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- Robert Dunning Dripps Professor and Chair of Anesthesiology and Critical Care Medicine, Professor of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
https://www.med.upenn.edu/apps/faculty/index.php/g319/p3006612
Such information will help improve productivity hypertension medical definition discount warfarin 1 mg visa, identify opportunities to blood pressure how to read cheap warfarin 1 mg on-line strengthen controls against error and events arteriogram generic 2mg warfarin with mastercard, and eliminate error precursors embedded in the task. To promote the use of post-job reviews on a routine basis, they should be easy and quick to do, and the worker must see appropriate changes in response to his or her feedback. Benchmarking Benchmarking is a powerful management tool that should be considered in strategic organizational improvement planning. Since top performers are not generally best in class? in every area, it is important to know exactly the areas being targeted in the top performing organization. Those areas should be matched to areas in the home organization where improvement has been shown to be necessary. From detailed gap analyses, organizations can implement action plans that include benchmarking to address performance shortfalls. Comparison of facility practices with the practices of other like operations that are considered best in class? is an ongoing effort. The implementation of changes resulting from benchmarking should include an overall strategy to disseminate the need, urgency, methodology, and responsibilities for changing a facility process to match that of a benchmarked organization. Adopting a new process should be carried out with specific objectives in mind that are tied to eliminating identified weaknesses in the pre-existing process. They are tools to help managers focus actions on pressing issues in order to drive continuous improvement. The Pareto principle, or 80/20 rule, states that 80 percent of the consequences stem from 20 percent of the causes. This naturally occurring pattern helps identify the big hitters, so that limited resources can be concentrated on resolving or improving the issues that comprise 80 percent (more or less) of all the problems. Once the big-hitter categories have been identified, analysts can plot each category over time, and they can then be addressed. Analysts can plot data over time for these categories to see how each category trends over time. Operating Experience There is a natural tendency for people to think It can?t happen here? or That won?t happen to me. The use of operating experience (using feedback acquired from previously operating equipment or a system, both internal and external to the facility) has proven effective in improving performance and keeping facilities safer. Operating experience helps ground individuals to the risks and vulnerabilities 3-20 Department of Energy Human Performance Handbook Chapter 3 Managing Defenses associated with specific activities. Operating experience is most effective when the right information is communicated to the right people in time to make a difference. Lessons learned can be reinforced during various training forums and through day-to-day activities such as pre-job briefings, coaching and reinforcement by supervisors, as well as through engineering design reviews. Managers routinely provide relevant operating experience information to workers at the time they have a need for it. The pre-job briefing is an excellent venue in which to share the operating experience. The challenge is to get workers to internalize the lessons learned and to apply them where appropriate to their upcoming job. Supervisors should ask individuals with key responsibilities in the work activity to explain how they will avoid specific errors committed in the events described. Supervision then considers appropriate controls to avoid or mitigate errors and the consequences suffered in the described event. Supervisors should elicit work history experiences from individuals experienced with the task and assigned to the present job. They will usually have pertinent information, notably about latent weaknesses that hampered previous job performance and what will prove very useful to the other assigned workers. Independent Oversight It is common for people to forget to be afraid of the risks and threats and to become complacent about latent weaknesses or flawed controls, especially when they are anxiously engaged day in and day out with their project or activities. Or, is it the absence of mindfulness, the presence of a certain mindset, or the existence of some unexplainable blind spots How is it that an individual from another operation visiting in the facility can readily spot a process weakness, an unsafe practice, an error-likely situation, or a weakness in a defense that has gone unnoticed by resident workers and staff? It is because the outsider brings a fresh set of eyes, perceptions based on an ideal mental model of what should be and expectations that unencumbered by local culture, experience and constraints. It is exactly this disparity between insiders and independent observers in their ability to recognize degraded conditions that makes independent oversight such a powerful tool.
