult cardiology (for those following a pediatric cardiology pathway) for either a total block or cumulative equivalent months, including exposure to adults with acquired heart disease through outpatient clinics, diagnostic laboratories (e.g., echocardiography, catheterization laboratory), and inpatient services, including consultations. Trainees with a pediatrics residency background prior to pediatric cardiology will require additional time gaining basic competencies in adult internal medicine and adult comorbidities.
8. Perform and interpret cardiopulmonary exercise testing in CHD individuals and apply that data to clinical assessment as well as exercise prescription.
9. Perform outpatient follow-up and inpatient management (with obstetrics/anesthesia) of pregnancy in CHD.
10. Participate in inpatient and outpatient care of CHD individuals with advanced heart failure, including consideration of mechanical support or transplant.
11. Participate in the inpatient and outpatient care of CHD individuals with significant pulmonary arterial hypertension, including specific medical therapies and transplantation.
12. Gain experience with the arrhythmic complications of CHD and the various approaches to their management, both pharmacological and interventional.
Training should include active participation in clinical and/or laboratory research in conjunction with clinical activities. Direct participation in cardiac catheterization procedures in CHD is necessary to develop and demonstrate a comprehensive understanding of the entire hemodynamic spectrum of anatomic abnormalities in CHD. The specific number of cases and methods of assessing competencies will be developed through the ACGME. Specialized training is necessary to achieve expertise in the appropriate timing of surgical and interventional procedures as well as expertise in the potential complications. Expertise in the management of all complications of a wide variety of simple and complex congenital cardiac lesions, both unrepaired and repaired, is necessary, including the treatment of heart failure, arrhythmias, pulmonary hypertension, and pregnancy, as well as contraception management and knowledge of indications for referral for genetic counseling. Finally, trainees must be competent in the interpretation of transthoracic and transesophageal echocardiograms across the spectrum of CHD as well as the diagnosis of valvular disease and cardiomyopathic conditions. The specific numbers of cases has not yet been determined by the ACGME. It is anticipated that such competence would require at least 300 transthoracic echocardiograms and 50 transesophageal echocardiographic examinations to ensure that adequate exposure and expertise have been acquired in the wide range of complex cardiac pathology that might be encountered in practice. Although Level III MRI or CT training is not required, the advanced trainee should also be trained in the indications for and interpretation of advanced imaging techniques (i.e., MRI and/or CT and angiography in CHD). Trainees who have completed this additional 2-year training will be eligible to take the ABIM subspecialty examination.
5 Evaluation of Competency
Evaluation tools in ACHD include direct observation by instructors, in-training examinations, case logbooks, conference and case presentations, multisource evaluations, trainee portfolios, and reflection and self-assessment. Case management, judgment, interpretive, and bedside skills must be evaluated in every trainee. Quality of care and follow-up; reliability; judgment, decisions, or actions that result in complications; interaction with other physicians, patients, and laboratory support staff; initiative; and the ability to make appropriate decisions independently should be considered. Trainees should maintain records of participation and advancement in the form of a Health Insurance Portability and Accountability Act (HIPAA)–compliant electronic database or logbook that meets ACGME reporting standards and summarizes pertinent clinical information (e.g., number of cases, diversity of referral sources, diagnoses, disease severity, outcomes, and disposition).
Under the aegis of the program director, the faculty should record and verify each trainee's experiences, assess performance, and document satisfactory achievement. The program director is responsible for confirming experience and competence and for reviewing the overall progress of individual trainees with the Clinical Competency Committee to ensure achievement of selected training milestones and identify areas in which additional focused training may be required.
The ACGME has defined the essential components of a specialized program for training in ACHD; the ABIM will begin to offer an examination for this additional certification in 2015. Information concerning the eligibility requirements for the examination can be obtained from the ABIM.
Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 14: Training in Care of Adult Patients With Congenital Heart Disease
|Committee Member
|Speakers Bureau
|Personal Research
|Institutional/Organizational or Other Financial Benefit
|Expert Witness
|Carole A. Warnes (Chair)
|Mayo Clinic—Director, Adult Congenital Heart Disease Clinic; Professor of Medicine
|Ami B. Bhatt
|Massachusetts General Hospital, Cardiology Division—Director, Adult Congenital Heart Disease Program
|Curtis J. Daniels
|The Ohio State University—Professor, Internal Medicine and Pediatrics
|Linda D. Gillam
|Morristown Medical Center—Chair, Department of CV Medicine
|Karen K. Stout
|University of Washington—Director, Adult Congenital Heart Disease Program
For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors' employment and reporting categories. To ensure complete transparency, authors' comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees.
ACC = American College of Cardiology; CV = cardiovascular.
Appendix 2 Peer Reviewer Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 14: Training in Care of Adult Patients With Congenital Heart Disease
|Speakers Bureau
|Personal Research
|Institutional/Organizational or Other Financial Benefit
|Expert Witness
|Richard Kovacs
|Indiana University, Krannert Institute of Cardiology—Q.E. and Sally Russell Professor of Cardiology
|Official Reviewer, ACC Board of Trustees
|Dhanunjaya Lakkireddy
|Kansas University Cardiovascular Research Institute
|Official Reviewer, ACC Board of Governors
|Howard Weitz
|Thomas Jefferson University Hospital—Director, Division of Cardiology; Sidney Kimmel Medical College at Thomas Jefferson University—Professor of Medicine
|Official Reviewer, Competency Management Committee Lead Reviewer
|Michael Emery
|Greenville Health System
|Content Reviewer, Sports and Exercise Cardiology Section Leadership Council
|Elyse Foster
|University of California San Francisco—Professor, Medicine and Anesthesia; Director, Non-Invasive Cardiology Laboratories
|Content Reviewer, ACPC Section Leadership Council
|Larry Jacobs
|Lehigh Valley Health Network, Division of Cardiology; University of South Florida—Professor, Cardiology
|Content Reviewer, Cardiology Training and Workforce Committee
|Andrew Kates
|Washington University School of Medicine
|Content Reviewer, Academic Cardiology Section Leadership Council
|Michael Landzberg
|Boston Children's Hospital—Medical Director, Adult Congenital Heart and BACH Pulmonary Hypertension Service Departments of Pediatrics, Medicine, and Surgery
|Content Reviewer, ACPC Section Leadership Council
|Arash Sabati
|Children's Hospital of Los Angeles
|Content Reviewer, ACPC Section Leadership Council
For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers' employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees.
ACC = American College of Cardiology; ACPC = Adult Congenital and Pediatric Cardiology.
Appendix 3 Abbreviation List
ABIM = American Board of Internal Medicine
ABMS = American Board of Medical Specialties
ACC = American College of Cardiology
ACCSAP = Adult Clinical Cardiology Self-Assessment Program
ACGME = Accreditation Council for Graduate Medical Education
ACHD = adult congenital heart disease
CHD = congenital heart disease
COCATS = Core Cardiovascular Training Statement
CT = computed tomography
HIPAA = Health Insurance Portability and Accountability Act
MRI = magnetic resonance imaging
The American College of Cardiology requests that this document be cited as follows: Warnes CA, Bhatt AB, Daniels CJ, Gillam LD, Stout KK. COCATS 4 task force 14: training in the care of adult patients with congenital heart disease. J Am Coll Cardiol 2015;65:1887–98.
- American College of Cardiology Foundation
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- Perloff J.K.,
- Child J.S.
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- Marelli A.J.,
- Ionescu-Ittu R.,
- Mackie A.S.,
- Guo L.,
- Dendukuri N.,
- Kaouache M.
- ↵
- Warnes C.A.,
- Liberthson R.,
- Danielson G.K.,
- et al.
- ↵
- Foster E.,
- Graham T.P. Jr..,
- Driscoll D.J.,
- et al.
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- Murphy D.J. Jr..,
- Foster E.
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- Child J.S.,
- Collins-Nakai R.L.,
- Alpert J.S.,
- et al.
- ↵
- Ross R.D.,
- Brook M.,
- Feinstein J.,
- et al.
- ↵
- Warnes C.A.,
- Williams R.G.,
- Bashore T.M.,
- et al.
- ↵
- Child J.S.,
- Freed M.D.,
- Mavroudis C.,
- Moodie D.S.,
- Tucker A.L.
Citation Manager Formats
Article Outline
- Top
- 1 Introduction
- 2 General Standards
- 3 Training Components
- 4 Summary of Training Requirements
- 5 Evaluation of Competency
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 14: Training in Care of Adult Patients With Congenital Heart Disease
- Appendix 2 Peer Reviewer Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 14: Training in Care of Adult Patients With Congenital Heart Disease
- Appendix 3 Abbreviation List
- Footnotes
- References


