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Effective on October 21st of this year, the Federal Trade Commission (FTC) issued a new final rule that is intended to better combat ​“fake” reviews and testimonials by prohibiting the sale or purchase of “fake reviews” as well as granting the agency the opportunity to seek civil penalties against ​willful violators. The FTC made only […]

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In 2010, Melanie Reid fell off a horse and was paralyzed below the shoulders.

“You think, ‘I am where I am; nothing’s going to change,’ ” she said, but many years after her accident, she participated in a medical trial of a new, noninvasive rehabilitative device that can deliver more electrical stimulation than similar devices without harming the user. For Reid, use of the device has led to small improvements in her ability to use her hands, and meaningful changes to her daily life.

“Everyone thinks with spinal injury all you want to do is be able to walk again, but if you’re a tetraplegic or quadriplegic, what matters most is working hands,” said Reid, a columnist for The Times, as part of a press briefing. “There’s no miracles in spinal injury, but tiny gains can be life-changing.”

For the study, Reid used a new noninvasive therapeutic device produced by Onward Medical. The device, ARC-EX (“EX” indicating “external”), uses electrodes placed along the spine near the site of injury—in the case of quadriplegia, the neck—to promote nerve activity and growth during physical-therapy exercises. The goal is to not only increase motor function while the device is attached and operating, but the long-term effectiveness of rehabilitation drills. A study focused on arm and hand abilities in patients with quadriplegia was published 20 May in Nature Medicine.

Researchers have been investigating electrical stimulation as a treatment for spinal cord injury for roughly 40 years, but “one of the innovations in this system is using a very high-frequency waveform,” said coauthor Chet Moritz, a neurotechnologist at the University of Washington. The ARC-EX uses a 10-kilohertz carrier frequency overlay, which researchers think may numb the skin beneath the electrode, allowing patients to tolerate five times as much amperage as from similar exploratory devices. For Reid, this manifested as a noticeable “buzz,” which felt strange, but not painful.

The study included 60 participants across 14 sites around the world. Each participant undertook two months of standard physical therapy, followed by two months of therapy combined with the ARC-EX. Although aspects of treatment such as electrode placement were fairly standardized, the current amplitude was personalized to each patient, and sometimes individual exercises, said Moritz.

The ARC-EX uses a 10-kilohertz current to provider stronger stimulation for people with spinal cord injuries.

Over 70 percent of patients showed an increase in at least one measurement of both strength and function between standard therapy and ARC-EX therapy. These changes also meant that 87 percent of study participants noted some improvement in quality of life in a followup questionnaire. No major safety concerns tied to the device or rehabilitation process were reported.

Onward will seek approval from the U.S. Food and Drug Administration for the device by the end of 2024, said study coauthor Grégoire Courtine, a neuroscientist and cofounder of Onward Medical. Onward is also working on an implantable spinal stimulator called ARC-IM; other prosthetic approaches, such as robotic exoskeletons, are being investigated elsewhere. ARC-EX was presented as a potentially important cost-accessible, noninvasive treatment option, especially in the critical window for recovery a year or so after a spinal cord injury. However, the price to insurers or patients of a commercial version is still subject to negotiation.

The World Health Organization says there are over 15 million people with spinal cord injuries. Moritz estimates that around 90 percent of patients, even many with no movement in their hands, could benefit from the new therapy.

Dimitry Sayenko, who studies spinal cord injury recovery at Houston Methodist and was not involved in the study, praised the relatively large sample size and clear concern for patient safety. But he stresses that the mechanisms underlying spinal stimulation are not well understood. “So far it’s literally plug and play,” said Sayenko. “We don’t understand what’s happening under the electrodes for sure—we can only indirectly assume or speculate.”

The new study supports the idea that noninvasive spinal cord stimulation can provide some benefit to some people but was not designed to help predict who will benefit, precisely how people will benefit, or how to optimize care. The study authors acknowledged the limited scope and need for further research, which might help turn currently “tiny gains” into what Sayenko calls “larger, more dramatic, robust effects.”

Top challenges impacting specialty pharmacy outcomes, and how health systems may achieve efficiencies and enhance performance for optimal outcomes.

The post An Integrated Approach to Optimizing Specialty Pharmacy and Accelerating Performance appeared first on MedCity News.

This paper begins with a look at both optimization modeling and discrete-event simulation modeling, and explores how they can most effectively work together to create additional analytic value. It then considers two examples of a combined optimization and simulation approach and discusses the resulting benefits.

