Dr. John Whyte, Board Chair, called the 29th meeting of the NABMRR to order at 8:35 a.m. Minutes from the previous meeting were approved.
December 2-3, 2004May 2-3, 2005December 1-2, 2005
Dr. Michael Weinrich, Director of the NCMRR, highlighted a new trans-NIH initiative, entitled Research Partnerships for Improving Functional Outcomes. This effort will support the development of multidisciplinary research teams with a focus on functional outcomes. The Board discussed potential peer-review issues and the challenge of educating the research community on cross-disciplinary issues. This solicitation is available at http://grants.nih.gov/grants/guide/pa-files/PAR-04-077.html.
Dr. Weinrich indicated that the NCMRR budget reached $65 million in fiscal year (FY) 2003, a small but growing portion of the total NICHD extramural budget (about $900 million). Although initiatives for the upcoming year are already in place, Dr. Weinrich discussed future activities (i.e., FY2005) with the Board. Funding constraints within the NICHD/NIH will limit the NCMRR to about three new initiatives. Discussion centered on possible initiatives in chronic pain, virtual reality, cognitive/behavioral management, electromyographically triggered prostheses and orthoses, outcome measurement (especially participation), and outcomes of inpatient rehabilitation for cancer and medically complex conditions (the "75% Rule"). The NCMRR will continue its emphasis on improving functional outcomes rather than on a strict disease focus. The Board briefly discussed the policy implications of NCMRR research, especially in the area of access to devices and services and the concept of medical necessity, but concluded that some of these issues may be more appropriate for other federal agencies.
Dr. Weinrich reviewed the federal budget process at the NIH. With guidance from the Office of Management and Budget (OMB), the president develops an initial budget outline, which gets passed down through the U.S. Department of Health and Human Services to each NIH institute. Within the framework of this outline, the institutes develop a unified response, which is transmitted through the Department to the president. After further consultation with OMB, the president submits the overall budget to congress. The budget is discussed in various congressional subcommittees in the context of 13 separate appropriation bills. These bills undergo intense lobbying from various outside interests (usually in February), which may lead to differences between authorization language and actual funds appropriated. The Congressional approval process involves various procedural votes, conference committees, and final floor approval. Within the appropriation bill, each NIH institute is singled out with specific committee recommendations (report language).
Dr. Weinrich discussed how the NICHD appropriation is allocated to research project grants, centers, cooperative agreements, training, contracts, and other activities. Despite current funding constraints, the NICHD remains committed to supporting investigator-initiated projects. The Institute has decreased the number of requests for applications (RFAs), increased scrutiny of larger grant applications (e.g., those requesting over $500,000 per year in direct costs), and reviewed cooperative agreements for unobligated balances. The Board discussed whether training activities should be re-evaluated in light of the more limited support for beginning researchers. It also encouraged the NICHD to continue seeking collaborations with other NIH institutes to support rehabilitation research.
Dr. Ralph Nitkin provided a brief review of the biennial NCMRR Training Workshop, which took place in Bethesda, Maryland, on December 1-2, 2003, just after the December Board meeting. More than 200 graduate students, postdoctoral fellows, and beginning investigators participated in the two-day meeting of research highlights, career development, networking, and NIH grantsmanship. The highlight of the workshop was the evening poster session, which included more than 80 research presentations on various aspects of pathophysiology, impairment, functional limitation, disability, and societal issues. Dr. Nitkin thanked the Board members who stayed over to participate in the Workshop. Slides and other background materials from the workshop are available at http://www.nichd.nih.gov/about/org/ncmrr/Pages/index.aspx.
As discussed in previous meetings, each Board member connects to multiple constituencies through their professional and personal networks, which provides special opportunities to promote medical rehabilitation research and the activities of NCMRR. At this point in the meeting, Board members provided brief updates of their outside activities to promote these goals primarily focusing on newer efforts. It was agreed the December meeting would be a good time to present a more comprehensive review of activities because that is when new members join the Board.