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Gross Revenues: $1,600,000
Cash Flow: $160,000
This is a very popular, established bar on the Southside. They have live entertainment, karaoke, pool tables, and tons of TVs. The facility is very nice with room for more than 300 people. They have a great menu and large selection of liquor and draft beer. This not a trendy place and most of customers are long-term regulars. It's fantastic opportunity for an owner-operator.
Facilities: Nice strp mall location
Support & Training: The seller will provide necessary support and training
Reason Selling: Retirement
Contact: Mandy Sheckles
Phone: 317-333-6655 x 113

subset: commoncrawl


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How the West Was Won?
All through our journey, we ate like kings. To me, the food in the west seems much fresher and healthier. I know I am making a generalization but it's a pretty safe one. It's like saying the French make great wines. Yup! No argument there.


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If you travel frequently, finding clothes that look good, perform well, and are versatile enough to be worn in a variety of situations is a must. ExOfficio has been delivering apparel that meets those standards for years, with shirts, pants, jackets, and even underwear that are designed specifically with the active traveler in mind. But the new Storm Logic Vest just might be the company's most travel friendly piece of clothing yet, which is saying something considering the brand's heritage.
Made with Primaloft Sport, the vest is lightweight, wind resistant, and quite warm. Its outer fabrics also feature a DWR coating that helps repel moisture, ensuring that the wearer stays warm and dry even when the weather takes a turn for the worse. Other nice touches include a drop-tail hem that provides extra coverage when needed, and a microfleece lining on the collar and two zippered hand pockets. These features make the vest a great choice when traveling to cool weather destinations or for wearing around town in the damp conditions of winter and fall.
But ExOfficio really went the extra mile when creating the Storm Logic by thinking long and hard about what travelers needed from their clothing. To that end, they added five pockets on the interior of the vest, each with their own specific purpose. For instance, one of the pockets is designed to hold a pair of sunglasses, and as such it is lined with a microfleece fabric to protect the lenses from scratches. Another pocket is sized appropriately for carrying a tube of chapstick, while a third is a secure place to store your passport. There is even a pocket built to hold a small tablet, and another for your smartphone. The latter comes complete with a touch-friendly plastic window that allows you to interact with the device without having to take it out.
But the real hidden feature of the Storm Logic Vest is its ability to convert into a surprisingly comfortable travel pillow. It takes just a matter of seconds to pack it into yet another hidden pocket, creating a soft, cosy support for your head. When in pillow mode, the vest even comes equipped with two straps that use Velcro to hold it in place around your neck on a long flight.
Frequent travelers will find the Storm Logic Vest is an excellent piece of gear to have in their wardrobe. it is tough to beat the convenience, versatility, and comfort that it provides. It is also quite reasonably priced at $125, and available in both a men's and women's version.


