Saturday, November 16, 2019
Transhiatal Approach Essay Example for Free
Transhiatal Approach Essay Abstract: Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord, which is directly related to filum fixation. Classic surgical approaches to the filum involve open surgery and include varying amounts of spinal bone removal. In an effort to reduce the morbidity and mortality of these procedures, we explored a less invasive method. We evaluated the ability, safety and feasibility for extradural endoscopic dissection of the filum terminale by performing upward orientated navigation in the sacral spinal canal through the sacral hiatus using a rigid endoscope. Four adult, phenol-formalin embalmed cadavers were used for extradural endoscopic dissection of the filum at the tip of thecal sac. After preparing the anatomical area of sacral hiatus, a rigid endoscope (Storz, of 3.8 mm external diameter with one working channel) was inserted into the sacral spinal canal and the filum was identified and cut easily. In all cases, it was possible to manipulate the rigid endoscope and inspect the full length of the extradural sacral spinal canal, especially at the S1-S2 level. Our results indicate that the tested transhiatal approach for upward orientated extradural endoscopy represents a minimally invasive procedure that provides an appropriate and feasible route to the extradural sacral spinal canal. Furthermore it is an attractive alternative for filum dissection in cases where tethered cord syndrome is not accompanied by any other pathology. Introduction Physicians and scientists have explored the clinical usefulness of spinal endoscopy over six decades. Endoscopic spinal surgery represents a major advance in the treatment of spinal disorders. It involves the use of small incisions that preserve normal tissues while allowing the spinal pathology to be fully treated. This technique carries interesting clinical benefits, and its utility continues to expand as technology advances. Tethered cord syndrome (TCS) is a manifestation of spina bifida occulta and can occur as a complication of surgically closed spina bifida aperta. The mechanical cause of TCS is an inelastic structure anchoring the caudal end of the spinal cord and preventing cephalad movements of the lumbosacral cord. Stretching of the spinal cord occurs in patients either when the spinal column grows faster than the spinal cord or when the spinal cord undergoes forcible flexion and extension. Symptomatic TCS can occur in adults as well as in children, manifesting with various clinical symptoms (Dachling, 1982; Kaplan, 1980; Klekamp et al. 1994), such as pain, neurological deficits, and bowel and bladder dysfunction. Further studies have shown that early surgical correction in adults is recommended because of the high risk for irreversible neurological deficits (Bermans et al. 2001). In recent years, further research efforts of scientists have ranged from full-fledged neurosurgery to minimally invasive approaches and have involved the use of flexible and rigid endoscopes for diagnosis and treatment of certain pathological entities (Heavner et al. 1991; Sabreski Kitahata, 1995 1996; Warnke et al. 2001, I, II; Warnke et al. 2003). Encouraging results from the performance of co-axial downward orientated thecaloscopic procedures, with flexible steerable endoscopes in the lumbar subarachnoid space in living humans (Warnke et al. 2003), prompted us to study further thecaloscopic procedures for filum terminale dissection by using a rigid endoscope. This procedure usually offers a better optical view of the studied anatomic structures. The aim of the present anatomic study was not only to determine if the tip of thecal sac could be clearly visualized. Based on the fact that epidural endoscopy through sacral hiatus was proved to be safe and possible (Sabreski Kitahata, 1995 1996; Sabreski Gerens, 1998), it also sought to explore the possibility of using a rigid endoscope to untether prefixed filum terminale. Materials and Methods For this study, four adult phenol-formalin embalmed male cadavers from the Anatomy Department of the Medical School of the University of Athens were dissected using microsurgical and endoscopic techniques. Neurosurgical technique Fig.2Insertion-of-the-rig Fig.1Sacral-Hiatus Cadavers were placed in the prone position. A midline skin incision was centered over the sacral hiatus [fig. 1]. After anatomical preparation, the rigid endoscope [fig.2] was inserted through the sacral hiatus and directed into the sacral spinal canal cephalad. It was angled in that manner in order that it would face the tip of thecal sac. The filum, which was holding thecal sac, was identified and dissected [fig.3]. The rigid endoscope used was a Storz with a 3.8mm external diameter and one working channel. For the documentation, a video-tape (Fuji VHS) was used and digital photographs were taken using a Fuji AS-205.  