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This stanza lays out Sun Tzu’s second strategic principle for the attainment of superiority—not only identifying but creating and subsequently fully exploiting the adversary’s vulnerability by acting beyond their physical abilities and mental calculations medications 10325 buy tolterodine 2mg on line. The adversary’s physical capabilities should be made vulnerable and overcome through ofensive and defensive manoeuvres symptoms meaning purchase tolterodine with amex, while the cognitive domain should be overwhelmed through sophisticated conceptual initiatives symptoms 7 buy discount tolterodine 2 mg. When a force can manoeuvre freely without external interference and can attack anywhere while retaining the capability to defend all its positions, military strategy is complete. The ability to be successful in attack depends primarily on the adversary’s weaknesses and perhaps more importantly on one’s own ability to correctly identify and exploit them. Similarly the ability to defend against all odds is a function of understanding the adversary’s strengths in the ofensive and guarding against that advantage being used efectively against one’s own weaknesses. Both ofensive and defensive action will encompass the creation of illusions that hide the reality—manipulating the cognitive domain—and physical actions that negate any advantage to the adversary. Achieving a dominant position, generating long term vision, and developing strategic concepts that are sure to succeed, are all functions of astute employment of knowledge. As a corollary, weaknesses emanate from ignorance or unawareness of one’s own position of strength. The adversary’s ignorance must be identifed and targeted while simultaneously leveraging one’s own strengths. This will create a situation wherein the actions being initiated are beyond the full comprehension of the adversary, leading to confusion both in the physical as well as cognitive domains. Essentially, a skilled commander will be able to take advantage of all opportunities to seize and exploit enemy vulnerabilities and act beyond enemy understanding. The last part of the stanza regarding the relative incompetence of the adversary in defence and ofence making it easier for the skilled warrior to triumph in both is an aphorism that states the essence of the entire strategy in a nutshell. This stanza is concerned with the concept of both ofence and defence in two distinct domains—the physical and the cognitive. In air power terms, the physical domain is about rapid mobility and lethal application of force both in the ofensive as well as on the defensive. Strategic global reach, achieved through air mobility, can bypass or avoid enemy defences and inhospitable terrain, becoming a war-winning capability in many instances. The responsiveness provided by airlift to contain emerging situations is unmatched and spans the entire spectrum of contemporary confict. Similarly, long-term surveillance and skilled analysis of information will also be able to ascertain the ofensive intentions of the adversary in advance, providing the opportunity to create sufciently robust defences. The point to be noted here is that air power is inherently ofensive in nature, making the defensive operations also tactically ofensive. In the cognitive domain, the same air power capabilities that shape the physical domain can be used in a nuanced manner to create deterrent forces at the strategic level. The ability of the air force to deploy surface forces rapidly to trouble spots, monitor enemy deployments and movements on a long-term basis and carry out lethal strikes if and when necessary has a salutary efect on the adversary. The demonstrated possession of these capabilities tends to make potential adversaries more amenable to diplomatic initiatives. Further, strategic long-term surveillance is the key to defning enemy centres of gravity prior to confict, monitoring force deployments and providing sufcient early warning of impending attacks to own forces. Airborne surveillance is critical to monitor the progress of the confict and the efects being created by strategic, operational and tactical level air activities. A fox asked him why he did this when there was neither huntsman nor danger threatening him. The fact that airborne assets—both in the surveillance role and the lethal application of force—have the reach, penetration and persistence to cover the entire theatre of operations and yet retain sufcient residual capacity to operate efectively beyond the immediate area of interest makes them coveted and critical elements in military capabilities. Sun Tzu’s ‘knowledge’ is translated to reality in the modern battlefeld by airpower, through airborne surveillance, manoeuvre options through air mobility, precision strike and time sensitive targeting. Strategic global reach of air power is a war-winning capability When employed in a nuanced manner, air power capabilities can create strategic deterrence Sun Tzu’s ‘knowledge’ is translated to reality in contemporary confict through the optimum employment of air power capabilities 158 Void and Reality Subtle! Sophisticated commanders should practice the art of subtlety and secrecy and be so subtle and insubstantial that they leave no trace; their strategy is so divinely mysterious that it is inaudible. Tese commanders create operations with nuances and cleverness and can therefore determine the enemy’s fate. This is Sun Tzu’s third strategic principle for the attainment of superiority—absolute impenetrability that assures absolute superiority.