I had been imbued with the notion that horror stories are best when they are ambiguous and low key and restrained blood pressure medication for young adults order 5 mg warfarin fast delivery. Horror stories were best when they were big and gaudy arrhythmia 10 year old warfarin 2 mg lowest price, when the natural operatic quality in them was let loose blood pressure medication lisinopril discount 5mg warfarin otc. Very much on my mind was doing something which would be very literary, and at the same time take on every kind of ghost situation I could think of. Also I wanted to play around with reality, to make the characters confused about what was actually real. The material is sort of naturally absurd and unbelievable, and therefore suits a narrative in which the characters are bounced around a whole set of situations, some of which they know rationally to be false. And it seemed fitting to me that this kind of plot would emerge from a group of men telling stories?it was self-referring, which always pleases me very deeply in novels. Rabbitfoot-this was for a story written by a trombonist named Trummy Young, who once played with Louis Armstrong. He gives Peter a copy of the Watchtower, which is forgotten by the reader in the explosive course of events over the next forty pages or so. He sees a bedroom door formed by an interlocking spray of pine needles while hunting in the woods. There are haunted-house stories beyond numbering, most of them not very good (The Cellar, by Richard Laymon, is one example of the less successful breed). My interest in the subject began when a friend and I took it into our heads to explore the local "haunted house"?a decrepit manse on the Deep Cut Road in my home town of Durham, Maine. This place, in the manner of deserted dwellings, was called after the name of the last residents. This ramshackle abode stood on a hill high enough to overlook a good part of our section of town?a section known as Methodist Corners. After having explored the downstairs thoroughly (and ascertained to our satisfaction that the old-fashioned sulphur matches we had found in the kitchen would no longer light but only produce a foul smell), we went upstairs. Unknown to us, my brother and cousin, two and four years older than my friend and I, had crept in after us. As the two of us poked through the upstairs bedrooms, they began to play horrible, jagged chords on the piano down in the living room. My buddy and I screamed and clutched each other?for a moment the terror was complete. Then we heard those two dorks laughing downstairs and we grinned at each other shamefacedly. Nothing really of which to be afraid; just a couple of older boys scaring the old Irish bejaysus out of a couple of younger ones. Years later I read a speculative article which suggested that so-called "haunted houses" might actually be psychic batteries, absorbing the emotions that had been spent there, absorbing them much as a car battery will store an electric charge. Thus, the article went on, the psychic phenomena we call "hauntings" might really be a kind of paranormal movie show? the broadcasting back of old voices and images which might be parts of old events. And the fact that many haunted houses are shunned and get the reputation of being Bad Places might be due to the fact that the strongest emotions are the primitive ones?rage and hate and fear. I did not accept the ideas in this article as gospel truth?it seems to me that the writer who deals with psychic phenomena in his or her fiction has a responsibility to deal with such phenomena respectfully but not in a state of utter, worshipful belief?but I did find the idea interesting, both for the idea itself and because it suggested a vague but intriguing referent in my own experience: that the past is a ghost which haunts our present lives constantly. And with my rigorous Methodist upbringing, I began to wonder if the haunted house could not be turned into a kind of symbol of unexpiated sin. The theory suggested that the inhabitants might indeed have gone on, leaving only a psychic residue behind. But even so (as Kenneth Patchen says), that did not rule out the possibility that the residue might be extremely harmful, as lead-based paint can be harmful to children who eat flakes of it years after it has been applied. So I went back to the house-as-psychic-battery idea and tried to write a story in which that concept would take center stage. The Shining is set in the apotheosis of the Bad Place: not a haunted house but a haunted hotel, with a different "real" horror movie playing in almost every one of its guest room and suites. The list is endless, and probably all of it goes back to the caveman who had to move out of his hole in the rock because he heard what sounded like voices back there in the shadows. Whether they were actual voices or the voices of the wind is a question we still ask ourselves on dark nights. I want to talk here about two stories dealing with the archetype of the Bad Place, one good, one great. Our homes are the places where we allow ourselves the ultimate vulnerability: they are the places where we take off our clothes and go to sleep with no guard on watch (except perhaps for those ever more popular drones of modern society, the smoke-detector and the burglar alarm).