Results With the help of a rigid endoscope, it is possible to visualize directly the tip of thecal sac and to perform a dissection of the filum terminale. A rigid endoscope was inserted into the sacral spinal canal and, with the benefit of the visibility it granted, was advanced cephalad with relative ease. The rigid endoscope provided a large field of view, which enabled the anatomical structures to be seen. The filum can be easily identified in fine detail, as it is the only structure adherent to the tip of thecal sac at the S1-S2 level. This procedure represents a minimally invasive method for direct visualization of the tip of thecal sac and dissection of filum terminale. Discussion Diseases of the spine predispose persons to chronic complaints ranging from mild discomfort to intense pain. Endoscopy of the anatomic structures contained within the spine makes possible thorough examinations for existing pathology and facilitates the application of appropriate methods of therapy (Warnke et al. 2003; Sabreski Kitahata, 1996). Use of neuroendoscopy has become widespread in spinal surgery for conditions ranging from degenerative disease to deformity correction (Heavner et al. 1991; Sabreski Gerens, 1998; Sabreski Kitahata, 1995 1996). The growth in the number of minimally invasive spine surgical procedures being performed has been spurred by both technical advances and by its associated reduction in operative morbidity (1998; 1995; 1996). However, minimally invasive techniques are primarily employed in extradural procedures. Transhiatal extradural filum untethering provides the ability to untether a prefixed filum in a minimally invasive way. When referred to a neurosurgical clinic, adult patients with tethered cord syndrome tend to show significant progressive neurological deficits (Klekamp et al. 1994; Dachling, 1982).  Some authors (van Leeuwen, et al. 2001) have advocated prophylactic surgical treatment for the prevention of progressive neurological symptoms, which is, in this case, related to low morbidity. As an alternative to the risky open surgical treatment procedure, we evaluated the extradural endoscopic procedure for untethering of filum in cadavers. Extradural filum untethering could be indicated in cases of prefixed filum without other accompanying pathology such as meningomyelocele, CSF fistula, or arachnoidal cysts. It could also be performed before a surgical intervention, which generally include dura opening and removal of various amounts of spinal bone. During inspection of the sacral spinal canal with the rigid endoscope, the declination of the sacral spinal canal did not bring difficulties for the upward manipulation of the endoscope. Following the physical inclination of the sacral spinal canal, the filum could be approached and dissected before reaching the lumbosacral angle. In some instances, it was difficult to dissect the filum because of its elasticity. However, the minimally invasive nature of neuroendoscopy provided by this procedure, and by the employment of the rigid endoscope, allows for a larger field of view at the sacral spinal canal through a smaller incision. This access and the ability to perform extradural inspection and filum dissection using this transhiatal approach are comparable with other therapeutic interventions used in neurosurgery, such as the endoscopic epidural placement of catheters in anaesthesiology. Conclusions This method of extradural endoscopic dissection of the filum terminale minimizes surgical trauma and provides excellent visualization of and access to the extradural sacral spinal canal. Furthermore, it enables the filum to be identified and thus provides a minimally invasive alternative to current open surgical procedures indicated for filum untethering. Utilization of this procedure could: (1) facilitate untethering of prefixed filum terminale without opening the dura and (2) minimize patient morbidity thereby presenting an overall attractive alternative to current methods of filum dissection. At present, neuroendoscopy is most widely used in minimally invasive spine surgery, but novel uses continue to emerge in the literature. As technology evolves and more experience is obtained, neuroendoscopy will likely achieve additional roles as a mainstay in spinal surgery. References Heavner JF, Cholkhavatia S, Kizelsheeyn G. (1991). Percutaneous evaluation of the      epidural and subarachnoid space with flexible endoscope. Reg. Anesth. 15 S1: 85. Iskandar BJ, Fulmer BB, Hadley MN, Oakes WJ. (2001). Congenital tethered spinal cord          syndrome in adults. Neurosurg. Focus 10(1): Article 7. Kaplan JQ, Quencer RM. (1980) The occult tethered conus syndrome in the adult.        Radiology 137:387-391. Klekamp J, Raimpondi AJ, Samii M. (1994) Occult dysraphism in adulthood: clinical   course and management. Child Nerv Syst 10:312-320. van Leeuwen R, Notermans NC, Vandertop P. (2001). Surgery in adults with tethered   cord syndrome: outcome study with independent clinical review. J. Neurosurg.    (spine) 94: 205-209. Pang D, Wilberger JE. (1982) Tethered cord syndrome in adults. J. Neurosurg. 57: 32-47. Sabreski LR, Gerens, F. (1998) Safety of epidural endoscopy. Reg. Anest. Pain Med.     23: 324-325. Sabreski LR, Kitahata LM. (1995) Direct visualization of the lumbosacral epidural        space through the sacral hiatus. Anest. Anal. 60: 839-840. Sabreski LR, Kitahata LM. (1996) Persistent radiculopathy diagnosed and treated with             epidural endoscopy. J. Anesth. 10: 292-295. Warnke JP, Tschabitscher M, Nobles A. (2001). Thecaloscopy Part I.: The endoscopy of           the lumbar subarachnoid space: Historical review and own cadaver studies.   Minim. Invas. Neurosurg. 42: 61-64 Warnke JP, Mourgela S, Tschabitscher M, Dzelzitis J. (2001) Thecaloscopy Part II:       Anatomical Landmarks. Minim. Invas. Neurosurg 44:181-185. Warnke JP, Kà ¶ppert H, Bensch-Schreiter B, Dzelzitis J, Tschabitscher M. (2003)           Thecaloscopy Part III: First Clinical Application. Minim. Invas. Neurosurg          46:94-99.