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I have read hundreds of books of greek and foreign literature. Actually, I think I have read more literature than science in my life.Even though I have stopped buying CDs since 2005, I have 900 heavy metal ones. I estimate that I have listened to approximately 3 thousand full music albums and I keep going. I have seen too many movies/series and I have been to a theatre at least 100 times (my mother is a huge fan). And many more. In fact, especially till 5 years ago my life had been "immersed" in art.
The thing that I find funny now is that I used to have somehow the belief that this meant that I was educated enough; that I had knowledge. You know, when we read books we believe that we know things. If we tell others that we read or we are fans of art they automatically consider that we are very cultured… But hardly anyone ever takes the discussion further, on the kind of books we read.
When I first started learning about personal development, I had the belief that, as I stated above, I was very well-educated and I had much knowledge. I had read so many books and in general I had so much avocation with art that there wasn't any contradiction to that in my mind. However, things are not always as we consider them. I was surprised to notice that there wasn't hardly a thing that I read that was previously known to me. Literally everything I was learning in science about how the brain works, how people evolved, why they behave as they behave and many others were totally new to me. I was amazed by the new horizons that had been broaden in front of me… And not only it was new, but this time there were specific explanations about all the statements. So accurate groundings that I could never imagine reaching that level. This, of course, is mandatory because only a scientific institution cares about the quality of the arguments, everyone else is free to speak their mind without necessarily thinking much about it in a western democracy.
On the one hand it was disappointing to realize that I was in a much lower level than I was expecting from all this extensive artistic avocation I had been through. On the other hand it was relieving. At last I had access to information that other people never will, not because it is hidden but for other reasons on which I will elaborate later. If I had remained in the mistaken belief that my artistic knowledge was enough to help my life I would certainly had never made the progress I have made the last years. And this stability can happen in two ways. Either you don't even read any scientific finding ever because you feel already content enough or you read but without curiosity and open mindset. You read it with a predisposition that you already know all these so you actually never keep the valuable information. This is the alpha and the omega in any approach of new knowledge; you need to approach it as an ignorant and then evaluate it. The close mindsets approach new knowledge from a perspective that they are already aware of things and as a result they won't retain the new information.
But why am I telling you this? Am I somehow an anti-art guy? Certainly not and I will never be; this would be silly. I just want to make things clear about what I consider as the role of art. You know there are millions of people who read novels and thanks to the information they acquire they believe they are cultivating a stable worldview. They have read many books so automatically they have knowledge of their environment. They don't recognize that what they have been reading was just someone else's speculations. And this person, as every human being, has a very limited understanding of the environment. This is how the brain works, it's not a speculation this time. The world in our brains is a coherent world, much simpler than what really is. Our brains jump to conclusions in order to generate models and create the "fake" feelings of confidence about our understanding.
So, as I have written in many articles in here, it may sound sad but we personally aren't capable enough of a thorough understanding of the world. The brains don't have that capacity and we just make stories from the limited amount of information we have every time. The less information, the most probable our belief is mistaken but ironically the more confident we feel. Look at the link in the previous paragraph and plenty of articles in this blog. It is selfish to believe that you are able to explain everything. In fact this is a limitation about your progress. If you think like that, probably you want to avoid getting out of your comfort zone and you convince yourselves that understanding and experience will come as if by magic. It's a typical mentality of someone who thinks that they owe him but s/he has never provided anything to expect that return. I'm afraid in the majority of the cases life doesn't teach us itself as my mother used to say when I was a child.
Let's assume that your shoes have a problem and you need to fix them. Will you go to a basketball player or to a shoemaker? Of course the second, you'll go to the expert, to the one that has given more effort to know very well the field of his interest. In this universe humans are just a tiny fraction of it with huge amounts of information still waiting to be explored. This shows how selfish it is to believe that we have reached an understanding without even reading what the experts have to say.
So, as human beings, in order to find answers, the rational thing to do was to build effective feedback systems to test hypothesis by letting reality to speak for itself. This is the main idea of a scientific experiment. Any scientific institution must comply with these rules. The thing is that only the scientific institutions have that foundations. All the others don't have any. And in any blog like this one. If I want I can tell you that I believe that the sun is moving around the earth, I certainly won't go to prison for that; the western world has freedom of speech.
So on the one side we have science that tries to follow all these complicated feedback processes to come to conclusions and everyone else just makes guesses dependent on the limited human cognition. Even science itself recognises its limitations and is expecting further findings to validate the already existing. However is undoubtedly the best we can do till now.
I will explain to you how simple it is if you break it down. Let's say an artist cares about two things. The aesthetics of his/her creation and the accuracy of the content. At the same time a scientist cares only about the accuracy of his/her content. Who do you think will be more effective in the accuracy? Also, think about it, as follows: We have two men that spend five years of extensive training. The first training his feet and arms and the second only his arms. Who do you think will have strongest arms after five years?
I personally cannot consider a rational choice to avoid looking at the findings of the experts in any given field and just believe that I know better. I try to remind it to myself all the time and not to fall in the delusion of confidence.
When I talk about science I want to make clear that I don't talk about its findings as undeniable facts. Then it would be another religion… On the contrary I am talking about the scientific thinking. The mentality of criticizing the information we come across, always learning and evaluating every new finding on evolving our understanding. So, I don't mean any authority should be blindly followed but certainly should be taken first into account.
If an alien was coming from Mars and was reading all these would be surprised. He would be wondering why most people pick the amateurs instead of the professionals to get what they want in terms of their worldview? The answer would be easy for him if he had studied the foundations of human nature. As stated in Geoffrey Miller's The Mating Mind, it seems that Evolution favored beings that were able to intuitively understand their basic needs and act according to them but it didn't produce efficient communication systems that would make us able to share them. Rich communication systems were selected but it seems they are more entertaining than accurate.
The brain seems to work as a sexual ornament always with the tendency to impress and "win"the environment and not so much to describe the world realistically. Same thing happens when we receive a representation of the world from others. Our brains work like a tabloid that projects the news but never bothers to check their validity.These tabloids contain politics, religions, pseudoscience, urban myths and tribal myths. These ideological phenomena were named memes by Richard Dawkins and are virus-like ideas that evolved to cultural level by being memorable, easily transmitted and able to grab our attention.
This means that the brain was never meant to be a truth-seeking mechanism. Humans find reasoning and arguments tiring. It requires focus of our attention. We tend to decrease our energy spending so we subconsciously avoid them. That's why scientific classes in school are difficult for most children and that's one reason why most people don't watch documentaries or read scientific literature but prefer novels and movies.
I am sure you can attend a dancing presentation even drunk but most possibly you can't follow a scientific class even after a beer. The brain accepts an artistic presentation easily, it doesn't require much effort. When I read scientific papers I slow down maybe on 1/3 compared to how quickly I am reading novels. I have never been able to read 200 pages of a book with arguments continuously as I was constantly doing with literature.
Halo effect, mating mind theory and many other theories describe our irrational tendencies to subconsciously judge "the content of a book by its cover". We read pompous language and strange words and we become impressed that the content rocks, as well. We watch nice shoots in a film and we enjoy it even though this doesn't provide us with any useful substance. I intentionally put more saturation in my pictures on instagram because I have noticed they get more likes. Colours become more alive and thus impressive.
At the same time, according to my experience, most artists aren't even aware of the fundamentals of the human brain when building characters, for example. And do you know where this results? In art maintaining the social programming. When the artists haven't read what the real human tendencies seem to be, the concept in their minds is many times primarily socially influenced which means that their content will be corresponding. So they build a beautiful and influential work of art which in fact describes plenty of inaccuracies that unfortunately will be believed by the ones that will be emotionally influenced.
Allegory of the cave and Plato
And the last thing I want to state is that when I was only into arts, I was actually living in the Plato's cave. I was reading a lot due to my curiosity to learn and I was feeling satisfied that a better explanation cannot be found.
By the way Plato in The Republic had expressed some intuitive contradictions about art. First of all he believed that even though it tries to imitate life and ideas it cannot do it accurately. And secondly that due to the emotional responses it can trigger to humans' souls, it's extremely dangerous. Many of you, I believe have some opinions about the way Hollywood has shaped people. Here you can see how Movies, TV shows strongly shape how we view love.
If art is not accurate then what?
Artistic creations are first of all a great inheritance of humanity. They are a representation of the incredible potential of the creativity of the human brain. It's an impressive way to give a shape to mental constructs. Also, even though art lacks accuracy in general compared to science, numerous artists have existed with splendid intuitive judgements that presented ideas that science found many years later . Moreover, art may not always perfectly demonstrate how we are but it can certainly teach us how we should try to be. The ethics presented by an influential painter or director can be valuable lessons for all of us in order to create a concept of how we would like to be both as individuals or as a society. The emotional responses it can trigger to us are valuable experiences. With arts we can dream, move our imagination forward and travel mentally. The way artists present their creations can be useful to teachers and mentors, too. By learning from their aesthetics we can present our grounded contents in a more effective way. Lastly the huge neuroscientist Robert Sapolsky describes in LA Times the usefulness of Art in the improvement of Theory of Mind . Theory of mind is the ability to attribute mental states — beliefs, intents, desires, pretending, knowledge,etc. — to oneself and others and to understand that others have beliefs, desires, and intentions that are different from one's own.
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This is a repost of Will Smith as Hancock: Lacking Human Moments published first on Yahoo Voices Jul 16, 2008.
Will Smith's movie "Hancock" is a superhero flick that struck me as lackluster at best. There are a few moments toward the end that worked but overall it was just a movie trying to win an audience through special effects.
In the beginning we find John Hancock curled up on bench in Hollywood, California. He's clutching a bottle of booze much to the chagrin of a little kid urging him to go get the bad guys. This scene is wholly confusing and I found myself guessing that he was a well known bum with amazing powers. Sounds stupid huh? Well, I was 100% correct. In the first 2/3 of the movie we see Hancock go through rehab and do jail time. I kept hoping we'd get something to hold onto in terms of a moral, but it never came. I suppose one could justify that big chunk of the movie by saying it shows people should be responsible and stay in jail even when they have the superhero ability to break any brick wall down (or thick steel for that matter). I'm sorry but the morals here, which are always there in great super hero movies, are cloudy if not non-existent. This superhero movie had no morals and therefore slipped and fell most of the way through. Now, in the last 1/3 of the movie it recovered somewhat, at least in the morals department. We find out he has a wife he didn't know about and he does a few things to save her life. Without giving away too much of the plot, I will just say this moral of "selflessness" is presented in the most cryptic way it takes a movie reviewer to glean it, at least that is this movie reviewers opinion. If I were to ask one of my kids what the moral is of the scenes between Hancock and his wife I have a feeling I'd get a blank stare.
Should superhero movies be that complicated?
The second area the movie flopped in my opinion was the lack of human moments. Ironically, superhero movies are great because they reveal the humanity through the characters. Not only did these characters lack endearing human qualities, they seemed one dimensional, like a storyboard that was never fleshed out with human characteristics. I found the characters flat and built to serve only the grossly overdone violence that never stops from the first scene. This movie has tons of CGI effects that are neat to look at but unfortunately they don't carry the weight needed to become a great superhero movie like "the Hulk" or "Spiderman." I am a big Will Smith fan, but unfortunately, not even Will Smith can save this colossal train wreck.
Hancock will be a good rental for kids that want to see things get destroyed or by drunks that find identification in going to jail to sober up. For the rest of us working class heroes that need good movies to inspire and propel us to do great things, this movie will fall on empty ears and desperately-seeking-for-more than "Hancock," human eyes. Those eyes, in case the makers of Hancock are interested, want morals and human moments in movies, it's what keeps us coming back.