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This could imply that a signifi the drugs themselves may increase the risk of manic switch or cant proportion of manic patients will be seen and treated treatment 4 lung cancer purchase discount tolterodine on-line, but mood instability medicine 1700s buy generic tolterodine 1mg on-line. In either case medications used to treat fibromyalgia buy tolterodine master card, they do not lend strong support actual practice appears to be inconsistent. A psychosis criterion to the use of antidepressants for unipolar depression in bipolar will usually exclude patients with bipolar I disorder who present cases (see later). The key objective must be two related ideas: first to reduce duration of untreated psycho to prevent recurrence and the accrual of disability in young sis and provide a service that was geared to treating younger people, because they tend to have poor clinical outcomes people; avoiding stigma was a key element. The optimal treatment choices or combi purpose was inspired by the idea of a prodromal presentation nations are not established; the available data to be reviewed and early intervention to prevent onset of syndromal illness. There is an inherent contradiction for these two approaches Any acute episode, regardless of polarity, should receive being pursued by the same service. Mania, in particular, is a relative emergency lished illness implies diagnostic confidence and an earlier because of the important personal and social consequences that choice of evidence-based treatments. In contrast, a prodrome is result from the errors of judgement that are intrinsic to a highly likely to be a relatively non-specific predictor of subsequent elevated mood state. The complexity of bipolar disorder makes illness, in the absence of a diagnostic biomarker. Hence, there it desirable that assessment should be offered by a trained psy would be tolerance of diagnostic uncertainty, and no estab chiatrist with an understanding of both the medicines and psy lished approach to treatment. The necessary diagnostic tools to identify bipolarity in within an episode, which must include the option of hospital the prodrome are under active investigation (Howes et al. However, we lack the necessary ser Appropriate use of legal powers of detention is essential for vice structure to deliver any clinical programme. An important caveat is that staging implies predicta with treatment because of difficulties in accepting their diagno ble progression (most classically in the context of a cancer diag sis, who use drugs, or in whom violence, risk taking or self-harm nosis) and bipolar illness course is much less predictable. Indeed complicate their mood change may require complex, commu the high rates of symptomatic diagnoses in young people suggest nity-based interventions, although the optimal approach remains the outcome can be benign in a significant number of individuals controversial (Burns et al. There is a reluctance to make a diagnosis in young people Risk assessment in bipolar disorder. This approach is problematic if it is based on the notion desirable, it may be unnecessary if symptoms and history are of accurate prediction – the predictive value of assessment scales obvious. If detailed assessment is not available, one result is for suicide and violent risk are currently poor to moderate, and Goodwin et al. Therefore, the idea that high-risk groups can be appropri pine and not lithium treatment (Ib, (Thies-Flechtner et al. Indeed, meta-analysis of all the randomized controlled All bipolar patients are at risk of suicide, especially if admit data for lithium suggests an important effect on suicide in stud ted to hospital, when their first episode is depressive, if prone to ies which are individually inconclusive because of inadequate recurrent depression and mixed states, have co-morbid anxiety power (I, (Cipriani et al. The logi and off treatment in a so-called quasi-experimental design, has cal approach is to provide good long-term clinical care to as confirmed lithium’s effect in reducing suicide attempts by 30%; many of them as possible. One area where suicide risk assessment needs to be exam Both lithium and valproate treatment were associated with 90% ined more carefully is in self-harm patients with bipolar disor reduction in completed suicide. Here the subsequent risk of suicide There is also recent evidence that treatment may be effective is high in the following year particularly (Tidemalm et al. The data again come from record linkage of medications effective targeting of those that need enhanced follow-up. Dopamine antagonists halved the rates of offend is important because risk may be underestimated in bipolar ing in bipolar disorder and schizophrenia. These results are impressive to suicide but were assessed as low risk (Clements et al. A systematic review of them in assessing the evidence supporting the use of medica the better known instruments suggest that they perform quite tions in the long term. Thus, there is little evidence to support the sample) who had died from suicide, and been in contact with routine use of the current set of commonly used instruments in mental health services in the previous 12 months (Clements bipolar disorder. This is an need to be scalable, evidence based, and not lead to patient harms important measure of how ineffective management strategies (as positive predictive values will be low).

