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By 1943 the German methods were well understood arteria umbilicalis cheap ramipril 1.25mg with visa, and on the way to being effectively copied: the very success of blitzkrieg brought its limitations to light arteria sacralis buy 1.25 mg ramipril visa. Second arrhythmia ekg strips ramipril 2.5 mg otc, the armoured division blood pressure chart different ages ramipril 1.25mg fast delivery, initially created for the offensive, turned out to be almost equally potent on the defensive. In essence, it has remained dominant in all major armies from the middle of the Second World War to the present day. Horses had disappeared from combat, although the poorer armies like the Wehrmacht and the Red Army still used them in large numbers for transport and supply. The skies above the armies swarmed with fighter-bombers, launching deadly attacks on transport, communications, rear echelons, and in some cases enemy fortifications as well as armoured vehicles. Neither the Soviets nor the Japanese (who, as an island people, concentrated on naval aviation) had anything comparable. Only the Germans tried to counter strategic bombing by means of ballistic missiles; these came too late in the war, however, and possessed neither the payload nor the accuracy to have decisive effect. Meanwhile, hidden in the south-western American desert, far away from the centres of hostilities, a new weapon was being forged which would ultimately render all its predecessors obsolete. In less than three years a combination of first-class scientific work, brilliant engineering, astonishing organizational Technology and War I 223 skills, and the unlimited resources made available by total war mobilization had borne fruit. In Hiroshima, in southern Japan, 6 August 1945 was a fine summer day, with a clear sky and excellent visibility. Against this background the first atomic bomb was dropped from a B29 heavy bomber; a thousand suns shone, and large-scale conventional modern war, as it had evolved since 1500, abolished itself. There were always strategic thinkers and practical commanders who recognized that battle was usually bloody and often indecisive. If an opponent could be psychologically unhinged, rendered helpless by subtle manoeuvre, or simply deprived of material means of resistance by the severance of his logistic sinews, so much the better. There were no certainties in combat, which was as damaging to reputations as to life and limb, and, especially during the eighteenth and nineteenth centuries, it was all too easy to see the results of years of laborious peacetime training knocked to pieces in an unlucky afternoon. Battle 225 It was not only military theory and cautious campaigning which contributed to the rarity of battle. For much of history pitched battle depended on the consent of both adversaries, and Clausewitz went so far as to say that `There can be no engagement unless both sides are willing. And even when great armies did clash, many of their soldiers found themselves in the wrong place at the crucial time. The proliferation of supporting services at the expense of combat arms-in itself one of the characteristics of modern war- made it increasingly easy for a soldier to experience war but never to see combat. By November 1918 the American Expeditionary Force in France had over a million men, many of them cooks, drivers, or quartermasters, in its forward zone, supported by 855,600 in the rear area. In mid-1966, when there were 276,000 Americans in Vietnam, with another 30,000 South Koreans and Australians, there were only 44,800 infantrymen in theatre, up to 35,000 of whom were actually available for operations away from bases. This tension between those whose primary function is to engage the enemy and those who support them underlines the fact that, for so many cultures, combat has been much more than a simple military necessity. For the medieval knight, scion of a caste bred to the sword, it was the supreme justification of his 226 Battle existence. It gave the Zulu warrior the opportunity of distinguishing himself and being rewarded with cattle by his king. Across history, hundreds of thousands of men have been impelled into military service by legal compulsion or sheer economic necessity. John Parrish, facing conscription as a medical officer during the Vietnam War, thought that he had three choices: Canada for life, three years in prison, or a year in Vietnam. People talk of their enlisting from their fine military feeling-all stuff- no such thing. Some of our men enlist from having got bastard children-some for minor offences-many more for drink; but you can hardly conceive such a set brought together, and it really is wonderful that we should have made them the fine fellows they are. In Second Empire France, Maurice Fleury was a well-educated young man who squandered his inheritance. Dismissive though Wellington was, we should not underrate the appeal of military service for young men bored by humdrum civilian lives. The test of your courage, your maturity, your sexual prowess; `are you really a man

Wagenaar and Tobler (2007) note that many server training laws "are not optimally designed blood pressure too low symptoms ramipril 1.25 mg for sale, do not ensure quality training pre hypertension low pulse buy ramipril 5mg without prescription, and do not ensure all servers are consistently trained blood pressure medication headache cheap 10 mg ramipril free shipping, or retained periodically" (p arteria lacrimalis ramipril 5mg line. Server training programs are the only segment of responsible beverage service for adults that has been documented and evaluated well. Activities directed at people under 21 are discussed separately in Chapter 1, Sections 6. Use: As of 2005, 17 States had some form of mandatory server training program in place; another 15 States had voluntary programs (Wagenaar & Tobler, 2007). Effectiveness: the findings on the effectiveness of server training have been mixed. They concluded that "intensive, high-quality, face-to-face server training, when accompanied by strong and active management support, is effective in reducing the level of intoxication in patrons" (p. When server training programs are not intensive and are not supported, they are unlikely to result in greater refusals of service to intoxicated patrons. Few studies have examined the effect of server training on alcohol-impaired crashes. An evaluation of a statewide server training program in Oregon found a 23% reduction in singlevehicle nighttime injury crashes following the program (Holder & Wagenaar, 1994). However, Molof and Kimball (1994) reviewed the same Oregon program and observed no decline in alcohol-related fatalities. Alcohol-Impaired