Zev Rymer directs the Midwest Regional Research Network, which promotes research opportunities and collaborations for medical rehabilitation researchers, particularly in the areas of bioengineering and robotics. Pat Kochanek, who is editor of the Journal for Pediatric Critical Care Medicine, helped publish an introductory article on the Pediatric Critical Care Program of NCMRR written by Carol Nicholson. He also added rehabilitation mentors to his departmental training grant, and he invited the NICHD to present to fellows at the Society of Critical Care Medicine. Lynn Underwood has been working with the Society of Behavioral Medicine to promote rehabilitative issues; she has also been working with other foundation contacts to enhance funding opportunities. Melanie Brown has been working on curriculum development for clinical fellows and made a push to increase consideration of rehabilitation issues and long-term outcomes. Meredith Harris has been working with the American Physical Therapy Association (APTA) to encourage connections with government funding agencies, especially to promote awareness of NCMRR as a focus for rehabilitation research. She has also been doing research on health care disparities, but finds very few publications in this area. John Whyte wrote a column on medical rehabilitation research for the Association of Academic Physiatrists (AAP) and he directs an NCMRR-funded national training program for physiatrists (see http://www.physiatry.org/?page=programs_RMSTP ). Ken Viste was been working on the legislative committee of the Academy of Neurology to examine the implications of the 75% Rule for support of inpatient rehabilitation services by the Center for Medicare and Medicaid Services (CMS). He is also working with the Foundation for Neurology to increase training opportunities for clinical researchers. Robert Dean is developing a course on prevention and rehabilitation engineering for the American Society of Mechanical Engineers, but is having trouble getting the Society to commit the necessary financial resources to attract top engineering faculty. Sue Swenson is advocating the Social Security Administration to increase employment and medical services for heart and diabetes patients. She is also writing columns for the Arc newsletter about family support for children with disabilities and the concept of seeking a cure versus seeking treatment. Audrey Holland arranged for the NCMRR to present at the annual American Speech-Language-Hearing Association (ASHA) meeting and developed a presentation on rehabilitative issues for the National Aphasia Foundation (NAF). Gerben DeJong is writing columns for the American Congress of Rehabilitation Medicine (ACRM) about funding opportunities and an introduction to the NCMRR; he has arranged for ACRM board members to meet with representatives from federal funding agencies. He is also highlighting disability and rehabilitation research with the Society for Health Services Research. Allan Bergman is continuing to advocate for research in traumatic brain injury and support of the NIH in general. The Brain Injury Association (BIA) is expanding support for research through its Web site, and Allan has invited the NCMRR to address the BIA stakeholders' meeting. Gail Gamble has been working to enhance rehabilitation research within her department and arranged for a visit from the NCMRR. She has been working with the Foundation for Physical Medicine and Rehabilitation (FPMR) in partnership with other organizations to increase research capacity and improve connections to federal agencies and research foundations. She got the American Academy of Physical Medicine and Rehabilitation (AAPMR) to highlight NCMRR activities including the regional research networks. Rory Cooper arranged for the NCMRR to present at engineering meetings and a major research retreat at Pittsburgh. He also wrote columns to highlight rehabilitation research for the Paralyzed Veterans of America (PVA), Assistive Technology (AT), and Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).
The following new members will be joining the Board in December 2004.
Dr. Diana Cardenas is a professor in the Department of Rehabilitation Medicine at the University of Washington. She got her clinical degree in physical medicine and rehabilitation and has published extensively in the areas of chronic pain, urinary tract infections, bladder management and pressure ulcer treatments for people with spinal cord injury (SCI). She has had major roles in research grants from the NIH and National Institute on Disability and Rehabilitation Research (NIDRR) and currently serves as principal investigator on a NIDRR SCI model systems grant. Her clinical responsibilities include Medical Director of the Rehabilitation Medicine Clinic, Clinical Director of the SCI Service, and Director of both the SCI and Adult Spina Bifida Clinics. She is active in several professional organizations including the American Congress of Rehabilitation Medicine (ACRM), American Academy of Physical Medicine and Rehabilitation (AAPMR), American Spinal Injury Association (ASIA), and Association of Academic Physiatrists (AAP).
Dr. Alberto Esquenazi is chairman of the Department of Physical Medicine and Rehabilitation (PM&R) at Albert Einstein Medical Center and chief medical officer at the Moss Rehabilitation Hospital (MossRehab). He also has faculty appointments in the PM&R Departments of Thomas Jefferson Medical College and Temple University School of Medicine. Dr. Esquenazi got his clinical degree in surgery and has been especially active in the areas of prosthetics and gait analysis. He directs several clinical facilities at the MossRehab, including the Gait and Motion Analysis Laboratory, Moss Regional Amputee Center, Prosthetic Clinic, Orthotic Clinic, and Post-Polio Clinic and has several research publications in the areas of prosthetics, orthotics, and gait analysis. He has been active several professional organizations, most notably the American Academy of Physical Medicine and Rehabilitation (AAPM&R).