No credit will be granted toward certification in a subspecialty for training completed outside of an accredited ocular hypertension purchase 1 mg warfarin otc. Transplant Hepatology met by aggregating full-time clinical training that occurs throughout At the time of application for certification in a subspecialty heart attack cafe discount warfarin 2mg fast delivery, physi the entire fellowship training period; clinical training need not cians must have been previously certified in Internal Medicine be completed in successive months heart attack 5 year survival rate warfarin 5 mg without prescription. Educational rotations To become certified in a subspecialty, a physician must satisfactorily completed during training may not be double-counted to satisfy complete the requisite graduate medical education fellowship both internal medicine and subspecialty training requirements. Likewise, training which qualifies a diplomate for admission to one Diplomates must be previously certified in either internal medicine subspecialty examination cannot be double-counted toward certi or a subspecialty to apply for certification in: fication in another subspecialty, with the exception of the formally. The following are Endocrinology, Diabetes, and Metabolism+ the procedural requirements for the two-year curriculum. Procedures for Subspecialties Critical Care Medicine Airway management and endotracheal intubation; ventilator Adolescent Medicine management and noninvasive ventilation; insertion and manage No required procedures. Practical experience is recom catheterization, including insertion and management of temporary mended. Continuous glucose monitoring* Pulmonary Disease Airway management including endotracheal intubation; fiberoptic * these new requirements will go into effect for those beginning fellowship in the 2016?17 academic year. Endocrinology recording systems; supervision of the technical aspects of pulmo fellows graduating in June 2018 and after will be evaluated on nary function testing; progressive exercise testing; insertion and the above procedures. Proficiency Gastroenterology in use of ultra-sound to guide central line placement is strongly Diagnostic and therapeutic upper and lower endoscopy. Diagnostic aspiration of and analysis by light and polarized light Hematology microscopy of synovial fluid from diarthrodial joints, bursae and Bone marrow aspiration and biopsy, including preparation, tenosynovial structures; and therapeutic injection of diarthrodial examination and interpretation of bone marrow aspirates and joints, bursae, tenosynovial structures and entheses. Transplant Hepatology Performance of at least 30 percutaneous liver biopsies,* including Infectious Disease allograft; interpretation of 200 native and allograft liver biopsies; No required procedures. The following are the revised procedures: performance as primary operator of 150 therapeutic interventional cardiac procedures in the two years prior to application for exam. A minimum of 20 liver biopsies, including native and allograft, therapeutic agents and biological products through all therapeutic should be performed. Plans for combined training should arrange for any additional training needed to achieve a satisfactory be prospectively approved in writing by both the rheumatology rating in each component of clinical competence. Dual Certification Requirements Admission to either examination requires: (1) certification in internal Hematology and Medical Oncology medicine; (2) satisfactory clinical competence; and (3) completion Dual certification in hematology and medical oncology requires of the entire three-year combined program. If accredited combined training, 18 months of which must be clinical the combined training must be taken in two different programs, 24 training in gastroenterology and 12 months of clinical training in continuous months must be in one institution, and both institutions transplant hepatology. Combined training must be completed in a must be accredited in both hematology and medical oncology. Those who elect to take an examination in one subspecialty following only two years of fellowship training will be required to complete four years of accredited training for dual certification. Should the candi training before being admitted to the Gastroenterology Certification date transfer to another training program, they would no longer be Examination. Certification in gastroenterology must be achieved eligible for dual certification unless they meet the standard training before the candidate is eligible to apply for admission to the requirements separately to apply for both exams. A minimum of 20 liver biopsies, including native and allograft, should be performed. Demonstrate knowledge of the indications, contra-indications, limitations, complications, alternatives and techniques of native and allograft liver biopsy and noninvasive methods of fibrosis assessment. Unless the trainee has already All trainees in the Research Pathway must satisfactorily complete achieved an advanced graduate degree, training should include 24 months of accredited categorical internal medicine residency completion of work leading to one or its equivalent. A minimum of 20 months must involve direct patient of the Research Pathway may be taken in a full-time faculty position responsibility. These requests must be the training program; rather, the program director has the discre made in writing and in a timely manner to ensure that the new tion to apply this policy to ensure the balance of time needed program director has the performance evaluations for review to assure competency in the discipline is achieved at the end before offering a position. The Deficits in Required Training Time policy is not intended to be Leave of Absence and Vacation used to shorten training before the end of the academic year. A six week permitted over the course of the training program for time away medical leave in the F-1 year causes the total cumulative leave from training, which includes vacation, illness, parental or family over the 24-month training period to exceed the 70 days of leave, or pregnancy-related disabilities.
