Tenormin

Christopher P. Holstege, MD

• Associate Professor, Departments of Emergency Medicine & Pediatrics
• Director, Division of Medical Toxicology, University of Virginia School
• of Medicine, Charlottesville, VA, USA

In contrast hypertension word parts 100 mg tenormin buy visa, presentations to middle managers and program administrators are more comprehensive heart attack feels like generic tenormin 50 mg mastercard. A two to three hour review of the data hypertension recipes purchase 50 mg tenormin fast delivery, and the methodology used to gather the data heart attack vegas purchase tenormin 50 mg visa, is not unusual. Use of audiovisual aids is recommended to enhance the understanding and engagement of managers and program administrators and a variety of media can be employed in the presentation of results. Similarly, engaging managers in the health promotion process, through individualized health risk appraisals or "personal training" with feedback, can be a useful way of educating the decision makers on the relevance of the program by doing so on an individual basis. It is imperative that all of the data, both positive and negative, be presented to decision makers. The credibility of the evaluation team hinges on its openness and honesty in presenting program results. If it is determined at a later date that misinformation was presented, or that critical information was omitted, then not only is the credibility of the evaluation team at stake but also that of the staff managing the program. In presenting results, the evaluator needs to help the audience interpret findings to reach valid conclusions. To the evaluator, the conclusions may be obvious, only because the evaluator has been working with the data for some time. To the audience members who are first exposed to the potentially voluminous and complex findings, results may be confusing and even contradictory. Thus, the evaluator should summarize and draw conclusions from the data to help the audience verbalize possible implications for action. Finally, the evaluator should prepare the audience for future results by speaking about ongoing evaluation activities, other studies that are planned, or follow up to the analysis just presented. Dashboards Results obtained from the descriptive analysis are typically displayed in tables and charts. A dashboard is a snapshot of the results, displayed graphically, and designed to be easily absorbed and interpreted by a manager who is not a statistician. Dashboards present data at the level of the entire sample or by intervention site. Highlighting one or two key measures or indicators for the overall sample can provide insight into how all employees fare in terms of health or healthcare utilization and costs regardless of job location. Similarly, highlighting the top three health risks across the entire sample may also be informative. If the rescreening costs are classified as programmatic costs, since such rescreening is itself an intervention, then the costs of study preparation and data analysis can often be accomplished with the above $5,000 - $10,000 budget, assuming the availability of internal staff expertise to design the measurement instruments, distribute the survey, code the responses, analyze the data, and prepare a final report. Financial impact studies are generally more elaborate and therefore more expensive to conduct. Typical retrospective absenteeism and medical claims studies can cost between $150,000 and $250,000 (in 2013 dollars including database build costs). More elaborate evaluation efforts that examine and relate multiple databases may cost many hundreds of thousands of dollars. Thus, when discussing evaluation activities directed at financial impact measures, program sponsors and evaluators need to be educated regarding the complexity of such studies and concomitant cost implications. An intervention site dashboard may contain information specific to the intervention implemented at a specific location. For example, for an intervention site that has introduced weight reduction programs, the dashboard may include a comparison of participants and non-participants on measures related to nutrition, physical activity, and weight. Other examples of dashboard reports include "top 10" claims by prevalence or cost. Depending on the frequency of data collection and the needs of managers, dashboards can be reported monthly, quarterly, semi-annually, or annually. Five to ten percent of the total intervention program budget is probably sufficient to cover evaluation costs, with higher amounts spent early on, when a baseline needs to be established and early results are presented to management. The key drivers in establishing an evaluation budget are the overall size and intensity of the intervention program. A $100,000 a year intervention program would require $5,000 to $10,000 to be spent annually for evaluation. This amount would cover the cost of surveys that ask about program participation, self-reported health improvements, effects on morale, and satisfaction with program components. Studies that examine health improvements among program participants require that a follow-up health risk assessment be conducted, typically at 12-month intervals. The costs of doing this type of study include those associated Analysis timetable Once all of the groundwork has been completed in planning the program, a plan for reporting results needs to be developed.