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We now offer online scheduling!!
There is a bit of an issue with the code for the scheduler, but the book now button is showing up at the bottom left of the website. You can find it on the home page, or on the schedule page. It is there though, and we are working to resolve the 'placement' issue.
Groupon customers can access online scheduling off of their groupon confirmation page, OR everyone (Groupon or not) can just come here! There is a book now button on the schedule page as well as on our home page.
Online scheduling is available for everyone regardless of Groupon status. Whether you had a Groupon, finished using it, and are now onto regular classes, or if you are just discovering our classes and want to test them out, sign up and come!
You can schedule, cancel, read class descriptions, get our address, and more all on the scheduler.
We look forward to seeing you all soon!


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When we were kids, it was pretty much the cardinal rule not to punch the kid who wore glasses. It was just wrong. It was crossing a line.
At the end of February, social media consultant Sarah Slocum was allegedly attacked in a bar in San Francisco for wearing glasses, her Google Glass, and allegedly filming bar patrons without their consent. In a more recent attack on April 11, San Francisco journalist Kyle Russell had his pair viciously stolen right off his face by a woman who yelled, "Glass!" and then fled, smashing the device on the ground as Russell pursued.
There is just something about Glass that makes people uncomfortable. Uncomfortable enough to spur a barrage of online rants about punching Glass wearers, hate/joke blogging, satirical skits, and the creation of anti-Glass groups like Stop The Cyborgs.
A Google Image search for Glass users brings up photos of happy or ultra-cool, seemingly all-knowing, cybernetic elite wearing their $1500 glasses. Maybe that's partly why there's been a recent string of Glass-related assaults. Do their privileged little faces make you want to punch them? I didn't even have to click on the image of one so-called "Glasshole" donning his pair in the shower to begin understanding why the rest of us, who are still wandering around with a smartphone in one hand, might want to use the free one to punch a Glass wearer in the face.
It is abnormal to want to punch a stranger in the face and at the same time not understand what's offensive about this new wearable technology. A Google spokesperson stated on Monday after the most recent attack, "Targeting anyone for a crime because of what they wear is wrong." Besides, the people themselves seem nice enough, maybe even overly friendly. Every Glass Explorer (yes, the lucky owners are called "Explorers") I talked to was incredibly warm and open and very eager to talk about their new toy. So I figured it couldn't be the people behind the glasses that the public hates on so hard. It had to be the glasses themselves.
But what is it exactly about Glass that is distasteful enough to incite property damage, theft, and assault? These days, it seems pretty hard to find any technology that isn't being embraced, especially if it's usable as a social deterrent.
It seems harder still to imagine anybody wanting to knock you out for wearing a pair when you check out their PCMag's review. They compare wearing the glasses in public to "having a cute dog." People are bound to walk up, touch, ask questions, and talk about them. This is because Glass doesn't exactly look like your everyday spectacles. They're more like something out of Terminator or Star Trek, with a distinct futuristic flavour in their streamlined design.
However, if you wear prescription glasses, you have to wear Glass overtop of them, which is nearly impossible to do. And since a standard pair goes for $1500 plus tax, they're a little out of range for your average Joe. An extra $225 could get you a more "normal" looking version of the current Glass, but they still look completely different from regular glasses.
You never see people walking up to people with cute dogs in the park and punching them out for it – not even those who keep their dogs in purses or dress them up in tiny degrading outfits. Or at least I hope not. Is this the "augmented reality" that Google promised? A bizarre world where random civilians, driven mad by perpetual surveillance and the wares of Silicon Valley, have witnessed one too many selfies, read one too many soul-sucking status updates, and tweeted out hard enough to take to the streets, unleashing their frustrations on some poor nerdy unsuspecting victim who could do all three of these tasks with no hands?
Experiences of the early adopters
In what seems to have been some excellent foresight, Google's Glass Explorers website lays out some pretty clear guidelines about the dos and don'ts of wearing their product. They warn users about the dangers of "glassing out" or "staring off into the prism" for too long, about sticking out in public, about using Glass in inappropriate spaces, and about being a "Glasshole" (yes, Google themselves have adopted the word). "Respect others and if they have questions about Glass don't get snappy, be polite and explain what Glass does," the website suggests. "Breaking the rules or being rude will not get businesses excited about Glass and will ruin it for other Explorers."
"Of course Explorers stand out," says H. David Shaw, a Glass Explorer who lives in Karachi, Pakistan, and has had his Glass since last November. "They all have something new and it is literally on their face."
Not only is it something new, it also comes with a very limited edition feel of exclusivity. These puppies went on the market on April 15th for one day only. There were no reports of website crashes, Internet glut, or stock running out except for the evidently more popular white-framed model.
Part of this Glass-knocking, paranoia, and nerd-bashing relates to a lack of understanding about what Glass even is. There are many misconceptions about what Explorers are using them for. One of the most common concerns about Glass is that the wearer might be recording everything you do in their presence without consent. According to the PCMag review, this is mostly a baseless fear: if a wearer is recording you, it's obvious because they will be looking above your face at their screen, and there will be a slight eerie glow emanating from behind the lenses.
One Explorer, Oliver Madsen of Fairbanks, Alaska, suggested that adding a red recording light onto the front of the camera so others could know when it is on could alleviate concerns about privacy. Madsen doesn't mind that Glass is still in developmental stages, saying "The main appeal for me was the chance to get something before it was ready for the world, to have a little bit of the future."
"One app I really like and am excited to see the future of is called Worldlense," Madsen continues. "It analyzes an image of text in one language through the camera, then replaces the text with the same words, translated into a different language. It is far from perfect now, but I think it's gonna get better."
Shaw is similarly excited to see how Glass will evolve. "I'm not a techie or a technophile, I just love tech toys," he says. "To be on the cutting edge of a new technology is great. Glass is handy. It allows me to do a lot of things while keeping my eyes front rather than being stuck in my device. But we are all still just beta testers, some of us longer than others. There are a lot of improvements needed, but it is still a really cool device."
Some pretty standard functions use voice controls to do things like search on Google, take pictures or video, navigate maps, send emails and text messages, and make phone calls. IFTTT, Google Now, news, and Twitter were listed by users as some of their favourite apps. There aren't many apps available through Google yet but they plan to make more.
If Explorers can't wait to dive into their new augmented reality, there are some pretty cool apps and mods coming out of the Glass-hacking and developer community. Toronto hosted the Glass Hackathon on April 25-27, 2013, organized by independent game developer and Google Glass Pioneer Macy Kuang.
The goal of the event is to make the development process faster and more efficient by bringing together developers, designers, and Explorers to dream up and bring to life wild new Glass apps.
Some of the more exciting (and maybe terrifying, depending on how you look at it) potentials for Glass are being explored by innovators outside of Google. In the hacking community, developers are working on apps that can show you entire building floor plans, do facial recognition, or measure the size of your date's pupils to see how attracted to you they are. A scary possibility was recently pointed out by two such developers, graduate researchers Mike Lady and Kim Paterson of California Polytechnic San Luis Obispo. These students built the prototype for the stealth sousveillance spyware that all the seemingly paranoid haters of Google Glass have been freaking out about: a program that takes a photo every ten seconds when Glass's display is off, uploading the images to a remote server without the wearer's knowledge, basically hacking their point of view. The only thing standing in the way of this technology being used is mere policy. There are no real security provisions against it.
In the meantime, maybe you're not ready to have your pupils measured by a cyborg the next time you're on a blind date, but that doesn't mean you necessarily have to deliver a roundhouse to someone's face. To bring back another one of those important life lessons they teach you in grade school: don't hate the player, hate the game.
The Google Glass is a product of a global revolution towards the creation of innovative technologies. However, citizens of the world may want to take note of their potentially discourteous behaviour towards Glass users and the technology itself. A Google Image search for Glass users brings up photos of happy or ultra-cool, seemingly all-knowing, cybernetic elite wearing their $1500 glasses. Maybe that's partly why there's been a recent string of Glass-related assaults. Do their privileged little faces make you want to punch them? I didn't even have to click on the image of one so-called "Glasshole" donning his pair in the shower to begin understanding why the rest of us, who are still wandering around with a smartphone in one hand, might want to use the free one to punch a Glass wearer in the face.
- Want This Now267
- Maybe182
- This Is The Future220
- Pipedream238