Kenneth J. Giacin is a general manager and businessman with a particular interest in assistive technologies. After a successful career in Naval aviation, he directed various programs within Johnson & Johnson (J&J), Bristol Myers, and Church & Dwight. His last assignment for J&J was the start-up and creation of Independence Technology, dedicated to providing products and services for people with disabilities (including the iBOTTM mobility system). He has extensive experience in research and development, operations, engineering, marketing, international market expansion, new business development, and licensing and acquisitions. He recently took on the role of president and chief executive officer of StemCyte, a company dedicated to promoting the banking and therapeutic use of umbilical-cord blood cells.
Dr. Murray Goldstein is currently the director and Chief Operating Officer of the United Cerebral Palsy Research and Educational Foundation. He has four decades of experience with the NIH, including directorship of the National Institute of Neurological Disorders and Stroke (1982-1993) and current service on the Advisory Council for the National Center for Complementary and Alternative Medicine. Dr. Goldstein got his clinical degree in osteopathic medicine with additional training in public health. He served in the Commissioned Core reaching the rank of Rear Admiral and Assistant Surgeon General. He is active in several professional organizations and foundations, most notably the American Academy of Neurology (AAN) and American Neurological Association (ANA). He has served on the editorial board of various clinical journals and has published extensively in the area of stroke and other neurological conditions.
Dr. Alan M. Jette is professor and dean of the Sargent College of Health and Rehabilitation Sciences at Boston University (BU) with an appointment in the Department of Social & Behavioral Sciences, BU School of Public Health and an adjunct appointment at the Massachusetts General Hospital Institute of Health Professions. He got his master's in public health in gerontology and his Ph.D. in public health behavior. Dr. Jette has published extensively in the areas of functional assessment and health outcomes, especially related to the elderly. He has served on national advisory panels and directed several major projects with research grants from the NIH, the National Institute on Disability and Rehabilitation Research (NIDRR), and other organizations. He has been active in various professional organizations and served on the editorial boards of several research journals.
Dr. Marca L. Sipski is associate professor of Rehabilitation Medicine in the University of Miami School of Medicine, with a joint appointment to the Miami Project to Cure Paralysis, after several years on the faculty of the University of Medicine and Dentistry of New Jersey and the Kessler Institute for Rehabilitation. She got her clinical degree in medicine with specialty training in rehabilitation. Dr. Sipski has published extensively in the areas of sexual function, reproductive health, and health support for women with disabilities (especially SCI) and has directed several research projects on these topics with grants from the NIH, Department of Veterans Affairs, and other research foundations. She has been active in several professional organizations, including the Eastern Paralyzed Veterans Association, Association of Academic Physiatrists (AAP), American Congress of Rehabilitation Medicine (ACRM), American Paraplegia Society (APS), and the American Spinal Injury Association (ASIA), where she is currently president-elect and director.
With the conclusion of this meeting, John Whyte will finish his one-year term as Chair, and Meredith Harris will advance from the position of Chair-elect to Chair. Nominations were sought for the next Chair-elect. After brief discussion, Dr. Rory Cooper emerged as the sole nominee and was elected by acclamation.
Laraine Glidden, St. Mary's College of Maryland, presented a talk on positive psychology, religiousness, and rearing children with developmental disabilities. Early models of adaptation examined how demand leads to stress and crisis, but their focus was only on negative outcomes. In the last decade or so, researchers have started to consider aspects of positive psychology, including human strengths, virtues, and potential benefits and rewards. In the updated model, the rearing of children with a disability is considered in terms of cultural and family contexts, economic resources, social support, intellectual resources, religiousness, and personality. Each of these factors contributes to adaptation in a positive or negative manner.
