What is a RAVE

What is a RAVE

DEA Provider Case Studies, Hospital Risk Mitigation and Credentialing Brief Washington Association of Medical Staff Services Annual Conference April 24, 2019 Prescription Drug Consulting LLC 2018 All Rights Reserved 1 Who I Am Retired DEA Special Agent in Charge - Chicago. 30 years of experience. Worked through the Indiana pill mill crisis during 2005 through 2014. Have been partnering with medical community/prescribers for last 10 years through

controlled substance programs. Developer of CME and CLE prescription drug risk mitigation programs focusing on prescriber safeguards, DEA compliance, MAT, pain and drug destruction. Prescription Drug Consulting LLC 2018 All Rights Reserved 2 Disclosure Statement This is to confirm that I do not have any personal financial or commercial affiliation to this subject matter. This is not a promotional talk for any pharmaceutical company. I will not discuss off-label/investigative use of any commercial product.

Prescription Drug Consulting LLC 2018 All Rights Reserved 3 Presentation Outline 82 Slides 40 minutes Provider studies Provider case studies Hospital risk and case studies Medical office risk and case studies Credentialing tips Drug updates What else? Q & A 20 minutes Prescription Drug Consulting LLC 2018 All Rights Reserved

4 Medical Provider Risk Prescription Drug Consulting LLC 2018 All Rights Reserved 5 Medical Provider Study #1 Prescription Drug Consulting LLC 2018 All Rights Reserved 6 PAIN MEDICINE

Physicians Charged with Opioid AnalgesicPrescribing Offenses Volume 9, Number 6, 2008 Study undertaken by Center for Bioethnics in partnership with the National Association of Attorneys General and the Federation of State Medical Boards Case review period, 1998 - 2006 725 doctors representing 0.1% Source: https://michigan.gov/documents/mdch/Pain_Medicine_Study.Sept08_270281_7.pdf Prescription Drug Consulting LLC 2018 All Rights Reserved 7 Specialty of Physicians Involved in Criminal and Administrative Cases Speciality

% General Practice 39.3 Physical medicine 2.7 Pain medicine 3.5 Psychiatry 8.1

Internal medicine 23.7 Anesthesiology 7.5 Emergency medicine 5.3 General Surgery 5.1 Obstetrician/Gynecologist

3.2 Pediatrics 2.9 Prescription Drug Consulting LLC 2018 All Rights Reserved 8 Physicians Involved in Criminal and Administrative Cases Gender %

Male 89.4 Female 10.6 Age Range % 35 & under 3 35 44

18.1 45-54 39.5 55-64 24 65 + 15.5 Prescription Drug Consulting LLC 2018 All Rights Reserved 9

Case Outcomes % Plead Guilty or No Contest 79.5 Plead Not Guilty 20.5 Plead Not Guilty Found guilty or susequently plead % 90.6 Prescription Drug Consulting LLC

2018 All Rights Reserved 10 What Drug Causes This? Source: Walworth County, WI SO Drug Unit Prescription Drug Consulting LLC 2018 All Rights Reserved 11 Extreme Heroin Use & Needle Use Source: Walworth County, WI SO Drug Unit Prescription Drug Consulting LLC 2018 All Rights Reserved

12 www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/ AnestheticAndLifeSupportDrugsAdvisoryCommittee/UCM220950.pdf page 16 Prescription Drug Consulting LLC 2018 All Rights Reserved 13 Medical Provider Study #2 Prescription Drug Consulting LLC 2018 All Rights Reserved 14

U.S. Physicians Disciplined for Criminal Activity From HEALTH MATRIX Vol. 16:335 Summer 2006. 1990 thru 1999 date range Criminal and medical board findings 31,110 disciplinary entries against 20,125 physicians 3,902 criminal convictions entries for 2,247 for physicians https://www.citizen.org/our-work/health-and-safety/article-health-matrix-us-physicians-disciplined-criminal Prescription Drug Consulting LLC 2018 All Rights Reserved 15 U.S. Physicians Disciplined for