While hospitals had evacuated some of their patients before landfall coenzyme q10 high blood pressure medication order tenormin 50 mg free shipping, they had retained others thought to be too frail for transport blood pressure index chart generic tenormin 100 mg without a prescription, and believed that by staying open they would be available to serve hurricane victims blood pressure chart with pulse rate discount tenormin 50 mg on line. Their strategy became untenable after landfall when power was lost blood pressure and dehydration 50 mg tenormin purchase fast delivery, and their backup generators were rendered inoperable by flooding and fuel shortages. Although they were required to have plans on file with local government, there was no process to ensure that there were sufficient resources to evacuate all the nursing homes at once, and dozens of patients who were not evacuated died. When evacuation became necessary, some sent their patients to the Superdome, where officials, struggling to handle the volume of patients already there, were obliged to accept still more. Long-Term Factors Contributed to the Poor Response 12 Actions taken ­ and failures to act ­ well before Katrina struck compounded the problems resulting from the ineffective leadership that characterized the immediate preparations for Hurricane Katrina: A Nation Still Uprepared the hurricane and the post-landfall response. While the Committee did not examine the conflicting political or budget priorities that may have played a role, in many cases the shortsightedness associated with the underfunding is glaring. Its police and fire departments, responsible for search-and-rescue activities, had five boats and no boats, respectively. Local and state officials have known since at least 1994 about the need to address this problem. For its part, the federal government, which knew about this problem for some time, neither 13 Executive Summary monitored their planning nor offered assistance. While the Superdome provided shelter from the devastating winds and water, conditions there deteriorated quickly. While the Secretary attempted to defend his inaction in a personal appearance before the Committee, the Committee found his explanations rang hollow, and his account of uncommunicated doubts and objections to state policy disturbing. Had his Department identified available buses or other means of transport for evacuation within the state in the months before the hurricane, at a minimum the state would have been prepared to evacuate people stranded in New Orleans after landfall more quickly than it did. There was little advance preparation for responders operating in an area with no power and where virtually all forms of pre-existing communications were destroyed. And while satellite phones were available to some, either they did not function properly or officials were not trained to use these relatively complex devices. These planning failures would have been of far less consequence had the system of levees built to protect New Orleans from flooding stayed intact, as they had in most prior hurricanes. The levee failures themselves turned out to have roots long predating Katrina as well. While several engineering analyses continue, the Committee found deeply disturbing evidence of flaws in the design and construction of the levees. For instance, two major drainage canals ­ the 17th Street and London Avenue Canals ­ failed at their foundations, prior to their flood walls being met with the water heights for which they were designed to protect central New Orleans. Moreover, the greater metropolitan New Orleans area was literally riddled with levee breaches caused by massive overtopping and scouring of levees that were not "armored," or properly designed, to guard against the cascading waters that would inevitably accompany a storm of the magnitude of Hurricane Katrina. The Committee also discovered that the inspectionand-maintenance regime in place to ensure that the levees, floodwalls, and other structures built to protect the residents of the greater New Orleans area was in no way commensurate with the risk posed to these persons and their property. Equally troubling was the revelation of serious disagreement ­ still unresolved months after Katrina ­ among officials of several government entities over who had responsibility, and when, for key levee issues including emergency response and levee repair. While the deadly waters continued to pour into the heart of the city after the hurricane had passed, the very government agencies that were supposed to work together to protect the city from such a catastrophe not only initially disagreed about whose responsibility it was to repair the levee breaches, but disagreed as to how the repairs should be conducted. Sadly, due to the lack of foresight and overall coordination prior to the storm, such conflicts existed as the waters of Lake Pontchartrain continued to fill central New Orleans. While the Committee did not specifically include this issue in its investigation, the Committee became aware of wasteful, and sometimes fraudulent and abusive spending practices, and held two hearings on the subject. It takes money to prepare, respond, and recover from a disaster, and typically the bigger the disaster, the more money it takes. As of March 8, 2006, the federal government had committed $88 billion to the response, recovery, and rebuilding efforts. Its Director would be assured of having sufficient access and clout by having the rank of Deputy Secretary, and having a direct line of communication to the President during catastrophes. Our second core recommendation is to endow the new organization with the full range of responsibilities that are core to preparing for and responding to disasters. These include the four central functions of comprehensive emergency management ­ mitigation, preparedness, response, and recovery ­ which need to be integrated. At the same time, it must not neglect to build those unique capabilities ­ like mass decontamination in the case of a radiological attack or water 16 Hurricane Katrina: A Nation Still Uprepared search and rescue in the case of flooding ­ that will be needed for particular types of incidents. Our third core recommendation is to enhance regional operations to provide better coordination between federal agencies and the states and establish regional strike teams. These regional Strike Teams should coordinate their training and exercises with the state and local officials and the private sector entities they will support when disasters occur.