Thursday, November 14, 2019
Nursing Practicum Proposal Essay -- nursing educator, practicum experi
Nursing students today are diverse with different learning styles. Nursing educators must shape students to become critical thinkers and there are a host of approaches for instructors to develop needed teaching skills (Kostovich et al., 2007). There are many models of education styles; one to fashion teaching after is from Kolb’s model in 1985 which suggests matching learning methods to teaching approaches. However, educators need to become proficient in identifying individual student learning styles. Nursing educators should also recognize their own teaching style and the effect it has on learner development and socialization (National League for Nursing, 2007). The National League for Nursing (NLN) has developed eight core competencies for nurse educators. The NLN proficiencies serve as a guide for faculty to follow in order to provide high quality education for nursing students (NLN, 2007). This paper is aimed at proposing a student teaching practicum at North Central M ichigan College (NCMC) in the nursing high fidelity simulation/skills lab for the winter 2014 semester. Scholarly Practicum Proposal The NLN has developed eight core competencies for nurse educators. The NLN proficiencies serve as a guide for faculty to follow in order to provide high quality education for nursing students (NLN, 2007). With a diverse student population, educators must be able to incorporate varied teaching strategies into curricula to meet the needs of each student. Older students have a tendency to prefer on line discussion and problem-based learning, while younger students prefer simulations and skills demonstration (Pettigrew, Dienger, & King, 2011). Used as a teaching tool, simulation promotes clinical skills, interperson... ...eved from http://www.nln.org/profde/corecompetencies.pdf . North Central Michigan College. (2013-14). Nursing program handbook. Retrieved from http://www.ncmich.edu/ Penn, B., Wilson, L., & Rosseter, R. (2008). Transitioning from nursing practice to a teaching role: The Online Journal of Issues in Nursing, 13(3):3 Pettigrew, A., Dienger, M., & King, M. (2011). Nursing students today: Who are they and what are their learning preferences? Journal of Professional Nursing, 27(4), 227-236. doi:10.1016/j.profnurs.2011.03.007. Rattray, J., & Jones, M. (2007). Essential elements of questionnaire design and development. Journal of Clinical Nursing 16, 234-243. Wayne, D., & Lotz, K. (2013). The simulated clinical environment as a platform for refining critical thinking in nursing students: a pilot program. Nursing Education Perspectives, 34 (3), 163-166.