David Duchovny and Gillian Anderson didn't speak to each other for "weeks at a time" when they worked on The X Files. The 64-year-old actor and Gillian, 56, enjoyed huge success with the iconic sci-fi series — but the duo actually had a turbulent relationship for many years. David said on the Fail Better podcast: "There was a long time, working on the show, where we were just not even dealing with one another off-camera. And there was a lot of tension. Which didn't matter, apparently, for the work cause we're both f****** crazy, I guess. We could just go out there and do what we needed to do." Gillian was amazed that they achieved so much success while their off-screen relationship was so tense.

Sep 28, 2022

As the best documented major crisis in history, in substantial part because Kennedy secretly taped the deliberations in which he and his closest advisers were weighing choices they knew could lead to a catastrophic war, the Cuban missile crisis has become the canonical case study in nuclear statecraft. Over the decades since, key lessons from the crisis have been adapted and applied by the successors of Kennedy and Khrushchev to inform fateful choices.

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Intimation under section 286(1) in Form No. 3CEAC, by a resident constituent entity of an international group whose parent is non-resident

Hi everybody.

The question I get most is: "Where do you get your ideas?"

Generally, when I'm asked this question, it's at a book event where it's difficult to answer, because… Well, the answer is long, and complicated, and hard to pin down, and most of the time, I don't really remember how it happened. When an idea starts to arrive, I get to work. I'm not paying attention to how it's happening, or how it would look to an outsider. 

But — a few weeks ago, a new book idea started knocking on the door of my mind. And this time, I decided to pay attention!

What follows is probably the most detailed explanation I'll ever give of where my ideas come from. More specifically, where this particular idea came from, because it's not always the same. But my experience of the past few weeks has been fairly typical for me, and I'll add that there are a few activities I need to engage in every single time, if I want an idea to take root. Namely: PATIENCE. LISTENING. And, LABOR. Book ideas require a certain honed receptiveness, and they require a LOT OF WORK. 

I'm yelling because I'm trying to push back against the idea that ideas simply come to writers. Yes, some parts of ideas come to writers. But when I first get a book idea, what "comes to me" probably comprises about 0.1% of what could properly be called a book idea. Often, it's little more than an inchoate feeling. With patience, listening, and labor, I transform the idea into something I can grasp, and work with.

I'll add that yes, we do hear sometimes of writers whose ideas "simply came to them," fully formed. I'm going to take a guess that (1) this doesn't happen very often, if ever, with books that have complicated structures or plots, and (2) writers who are blessed by ideas in this way probably have a long-honed practice of receptiveness.

Anyway. Warning upfront that this may be a little unstructured, because the process is a little unstructured. It's challenging to describe, and I'm still in the middle of it. But here's what my last few weeks have been like.

A few weeks ago, while watching a TV show that had a certain mood/aura that'd really sucked me in, I found myself drawn to the idea of a story involving three characters. I'm not going to tell you what TV show I was watching, and I'm not going to tell you anything about my three characters, because story ideas are intensely, intensely private. The first time I say anything publicly about it will probably be years from now, if and when this book is ever scheduled for release. But let me try to explain a bit about that moment when the first glimmering of the idea appeared. 

Like I said, I'd been watching a TV show when it happened. But my three characters weren't characters in that TV show. Nor did anyone in that TV show relate to each other the way my three characters seemed to want to relate. Nor did my three characters seem to live in a world like the world of the TV show. The TV show helped to launch the idea at me because of the show's mood and its feeling, and how much I cared about the people in it. But my idea? As is often the case, my idea came from something I saw missing in the TV show. Not missing because there was a flaw in the TV writers' story; I loved their story! But missing (for me and possibly only me) because their story was not the story I would have told.

I think that a lot of my idea seeds come from my adoration of other people's stories, but also from my noticing what's missing in those stories, for me. What story I would've like to have seen told; what characters the story lacked.