Criminal Activity From HEALTH MATRIX Vol. 16:335 Summer 2006. Findings Physicians disciplined for criminal offenses were older than the national physician population. 51.9% were 45 or older when disciplined 70.7% were 45 or older when criminally convicted https://www.citizen.org/our-work/health-and-safety/article-health-matrix-us-physicians-disciplined-criminal Prescription Drug Consulting LLC 2018 All Rights Reserved 16

U.S. Physicians Disciplined for Criminal Activity From HEALTH MATRIX Vol. 16:335 Summer 2006. Findings Physicians between 55 and 64 had highest risk ratio. General practice had highest risk of 4.93 Psychiatry had risk of 2.24 Family practice had risk of 1.97 Child and adolescent psychiatry had risk of 1.75 https://www.citizen.org/our-work/health-and-safety/article-health-matrix-us-physicians-disciplined-criminal Prescription Drug Consulting LLC 2018 All Rights Reserved

17 U.S. Physicians Disciplined for Criminal Activity From HEALTH MATRIX Vol. 16:335 Summer 2006. Findings 61.5% of all U.S. physicians are board certified only 41.5% of disciplined physicians were board certified. https://www.citizen.org/our-work/health-and-safety/article-health-matrix-us-physicians-disciplined-criminal Prescription Drug Consulting LLC 2018 All Rights Reserved

18 U.S. Physicians Disciplined for Criminal Activity From HEALTH MATRIX Vol. 16:335 Summer 2006. Physicians disciplined for drug-related offenses: General Practice & Family Practice highest Physicians disciplined for fraud offenses:

General Practice & Psychiatry highest https://www.citizen.org/our-work/health-and-safety/article-health-matrix-us-physicians-disciplined-criminal Prescription Drug Consulting LLC 2018 All Rights Reserved 19 Providers in Trouble Case Examples Prescription Drug Consulting LLC 2018 All Rights Reserved 20

Dr. M Opened one provider pain clinic ISO and search warrant took him out Open until 6 am in morning Fired from hospital In 50s Internal medicine Major city Prescription Drug Consulting LLC 2018 All Rights Reserved 21 Dr. H

One provider pain clinic Cash only Cell phone appointment Other patient referral only Psychiatrist In 50s Major city Prescription Drug Consulting LLC 2018 All Rights Reserved 22 W Clinic Death Focused 27+: been at a long time started from coroner

Family practice providers and three PAs Involved numerous pre sign prescriptions One provider had been fired from local hospital Five males & one female All 50 plus Prescription Drug Consulting LLC 2018 All Rights Reserved 23 Dr. R One provider office Trained in Nigeria Family practice Pain clinic

Near 50 Sexually assaulted 30 plus women ISOed Pleaded guilty 4/2014 10 years Prescription Drug Consulting LLC 2018 All Rights Reserved 24 U.S. Medical Regulatory Trends and Actions Federation of State Medical Board Study 2018 Year Data 970,090 active physicians 4,081 physicians disciplined Surrendered 570

Revoked 264 Denied 97 Total 931 https://www.fsmb.org/siteassets/advocacy/publications/us-medical-regulatory-trends-actions.pdf U.S. Medical Regulatory Trends and Actions Federation of State Medical Board Study 2018 Year Data https://www.fsmb.org/siteassets/advocacy/publications/us-medical-regulatory-trends-actions.pdf U.S. Medical Regulatory Trends and Actions Federation of State Medical Board Study 2018 Year Data

https://www.fsmb.org/siteassets/advocacy/publications/us-medical-regulatory-trends-actions.pdf Prescription Drug Consulting LLC 2018 All Rights Reserved 27 Dr. B One provider office Family practice Four overdose deaths 50 plus Surrendered his license Also a weight loss provider Suburb of large city Prescription Drug Consulting LLC 2018 All Rights Reserved

