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Deputy Director, Tulane University School of Medicine

For strategic analysis anti fungal bacterial cream buy generic fulvicin 250 mg line, deficiencies of naval theory in a way can be more serious than deficiencies of force structure yogurt antifungal order 250 mg fulvicin with mastercard. For without an adequate theory of sea power and the use of the sea with prevailing 288 concepts of national power and international circumstances anti fungal mould wash cheap 250mg fulvicin otc, it is impossible to perceive accurately the real correlation of world forces fungus gnat recipe buy 250 mg fulvicin with mastercard. Without integrated and usable theories of naval and national power, one can never know accurately his own strengths and weaknesses or those of his allies and adversaries. In this same sense, the Navy in the 1970s needed to reconsider-and to refine-its classical theory of sea power. The questions that national security managers asked, and to which Navy leaders had to respond, could not be answered without a surer grasp of fundamentals. There was a natural desire to fix such problems in time for the next iteration of the budgeting and programming cycle. In addition to assumptions divergent from those of others in the national security community and a dated theory of sea power, a third problem attenuated Navy ability to hold its own in national security debates of the early and middle 1970s: misapplied methods of analysis and argument. As most people know, it is possible to be right and still to lose, whether in formal debate or in the less formal, but deadly serious, arena of political-military decisionmaking. This perception was without doubt truer at some times and on some issues than others. In 1978-79, for instance, the Secretary of the Navy and the Chief of Naval Operations differed over whether another carrier should have a nuclear or conventional power plant. The effect was to weaken the ability of the leadership to advance any particular program without fear of opponents armed with contrary views of equally professional and competent naval authorities. It is natural, and by no means exclusively a Navy sin, to augment failing arguments with fateful auguries. There was no agreement on the exact extent of American national interests and what they might require in the way of defense; there was no general understanding of what maritime superiority might be and what benefits it could confer on the United States; there was no common concept of the political and strategic implications of having either the first or second navy in the world, nor even any common standard for measuring one navy against another. In this situation, suggestions of imminent or ultimate doom robbed the Navy of credibility; they did not win fundamental or budgetary arguments. A third defect in Navy approaches to 1970s national security debates was an over-reliance on scenario building. But it is an extremely weak debating tool when discussing political expectations, likely next events, or future conditions. The reason for its weakness lies in its accessibility: anyone can play, and everyone does. It is impossible to invent a scenario, introduce it into discussion, and prevent its being altered in ways large and small, often as not to the disadvantage of its sponsor. There neither are rules of evidence nor iules of engagement adequate to prevent the recasting of assumptions, the postulating of alternative results. Scenario building can be a way of formulating ideas about the future; it can never be a method of validating them. Scenario building is most useful in preparing cost and feasibility studies, but even in this, such scenarios often are not sufficiently distinguished from the business of anticipating the future. It is possible by scenario building or game playing to test the ability to cope with various eventualities; it is impossible to prove in such ways that those 290 eventualities will come to pass. The presumption that scenarios used for cost and feasibility studies may actually approximate real world politics and circumstances often leads to inept efforts to exaggerate their meaning. On other potential audiences in academia, the public, the congressional, White House, and National Security Council staffs, and the media, the Navy in the 1970s expended relatively scant and undifferentiated effort. There would be something wrong if such offices were not susceptible to political guidance. Instead, those problems were about present and future circumstances assumed to be realities of varying likelihood and varying importance in budgetary and program planning. In this sense the arguments were political, not analytical in any quantitative sense except in the most minute-and still conjectural4etails. Another weakness of Navy methods in national security debates in the 1970s was the overemployment or inappropriate use of systems analysis and force structure analysis. The Navy had-and in some measure retains-a regrettable tendency to talk hardware and hulls to politicians. Temporarily, at least, the Navy seemed to have lost sight of the uses of systems analysis as a method of evaluating decisions on the margin, rather than in the center, and it was encouraging to see Navy leaders such as Under Secretary R. This is a classic error, one perhaps possible in the Navy in that time only because of shortcomings mentioned earlier: the overconfidence in an enfeebled theory, and relative inattention to people in the national security community holding the power over assumptions. Second, the Navy attempted to use force structure and systems analysis to prevail in arguments about essentially political assumptions.