Monday, November 11, 2019
Succubus Heat CHAPTER 16
â€Å"Georgina.†My name came to me from far away, from far down a tunnel without an end. It echoed off the walls of my mind, loud at first and eventually fading to nothing. â€Å"Georgina. Look at me, sweetie.†â€Å"Let her sleep, Hugh.†â€Å"No, I need to talk to her and make sure she doesn't have a concussion. Georgina, come on. Open your eyes for me.†Through a mist of black fog, my brain parsed the words and slowly found meaning in them. Some basic response in me wanted to comply, but my eyelids felt like they were stuck together. Thinking-let alone answering-was too hard, but more words came to encourage me. â€Å"There you go, sweetie. Try it again. You almost had it.†With much effort, I finally managed to open my eyes. It was excruciating. My lids felt like they were made of lead. At first, I could only perceive one thing: light. I winced, wanting to sink back into that oblivion I'd been pulled from. And with this slight stirring of consciousness, all the pain I'd escaped from before suddenly returned. My head throbbed. My back burned. The clich? ¦ about breaking every bone in the body seemed like a very real possibility all of a sudden, and I was pretty sure I'd broken a few that weren't in my body. Sure, that didn't make sense, but with as bad as I felt, little did. â€Å"Oh God.†At least, that's what I tried to say. It came out as more of an indistinct moan. â€Å"Easy there. You don't have to say anything.†I opened my eyes again, this time making out a figure leaning over me. I knew his voice so well that I didn't need to see his face, which was a blur anyway. â€Å"Hugh,†I croaked. â€Å"Hey, ask her what-â€Å" â€Å"Shut up,†Hugh snapped. The jerky movement of his head made me think he'd glanced behind him, but I couldn't be certain. He moved his face closer to mine, bringing his features into sharper relief. He was paler than I'd ever seen him, his face filled with lines of worry and fear I'd never thought him capable of. He looked even more upset than when he'd come to tell us about Jerome's summoning. Reaching out, Hugh held the lids of one of my eyes open and shone a small light into it. I squirmed at the brightness-or at least I tried-but he was fast and did it to the other eye before it caused too much discomfort. When he finished, he moved his finger around in the air and studied my eyes as I followed it. â€Å"What's your name?†he asked. The voice behind him piped up. â€Å"You already said her name.†Hugh sighed and jerked a thumb over his shoulder. â€Å"What's his name?†â€Å"Cody,†I said. It was getting easier to speak, but the pain was going up the more conscious I became. Cody's voice was as familiar to me as Hugh's, and I felt certain Peter was here too. Hugh asked me a few other factual questions, like the current year and the location, and also if I was nauseous. â€Å"It all hurts,†I said, voice still slurred. I couldn't even move, let alone distinguish nausea from the rest of my pain. â€Å"Yeah, but do you feel like you're going to throw up? Right here? Right now?†I thought about it. My stomach hurt, but it was less of a queasy discomfort and more of a someone-just-kicked-me-with-stilettos discomfort. â€Å"No,†I said. Hugh sat back, and I heard him sigh in relief. â€Å"It all hurts,†I repeated. â€Å"Can you†¦make it stop?†He hesitated, and a moment later, Cody appeared beside him. â€Å"What's the matter? You've gotta give her something. Look at her. She's suffering.†â€Å"Understatement,†I mumbled. Hugh's face was still drawn. â€Å"I'm not gonna knock her out if she's got a concussion.†â€Å"She passed your tests.†â€Å"Those are field tests. They're not one hundred percent accurate.†â€Å"Please,†I said, feeling tears well in my eyes. â€Å"Anything.†â€Å"We know it won't kill her,†I heard Peter say. I'd been right about him being here. Hugh hesitated only a little longer. â€Å"Go get some water.†Cody disappeared, and Peter replaced him by Hugh's side. Hugh's expression was still grim. â€Å"Sweetie, I've got to clean up your back, and it's going to hurt.†â€Å"Worse?†â€Å"A different kind of hurt. But this has to be cleaned up so you don't get an infection, and then I need to shift you to check out the rest of you. The drugs'll help, but it's all going to hurt at first.†â€Å"Go for it,†I said, steeling myself. At this point, I couldn't really imagine worse pain. Besides, Hugh was a doctor. Everything was going to be okay now. Cody returned with a glass of water. Hugh made me drink some first, just to make sure I could keep it down. When I did, he gave me two pills to take with the rest of the water. I nearly choked on them-my throat felt raw and swollen, maybe from screaming-but I got them down. I wanted to ask what I'd just taken, but it seemed like too much work. â€Å"Should kick in in about twenty minutes,†Hugh said. I could see him fumbling with something in his lap. Standing up, he leaned over my back. Something wet touched my skin. â€Å"Son of a bitch!