and Drugged Driving Costs: A typical alcohol server course takes about 4 to 8 hours. Course costs can be borne by the servers themselves, their employers, or the State. Time to implement: Server training courses are offered by several private vendors and can be implemented in a few weeks. A statewide requirement for server training or more general responsible beverage service policies would require time to enact any necessary legislation, establish policies, and provide for program administration. The Alcohol Epidemiology Program (2000) cites several server training program evaluation studies that found no effect and notes that these programs may have been poorly supported or implemented. The potential threat of legal liability can provide strong encouragement to retailers to adopt responsible beverage service policies and practices. Research shows the implementation of dram shop laws is associated with reductions in alcohol-related crashes and fatalities (Voas & Lacey, 2011). As a result, action against licensed establishments has historically been limited to case law action involving serious crashes. Although alcohol enforcement by police is almost exclusively directed toward drivers, research has demonstrated that enforcement of alcohol service laws can help ensure alcohol retailers follow responsible serving practices. For example, an enforcement program in Michigan resulted in a three fold increase in refusals of service to "pseudo-patrons" who simulated intoxication (McKnight & Streff, 1994). Alternative transportation supplements normal public transportation provided by subways, buses, taxis, and other means. Ride service programs transport drinkers home from, and sometimes to and between, drinking establishments using taxis, private cars, buses, tow trucks, and even police cars. Many are free; some charge users a minimal fee; some are operated commercially on a for-profit basis. Ride service programs are relatively inexpensive and easy for communities to implement. Use: During the 1980s, 325 programs were in operation in 44 States and the District of Columbia (Harding, Apsler, & Goldfein, 1987). Both functioned smoothly and delivered rides but neither demonstrated any effect on crashes (Molof et al. The second study examined a yearround program in Aspen, Colorado, and concluded that it reduced injury crashes in the surrounding county by 15% (Lacey, Jones, & Anderson, 2000). Finally, a program in Wisconsin that provided rides to and from bars using older luxury vehicles resulted in a 17% decline in alcohol-related crashes during the first year (Rothschild, Mastin, & Miller, 2006). The program became largely self-sustaining through fares and tavern contributions. Time to implement: Short-term ride service programs can be established and operated informally in a few weeks. Longer-term programs need to establish long-term strategies for funding and managing the program.

This symposium will document some of the unique challenges for individuals affected by rare diseases toprol xl arrhythmia discount 2.5mg ramipril visa, including uncertainty about their disease course and treatment and interpersonal conflict; demonstrate the value of adaptive coping and social support in enhancing adjustment; and underscore the need for empirically-supported interventions to improve well-being in individuals with a rare disease and their family members arrhythmia symptoms and treatment ramipril 5mg fast delivery. Chart reviews showed an increase in overall screening rates from baseline (11%) to project end (86%) blood pressure medication glaucoma order 2.5mg ramipril with mastercard. Of screens completed hypertension kidney disease symptoms purchase ramipril 5 mg visa, results showed improvements in using an approved screening tool (1% to 85%), scoring and documenting results (26% to 85%), and billing (26% to 82%). Family members faced with this information must cope with their individual and shared cancer risk. The social environment that surrounds at-risk families can be a source of stress through interpersonal conflict, and can provide coping resources through social support - both of which are important predictors of psychological well-being and health. Approximately three years following identification of the family mutation, 157 individuals from 34 families enumerated social network members and indicated who provided social support and with whom they experienced conflict. Individuals who received genetic services reported more emotional support from and less conflict with network members than those who declined. Consideration of family network structure in a subset of families showed decreased likelihood of emotional support provision from those who received genetic services to those who declined genetic services. Further, there was an increased likelihood of emotional support exchange among those who shared support partners, suggesting ongoing communal coping in response to genetic testing and cancer risk. The diminished emotional support and elevated conflict experienced by individuals who declined genetic services may help explain their reluctance to receive such services, and undermine their willingness to pursue testing. Communal coping may bond family members who receive genetic testing and marginalize family members who decline testing. Recent improvements in medical technology have allowed patients with severe chronic illnesses to live longer lives. Psychosocial challenges fell into four broad domains: Physical, Medical, Cognitive Perceptual and Social. Findings support the need for increased awareness among providers and future investigation into potential interventions to enhance well-being in this population. There has been little systematic research on psychosocial factors associated with these disorders and there is a lack of psychometrically sound measures tailored to this population to enable such research. We have developed and piloted appropriate measures of quality of life, resilience, social support and diseaserelated distress in this population. Almost two-thirds (64%) experienced clinically meaningful depression symptoms, a rate higher than that reported for individuals with comparable chronic diseases. Participants also reported high levels of support, quality of life, resilience, and disease-related distress on average. Coping by seeking support, problem-solving, positive reappraisal, and selfcontrol were most common; distancing, escape/avoidance, confrontation, and accepting responsibility were less commonly reported ways of coping. There was no gender difference in depression but women reported greater use of several ways of coping, greater disease-related distress, poorer quality of life, and more physical symptoms than men. This