The laboratory technician plays a leading role in the planning and design of laboratory facilities medicine urinary tract infection proven tolterodine 2mg. Therefore medicine 75 yellow buy genuine tolterodine on line, he/she must 37 Health Laboratory Management and Quality Assurance have full knowledge of the needs of a clinical laboratory medications every 8 hours order tolterodine 4mg without a prescription, particularly: the geographical area where it will serve best the space and equipment required the lab technician should workout this in collaboration with the health administrator and the architect, to prepare a functional program giving details on the size and the general characteristics of the laboratory to be designed, taking budgetary considerations into account. This functional program will consist of a detailed description (qualitative and quantitative) of the activities of each unit and thus determine the space and equipment required. It should also give full information about the operation of the laboratory so that the architect may design the layout more efficiently. Standard Design for Laboratories In Ethiopia like in other developing countries, laboratories do not have standard designs. If laboratories do not have standard designs, it is impossible to expect effective and efficient laboratory services. The procedures for establishing basic requirement for laboratory facilities are determined after considering the following points. The amount work to be performed 38 Health Laboratory Management and Quality Assurance 2. Utility Services and Distribution the basic utility services such as water supply, sanitary drains, electricity etc, should always be provided in a laboratory. Proper and adequate supplies of these utilities have to be well thought and provided for a continued operation. In high laboratories, power failures or voltage drops may cause a lot of damage on expensive equipment. Therefore, adequate provision of power and emergency power supply like generator, have to be provided. The main objectives of an emergency power system are: To ensure continued operation of safety equipment To prevent loss of specimens and reagents due to insufficient refrigeration or incubation. The following considerations are worth noting in the making of a laboratory building. They can be made from a wide variety of materials depending on the cost and performance. Internal walls or inter-laboratory partitions especially for regional/referral hospitals and regional public health laboratories are to be considered as temporary; relatively inexpensive wall materials should be used so that they can be replaced easily at minimal cost. Ceilings Ceilings in laboratories must be of material that can be easily cleaned and disinfected. The entire ceiling area must provide a continuous seal to prevent contaminants from seeping through. Floors Floors should be preferably of materials that are resistant to acids, alkali and salts. Doors Doors should provide an easy exit and be located in places where they will not interfere with equipment and laboratory benches. Laboratory doors should not be less than 1 meter wide so that equipment can pass through with ease. Splitting the main door in half, and keeping the upper half open when the laboratory is in use can increase ventilation of the main laboratory room. The main laboratory working room should be built with large windows to provide a bright working environment. This is also essential since laboratory workers frequently handle and use volatile toxic chemicals, hazardous biological materials, etc. This helps to avoid disturbance of weighing scales, blowing away of fine powders, excessive movement of fine particles in wet preparations. The windows should be protected and placed so that direct sun light does not enter the laboratory. Air handling Complete control of air circulation can be best achieved by taking advantage of natural ventilation, shading and thermal barriers. The use of natural ventilation includes the following measures: Provide windows with screens for maximum flow of air and protection from insects, Provide vents in the upper portion of the roof to allow hotter air to escape from the building through the ceiling vents; Orienting the building to take full advantage of prevailing winds. The use of shading includes the following: Providing wide roof coverage to protect windows from direct sunlight; Planting trees or building screens to provide shade to buildings during the hottest period of the day; Orienting or designing the building to decrease the amount of afternoon sun exposure. The use of thermal barriers include the following: Providing insulation in the roof and exterior walls to decrease the transmission of heat into building.