28 Med 1st Chiropractors and Doctor One family practice provider Several NPs Two chiropractors managers Medicaid patient focused All 50 plus Large city Focused on back injections Prescription Drug Consulting LLC 2018 All Rights Reserved 29

Dr. W Family practice 50 plus Law enforcement complaints Hospital affiliated Later forced to retire Rural area Naive Prescription Drug Consulting LLC 2018 All Rights Reserved 30 MCCHC Federally funded health clinic Rural city

Family practice provider 84 years old Two rookie PAs Hundreds of pre-signed scrips to PAs Managed by non-medical CEO Nine overdose deaths Reimbursed $115 per poor patient Voluntary surrender Prescription Drug Consulting LLC 2018 All Rights Reserved 31 Indiana Pill Mill Prescription Drug Consulting LLC

2018 All Rights Reserved 32 Hospital Investigations What do we see? Nurses/doctors self abusing liquid painkillers from patients Do not see significant practitioner issue in hospitals due to management oversight, policies & peer pressure Controlled substance thefts and diversion Usual cause is poor oversight of drugs in pharmacies Prescription Drug Consulting LLC 2018 All Rights Reserved 33

Most Common Hospital Risk Case Example #1 Risk mitigation Hospital Provider/nurse diverting drugs for self-abuse (Painkiller/benzo) Distribution? Bar raised

Get in treatment asap to mitigate Protect licenses if possible Diversion of liquid drugs most common Fentanyl/morphine to saline Due diligence & policies Notification?

LE Boards Take action - Colorado Maintain rule of two over CSs to mitigate Prescription Drug Consulting LLC 2018 All Rights Reserved 34 Hospital Risk Case Example #2 Large Hospital $250,000 dollar fine Diversion of 96,000 oxycodone tablets by nurse at cancer center Nurse would draft prescriptions and get signed by

providers and she would get filled at in-house pharmacy to help patients No due diligence by pharmacists Prescription Drug Consulting LLC 2018 All Rights Reserved 35 Hospital Risk Case Example #3 Large Hospital One million dollar fine Only one pharmacy was registered. (Hospital had multiple pharmacies at different addresses. All sites must be registered.) Invoices for drugs were not kept on-site for two years. (Had been destroying them.) No biennial inventory conducted. (Lack of records.) Drugs were being destroyed but no destruction records. (DEA

41 forms required & options to destroy. Employee destroying by himself in alcohol) Poor security (significant theft multiple employees had keys for CS access. Local DTF made DEA aware of drugs on street.) $10,000 CFR fine per violation Prescription Drug Consulting LLC 2018 All Rights Reserved 36 What is this? Prescription Drug Consulting LLC 2018 All Rights Reserved 37 X-Ray of Cocaine Pellet Body Carrier

Prescription Drug Consulting LLC 2018 All Rights Reserved 38 Hospital Risk Case Example #4 Large Hospital 39

Fined $2.3 million Nurses stealing drugs 14,000 oxycodone tablets from ADM (had been falling asleep at work) Had not been keeping ADMs access up-to-date No supervisory review of ADM usage Multiple diversion of drugs by nurses with no discipline Loose control over CSs some brought to lunch room Corrective Action Plan

Establish FT Drug Diversion (DD) Compliance Officer Establish DD Team CO, pharmacy, nursery & police/security Annual training Instituted ADM software Limited access to drug vault & server to pharmacists and techs Instituted daily and weekly reviews and audits of drug usage Prescription Drug Consulting LLC 2018 All Rights Reserved Most Common Medical Office Risk

Case Example Risk mitigation Medical office Office provider dispensing CSs without maintaining required records Office maintaining CSs without proper security and recordkeeping