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MAN HURT FLYING KITE FROM MOVING VEHICLE: RIVERSIDE . (AP) — A 22-year-old man was critically hurt in Southern California when he fell off the trunk of a car while attempting to fly a kite from the moving vehicle.
The Riverside Press Enterprise says the man struck his head on the pavement in the fall Sunday night in Moreno Valley, which is in Riverside County.
Sheriff's officials say the white Nissan Maxima was moving slowly when the man fell off.
Paramedics treated the man at the scene and he was taken to a hospital, where he was in critical condition.
Authorities say the car's driver wasn't injured and alcohol was not involved.
72-YEAR-OLD GARDENER DROWNS IN LA POOL: LOS ANGELES (AP) — Authorities say a 72-year-old gardener has drowned in the pool of a San Fernando Valley home where he was working.
City News Service says the man had a leaf blower strapped to his back when he was pulled from the water Tuesday night in the Shadow Hills neighborhood.
Police Lt. Brian Bixler says the homeowner came home in the evening and noticed the gardener's truck was still parked at the residence, even though he usually finishes up around midday.
The homeowner checked with neighbors and then called the gardener's family to the scene when the man could not be found.
He was eventually discovered in the pool by one of the neighbors.
The man, whose name was not released, was pronounced dead at the scene.
SACRAMENTO TO PAY $800K IN HOMELESS CAMP LAWSUIT: SACRAMENTO (AP) — The city of Sacramento has been ordered to pay nearly $800,000 in fees to attorneys who represented homeless people who lost their belongings during raids of illegal tent camps.
The Sacramento Bee (http://bit.ly/ZZjynv) reports the order was issued Friday by U.S. District Judge Morrison England, who reduced the amount from the $1.8 million the lawyers had requested.
The attorneys represented homeless people who filed a class-action lawsuit charging police with violating their constitutional rights when they failed to protect their belongings during the raids starting in 2005.
The city has already made $796,000 in payments to people who lost personal property, including tents, lanterns and prescription medications.
In response to the lawsuit, the city and county of Sacramento have agreed to new rules for handling property seized during raids.
VIRTUAL TRAFFIC COURT COMING TO FRESNO COUNTY: FRESNO (AP) — Rural residents will no longer have to drive all the way to the city to take care of a traffic ticket when Fresno County opens its new virtual traffic court.
Sstarting next week, traffic judges in downtown Fresno will use video-conferencing to hold court at two remote locations. It's a technological innovation that court officials are billing as the first of its kind in California and possibly the nation.
The newspaper says drivers who are cited for traffic violations 15 miles or more from Fresno's downtown traffic court will have the option of disputing their tickets in virtual courtrooms in either Coalinga or Mendota. The defendants appear before a judge on a video screen.
Residents of rural areas were stuck with a long commute when seven satellite courts were closed last summer.
SMALL QUAKES SHAKE REMOTE SOCAL AREA: LA QUINTA (AP) — Several small earthquakes have shaken a remote area of Southern California.
The U.S. Geological Survey says the tremors over about a half-hour span late Wednesday morning had magnitudes of 3.4, 3.7 and 2.6.
All were centered a little more than a dozen miles southwest of La Quinta in Riverside County.
The area is mostly rugged wilderness.