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Practical advice for implementation the MexMode workers’ tale is an old-fashioned union success story treatment ind order tolterodine amex, in which a handful of workers took great risks to acne natural treatment discount tolterodine 4 mg free shipping organize and make substantial changes the treatment 2014 online purchase tolterodine paypal. Best of all, MexMode appears to be doing well financially as a result, as measured by the increased demand for overtime to meet work orders. Nike, for one, re-established business ties with MexMode as a direct result of improved working conditions. Aside from the generous 14-peso subsidy, MexMode merely allowed five food vendors to come to its facility. This arrangement saves MexMode the cost of establishing its own canteen with its own staff. Even without the subsidy, this would be a simple and useful food solution to bring safe food to workers during working hours. Union/employee perspective the Government does not specify the quality of worker mess room or length of meal break. Nor does the Government monitor food safety and quality in the maquiladoras sector. The new mess room has been such a morale booster that change in the area of workers’ nutrition may sweep the maquiladoras. Street vendors are relatively close, but employees do not care to eat this type of food on a daily basis. Food solution In 2000, Boncafé began a concerted effort to improve the health of its employees. One key change has been the enhancement of kitchen areas (which the company calls “cooking points” or “pantry rooms”) to encourage home cooking, which is usually healthier than nearby street food in terms of nutritional content and food safety. Cooking facilities, located in several areas within the multi-level factory, may include a steam cooker, an oven, a food warmer, a refrigerator, a sink, pots and, of course at Boncafé (as if the pervasive factory aroma of coffee wasn’t enough to perk you up), a coffee maker. Male employees often bring warm, home-cooked meals to work, which they place in a food warmer to keep warm. Ideally, foods should be kept cold or hot, below 5°C or above 60°C, to stop or slow the growth of food-borne pathogens. It is not clear whether the food warmer routinely achieves this; but, in tropical Singapore, placing food in a food warmer is a better choice than leaving it at room temperature. Typical healthy dishes include fish porridge, bee hoon soup, tuna fish sandwiches on wholegrain bread and rice with green leafy vegetables, broccoli, beans or peas. Occasionally the women prepare popiah, a type of spring roll with vegetables, which needs to be prepared and eaten fresh because the texture and taste quickly degrades. There seems to be ample room for employees to cook and eat together, and many look forward to preparing food at work. Factory manager Eric Huber, who has initiated many of the changes at the cooking points, occasionally purchases apples and oranges for staff consumption. Huber said one of his objectives is to inculcate healthy habits – namely a proper and healthy diet and regular exercise. As such, he takes a personal approach to his staff’s health by regularly dining with them. The company doesn’t believe in mandates (other than the no-smoking policy on factory grounds), but rather tries to encourage healthy habits through the posting of nutrition information in the eating areas and through occasional invited talks by medical experts. Huber has noticed a significant change in employees’ diets in the past three years, with far less “junk food” and far more vegetables and fruits now that the workplace has become conducive to change. The company takes a three-pronged approach to wellness: education, facility (the kitchenettes) and physical activity. A recent evaluation revealed that although 30 per cent of the staff had some form of improvement in their health screening results, 23 per cent showed no improvement at all. The number of employees with blood pressure at the “normal-high” level rose 207 Food at work: Workplace solutions for malnutrition, obesity and chronic diseases Workers at Boncafé can cook soups and other healthy meals in the “cooking points”. So the wellness programme has shifted to target those employees with poorer health. Costs and benefits to enterprise Boncafé did not need to purchase any of the cookware or food storage and cooking appliances, because these have been donated by the employees themselves. Medical costs have dropped since 2002 by 37 per cent and medical leave has dropped by 25 per cent. There has also been a noticeable improvement in the incidence of stroke and diabetes, although of course the sample size (60 employees) is small. The health of one employee diagnosed as having a mild stroke due to hypertension 208 Mess rooms and high cholesterol has improved significantly; within a year, through diet and medication, his blood pressure and cholesterol levels have dropped to normal.

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