Prescribe only - if possible Prescribing vs dispensing Dispensers must maintain records CSs must be stored in securely locked, substantially constructed cabinet or safe Limit access to CSs Use pharmacist if possible Should small offices not

maintain CSs? Prescription Drug Consulting LLC 2018 All Rights Reserved 40 Other Healthcare Risk What do We See? Healthcare practitioners paid by # of patients seen & tied to CS prescriptions. Prescriptions sometimes tied to back injections Rural more than urban settings Almost always involves older male doctors, 45 yoa + Sex for drugs on some occasions Prescription Drug Consulting LLC

2018 All Rights Reserved 41 Pharmacy Investigations What do we see? Controlled substance thefts and diversion by pharmacy techs. Prescription Drug Consulting LLC 2018 All Rights Reserved 42 Ambulance Service Investigations What do we see? EMT personnel self abusing liquid

painkillers from kits. Poor accounting of CSs Prescription Drug Consulting LLC 2018 All Rights Reserved 43 Credentialing Thoughts Dont believe it unless you can corroborate it. The power of Google Follow national guideline, if possible if not develop one as group Document and build file If it isnt written, it didnt happen

Prescription Drug Consulting LLC 2018 All Rights Reserved 44 DEAs Role with Medical Providers DEA's authority under the CSA is not equivalent to that of a State medical board. DEA does not regulate the general practice of medicine. The responsibility for educating and training physicians so that they make sound medical decisions in treating pain (or any other ailment) lies primarily with medical schools, postgraduate training facilities, State accrediting bodies, and other organizations with medical expertise. DEAs authority is limited to controlled substances only. Prescription Drug Consulting LLC 2018 All Rights Reserved

45 Credentialing Thoughts Surrender versus administrative action. (800 a year) DEA will notify state officials on a providers DEA # surrender. DEA will usually not confirm or deny a surrender. Check via DEA website. All DEA administrative & criminal actions are listed at Cases Against Doctors. State versus fed for timeliness. DEA for drugs HHS for fraud. All medical licenses are linked. Prescription Drug Consulting LLC 2018 All Rights Reserved

46 Drug Updates & Emerging Trends Prescription Drug Consulting LLC 2018 All Rights Reserved 47 National Forensic Laboratory Information System NFLIS 91% all evidence from 273 participating labs from 49 states https:// www.nflis.deadiversion.usdoj.gov

Prescription Drug Consulting LLC 2018 All Rights Reserved 48 Most Commonly Abused Pharmaceutical Drugs Prescription Drug Consulting LLC 2018 All Rights Reserved 49 Top Five Narcotic Analgesics Submitted to Crime Laboratories (NFLIS) Oxycodone (Percocet/OxyContin) 32%

Hydrocodone (Vicodin/Lortab) Buprenorphine (Suboxone) Fentanyl 21% 14% 11% Prescription Drug Consulting LLC 2018 All Rights Reserved 50 Top Three Benzodiazepines Submitted to Crime Laboratories (NFLIS) Alprazolam (Xanax)

56% Clonazepam (Klonopin) Diazepam (Valium) 7% Prescription Drug Consulting LLC 2018 All Rights Reserved 15% 51 The Holy Trinity Prescription Drug Combination that Gives Heroin - Like - High Hydrocodone Vicodon/Lortab/Norco

Alprazolam - Xanax Soma - Carisprodol No legitimate medical purpose Prescription Drug Consulting LLC 2018 All Rights Reserved 52 Source: DEA 2017 Drug Threat Assessment Prescription Drug Consulting LLC 2018 All Rights Reserved 53 Fentanyl from China: the New Opioid Threat

https://www.deadiversion.usdoj.gov/nflis/2017fentanyl.pdf Prescription Drug Consulting LLC 2018 All Rights Reserved 54 Chinese Fentanyl Flow Source: https://www.dea.gov/docs/Counterfeit%20Prescription%20Pills.pdf Prescription Drug Consulting LLC 2018 All Rights Reserved 55 Chinese Sourced Fentanyl

Prescription Drug Consulting LLC 2018 All Rights Reserved 56 DEA Action Against Emerging Fentanyl's November 9, 2017 February 7, 2018 DEA announces intention to emergency schedule all fentanyls. DEA emergency schedules all fentanyls.