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Dill's Cemetery TributesUpdated for 2019! We now offer a round-the-year program that allows you the ease of pre-ordering your cemetery tributes. Click the link below and return your form with payment to the store, and we will do the rest!Dill's Cemetery Program Form
Our cemetery and grave arrangements have many variables: - style/design - container - size - fresh/silk - pre-made/custom designsMost of our cemetery tributes are 100% custom designs. This means, we can work with your budget and your requests to make the ideal arrangements for your loved one's gravesite.Below are examples of cemetery flowers, bouquets, and tributes:(Note: These are only examples and may not be available currently) - Graveblanket or Grave Blanket: a covering made of assorted Christmas greens that is placed directly on the grave during the winter months. Typically available the month of December. - Starting at $64.99, decorated. <-- Undecorated Grave Blanket (standard decorations include poinsettias, pinecones, and ornaments) - Cemetery Can/Cone: fresh or silk flowers arranged in a cone or can to be placed at the gravesite where no vase or container is present. - Starting at $24.99 <-- Patriotic Cemetery Can - Cemetery Bush: fresh or silk flowers arranged in a hand-tied fashion without a cone, can, or means of display; to be placed in an existing cemetery vase, urn, or container at the gravesite. - Starting at $14.99 <-- Cemetery Bush of hot pink roses - Tombstone Saddle: a cage-like bouquet that is created on a wire/metal frame that clamps over the top of a tombstone; Most often done in silk or artificial flowers. - Starting at $64.99 <-- Tombstone Saddle in summer colors - Cemetery Cross: white, styrofoam cross decorated with ribbon and silk or artificial flowers. Most common use at Easter but available year round. - Starting at $14.99 <-- Dill's Easter Cemetery Crosses (small: top row; large: bottom row) - Cemetery Wreath: round wreath (grapevine or Christmas greens) decorated with artificial flowers; - Christmas designs start at $34.99; Other designs available from $39.99 and up. <-- Dill's Christmas Cemetery Wreath
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The V2 Roll Kit is the cousin to Str8's signature Roll Kit. The V2 is the perfect kit for both paper rollers and cone stuffers. The divider slots were perfected in design to organize all of the essentials into one lockable box and has enough extra storage to store your hand pipes and grinders up to 63mm. Most importantly, the included STR8 Rolling Tray magnetizes to the inside lid.
STR8 Roll Kit V2 Includes:
8? STR8 Roll Case
STR8 Rolling Tray
STR8 Mylar Bag
STR8 Clipper lighter w/ removable flint
Pop Top x 2
Cone Tube x 2
J-Tube x 2


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Coffee and hypertension: no risk but beneficial effects, according to a new research of the University of Naples
Coffee comes out again victorious not only for its extraordinary taste, but also for the beneficial effects on human health.
Coffee comes out again victorious not only for its extraordinary taste, but also for the beneficial effects on human health.
Besides being a fabulous and an unmissable drink for an incalculable number of people, coffee is for many a way of living.
Wines, local agricultural products, typical regional dishes... everything that Italy produces related to food and wine field is by definition unique, traced, regulated and (hopefully) protected by well-defined laws.
The coffee export industry can definitely be satisfied in the last year: the latest figures from the International Coffee Organization show an unprecedented growth.
Eight hundred thousand automatic vending machines and about three billion coffee cups dispensed annually: these are the impressive numbers that make Italy the leading country in Europe for automatic beverage and food machines.
Water is a basic ingredient for coffee, since it is the most present element in the beverage and it allows its extraction from the powder.
According to some researches, about 1.6 billion cups of coffee are drunk every day all over the world: it is the most consumed drink after water!
Those who are passionate about quality coffee can only agree with those who criticize the current situation in many Italian restaurants.
Once again, science has confirmed what consumers have known for a long time: coffee is good for those who drink it.
Many consumers and experts over time have been questioning about the possible harmfulness effects of decaffeinated coffee, which is almost entirely decaffeinated by industrial processes.
Via Piemonte 5/11
24052 Azzano S. Paolo (BG) - ITALY
Tel. +39 035 688111
Fax +39 035 320149


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La Aroma De Cuba
The new and improved La Aroma de Cuba! Now handmade in Nicaragua by Pepin Garcia, the new LADC features gorgeous chocolaty Connecticut Broadleaf wrappers and a rich, spicy blend of Nicarguan tobaccos. For the past 18 months, we have been working very closely with the Garcia family to bring this new cigar to fruition. We believe we have successfully improved the flavor and quality of the cigar without compromising the richness and spiciness that loyal LADC smokers have relished for years.
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- La Aroma De Cuba
Starting at $124.20
- La Aroma De Cuba Edicion Especial
Starting at $168.75
- La Aroma De Cuba Mi Amor
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- La Aroma De Cuba Mi Amor Reserva
Starting at $199.80
- La Aroma de Cuba Noblesse
Starting at $302.40Out of stock
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This is a letter about funny things. A random collection perhaps, but some readers may discern a veritable fountain of flummery, deep and wide, that flows through them all.
Funny thing about that young bigot slaughtering all those people away yonder in a Charleston church just a few weeks ago. Suddenly there's a surge of patriotism right here in Hot Springs. Grown men and women are waving flags, honking horns, and revving engines. Loud and proud they are once a week, driving by an 80-year old statue dedicated to the memory of a 150-year old war.
Funny thing about that war. Lots of Americans were butchered on the altar of states' rights. Seems like the most important state right was to keep right on allowing human beings to be bought and sold like cattle and farm implements.
Funny thing about that statue, too. The Confederate battle flag is carved on its northern side, presumably to taunt visiting Yankees. Another is hoisted high above where it flutters only when passing winds, well, pass. Mostly it just hangs there, limp and forlorn. (Note to readers: since this was first written, a bright new flag has replaced the old one.)
Another funny thing is where the statue is located. It's just north of where the Como Hotel used to be, on a patch of land once called Como Triangle. And it was right there in 1922, about twelve years before the statue was erected in loving memory by the United Daughters of the Confederacy, that 28 year-old "negro" Gilbert Harris was politely escorted from the city jail and hanged by a mob of 500 "very orderly" men. Nice of them, it was, to be so very orderly. You can still read all about it at the public library, in the archives of the Hot Springs New Era.
Funny thing about that newspaper. The word "negro" got mentioned an awful lot that day. Maybe, just maybe, being a "negro" was what helped that very orderly mob decide to forgo all those fussy things like a court trial. Something to think about the next time you see grown men and women waving flags, honking horns, and revving their engines.
Another funny thing about that newspaper. The next day all was forgotten. There was no mention of the previous day's violence. At the top of page one, there was a large ad by the Hot Springs National Park Klan No. 7, bragging about their $50 donation to the Boy's Work Fund. "The Ku Klux Klan stands for better homes and a better nation and anything for the betterment of the boys will make our homes and our nation a better place in which to live."
Funny thing about being a "negro" in America. That heritage we're all so proud about right now is all because we used to think somebody else's pedigree wasn't near as good as ours. Some of us still think that way. Once upon a time, having the word "negro" show up in your pedigree could get you sent back to your Southern slave masters. In 1922 it got a man lynched. For the last century and a half, it has kept people from voting, and relegated them to second-class schools and second-class jobs and second-class justice.
Deep and wide, deep and wide, there's a fountain flowing deep and wide.
Monsieur d'Nalgar
Hot Springs, Arkansas
PS – Funny thing about human pedigrees. They're mostly just made up. There's a fascist impulse that still rages in far too many of us. It whispers that my race, my ethnicity, my religion, my skin color, my civilization, my heritage – they're all superior to yours. Surrender to that impulse has invented pedigrees that justified centuries of slavery and cleansed the American landscape of its first peoples. The Germans used theirs as an excuse to exterminate millions of Jews. Funny thing is, now even Israel peddles imaginary pedigrees to perpetuate its brutal occupation of Palestine. Several years ago, at a Jerusalem rally simulcast here in Hot Springs (organized by our local tea party), I saw Glenn Beck weep crocodile tears as Israel's frothy prime minister, always itching for Armageddon, revealed an ancient artifact inscribed with "Netanyahu." The message was hardly subtle. Here was unimpeachable evidence of an anointed pedigree reaching all the way back to the bloody Old Testament's glory days.
Funny thing about facts, though. Bibi's daddy was one Benzion Mileikowsky. From Warsaw. His "chosen people" pedigree points to Poland, not the Promised Land. Old Benzion lived most of his life right here in the USA. His father Nathan was born in what is today known as Belarus. Awkward facts all, and yet our obeisant Congress still fawns over Netanyahu so much it's just plain embarrassing. For them, "Bomb Iran" Bibi is their latter-day Joshua, their long-lost machismo reborn in the nick of time to smite today's philistines. Huzzah, huzzah! Facts be damned, preach our hyperbolic, gilded evangelists and purchased politicians, we must forever stand with Israel even if it is an illegal colonial outpost and the Middle East's schoolyard bully, a fascist, racist, apartheid blot on the blood-soaked Holy Land (as it is called by ignorant fundamentalists who have turned the place into a false idol and who lust after an ultimate clash of civilizations).
So stand with Israel if you must, and wave your flags if you must. These, too, are funny things. Deep and wide, deep and wide, there's a fountain flowing deep and wide.