It can take up to blood pressure numbers generic warfarin 1 mg on-line an hour to blood pressure chart by age cheap 5mg warfarin fast delivery estimate the model parameters depending on the speed of your computer high blood pressure medication list new zealand purchase warfarin 1 mg with visa. The Sin(Data)-Region i option will show the sin of the phase data in region i, for the? The Coupling(As) and Coupling(Bs) buttons display the estimated endogenous and modulatory activity shown in Figure 44. These can then be changed by an amount bij as shown in the modulatory parameter matrices. In this case it is possible to specify more generic phase interaction functions, such as arbitrary order Fourier series. The generative model now reports coherence and signal covariance as well as complex spectral densities (from which the former are derived). The rodent was presented with a white noise auditory input for several minutes at each anaesthetised level and time series recordings were obtained for the entire epoch. We demonstrate in this chapter the consistency of the model comparison and conditional parameter estimates across di? The smaller this value, the greater the gain on this cell population due to the modulation. These three subpopulations are connected with intrinsic coupling parameters (which can be found in spm fx mnn nmda). Lateral, inter-hemispheric connections are modelled with a postsynaptic response that is elicited in all layers. This outperformed a model comprising the same two neural masses with the same extrinsic connections but where the e? The conversion script can be altered to suit your own conditions/sampling parameters. Since we are interested in the anaesthetized trials we enter [1 2 3 4] under the trials label and Iso 1. Right: Data time series for two intracranial electrode recordings from 25000 to 30000 msec. Bottom: conditional probability for each model assuming equal priors on model space. You will see at the top, a bar plot of the log-model evidences for all models (Figure 45. The bottom panel displays the conditional probability, for each model assuming equal priors on model space. By convention, a model can be said to be the best among a selection of other models, with strong evidence, if its log-model evidence exceeds all other log-model evidences by at least 3. As neuronal process requires extra delivery of oxygen, this hemodynamic change provides a marker of under lying neuronal activity. However, due to complex relationships between neurodynamic and hemodynamic processes, functional con nectivity often di? In the second session, the subjected was instructed to perform kinesthetic imagery of the same hand movement, but without moving the hand. Select yes? to average the optical density signal across trials, and then specify averaging window length [secs] for each experimental condition. You can refer to sensor positions shown in Figure 1: Optode and Channel Positions. Middle: Regions receiving driving input (eg, motor tasks encoding the occurrence of motor execution and motor imagery tasks). It is also suggested that Native Space versions of the tissues in which you are interested are also generated. Segmentation can require quite a lot of memory, so if you have large images (typically greater than about 256? The next step is to estimate the nonlinear deformations that best align them all together [4]. This is achieved by alternating between build ing a template, and registering the tissue class images with the template, and the whole procedure is very time consuming. If you run multiple Dartel sessions, then it may be a good idea to have a unique template basename for each. Template generation incorporates a smoothing procedure [10], which may take a while (several minutes).