Source: https://www.dea.gov/divisions/hq/2017/hq110917.shtml Prescription Drug Consulting LLC 2018 All Rights Reserved 57 What Else is New? Prescription Drug Consulting LLC 2018 All Rights Reserved 58 Drug Disposal Options Take Back Days Law Enforcement

Boxes Pharmacy Take Back Authorized Collectors Prescription Drug Consulting LLC 2018 All Rights Reserved 62 59 Drug Disposal Options Kentucky NABP www.awarerx.com (48 + locations, Floyd Memorial & Carroll Co. Memorial) DEA https:// apps.deadiversion.usdoj.gov/pubdispsearch/spring/main? execution=e1s1 (29 locations, U of L Hospital, Clark Memorial & VA

Lexington) Walgreens (multiple locations) https:// www.walgreens.com/storelistings/storesbystate.jsp?reque stType=locator CVS (multiple locations) https://www.cvs.com/content/safer-communities-locate Prescription Drug Consulting LLC 2018 All Rights Reserved 60 PDMP Mandatory Query by Prescribers and Dispensers VT (Listing of the specific conditions for mandatory query)

NH WA MT ND MA MN OR NY WI SD WY

N NV UT CO CA KS DC AZ AR AK IA

PA MP TTAC PDMP TTAC IL IN WV VA K Y *M O RI NJ D

E MD SC NM TX M LA S A L GA FL

MP TTAC PDMP TTAC PDMP TTAC PDMP TTAC MP TTAC PDMP TTAC PDMP TTAC PDMP TTAC Prescribers and Dispensers (14) MP TTACPrescribers PDMP TTAC PDMP Only TTAC (24) PDMP TTAC Drug Consulting LLC as Prescription of August 2017 2018 All Rights Reserved Mandatory Query

(14) MP TTACNo PDMP TTAC PDMP TTAC PDMP TTAC 61 PDMP Data Interstate Sharing http://www.pdmpassist.org/pdf/Interstate_Data_Sharing_20170920.pdf Prescription Drug Consulting LLC 2018 All Rights Reserved 62

Comprehensive Addiction and Recovery Act (CARA) Highlights In effect since July 22, 2016 Qualifying physicians can treat up to 30, 100 or 275 patients Qualifying NPs and PAs can treat up to 30 or 100 for a five year period depending on state laws. New TIP 63 out on February 15, 2018. When in doubt email SAMHSA. Data Waived Physicians as of 1/2019 - SAMHSA 30 patient limit 43,403 100 patient limit 11,410 275 patient limit

4,635 Total 59,430 Medication Assisted Treatment (MAT) Updates Increase of Methadone clinics tied to hospitals & health clinics State laws & oversight of buprenorphine clinics Mid-level MAT provider expansion Prescription Drug Consulting LLC

2018 All Rights Reserved 64 What Else Should I Know? Emerging updates CDC prescribing guidelines VA Study State laws on OME limits amounts & days Hospital OME limits Increased use of naloxone due to fentanyl overdoses Prescription Drug Consulting LLC 2018 All Rights Reserved

65 What Else Should I Know? Emerging updates & possible risk? What is your complaint process? (Larry Nassar small office & little oversight?) Importance of rule of two Provider compensation tied to patients seen & CSs raises risk Risk relative to provider characteristics Providers contracting with others - while employed by you Prescription Drug Consulting LLC 2018 All Rights Reserved

66 Community Partnerships? Hold a Drug TakeBack Event? Take-back events with law enforcement partnerships Table & flyers Mail-back programs with pharmacy oversight Collection receptacles inside hospitals with pharmacy oversight Prescription Drug Consulting LLC 2018 All Rights Reserved 67

Community Partnerships? Form a Task Force? Treatment, hospital, school educators, law enforcement, PDMP officials, lawmakers and other groups meeting bimonthly to better their communities. Website with links and resources Prescription Drug Consulting LLC 2018 All Rights Reserved 68 Community Partnerships? Develop Drug Prevention Programs with Schools?