Anyway. So this idea of these three characters came to me. But when I say "idea of these three characters," already that sounds more substantial than it was. I knew they were three humans (or humanoids; I didn't know what genre the story was, so they could've been aliens on another planet, for all I knew. In fact, I actively considered whether they might have different biology than ours). I knew they cared about each other, but I didn't know in what way. I knew they were facing a challenge that would strain all of their relationships. I thought they might be grown-ups, but I wasn't sure. I thought I knew at least two of their genders, but I wasn't sure. I knew they lived in a world with magic, but I didn't know what "magic" meant in the context of their world. I didn't know where they lived, or when they lived (past? future? futuristic past? postindustrial future? any of about a hundred other possibilities). I knew a whole lot of things that the characters weren't, and that the world wasn't — which is another way of saying that my sense of what this story was was actually more defined by all the things I knew it wasn't. (Apologies if this is vague. I'm not being intentionally vague! I'll try for some concrete examples: I knew I didn't want to write a story where partway through, someone suddenly discovers they have an inborn power they didn't know they had. I knew I didn't want to write a love triangle. There's a certain kind of high-handed fantasy tone that I knew wasn't right for this story. But I didn't know what I did want yet at this point.)

Really, all I knew was that I seemed to be having an idea.

So, like a writer, I did what I needed to do: 

• I made space in my mind for receptiveness. (I scheduled uninterruptable alone time. I stopped listening to podcasts while I was out walking, and instead, just walked, so my mind could wander. I put aside non-urgent tasks for a while so that I didn't have the feeling of a to-do list hanging over my head. I gave myself permission to wool-gather, to become vague and absent-minded. I set three timers any time I cooked anything so I could feel free to forget I was cooking, but also not burn the house down. I remembered to thank my husband frequently for being willing to live with a space cadet.)
• I thought about what fertilizer might help the idea to grow, especially fertilizer in the form of books, TV, and movies. I put all other books, TV, and movies aside. (I kept watching that same TV show, and I also began reading almost exclusively one writer who had a narrative tone — and also subject matter — that helped me sustain a mood that felt concurrent with the mood of my own idea. Why does this kind of intake help? It keeps my mind in a story space, while also giving me something to bounce my own ideas off of. It's a kind of reading, or watching, that involves a state of constant interactivity and reactivity. Everything I'm consuming becomes about something else that I'm looking for. It's difficult to explain, maybe because it gets back to that inexplicable moment when new ideas form.)
• I made sure that every single time I had any new thoughts relating to my idea, I wrote them down. (This meant making reminders on my phone; sending strings of emails to myself; choosing a notebook where I began to jot things down; sending texts to myself on my husband's phone, if his phone was closer to hand than mine.)
• I looked at my schedule to give myself a sense of if and when I might have a few days soon to put my current writing project aside and give some true, devoted time to this new idea. (I was, and still am, in the middle of revisions of the next Graceling Realm book when this happened, and that was, and still is, my absolute first priority. As exciting and intense as a new idea can be, it can't unseat me from my current object of devotion.)

By chance, last week, I did in fact have some time away from my revision while it was briefly with my editor. I was able to devote an entire week to the new book idea. So, next, I'll try to describe what a week of intense idea-gathering looks like for me! (Though I should say that this will differ from book to book. It's been pretty clear to me from the beginning that this new idea is going to be slow to grow — planning this book will take way more than a week. In contrast, last fall, I found myself with a new and sudden book idea that coincided with the end of another project, so I had some free time and was able to sit down and hammer out the entire book plan, which took only a few days. I think this is because that book was shorter and less emotionally complicated than this new book will be, and was set in a less complex world. Also, at the time, I was absolutely thrumming with the adrenaline and momentum of having just finished a writing project, so book-planning became a way to channel that energy. Often these processes are subject to whatever else is going on in my life.)

So. My week of intense idea-gathering looked a lot like what I've already described — reading, watching TV, but now also with long hours of sitting staring at a blank page and/or lying on my back staring at the ceiling — but with a more specific goal. Namely, I was trying to figure out what my main questions were. For me, every book starts (and continues, as I write) with an extremely long list of questions that I'm trying to find the answers to, but it takes work to figure out what the questions are. The questions can be very different from book to book. And it's essential, at the beginning, to identify what the main questions are.

When I'm first idea-gathering, I use very short notebooks in which I scribble down all my random thoughts as they come (I like using these twenty-page notebooks from Laughing Elephant, because they're short enough not to feel intimidatingly important). Then I have one longer, thicker notebook which is for my more coherent thoughts — my more serious book planning. During my week of active idea-gathering, I came up with the following list of major questions, worthy of being written down in my thick, "serious" planning notebook:

MAJOR QUESTIONS.