†Again, my words were slightly incoherent, but I think he caught my meaning. Stinging pain-a â€Å"different†pain, indeed-raced across my skin where he'd touched it. It was electric, sharp where the rest of my body throbbed. My desire to get away from that horrible stinging was so strong that I actually managed to move a little, but all that did was trigger the hurt in the rest of my body. The world blurred once more. â€Å"You're making it worse,†he warned. â€Å"Stay still.†Easy for him to say. I bit my lip as he continued. He was using antiseptic to clean the places Nanette had cut me. Necessary, as he'd said, but God, did it hurt. â€Å"Talk to her,†Hugh said to no one in particular. â€Å"Distract her.†â€Å"What happened?†asked Peter. â€Å"Who did this to you?†â€Å"Nice distraction,†said Hugh. â€Å"Nanette,†I said. Saying her name made my stomach turn, and I hoped I wouldn't have to go back on what I'd said to Hugh about throwing up. â€Å"She was†¦mad.†â€Å"I guess,†said Peter. â€Å"Mad I told Cedric about her†¦Ã¢â‚¬ â€Å"Doesn't this kind of confirm your suspicions, then?†asked Cody. Yeah, if beating up the person who'd ratted out your secret plans didn't sound suspicious, I didn't know what did. But if Nanette really was behind Jerome's summoning, why not just kill me outright and leave no witnesses? Explaining that would take too many words and too much effort, so I just said, â€Å"I don't know.†â€Å"There,†said Hugh, straightening. â€Å"That wasn't so bad, was it?†I tried to glare, but I don't think he noticed. He rummaged in his kit once more and then leaned back over to start bandaging up the wounds. With as much as he was piling on me, I had the feeling I was going to look like a mummy. â€Å"Why didn't Dante stick around?†asked Cody. â€Å"Huh? Dante?†The bandage pressure wasn't as bad as the cleaning, but it was still uncomfortable. I wondered when those goddamned drugs were going to kick in. â€Å"He was here,†said Cody. â€Å"He called Hugh and told him to come over.†Some of the exact details of what had happened with Nanette were foggy, but I felt pretty confident, head trauma or no, that I would have remembered Dante being around. â€Å"Dante wasn't here,†I said. Hugh paused and looked me in the eye. â€Å"Then who called me? It was a guy, from your cell phone. Said to get over here and bring medical supplies-that you'd been hurt.†I frowned, and it came back to me, a shadow in the pain-filled haze of my memory. The strong arms and gentle voice. â€Å"There was someone here†¦Ã¢â‚¬ I began slowly. â€Å"Not Dante. Someone else. He put me to bed.†Silence fell. A slight fuzziness was starting to tingle the edges of my senses, which I took as a good sign. It was more of a pleasant, dreamlike fuzziness-not the I-can't-handle-this-pain-anymore kind. There was still a fair amount of that, though. The guys exchanged puzzled looks. â€Å"Are you sure it wasn't him?†asked Cody. â€Å"Why would Dante leave her, though?†asked Peter. Hugh snorted. â€Å"No telling with him.†â€Å"Stop,†I mumbled. â€Å"It wasn't him.†â€Å"You can't remember a face or anything?†Peter asked. â€Å"Was it even someone you knew?†I thought again, desperately trying to dig out the memory. There was nothing, though. Only that he'd been someone familiar. â€Å"I knew him†¦Ã¢â‚¬ That pleasant drowsiness was growing stronger. I wished it would hurry up. â€Å"There,†said Hugh. â€Å"All bandaged up. Help me move her so I can look at her ribs.†That was not fun, and the discomfort of the three of them turning me over-no matter how gentle they tried to be-was enough to momentarily break me out of the drug's soothing embrace. They managed to flip me over, putting moderate pressure on my back when I rested back against the bed, but allowing Hugh to examine the rest of me. He poked and prodded and had me take deep breaths. His final analysis was that I had a couple of broken ribs and a lot of bruising and pain that would just go away with time. â€Å"Great,†I said. I was so loopy by that point that I didn't even know if I was being sarcastic or not. Cody was still unable to give up my benefactor. â€Å"But who was here?†â€Å"The man†¦Ã¢â‚¬ I said. â€Å"You aren't going to get anything else out of her,†said Hugh wearily. â€Å"Not for a while. She's going to be in Dreamland any minute now.