Educator Lesson Plans Drug Prevention www.operationprevention.com www.redribbon.org www.robertcrown.org Parent Drug Website www.drugfree.org Prescription Drug Consulting LLC 2018 All Rights Reserved 69 Community Partnerships? Develop A Way Out Program with Law Enforcement & Treatment Providers? A Way Out is a Law Enforcement Assisted Diversion pilot program, designed to fast-track users to substance abuse

programs and services. This program is available 24 hours a day, 7 days a week at participating police departments and ensures no criminal charges will be sought for those that may be in possession of narcotics or paraphernalia, as long as assistance is sought out by the prospective program participant. Also known as a Angel Program or Police Assisted Addiction & Recovery Initiative (PAARI) http://awayoutlc.org/ http://paariusa.org/ Prescription Drug Consulting LLC 2018 All Rights Reserved 70 What Drug Causes This? Prescription Drug Consulting LLC

2018 All Rights Reserved 71 Meth Mouth Courtesy of Dr. Stephen Wagner DDS & American Dental Association Prescription Drug Consulting LLC 2018 All Rights Reserved 72 Telemedicine - 21 USC 802 (54) Ryan Haight Act - Federal

Background Allows for telemedicine after a in-person evaluation Provider must be licensed in states which it occurs Patient must be in the physical presence of a doctor sitting in medical office New exception regulation by DEA forthcoming

Risk mitigation Evolving medicine & law Risk increases with CSs Equal state & fed? Ensure oversight & guideline adherence Stay current 73

Prescriber Notification Initiative for Opioids ATLANTA The U.S. Attorneys Office for the Northern District of Georgia has identified approximately 30 medical professionals who are prescribing opioids in significantly higher quantities or doses than their peers or to patients who may pose a high risk of abuse or diversion. The U.S. Attorney will provide these prescribers with specific information about their prescription patterns and will refer them to educational materials, such as the Centers for Disease Control and Prevention (CDC) Guidelines for Prescribing Opioids for Chronic Pain, related to safe opioid prescription practices. The Department of Justice has made no determination, at this time, that prescribers who receive these letters have violated the law. We have a duty, however, to protect the lives and safety of our citizens, and making information available to prescribers within the District has the potential to save lives. (Also done in MA & PA) https://www.justice.gov/usao-ndga/pr/prescriber-notification-initiative-opioids

Coroner sent letters to doctors whose patients died of opioid overdoses. Doctors habits quickly changed Los Angeles Times, August 9, 2018 Started in San Diego Letters sent to doctor when a patient overdosed and died. Offered five prescribing tips. Study published in the Journal of Science Saw prescribing change http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-letter-20180809-story.html Death Certificate Project Terrifies California Doctors Hundreds threatened with disciplinary action for opioid scripts to patients who overdosed California August 2018 Rather, Lenzkes is one of hundreds of California physicians caught up so far in the medical board's aggressive "Death Certificate Project," a

program that attempts to stop the epidemic of accidental deaths from prescription opioid overdoses. The California project takes death certificates in which prescription opioids are listed as a cause, then matches each with the provider -sometimes more than one -- who prescribed any controlled substance to that patient within 3 years of death, regardless of whether the particular drug caused the death or whether that doctor prescribed the lethal dose. https://www.medpagetoday.com/painmanagement/painmanagement/74856 Prescription Drug Consulting LLC 2018 All Rights Reserved 76 Safeguards & Risk Mitigation for Providers Treat your prescription pad like your checkbook