Dr. Glidden reviewed her studies of families who knowingly adopted a child with disabilities and compared their outcomes to those of birth families raising a child with disabilities. Initially, the adoptive parents demonstrated much better adaptation skills, but once the child reached the teen years the long-term adjustments between the adoptive and birth families were quite similar. The major factor in long-term adjustment for the parents was personality, especially general mental health and stability; religiousness was a minor factor. Parents rearing children with disabilities actually reported many positive outcomes. Dr. Glidden concluded that future studies need to look for positive factors, such as strength and resilience, as well as more tradition measures of stress and burden.
Dr. Lynn Underwood discussed her research on psychosocial variables that affect outcome in chronic disease. She focused on the role of religiosity and spirituality, which can act through behavioral, social, psychosocial, or even physiological mechanisms. As an example, she reviewed a study on how psychosocial factors contribute to improved management of chronic pain. But, in order to address the impact of spirituality, she noted there was a need to develop quantitative measures based on psychosocial constructs. Although definitions of spirituality and religiosity have changed over time, they represent overlapping but not identical domains. Dr. Underwood introduced a multidimensional measurement tool that she developed as part of collaboration between the National Institute on Aging and the Fetzer Foundation. Her studies revealed that researchers tend to underestimate the impact of spirituality in the general population. She found that spirituality contributes to positive psychology, and it should be considered in outcome studies involving chronic diseases.
Dr. Gerben DeJong discussed some health services research commissioned by the Agency for Healthcare Research and Quality (AHRQ). Two key issues are the organization/delivery/financing of health services for individuals with disabilities and the organization/delivery/financing of health services for post-acute care. Research translates findings from basic to clinical to outcomes to health services. In the context of health care needs, people with disabilities have: a more narrow margin of health, more limited opportunities to participate, earlier onset of chronic health and secondary functional loss, requirements for more complicated and prolonged treatments, increased need to access durable medical equipment and assistive technologies, and often require access to long-term services. Therefore, they are major users of health care services. Access to proper health care can be limited by physical, social, and communication barriers, as well as by limitations in financial resources and health plans.
Dr. DeJong's studies indicated that people with disabilities have the same levels of health coverage as the general population, but that they have more reliance on Medicare and Medicaid. The concept of medical necessity is crucial to providing access to needed resources. However, medical necessity is generally modeled on the acute care model, rather than on the need to maintain or enhance function. Along the continuum of services, primary care physicians are ill equipped to deal with people with chronic disabilities. Managed-care systems may provide better access to primary care, but poorer access to specialists, and their record on preventative care is mixed. Rehabilitative care is provided in multiple venues, which varies across health care plans. However, limits in access to outpatient services have created significant upheaval in post-acute care. Positive developments include community-based resources, tele-health to broaden contact with providers, and e-health to improve information access.
Dr. DeJong had several research recommendations: identifying barriers to access, tracking health care experiences, improving definitions of medical necessity, improving understanding of the needs of people with disabilities, promoting health maintenance and prevention, and evaluating outcomes and effects of payment systems.
Dr. Laurie Feinberg of the Office of Health Standards and Quality, Centers for Medicare and Medicare Services (CMS), discussed the Medicare support for rehabilitation. In FY2004, Medicare supported more than 41 million beneficiaries (including almost 6 million people with disabilities under age 65) at a total cost of about $295 billion. Congress sets the eligibility criteria, but policies differ by the provider type. Typically, the issues for beneficiaries are: is it covered? How much can be paid? And, who can be paid? As discussed below, CMS expenditures include outpatient services, home health, inpatient services, and durable medical equipment, prosthetics, and orthotics. Although outpatient services are delivered in various settings, since 1999 all services have been paid on the same basis. Home-health care is only provided to homebound patients and typically involves part-time, intermittent services. Inpatient support must be delivered through "rehabilitation" hospitals and their units and is defined as a length of stay of greater than 25 days. CMS provides about $500 million for prosthetics, $400 million for orthotics, and $8 billion for durable medical equipment.
Although Medicare predominantly focuses on acute-care benefits, this distribution could be influenced by rehabilitation research. This change would require studies on functional outcomes consistent across various settings to assess the comparative efficacy of therapeutic interventions.
Dr. Louis Quatrano provided an overview of health services research supported by the NIH. Current research studies tend to be largely driven by economists and focus more on fiscal constraints than on health outcomes. Because health services are delivered in different settings, it is difficult to compare and contrast processes and outcomes. The NCMRR currently supports a small number of grants in health services, but the NIH has a peer-review group with particular expertise in this area.