†â€Å"Dreamland. The man†¦Ã¢â‚¬ I repeated. Suddenly, I giggled. â€Å"The man in the dream†¦Ã¢â‚¬ I saw them exchange pitying looks, just before my eyelids drooped closed. They thought I was talking nonsense. None of them knew about the story of the man in the dream, of that alluring and improbable alternate life that Nyx had shown me. But as I drifted off to Dreamland, it wasn't Nyx's vision I saw. It was more of that same, painless black†¦at least, it was until I got jolted by a million volts of electricity. I let out a small cry of surprise, my eyes popping open. It felt like hundreds of icy needles were dancing along my body, piercing every nerve. The room's details, as well as my friends, came to me in sharp, crystalline detail. No more fuzziness. Turning my head slightly, I saw a fourth person. Mei. She stood beside my bed, face blank and emotionless, arms crossed across her black silk blouse. â€Å"What happened?†I asked. My words were still thick, but my speech capabilities had improved by leaps and bounds. â€Å"I healed you,†she said flatly. â€Å"Inasmuch as I can. You're still going to hurt.†Demons, though once angels, didn't possess that power to heal that their heavenly counterparts had. They could do it in small bursts, however, and in expanding my senses to assess my body, I could feel how she'd gotten rid of the worst of my pain. I still ached in some places, and even bandaged, my back still stung. I no longer wanted to die, however, so that was definitely an improvement. â€Å"Thank you,†I said. Mei didn't look particularly compassionate or benevolent. Her expression darkened. â€Å"They say Nanette did this?†I hesitated. I'd already gotten in enough trouble with the archdemoness for telling on her. Of course, my friends had undoubtedly already told Mei the truth, and anyway, she was the closest I currently had to a boss. I wasn't entirely sure if I could trust her, but if I had to place my money on the demon most likely to have my back right now (no pun intended), it was her. â€Å"Yeah,†I admitted. â€Å"I told Cedric that Nanette had met with Jerome. She'd met with Cedric too, so it seemed kind of like she was manipulating both of them.†Mei's face grew harder still. Whether she agreed with me or not, she didn't reveal. â€Å"Nanette won't bother you again.†And with no more than that, the demoness vanished. â€Å"Girl fight,†said Hugh, looking the happiest I'd seen him today. â€Å"I don't think it's going to be in creamed corn or anything like that,†I remarked dryly. â€Å"Her sense of humor returns,†said Peter. â€Å"Definitely on the road to recovery.†I tried to sit up and winced. â€Å"Or not.†â€Å"Don't push it,†warned Hugh. â€Å"Mei can only do so much-â€Å" â€Å"What the hell's going on?†We all turned. Dante stood in the doorway to my bedroom. His face was a mixture of incredulity and utter confusion. Without waiting for an answer, he hurried over to the bed and knelt down so that he was at my level. â€Å"Are you okay? What happened?†His expression was so tender, so full of concern that I was momentarily taken aback. Dante was indeed selfish and arrogant, but he did care about me, no matter what my friends thought. And in dire situations-like now-that bitter faà §ade of his fell, revealing someone whose soul hadn't turned completely black yet. He tried hard to hide this side of himself, but I knew it was there. â€Å"I had a run-in with a demon,†I said. I gave him a brief explanation of what had happened. He grew more and more incredulous as I spoke. When I finished, he glanced around the room, studying everyone accusatorily. â€Å"How does something like this happen? I thought demons couldn't go around roughing people up. Aren't you under some kind of protection?†â€Å"Technically Jerome's,†I said. â€Å"But he's kind of busy right now.†â€Å"Maybe you're under Grace and Mei's protection now,†mused Cody. â€Å"Mei looked pissed.†â€Å"She always looks pissed,†said Hugh. â€Å"I should hope so,†snapped Dante. â€Å"Are they going to go kick this other demon's ass?†â€Å"She's not likely to smite her, if that's what you mean,†said Hugh. â€Å"Grace and Mei are under the same scrutiny as everyone else, but I bet Mei'll bitch Nanette out.†â€Å"Great,†said Dante. â€Å"A stern talking-to. That'll show her.†â€Å"It's unlikely Nanette'll do anything else. If she was going to kill Georgina, she would have already.†There was an almost gentle tone in Peter's voice. I think Dante's outrage and concern had convinced the vampire that Dante might not be the complete and total bastard he'd always believed. My immortal (or not so immortal) friends finally decided I was in reasonable enough condition to leave me in Dante's care. Hugh promised to check on me tomorrow, and I thanked him again for his help. He and the others looked like they wanted to hug me, but with my back, they knew better. When they were gone, Dante went out to the kitchen and came back with a bowl of ice cream. â€Å"Good for what ails you,†he said. I was surprised to discover I had a considerable appetite. Judging from the time, I'd been out quite awhile before Mei had shown up. It had only felt like a few seconds. â€Å"Careful,†I teased. â€Å"People are going to think you're a nice guy.