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Richard Myers heart attack effects tenormin 100 mg buy amex, "Defense Department Operational Update Briefing arrhythmia associates generic tenormin 100 mg buy line," news briefing pulse pressure gap tenormin 100 mg buy amex, Sept heart attack maroon 5 generic tenormin 50 mg without prescription. Army, former Commander of First Battalion, 148th Infantry, Ohio National Guard, conducted on Feb. It seeks to delineate the mechanisms for coordinating federal support to states, localities, and tribes; for interacting with nongovernmental and private-sector entities; and for directly exercising federal authority when appropriate. It is a complex, ambitious, 400-pluspage, high-level plan that was well described in a document produced to the Committee by the Office of the Vice President as "a very detailed, acronym-heavy document that is not easily accessible to the first-time user. Both positions have coordination responsibilities, but they are not clearly distinguished. It was not designed to address specific scenarios or geographic areas, or to provide operational details. The Catastrophic Incident Annex sets out the broad principles of a proactive response; the Catastrophic Incident Supplement was supposed to fill in significant, operational details. The heart of the Supplement is an Execution Schedule that provides an agency-by-agency (and hour-by-hour) list of the assets various federal agencies are to deploy automatically to the affected area once the Secretary of Homeland Security orders implementation. Even if the Supplement had been implemented, however, it is not clear that it would have been adequate to the task at hand. The Execution Schedule is essentially a method of pre-prioritizing a certain set of assets ­ an important and potentially very useful function, but not by itself likely to constitute a sufficient response to an event of catastrophic magnitude. In testimony before the House of Representatives, the Secretary said, "I did it because we were going to have a Cabinet meeting the next day and I wanted to have some kind of a documented notification of the steps I had taken. Some of his duties appeared to be assumed by his Deputy, Patrick Rhode, but he took no formal steps, nor was he asked to take any, to relinquish his other responsibilities. Indeed, on September 1, 2005 ­ three days after Katrina made landfall ­ an earthquake struck California. The development of another potentially devastating hurricane, Hurricane Rita, a mere four weeks after Katrina further underscores the problems inherent in tying the Director to the management of a single, specific incident. It does, however, set a policy and tone for an urgent and proactive response that moves beyond the usual procedures in responding to an "ordinary" disaster. After landfall, it should have been immediately apparent that the catastrophe had occurred. Indeed, Secretary Chertoff would eventually describe Katrina as an "ultra catastrophe. The yet-to-be-issued Catastrophic Incident Supplement was somewhat more explicit, stating that it is intended to apply to "no-notice" or "short-notice" events. As Comptroller General David Walker testified, "the idea that we would be less proactive in dealing with a known natural disaster [than with a no-notice event] just defies common sense. Even in the case of a minor incident involving a single response agency, response personnel must quickly determine what is happening and then coordinate and control many separate activities at the scene to ensure everyone is working toward a common, productive goal. If the incident is a disaster or catastrophe, the failure to coordinate multiple agencies from different jurisdictions, each with its own internal lines of communication and authority, can seriously degrade the capabilities of the government as a whole to respond effectively. The absence of interoperable communications or an effectively trained and exercised plan will further undermine the response. Hurricane Katrina brought about an attempt to establish a unified command among multiple agencies during a significant natural disaster. Agencies work together through the designated members of the Unified Command to establish their designated Incident Commanders at a single [location] and to establish a common set of objectives and strategies and a single Incident Action Plan. When multiple agencies or multiple jurisdictions are involved, they should adopt a unified command. The precise nature of a unified command structure will depend on particulars of the incident, but in general, each agency with jurisdictional authority or functional responsibility will participate in a collaborative process. Health and medical folks, while they want to comply with it, are just not familiar with it. So as opposed to having a knee-jerk reaction to a very hard-hitting federal mandate, we thought it was an appropriate response to phase it in over time, do the cultural awareness, migrate; while there were negative incentives in there in terms of provision of grant assistance, where we were trying to get to was that we were moving in that direction because it was a good idea, not because it was a federal mandate. Lokey, Wells, and Colonel Smith worked alongside one another in the State Emergency Operations Center in Baton Rouge.