Dr. Duane Alexander, Director of the NICHD, thanked Board members for their service to the NIH. Patrick Kochanek has also served as liaison to the National Advisory Child Health and Human Development (NACHHD) Council. (Note: Medical rehabilitation is also represented on the NACHHD by Wise Young, David Gray, and Mindy Aisen; see also http://www.nichd.nih.gov/about/overview/advisory/nachhd/Pages/index.aspx).
Dr. Alexander indicated that the NICHD would receive only a 3.1percent increase in FY2005, which would limit the number of new initiatives. For the next fiscal year, Senator Arlen Spector has proposed a $1.3 billion increase for the NIH, but it is unlikely that there will be comparable support for this increase in the House. Recent Senate testimony from NIH Director Elias Zerhouni focused on reduced administrative support within the NIH and current research in certain areas of science and disease. The House had two full days of hearings on the NIH, which were mostly positive in nature. It is unlikely that the FY2005 budget will be finalized in a timely fashion, but the NIH is developing contingency plans with the likely passage of a continuing resolution.
The five-year "doubling" of the NIH budget was not quite realized due to set asides for bioterrorism research, and the more gradual increases of FY2004 have resulted in decreased paylines across the institutes. Within the NICHD, the payline for investigator-initiated proposals dropped from the 20 th percentile down to the low teens. The institute is trying to recover funds from current programs (e.g., unobligated balances from research networks) and is postponing the start of some other activities. The reduced paylines are also driven by the dramatic increase in the number of research applications across the NIH. For example, the number of NICHD applications increased from about 12,000 pre-doubling to 16,000 after the doubling, and are now at about 22,000. In some cases, the NICHD transferred applications to other institutes to provide support for meritorious research.
The NIH convened a blue-ribbon panel to look at the influences of outside activities and potential conflicts of interest. The panel recommended that, in order to remain competitive, the NIH should continue to support staff involvement in outside activities provided that there is no conflict of interest, especially because government salaries are less than those of the private and academic sectors. But regulations on outside activities need to be transparent and consistent across the NIH Institutes. Consultation with industry should not be allowed for very senior NIH officials, but intramural scientists should be allowed to engage in outside activities, provided that total remuneration does not exceed 50 percent of their current NIH salary, and that the activities do not exceed 400 hours per year. The panel felt that enforcing such recommendations was key to maintaining public trust in the NIH and continued participation in clinical trials.
NIH Roadmap activities (see http://nihroadmap.nih.gov/) have gotten a positive response from the research community, and some of these activities have particular relevance to the NICHD. Each NIH institute is contributing funds to support Roadmap activities through across-the-board taps (currently 0.3 percent increasing to 0.6 percent next year and beyond). Other major research initiatives within the NICHD include studies of prematurity and low birth weight infants, as well as the National Children's Study. The latter is a major longitudinal study of environmental influences on child development that was mandated by Congress in 2000. The Study will recruit 100,000 families with children will be studied from pregnancy through early development, school, and up to age 21. Continued funding for this project has not yet been secured, although the NICHD has already invested $7 million in the initial planning stages, along with contributions from other federal agencies. The National Human Genome Research Institute (NHGRI) has shown some interest in supporting a cohort of about 500,000 adults in which to study the complex genetics of disease; perhaps this effort can be linked to the National Children's Study.
Dr. Alexander indicated that the Institute is rethinking its planning activities. In the past, the NICHD developed an overall "strategic plan", which was re-evaluated every five years though input from program staff. He noted a need to increase involvement of the outside community (e.g., researchers and advocacy groups) in developing this plan, much as the NCMRR works with this Board to help identify and refine research opportunities.