†â€Å"Well, I'll have to go rob some orphans to save my reputation.†He lay in bed beside me, curled on his side so that he could gently keep his hand on my arm and talk to me. As the evening passed, our conversation mostly touched on inconsequential things, topics to distract me from Seattle's increasingly dangerous situation. Finally, when it came time for both of us to sleep, Dante brought up the attack again. â€Å"Succubus†¦who was here earlier?†I knew he didn't mean Hugh and the vampires. I frowned. Even with Mei's healing, my memories were sketchy. â€Å"I don't know. But I think†¦I think it might have been Carter.†â€Å"Really? I still can't believe that angel hangs out with you guys. But if it was him, why didn't he heal you? He could have fixed everything.†Through the fog of that ordeal, I recalled my rescuer's words. I can't heal you . â€Å"Because he's not supposed to interfere,†I said slowly, remembering my earlier rumination on whether blowing up a stove was interference. â€Å"Heaven's supposed to stay out of this. He probably shouldn't have even carried me to bed-which is why he would have then gotten out of here and left it to Hugh to patch me up.†â€Å"An angel breaking the rules and a demon healing the sick,†Dante said. â€Å"You and your associates just get more and more fucked up.†I shifted slightly, cautious of my back, and rested my head against him. â€Å"That's for damned sure.â€
Saturday, November 9, 2019
Greenhouse Effect Is the Result of Deforesting
Can you imagine our world facing everyday hurricanes, tsunamis, earthquakes, climate change, extinction caused indirectly by human activities? Yes, you can because it is happening right now while you are staying here in the classroom. A few days ago, Japan has been devastating by a massive earthquake of 8. 9 magnitudes, followed by a powerful force of a tsunami. Some scientists will say that it is a natural disaster and we have nothing to do with it, other will say that human activities help to accelerate these natural phenomenons.Human footprint has left behind him not only a new era of technology’s revolution, but also the destruction of nature. Today, environmental concern such as the growth of carbon emission in the atmosphere seems of high importance in global news. The greenhouse effect continues to increase rapidly and meanwhile accelerate global warming. In fact, your car, your house and even your air conditioning are used to produce energy and, meanwhile, used to enha nce greenhouse effect. Indeed, human activities such as burning fossils fuels contribute to accelerate the natural phenomenon of greenhouse effect on Earth.More carbon dioxide in the air, more infrared rays are being trapped in the Earth and as a result temperature increased. Can you imagine living with a high temperature? Believe it or not, but this happened. In 2005, Las Vegas has almost reached 50oC, a temperature record in North America in 21st century. Although, many scientists believe that the Earth has always had natural disaster. Nonetheless, it is not a coincidence if the number of natural disaster increases while the number of human activities increases. We play a major role on the vulnerability of natural disaster. The whole world is interconnected. Climate change doesn't just affect the atmosphere and the oceans but the earth's crust as well. ’’ said Professor Bill McGuire of University College London. He also added that â€Å"When the ice is lost, the ear th's crust bounces back up again and that triggers earthquakes, which trigger submarine landslides, which cause tsunamis†. According to experts, human activities influence the equilibrium of nature. We must begin to consider the consequences of greenhouse effect. We must begin to preserve our nature. We must begin to stop deforesting. We must begin to see life in green.In every consciousness of human beings, we must find an ecological thinking. Men, women, children, human beings of this planet, we must begin to recognize the alarming situation of our environment and together work to solve it. For the sake of our lives and for future generation, it is time we stopped ignoring our responsibility on the environment. Today, we can change and this will certainly serve as a milestone in our environment. Thank you We must stop pointing others, and see that our three other fingers are pointing ourselves, because we are the one who can change things.