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A straight-talking, and visually enticing, student campaign is helping to promote student enterprise and entrepreneurship at City University London.
City University London attracts some of the country's most innovative minds and is located on the doorstep of Tech City, Europe's leading cluster for tech startups. Its diverse culture and progressive outlook provides the inspiration and nesting ground for entrepreneurial spirits.
Keen to demystify the stereotypes exampled by Dragons Den and The Apprentice, City University created CityStarters, which aims to challenge students' perceptions about what being an 'entrepreneur' really means.
Fabrik was briefed to create a visual identity for CityStarters and its supporting initiatives.
Adopting a Tech City startup-inspired design was important in order to appeal to both students and actual startups. Since many business ideas have been born from a scribble on a Post-it note (or equivalent), an identity combining graphics, stylised illustrations and photography was developed. Supported by a straight-talking tone of voice, CityStarters is fun, engaging, and makes enterprise accessible to all.
The creation of dedicated materials has enabled all streams of enterprise-related activities to be promoted, while the full range of initiatives is available through a branded area on the CityUniversity website.
Fabrik took our fledgling idea and brought it to life through a distinctive campaign identity that has captured the essence of the initiative and led to much interest. The deadlines were tight, but that was never a problem. A flexible, creative and super-well organised group of people to work with.
Enterprise Education Manager
City University London
If you're interested in starting a project together, we'd like to hear from you. Alternatively, if you would just like to know when we have something meaningful to say (or show) let us have your email address and we'll drop you a line. In return, we promise not to sell or rent your details, or send you junk!


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Self-catered apartment |
Appartment of 38m2 located in Schuss residence, with lift, ski room, terrace and balcony
Slalom area, 30m from ski slopes
Appartment of 38m2 located in Schuss residence, with lift, ski room, terrace and balcony
Slalom area, 30m from ski slopes
The apartment 2 rooms plus cabin for 8 people (around 35m² with terrace and balcony) has a cabin with two bunk beds, a bedroom with a double bed, two bunk beds in the corridor, and a living room with 2 single sofa beds. The kitchenette is fully equipped: electric cooktop, fridge, microwave and dishwasher. Toilets are separated from the bathroom, which has bathtub and washbasin.
The Schuss is a small residence which has various apartments. The residence is situated less than 30 meters from the slopes and right next to the daycare for children. The residence is located on Place Peclet, one of quietest places of the Val Thorens resort, close to the commercial gallery. The local market which takes place Tuesday and Thursday is also within walking distance.
In each apartment there is a TV. Bed linen and towels can be rented in the residence (bed linens for a single bed 9€; bed linens for a double bed 15€ and the towels kit for 7€ that includes one big bath towel, one towel and a bath mat). You have a lift and an individual ski locker. Access WIFI paying throughout the residence. Residence Le Schuss is located near the commercial Gallery of Peclet. You will find news, supermarket, Bank, bakery, skis shop, pubs, restaurants and even a pharmacy. At few steps from the residence is Peclet square, where takes place the regional product market twice a week.
A charged Wifi connexion is available (subject to network coverage).
One parking space which is already included in the price of the rent is available in the basement of the residence Le Schuss.
On the day of arrival the reception is open from 17h till 20h where you will get the keys. Departure is on Saturday morning before 10am. Local residence taxes of 0,9€ per day per adult will be collected directly by the reception on the day of arrival as well as the deposit. The deposit will be entirely returned on the day of departure is the apartment is not damaged.