The Board encouraged Dr. Alexander to maintain support for training and new investigators, especially in these times of reduced paylines. They discussed the balance between special funding initiatives and investigator-initiated proposals. Dr. Alexander indicated that the NIH always seeks to support new ideas and pointed out that the NCMRR has had its share of RFAs despite the lean funding. The Board asked whether it was possible to reallocate funds from established programs and contracts to new and competing grants. Dr. Alexander pointed out that the NICHD has several diverse programs and some, like AIDS clinical trials and contraceptives research, must use contract mechanisms. The Board asked how the Institute monitors the productivity of established projects that may no longer be as productive. Dr. Alexander assured them that all projects must periodically compete in the very competitive peer-review process to get renewed, and added that program staff monitors annual progress reports. The Board asked whether medical rehabilitation was specifically brought up in any of the congressional hearings. Dr. Alexander indicated that such questions were rare, but he has continued to highlight NCMRR activities in his annual testimony. The Board asked about the total cost of the National Children's Study and what effect the Study will have on NICHD paylines in the future. The entire study will cost about $2.7 billion over 21 years, but Dr. Alexander pointed out that the Study had tremendous potential for reducing health care costs (e.g., reducing incidence of asthma). Completion of the Study would require multi-agency support and additional appropriation support. The Board asked about NIH Roadmap activities and how these efforts connect to NICHD strategic planning. Dr. Alexander indicated that all institutes participated in developing the Roadmap priorities, and that the broad focus is on reducing barriers to research and promoting trans-NIH activities. Some of the research goals are particularly relevant to the NICHD mission (see http://nihroadmap.nih.gov/).
Dr. Rory Cooper provided some background and history on rehabilitation engineering. The demand for rehabilitative solutions and assistive technologies is increasing and involves several federal agencies, including the National Academy of Sciences, the Department of Veterans Affairs, the Department of Education, the Department of Health and Humans Services, the Department of Justice, and the National Science Foundation. Rehabilitation engineering began to emerge as a formal discipline in the 1950s and is currently supported through professional organizations, specialty research journals, and various commercial interests. Third-party payers have been reluctant to support rehabilitation engineering and assistive technologies, and the situation is further complicated by occasional stories of fraud and abuse.
Despite growing support abroad, there are few doctoral-level rehabilitation engineers in the United States and existing program graduates tend to be drawn into industrial rather than research positions. There are a handful of academic programs accredited in rehabilitation engineering, but there is a shortage of faculty with training in rehabilitative specialties. Some of the research opportunities in this area include: material sciences, robotics (especially in therapeutic delivery), assistive animals, computer modeling, tele-rehabilitation and virtual reality, microelectronics, communications and computing, nanotechnology, automation and controls, genetic engineering, and manufacturing technology. Dr. Cooper encouraged the NIH to promote clinical outcomes, support technology development proposals that may not be hypothesis-driven, enhance collaborations between engineers and clinicians, develop national training programs for engineers, and include more rehabilitation engineers on NIH review panels.
Within the NIH, some rehabilitation engineering is supported through the Small Business Innovation Research (SBIR) projects. Dr. Cooper indicated that the establishment of the new National Institute of Biomedical Imaging and Bioengineering (NIBIB) provided additional opportunities for rehabilitation engineers. The National Science Foundation has supported engineering outcome studies. Nonetheless, rehabilitation engineers need more experience in understanding the needs of people with disabilities, evaluating outcomes, and accounting for means of payment.
Dr. Zev Rymer also discussed the role of the NCMRR in support of rehabilitation engineering, specifically in the development of technologies and applications for people with disabilities. Because technologies advance and change so rapidly, the NCMRR should not commit to any particular technology or approach, but rather should support research into applications and theory. Dr. Louis Quatrano highlighted recent NCMRR funding initiatives in the area of rehabilitation engineering, especially in the support of networking and cross-disciplinary studies. There is a specific career development mechanism (K25) that is targeted to engineers and investigators with quantitative backgrounds. He also discussed the trans-NIH Bioengineering Consortium http://www.nibib.nih.gov and Bioengineering Research Partnership grants.
The Board suggested that a major portion of the next meeting be dedicated to strategic planning for medical rehabilitation within the NICHD. NCMRR staff suggested that, as homework, each Board member should suggest three research priorities for discussion. These topics could include a mix of short-term and long-term priorities, which would be discussed in breakout sessions within the context of potential human impact and research opportunities. Other agenda items would include a discussion of quality-of-life issues, functional assessment, and how NCMRR supports the transition from trainee to independent investigator.
The NCMRR noted its appreciation for the efforts of the following Board members who have completed their terms: Allan Bergman, Melanie Brown, Robert Dean, Gerben DeJong, Lynn Underwood, and especially John Whyte, who served as Chair in his final year. The retiring members were presented with special certificates signed by the NIH Director. The retiring members shared some personal reflections and thanked their Board colleagues and the NCMRR staff for the productive interactions.
The meeting was adjourned at 12:10 p.m.