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A study in one teaching hospital in 1992 found that 11% of time on attending rounds occurred at the bedside (Miller) zeasorb antifungal treatment purchase fulvicin 250 mg with mastercard. A similar study at another teaching hospital in 1993 also found that 11% of medical rounds (an average of 10 minutes out of 90) was spent interacting with patients (Elliot) antifungal wipes purchase fulvicin 250mg on line. Bedside teaching will be discussed in the next section and more fully in Chapter 9 antifungal ear spray cheap fulvicin 250mg amex. The keys to successful inpatient teaching rounds include pacing the session anti fungal infection medicine discount 250mg fulvicin visa, blending teaching with supervision, and helping individuals learn to think in a problem solving way. Realize that you usually do not have an hour to discuss just one case and that some of the ideals for a case discussion may be luxuries that you cannot afford in this setting. For example, while you certainly want everyone to contribute during the session, it is not practical to hear from everyone about every case, and while ideally you might want to discuss all aspects of all cases, time may not permit. There may be times when you have to explain the pathophysiology or provide the most likely diagnosis and best management without much discussion. In general, however, the more the learners are challenged to think and contribute, the better. To paraphrase an old adage, "Solve a problem for an intern today, and you help that intern today. If there are multiple findings or problems, show the learners how to think about possible relationships among these findings. The correlation of basic pathophysiologic principles with the disease process should be stressed. Rounds that focus on the educational objectives of inpatient care must be held at least three times per week and may not be replaced by rounds that are primarily work-oriented. Teaching rounds must include direct resident and attending interaction with the patient, and must include bedside teaching and the demonstration of interview and physical examination techniques. Knowledge is gained not simply by accumulation, but by extending and revising existing knowledge. Sometimes, you just need to give the team the facts and move on to the next patient. Irby analyzed the thinking process of six "distinguished teachers" in internal medicine on attending teaching rounds. The format of the study was a case oriented group discussion led by the attending physician and was artificial in that the house officer or student presented a case from a script rather than a real case on the ward. Irby found that the attending physicians analyzed the cases and the learners simultaneously, that is, they ran both a clinical and an 73 Turner, Palazzi, Ward instructional differential diagnosis and plan simultaneously. Case analysis includes pattern recognition, differential diagnosis, pathophysiology, management, and economic and psychosocial dynamics. Analyzing the learners means not only assessing their knowledge and understanding but also being aware of their comfort level with the session and with group dynamics. Many of the tools and techniques discussed in the chapter on teaching in the ambulatory setting (Chapter 7) can be applied to the inpatient setting, especially when you are working with a single learner, one-on-one. Demonstration, activated demonstration, and observation are useful techniques for inpatient teaching. These tools are discussed in detail in Chapter 7 and will be reviewed here only briefly. The five steps in the microskills model are: 1) getting a commitment; 2) probing for supporting evidence; 3) teaching general rules; 4) reinforcing what was right and; 5) correcting mistakes. The final step, correcting deficiencies, requires more grace and finesse when done in a group than when done one-on-one. The learner Summarizes the history and physical examination, Narrows the differential diagnosis to the major possibilities, and Analyzes these by comparing and contrasting them. Next, the learner Probes the teacher (rather than the reverse) in regard to any question or uncertainties he has and for alternative diagnoses or explanations. Then the learner develops a Plan for management of the patient, and finally, the learner Selects an aspect of the case for self-directed learning. Demonstration and observation are usually done at the bedside, although to some degree, they can be accomplished through role-playing. Time spent with the learner, reviewing, his admission note, history and physical, progress notes, and orders can be invaluable.

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Acute Injuries and Overuse Injuries A sports injury may be defined as damage to the tissues of the body that occurs as a result of sport or exercise antifungal over the counter oral cheap 250 mg fulvicin with visa. In this book antifungal acne cream fulvicin 250mg on line, the term applies to any damage that results from any form of physical activity antifungal treatment for tinea versicolor cheap 250 mg fulvicin otc. Physical activity can be defined as moving or using the body xylitol fungus sinus cheap 250 mg fulvicin with amex, and it includes numerous forms of activity such as working, fitness exercise, outdoor activity, playing, training, getting in shape, working out, and physical education. Sport injuries can be divided into acute injuries and overuse injuries, depending on the injury mechanism and onset of symptoms. In most cases, it is easy to classify an injury as acute or overuse, but in some cases it may be difficult. However, an important concept with overuse injuries is that they exist along a spectrum where the inciting events are below the threshold for clinical symptomatology, but if not rectified, they eventually produce sufficient tissue damage to result in clinical symptoms. Such a response may ignore the underlying clinical symptomatology and thus may interfere with effective treatment. For example, an athlete with a stress fracture (a fatigue fracture) in the foot will often state that the symptoms originated during a specific run, perhaps even from a specific step. However, the actual cause of the stress fracture is that the specific run was a precipitating event on top of the underlying spectrum of tissue damage on the skeleton from overuse over time. Perceived moment of tissue injury 100% Attempted return to sport Antecedent pain Pain threshold Subclinical episodes of failed adaptation Hypothetical point in time when healing is sufficient for sports activity Period of overuse 20% permanent loss of function Time (weeks or months) As shown in Figure 1. Repetitive low-grade forces that lead to microtrauma in the tissues cause overuse injuries. However, if this process continues, the ability of the tissue to repair can be exceeded, resulting in a clinical overuse injury with symptoms. It is vitally important that athletes as well as therapists and physicians understand this concept so that correct treatment can be initiated. The difference between acute injuries and overuse injuries can also be described in biomechanical terms. Dynamic or static muscle action creates internal resistance in the loaded structures (stress) that counteracts deformation (strain) of the tissue. All tissue has a characteristic ability to tolerate deformation and stress, and injuries occur when the tolerance level is exceeded. An acute injury occurs when loading is sufficient to cause irreversible deformation of the tissue, whereas an overuse injury occurs as a result of repeated overloading either in the loading itself or through inadequate recovery time between loadings. Each incidence, alone, is not enough to cause irreversible deformation, but the repeated actions can result in an injury over time. Acute injuries are most common in sports in which the speed is high and the risk of falling is great. Overuse injuries make up the large portion of injuries in aerobic sports that require long training sessions with a monotonous routine. But a large number of overuse injuries also occur in technical sports, in which the same movement is repeated numerous times. The basic principle for training is that the body reacts to a specific physical training load with specific predictable adaptation. Loading that exceeds what an athlete is 2 Total tissue damage Pain level used to will cause the tissue that is being trained to attempt to adapt to the new loading. For example, training provides a stimulus that causes the muscles to increase the production of contractile proteins, the muscle fibers become larger (and more numerous), and the muscle fibers specifically adapt to whether the training requires primarily endurance or maximum strength. This could result from an increase in the duration of individual training sessions or an increase in training intensity or the frequency of training sessions. Often the duration, intensity, and frequency of training increase at the same time, such as at a training camp or at the beginning of the season. Therefore, it is common to say that overuse injuries are due to "too much, too often, too quickly, and with too little rest," which means that training load increases more quickly than the tissue is able to adapt. Biological properties Various Types of Injuries Sport injuries can be divided into soft-tissue injuries (cartilage injuries, muscle injuries, tendon injuries, and ligament injuries) and skeletal injuries (fractures).

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