Towards this last end blood pressure chart runners cheap warfarin 1 mg with amex, he recommended employing potions to blood pressure levels high discount warfarin 5mg with amex clog and stupefy the senses blood pressure medication heart rate cheap warfarin 2mg on-line, thereby producing visions. He also advocated dream interpretation, the use of herbs and magical stones, animal potions and images engraved on gems. When these practices did not work, Albertus maintained the defects were not to be found in the science of natural magic but in the souls of those who abused it. Renaissance Explorations Cornelius Agrippa Cornelius Agrippa 45 As for the art of invoking spirits, Cornelius Agrippa, a magus whose influence was considerable in his day, has left us a description: If you would call any evil Spirit to the Circle it first behooveth us to consider and to know his nature, to which of the planets he agreeth, and what offices are distributed to him from the planet. This being known, let there be sought out a place fit and proper for his invocation, according to the nature of the planet, and the quality of the offices of the same Spirit, as near as the same may be done. For example, if his power be over the sea, rivers or floods, then let a place be chosen on the shore, and so of the rest. In like manner, let there be chosen a convenient time, both for the quality of the air - which should be serene, quiet and fitting for the spirits to assume bodies - and for the quality and nature of the planet, and so, too, of the Spirit: to wit, on his day, ignoring the time wherein he ruleth, whether it be fortunate or unfortunate, day or night, as the stars and Spirits do require. These things being considered, let there be a circle framed at the place elected, as well as for the defense of the invocant as for the confirmation of the spirit. In the Circle itself there are to be written the general Divine names, and those things which do yield defense unto us; the Divine names which do rule the said planet, with the offices of the spirit himself; and the names, finally, of the good Spirits which bear rule and are able to bind and constrain the Spirit which we intend to call. If we would further fortify our Circle, we may add characters and pentacles to the work. So also, and within or without the Circle, we may frame an angular figure, inscribed with such numbers as are congruent among themselves to our work. Moreover, the operator is to be provided with lights, perfumes, unguents and medicines compounded according to the nature of the Planet and Spirit, which do partly agree with the Spirit, by reason of their natural and celestial virtue, and partly are exhibited to the Spirit for religious and superstitious worship. The operator must also be furnished with holy and consecrated things, necessary as well for the defense of the invocant and his followers as to serve for bonds which shall bind and constrain the Spirits. Such are holy papers, lamens, pictures, pentacles, swords, sceptres, garments of convenient matter and color, and things of like sort. When all these are provided, the master and his fellows being in the Circle, and all those things which he useth, let him begin to pray with a loud voice and convenient gesture and countenance. If he will read any prayers, psalms or gospels for his defence, these should take the first place. Thereafter, let him begin to invocate the Spirit which he desireth, with a gentle and loving enchantment to all the coasts of the world, commemorating his own authority and power, Let him then rest a little, looking about him to see if any Spirit do appear, which if he delay, let him repeat his invocation as before, until he hath done it three times. If the Spirit be still pertinacious and will not appear, let him begin to conjure him with the Divine Power, but in such a way that all the conjurations and commemorations do agree with the nature and offices of the spirit himself. Reiterate the same three times, from stronger to stronger, using objurations, contumelies, cursings, punishments, suspensions from his office and power and the like. But if in anything the Spirit shall show himself obstinate and lying, let him be bound by convenient conjurations, and if you still doubt of any lie, make outside the Circle, with the consecrated Sword, the figure of a triangle or pentacle, and compel the Spirit to enter it. If you would have any promise confirmed by oath, stretch the sword out of the Circle, and swear the Spirit by laying his hand upon the sword. Then having obtained of the Spirit that which you desire, or being otherwise contented, license him to depart with courteous words, giving command unto him that he do no hurt. If he will not depart, compel him by powerful conjurations and, if need require, expel him by exorcism and by making contrary fumigations. When he is departed, go not out of the Circle, but stay, making prayer for your defense and conservation, and giving thanks unto God and the good angels. But if your hopes are frustrated, and no Spirit will appear, yet for this do not despair but, leaving the Circle, return again at other times, doing as before. Occult scholarship attempted to systematize everything from tastes, smells, colors, and body parts, to herbs, charms, spirits and dreams. It was an imaginative effort based primarily on introspection and reflection, but without proper standards of measurement and adequate means of correcting error. Nevertheless deep levels of the psyche were involved in this effort to condense esoteric knowledge into meaningful symbols. This in-depth study of the intuitive and emotional connections between consciousness and the external world has a built-in difficulty in that the exact conditions necessary to create subtle intuitions and visions do not readily repeat themselves.
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