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New Snapcodes Unlock Special Simpsons-Themed Filters Starting November 23
Longest-Running Marathon in TV History Features 600 Episodes of The Simpsons in Chronological Order Beginning Thanksgiving Day, November 24 at 12 PM ET/PT and Concluding December 7 at 12 AM ET/PT
LOS ANGELES, November 22, 2016 -The Simpsons 600 Marathon will celebrate its record-setting run by giving fans new and exclusive The Simpsons-themed Snapchat filters beginning Wednesday, November 23 and throughout the 13-day telecast. The 27-season, 600-episode, 300-hour The Simpsons marathon kicks off Thursday, November 24 at 12:00 PM ET/PT and concludes on Wednesday, December 7 at 12:00 AM ET/PT on FXX.
Beginning November 23, fans will get a chance to use three different Thanksgiving-themed Simpsons filters throughout the day. Then, starting on Thanksgiving when the Simpsons marathon begins, Snapcodes will appear during commercial breaks and across all of FXX's Simpsons social channels will unlock exclusive The Simpsons 600 Marathon-themed custom filters, which allow users to share that moment with a friend or post it to their Snapchat Story. Featuring seven filters in total, this partnership between FX Networks and Snapchat marks the first time "Snap-to-Unlock" filters have been used across a multi-day television event.
The Simpsons 600 Marathon, which will air every episode of The Simpsons' 27 seasons in consecutive order, will become the longest-running marathon in television history, surpassing the previous record holder, FXX's 552-episode, 12-day Simpsons marathon, which ran from August 21, 2014 at 10:00 AM to September 1 at midnight. That marathon propelled the nascent FXX to cable's #1-ranked network primetime in Adults 18-49 and Adults 18-34 for 12 consecutive days.
FXX is the cable network home for all seasons of The Simpsons, excluding seasons airing in their first run on FOX. FX Networks' app, FXNOW, is the exclusive non-linear home for all seasons of The Simpsons, excluding seasons airing in their first run on FOX.
FXX's "Simpsons World" is the ultimate Simpsons digital experience featuring enriched branded content through SimpsonsWorld.com and handheld/connected devices via FXNOW, the authenticated multi-network on-demand video service supporting FX, FXX and FXM.
The longest-running scripted show in television history, THE SIMPSONS exploded into a cultural phenomenon in 1990 and has remained one of the most groundbreaking and innovative entertainment franchises, recognizable throughout the world. Currently airing its record-annihilating 28th season, THE SIMPSONS has won 32 Emmy Awards, 34 Annie Awards, a 2016 People's Choice Award, was the first animated series to win a Peabody Award, and was nominated for an Academy Award in 2012 for the theatrical short "The Longest Daycare." The Simpsons Movie was a hit feature film, their mega-attraction The Simpsons Ride at Universal Studios has received historic expansion updates with the addition of 'Springfield' and the show was honored with a Star on The Hollywood Walk of Fame in 2000. It has been named the "Best Show of the 20th Century" by Time Magazine, called the "Greatest American Sitcom" by Entertainment Weekly in 2013, and declared "The Best TV Show Ever" in 2016 by Vulture.com.
THE SIMPSONS is a Gracie Films Production in association with 20th Century Fox Television. James L. Brooks, Matt Groening, and Al Jean are the Executive Producers. The Gracie Films Worldwide Brand Division develops and produces the licensed content for the series.
FXX is the newest basic cable entertainment network from FX Networks which launched on September 2, 2013. Geared towards a young adult audience, the schedule features original series, movies, and acquired series. The channel is anchored by the acclaimed hit comedies It's Always Sunny in Philadelphia, You're the Worst and Man Seeking Woman. FXX is also the exclusive cable home to The Simpsons, the longest-running comedy in TV history, and acquired hit series such as In Living Color, Mad About You and Parks and Recreation. FXX is carried in 82 million homes. FXX and its sister channels FX and FXM comprise FX Networks, a business unit of 21 Century Fox.
Over 150 million people use Snapchat every day (60M in US and Canada) to Snap with family and friends, watch their Stories, and explore content from top publishers and around the world. Snapchatters watch over 10 billion videos per day, up 350%+ in the last year. On any given day, Snapchat reaches 41% of all 18 to 34-year-olds in the U.S. (Nielsen research commissioned by Snapchat).
Twitter: @everysimpsons
Facebook: Facebook.com/everysimpsonsever


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Renew300: Advancing Renewable Energy in Affordable Housing
HUD's Renew300 Initiative aims to help federally assisted housing save money through the installation of onsite or community-based renewable energy technology. Federally assisted housing includes HUD's rental housing portfolio (Public Housing, Multifamily Assisted) and USDA's Rural Development Multifamily Programs, as well as rental housing supported through the Low Income Housing Tax Credit (LIHTC).
The 300 MW target aims to make use of millions of federally subsidized roofs with on-site or community generation potential. Supported renewable energy technologies include Solar PV and Solar thermal, wind, geothermal, small biomass, combined heat and power, and small hydro projects.
Make a Commitment
HUD encourages organizations to make a public commitment toward the Federal Renewable Energy Target. Organizations may establish their own goals for how much renewable energy technology to install. Optional technical assistance is available for organizations that have made a commitment toward the federal renewable energy target in order to help advance solar deployment and other on-site renewable energy installations in affordable housing.
Renewable Energy Resources
Technical resources, policy guidance, case studies, and other resources are provided to assist organizations with increasing organizational capacity and installing renewable energy on federally assisted housing.
View renewable energy resources.
Renewable Energy News & Announcements
New Solar Site Selection Guide and Tool Added to Renew300 Renewable Energy Resources
Date Posted: October 13, 2017
Materials Posted: Solar Project Development for Public Housing Authorities Webinar
Date Posted: June 1, 2017
Materials Posted: RENEW300: Advancing Renewable Energy at HUD-Assisted Housing Workshop
Date Posted: June 23, 2016
Fact Sheet: President Obama Announces New Actions to Bring Renewable Energy and Energy Efficiency to Households Across the Country
Date Posted: August 24, 2015
Fact Sheet: Administration Announces New Initiative to Increase Solar Access for All Americans
Date Posted: July 7, 2015
Administration and California Partner to Drive Renewable Energy and Energy Efficiency in Multifamily Housing
Date Posted: January 29, 2015
Astrum Solar DC Ribbon Cutting with HUD Secretary Castro
Date Posted: September 18, 2014
HUDdle Blog: A solar future, today
Date Posted: September 18, 2014
HUD Announces New Renewable Energy Partnerships
Date Posted: May 9, 2014
President Obama Announces Commitments and Executive Actions to Advance Solar Deployment and Energy Efficiency
Date Posted: May 9, 2014
Strengthening Local Partnerships to Advance Solar Energy in Affordable Housing
Date Posted: April 18, 2014


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Budget and Planning Forms
Budget Transfers
Budget transfers are the mechanism used to modify appropriations identified in the approved Redbook budget. The Redbook budget reflects the approved spending authority for the various funds and department program codes at UW Oshkosh. Budget transfers are governed by UW System.
The following procedures are for processing budget transfers:
- Budget transfers are only processed for General Program Revenue (GPR) Funds
- The individual/department initiating the budget transfer request should prepare the request using the Budget and Transfer Form.
- The request should be approved by the account manager and sent to Budget Planning and Development – Dempsey 236.
- Budget staff will review and process the budget transfer and post it to the Peoplesoft Shared Financial System.
- Once the budget transfer is done you will see it reflected on your account in WISER.
Cost Recovery Program (CRP) General
Cost Recovery Program (CRP) Short Term - UNDER CONSTRUCTION - LINKS PROVIDED SOON!
- Short Term CRP Request Process
- Short Term CRP Procedures
- Short Term CRP Narrative Proposal
- Short Term CRP Budget Workbook


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Welcome to the Class of 1985. We'd love to hear from you. Please take a few moments and share your news with classmates.
For question or to get involved in class activities, please contact Ashley Nemer '10, '12G at (207) 581-1144.
HOMECOMING WEEKEND 2019 – October 25 – 27
Events include:
- Tours of new and renovated facilities on campus
- Welcome Home Reception at Buchanan Alumni House
- Alumni Village Tailgating Tent
- Alumni Association Craft Fair
- UMaine Football vs. William & Mary
- & More