• What is magic?
• How does bad human behavior manifest in this world? (for real *)
• Where/what culture does each of them come from? What family?
• How is society governed?
• Who is each of them — as a person and as a power manifestation?
• How is the narrative positioned?
• What is the plot?
• How do humans relate to the rest of the natural world?
• What is gender? (for real *)

* and by societal definition

As I began to hammer out my questions, I continued to read, watch things, and wool-gather, but with more intense focus. Because now I was also trying to answer these questions as they came. It was interesting to observe the order in which I began to find the answers. Not surprisingly, probably since my novels tend to be character-based, it was the character-based questions that drew me in first. “What is gender" in particular, because I have a sense that in this story, my characters' relationships to gender are absolutely integral to who they are, and I can’t get very far with a book plan if I don’t know who my characters are. I also started to gather some clues about their personalities and their strengths. Enough that after a couple of days, I got to the point where I suddenly knew I needed their names. Names ground everything, and they can also change some things; at a certain point, I can't make any further progress without names. I spent one entire day last week mostly just trying to figure out three people's names. Once I had the names, I was able to return to my questions.

Then, not too long after that, a moment arose where I knew, again quite suddenly, that what I needed next was at least the broad strokes of a plot. If I’m a little scornful about the concept of inspiration — because it’s a concept that dismisses how hard I work! — I do believe in intuition, and also in experience. Intuition and experience told me that I'd reached the point in my planning where the needs of my plot would hold the answer to a lot of my other questions. Like, how this place is governed; what constitutes bad behavior; and even some character things, like what culture each of my characters is from. Sometimes, once you know what needs to happen in a story, it becomes easier to picture the structure of your world. Because a plot comes with needs; once a plot exists, it limits some of your other options. For example, let's say your plot involves a particular kind of government-based corruption. Well, thinking about that corruption will probably start to show you some of your options for the structure of the government. Once you know the structure of the government, you might begin to understand who holds governmental power — which can lead to answers about how families are structured. Which can lead to answers about culture, which can lead to answers about the societal definition of bad behavior, etc.

So. I reached the point where I needed at least a sense of my plot. But: plotting is a HUGE job. I knew it wasn't something I could do in just a few days, and at this point I also knew that I was going to need to return to my revision soon. So, intuition told me that it was time to stop. Not stop being receptive; not necessarily stop reading or watching the helpful things; not stop sending myself emails, texts, and reminders; but stop trying to make any real, meaty, major progress on this book idea. I needed to save the job of plotting for when I next had a stretch of uninterrupted worktime. Maybe another free week or two somewhere, between other projects.

So, I did some final organizing of my notebook. I transferred things into it from other notebooks and I designating a huge number of empty pages in it for future plot thoughts and future character thoughts. I did this even though in this book, as in most of my books, I sense that character and plot will ultimately end up being the same thing, so it's not going to matter much which thoughts I file where. (In other words, most of my plot is going to spring from who my characters are, and many of my characters will spring from the needs of the plot.) But at this messy stage in planning, it's important to me to feel organized. The illusion of organization stops me from feeling as overwhelmed as I probably should be feeling. So I label things, and delude myself that I can contain this messy process inside a nice neat notebook ????. 

I organized my notebook, and then I put it aside. Today I'm still open to thoughts about my new book idea, but it's not my entire worklife anymore... it's more of a promise for the future. It'll probably be good to have it simmering on the back burner for a while. I'll be able to approach it with a new freshness when I sit down with it again one day.

So. I'm not sure how satisfyingly I've answered the question "Where do you get your ideas?" After all, this idea is still very much in progress. I figured out a lot of stuff last week, but mostly what I figured out is a long list of all the things I don't know yet. There will be many, many more workweeks to go before I'll be able to claim that I truly have an idea for a book. 

But this is my best shot at an answer to the question of where my ideas come from! I guess the point I want to convey is this: I don’t necessarily believe in inspiration. But I believe that sometimes a writer will start to get the merest sense of a story that's missing from the world, and find herself wanting to write that story. At that point, if circumstance allows her the time and space to enter a state that is extremely internally-focused and possibly involves a lot of intake (reading, watching other stories), or if not that, at least an extreme level of sensitivity and receptiveness, of seeing, of listening... And if she puts in the work… her idea-seed will start to take root, and grow into a real, workable idea that might one day be the beginnings of a book! 

And of course, every writer does this differently. Many writers don't plan or plot ahead of time. They figure out the idea as they write. So there's no right or wrong way to do it. 

But this is my best explanation of how I do it.

Godspeed to all writers.

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