After an early general sampling heart attack and water tenormin 50 mg low price, the frontally damaged patients systematically turned more cards in the A and B decks arteria occipital tenormin 100 mg lowest price, and fewer and fewer cards in the C and D decks blood pressure kit cvs order 100 mg tenormin fast delivery. Despite the higher amount of money they received from turning the A and B cards blood pressure chart homeostasis buy generic tenormin 100 mg line, the pen alties they kept having to pay were so high that halfway through the game they were bankrupt and needed to make extra loans from the experimenter. In the case of Elliot, who played the game, this behavior is especially remarkable because he still describes himself as a conservative, low-risk person, and because even normal subjects who described themselves as high-risk and as gamblers performed so differently, and so prudently. Moreover, at the end of the game, Elliot knew which decks were bad and which were not. When the experiment was repeated a few months later, with dif ferent cards and different labels for the decks, Elliot behaved no differently from how he did in real-life situations, where his errors have persisted. It engages the subject in a quest for advantage, it poses risks, and it offers choices but does not tell how, when, or what to choose. It is full of uncertainty, and the only way to minimize that uncertainty is to generate hunches, esti mates of probability, by whatever means possible, since precise calculation is not possible. The neuropsychological mechanisms behind this behavior are fascinating, in particular for the frontally damaged patients. Clearly Elliot was engaged in the task, fully attentive, cooperative, and interested in the outcome. As with his other behaviors, we can invoke neither lack of knowledge nor lack of understanding of the situation. Normal controls pre er decks C and D f overall, whilefrontal patients do the opposite. And yet he persisted in choosing the $lOo-paying decks, which brought him loss every time he was penal ized. We cannot even suggest that a continuation of the game required an added memory load, because the continued dire or positive results were made explicit, so often. As their losses accumu lated, Elliot and the other frontally damaged patients had to take loans which served as obvious proof of the negative course of their playing. And yet they persisted in making the least advantageous choices for longer than any other group of subjects so far observed in this task, including several patients with brain damage outside the frontal lobes. Patients with large lesions elsewhere in the brain-for instance, outside the prefrontal sectors-can play the gambling game as nor mals do provided they can see and can understand the instructions. A patient with a severe naming defect caused by dysfunction of the left tem poral cortex played the entire game worrying aloud, in her broken, aphasic language, that she could not make any sense of what was going on. They are no longer sensitive to punishment as normal sub jects are, and are controlled only by reward. They have become so sensitive to reward that its mere pres ence makes them overlook punishment. They are still sensitive to punishment and reward but neither punishment nor reward contributes to the automated mark ing or maintained deployment of predictions of future out comes, and as a result immediately rewarding options are favored. Now punishment came first, in the form of large or not-so-large payments with every card-turning, while reward came interspersed with the turning of some cards. As was the case in the first game, two decks yielded a gain and two decks yielded a loss. In this new task Elliot performed pretty much as normal subjects, and the same was true of other frontal lobe patients. In other words, the idea that Elliot and other frontally damaged pa tients were merely insensitive to punishment could not be correct. The profiles showed that immediately after making a penalty payment, the patients avoided the deck from which the bad card had come, just as normal subjects did, but then, unlike normals, they returned to the bad deck. This also suggests that the patients were still sensitive to punishment, although the effects of punishment did not seem to last for very long, probably because it was not connected with the formulation of predictors concerning future prospects. Deprived of the marking or sustained deployment of predictions of the future, these patients are con trolled largely by immediate prospects and indeed appear insensitive to the future. This suggests that patients with frontal lobe damage suffer from a profound exaggeration of what may be a normal basic tendency, to go for the now rather than bank on the future. But whereas the tendency is brought under control in normal and so cially adapted individuals, especially in situations where it does matter personally, the magnitude of the tendency becomes so over whelming in frontal lobe patients that they easily succumb. Inebri ation does narrow the panorama of our future, so much so that almost nothing but the present is processed with clarity. One of the most distinctive human traits is the ability to learn to be guided by future prospects rather than by immediate outcomes, something we begin to acquire in childhood.

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