& secure other pads Never sign prescription blanks in advance Use PMPs more - than less Be extremely careful when prescribing methadone for pain Be careful with opiate/benzodiazepines combinations drug seeker combo & increases possibilities of death. Prescription Drug Consulting LLC 2018 All Rights Reserved 77 Safeguards & Risk Mitigation for Providers

Consult with ER & addiction treatment physicians for drug updates (they see what we see) Men and middle aged patients be careful, highest death rate Do not maintain controlled substances unless you have to. If you are a easy prescriber, word will get out and you business will increase. Prescription Drug Consulting LLC 2018 All Rights Reserved 78 Safeguards & Risk Mitigation for Providers

Maintain robust security and recordkeeping for CSs Limit the locations where CSs are kept Prescribe rather than dispense whenever possible Police yourself by peer review Use the rule of two in high risk situations patients & CSs Follow national/state/best practice guidelines whenever possible Practice due diligence & have a process

Prescription Drug Consulting LLC 2018 All Rights Reserved 79 Safeguards & Risk Mitigation for Providers On questionable patients consider speaking with family members. Address complaints by family members and others, act.

Watch putting up the HIPPA wall. Peer review in hospitable and practices work. Develop policies for positive drug screens, doctor shoppers, etc., Having a policy takes blame off you and minimizes risk. Protect your great name no stupid emails or Facebook posts -1st lawyer move. Prescription Drug Consulting LLC 2018 All Rights Reserved 80 Questions Dennis Wichern [email protected] 312-859-2430 Prescription Drug Consulting LLC

2018 All Rights Reserved 81

Recently Viewed Presentations

  • www.dejazzer.com

    www.dejazzer.com

    Specification language requirements. Hierarchy. behavioral and structural. Compositional behavior. Must be "easy" to derive behavior from behavior of subsystems. Timing behavi
  • Our Mission Appalachian Crossroads empowers people with disabilities

    Our Mission Appalachian Crossroads empowers people with disabilities

    Matt Tasker was hired at Pifer& Son's Auto Repair. He works from 9:00 a.m. - 2:00 p.m, 4 days a week. He changes oil, tires, brakes, rotors, etc. Received additional DORS funding (tools, specialized clothing, safety gear).
  • ENSC 105W: Process, Form, and Convention in Professional Genres

    ENSC 105W: Process, Form, and Convention in Professional Genres

    Services and resources for FIC students . Your FIC card is your library card. Checking out books and equipment. Using library's electronic resources
  • TITLE

    TITLE

    There is an abundance of initiatives at the national, regional, state and local levels that have goals consistent with SNAP-Ed. Joining forces in coordinated efforts has been shown to achieve unprecedented results; for SNAP-Ed there is promise of increased the...
  • The US Congress - Houston Community College

    The US Congress - Houston Community College

    The U.S. CongressThe Partisan Split. The Balance of Power (116. th. Congress) US House of Representatives (435 members) 235 Democrats. 199 Republicans. The composition of the US House changes fairly often between elections, usually because of resignations, deaths (due to...
  • Massage of the back

    Massage of the back

    Swedish Technique Class
  • Simple C Programs - University of Texas at San Antonio

    Simple C Programs - University of Texas at San Antonio

    Be careful! No data loss * Exercise: swap Write a set of statements that swaps the contents of variables x and y 3 5 x y Before After 5 3 x y * Exercise: swap First Attempt x=y; y=x; Before...
  • Texture Mapping Progressive Meshes - Harvard University

    Texture Mapping Progressive Meshes - Harvard University

    SIGGRAPH 2001 Texture-Mapping Progressive Meshes Pedro V. Sander Steven J. Gortler John Snyder Hugues Hoppe Harvard University Microsoft Research Texture-Mapping Progressive Meshes "Texture mapping" "Texture mapping" Our problem Sample the surface signal into a texture: (e.g. normal, displacement, BRDF, …)