presentation will elucidate the psychosocial condition of individuals with a Mast Cell Disorder and provide a framework for further research and intervention to improve quality of life among affected individuals. The panel will focus on topics related to early career transitions of interest to graduate students and other early career professionals within and outside the academy. The panelists represent a variety of training experiences that include: transitioning from graduate school to an assistant professor position with and without post-doctoral training, adjusting to an assistant professor position within a medical school and at a research-intensive institution, conducting research in several areas of behavioral medicine, and establishing a career outside of a traditional academic setting. Each member of the panel will provide a brief overview of their training, career path, and share a few lessons learned from these experiences. Potential topics might include: identifying a new network of collaborators, managing start-up funds, work-life balance, maintaining a relationship with a former mentor, establishing relationships with new mentors, managing students and staff, and grant writing. Presentations from the panel will be followed by a question and answer session with the audience. Successful mentoring accomplishes many goals including helping the protege to create a programmatic line of research, conduct quality studies, present and publish data, network, and seek funding. High quality mentor-protege relationships also offer many benefits to the mentor including expanding research topics, giving back to the research community, and productive collaborations. However, proteges may be limited in their on-site mentor options and/or may move away from their mentor as they progress through their career.

However heart attack cpr buy generic ramipril 10mg, results of the confirmatory factor analyses suggest the items fit best onto two factors blood pressure under 100 proven ramipril 1.25 mg, which was different from the three factors found in the original scale blood pressure goes up after eating discount ramipril 10mg online. Additionally blood pressure young adult ramipril 5 mg without prescription, the frequency of cigarette smoking was statistically associated with discrimination, but not suspicion. These results are relevant to developing behavioral interventions in smoking cessation of formerly incarcerated men and point to the urgent need for understanding how male smokers across the criminal justice spectrum perceived trust of medical health providers. Eliminating medical mistrusts as a barrier may be an important first step toward eliminating health disparities experienced by criminal justice populations of color. Intensive longitudinal data are increasingly obtained in health studies to examine subjective experiences within changing environmental contexts. In this presentation, we focus on data from an adolescent smoking study using ecological momentary assessment in which there was interest in examining the time to first cigarette in a day, a reported marker of smoking dependency. Consistency in time to first cigarette may be a more meaningful maker of dependency in adolescents, who may not always have as much control over their environment or freedom to smoke at will. These mixed-effects location scale models have useful applications in many research areas where interest centers on the joint modeling of the mean and variance structure. In the last two decades, Latinos have increasingly settled in "non-traditional" rural areas across the country with little to no support systems. Racial/ethnic healthcare disparities arise in the context of social and economic inequalities, including racial and ethnic discrimination and mistrust. However, little research has analyzed mistrust and discrimination influencing health care outcomes among Latinos, particularly those living in rural areas. Using the Behavioral Model of Vulnerable Populations as our guiding theoretical framework, we examined the associations between medical mistrust, perceived discrimination, and satisfaction with health care among young-adult rural Latinos. Our sample included 387 young-adult Latinos living in rural Oregon who participated in a larger project, Proyecto de Salud Para Latinos. In ordered logistic regression models, medical mistrust and perceived discrimination were independently associated with satisfaction with health care, adjusting for other covariates. These results suggest that, although medical mistrust and perceived discrimination are prevalent, they may have a more significant impact on satisfaction with services provided rather than the number of visits. It should be noted that, by design, our study excluded participants who never used health care services. Despite study limitations, we contribute to the broader literature documenting the pervasive effects of medical mistrust and perceived discrimination on racial/ethnic disparities in access to and quality of care. There is increased recognition of the value of palliative care psychologists in medical care. As palliative service expands, treatment teams change in composition, and models of patient care and practitioner self-care develop, there are many questions regarding how to best provide efficient, and quality care. This symposium presents research on the value and challenges of different models of palliative care. In the first presentation will examine the role of patient experience in the development of future palliative care models. The "Patient as Teacher" model uses a mixed method approach as teaching tools for current and future health care providers. The second study presentation will describe the feasibility and effectiveness of a community multi-disciplinary "high-touch" treatment model of palliative care for homebound patients. It will examine patient characteristics and care delivery in a novel palliative care model. Our discussant will examine how this research into the changing models of palliative care may affect the future trajectory of palliative care service delivery for both practitioners and patients. Each of these presentations will examine key aspects of palliative care to inform the future of palliative care research and clinical practice. Adolfo Cuevas, PhD Mistrust in healthcare is associated with lower use of healthcare services and lower adherence to treatment among patients who are African Americans. Past experiences of discrimination may help explain why African Americans may be reluctant to trust healthcare and healthcare providers. However, some African Americans may also be more vulnerable to perceptions of discrimination than others.

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