Thursday, November 7, 2019
Definition and Examples of the Bandwagon Fallacy
Definition and Examples of the Bandwagon Fallacy Bandwagon is a fallacy based on the assumption that the opinion of the majority is always valid: that is, everyone believes it, so you should too. It is also called an appeal to popularity, the authority of the many, and argumentum ad populum (Latin for appeal to the people). Argumentum ad populum proves only that a belief is popular, not that its true. The fallacy occurs, says Alex Michalos in Principles of Logic, when the appeal is offered in place of a convincing argument for the view in question. Examples Carling Lager, Britains Number One Lager (advertising slogan)The Steak Escape. Americas Favorite Cheesesteak (advertising slogan)[Margaret] Mitchell enhanced the GWTW [Gone With the Wind] mystique by never publishing another novel. But who would be so churlish as to want more? Read it. Ten million (and counting) Americans cant be wrong, can they? (John Sutherland, How to be Well Read. Random House, 2014) Hasty Conclusions Appeals to popularity are basically hasty conclusion fallacies. The data concerning the popularity of the belief are simply not sufficient to warrant accepting the belief. The logical error in an appeal to popularity lies in its inflating the value of popularity as evidence. (James Freeman [1995), quoted by Douglas Walton in Appeal to Popular Opinion. Penn State Press, 1999) Majority Rules The majority opinion is valid most of the time. Most people believe that tigers do not make good household pets and that toddlers shouldnt drive...Nonetheless, there are times when the majority opinion is not valid, and following the majority will set one off track. There was a time when everyone believed the world was flat and a more recent time when the majority condoned slavery. As we gather new information and our cultural values change, so too does the majority opinion. Therefore, even though the majority is often right, the fluctuation of the majority opinion implies that a logically valid conclusion cannot be based on the majority alone. Thus, even if the majority of the country did support going to war with Iraq, the majority opinion is not sufficient for determining whether the decision was correct. (Robert J. Sternberg, Henry L. Roediger, and Diane F. Halpern, Critical Thinking in Psychology, Cambridge University Press, 2007) "Everyone's Doing It" The fact that Everyones doing it is frequently appealed to as a reason why people feel morally justified in acting in less than ideal ways. This is particularly true in business matters, where competitive pressures often conspire to make perfectly upright conduct seem difficult if not impossible. The Everyones doing it claim usually arises when we encounter a more or less prevalent form of behavior that is morally undesirable because it involves a practice that, on balance, causes harm people would like to avoid. Although it is rare that literally everyone else is engaged in this behavior, the Everyones doing it claim is meaningfully made whenever a practice is widespread enough to make ones own forbearing from this conduct seem pointless or needlessly self-destructive. (Ronald M Green, When Is Everybodys Doing It a Moral Justification? ​Moral Issues in Business, 13th ed., edited by William H Shaw and Vincent Barry, Cengage, 2016)​ Presidents and Polls As George Stephanopoulos wrote in his memoir, Mr. [Dick] Morris lived by a 60 percent rule: If 6 out of 10 Americans were in favor of something, Bill Clinton had to be, too... The nadir of Bill Clintons presidency was when he asked Dick Morris to poll on whether he should tell the truth about Monica Lewinsky. But by that point he had already turned the ideal of the presidency upside down, letting arithmetic trump integrity as he painted his policies, principles and even his family vacations by the numbers. (Maureen Dowd, Addiction to Addition, The New York Times, April 3, 2002)
Monday, November 4, 2019
Computerized Management Systems Research Paper Example | Topics and Well Written Essays - 1250 words
Computerized Management Systems - Research Paper Example sharing of information such as lab results and patient information has been well facilitated between medical practitioners, clinics, healthcare providers and pharmacists. This tends to harmonize consultation process that improves the delivery of healthcare. The cumbersome nature of doctors in Emergency room(ER) that operate without computerized systems always delivers (Goldsmith, 2010) dismal performance as they have to work with manual student records. It is through the availability of interoperable tools that clinicians are well able to make sound decisions that improve their chances of saving lives and minimizing suffering. Through computerized management healthcare systems, its interoperability nature is able to provide clinicians with access to updated medical decision support. Furthermore they are capable to provide (Goldsmith, 2010) standard protocols to multiple medical situations. Clinicians and especially doctors will be better placed to select the protocol they find suitable and which can be revised from time to time to improve the standards health care practices. There are many types of computerized health care that can be adopted in any clinical settings. Common to these are electronic medical record systems (EMR). These are systems that provide for a paperless interoperable medical recording system. The present reality of these systems have been greatly favored on grounds of offering quality and cost effective means of handling medical information and data. Secondly we have the electronic healthcare record systems (EHS). This unlike the electronic medical recording systems (EMS), provides a means for which patient records are distributed across several institutions (Frans Turisco, 2008). This furthermore allows for knowledge and decision-support systems that improves quality and safety of patients care across different healthcare sectors. These are just but a few among several computerized healthcare systems that are used in the medical scene
Saturday, November 2, 2019
Politics vs. Religion Essay Example | Topics and Well Written Essays - 500 words
Politics vs. Religion - Essay Example It is based on reason and practicability and seeks to improve the way and quality of life of the people. Politics is basically focused on the life here on earth on how to better it. Religion on the other hand is concerned on the life after our earthly existence. It seeks for the greater glory of God of whatever name it may call. It seeks to implement policy of what it believes to be consistent with divine mandate which could be impractical and counter-progressive. The classic example is the current debate in the Philippines where the Catholic Church is blocking the Reproductive Health Law because it believed it run counter to the Catholic teaching which is to go forth and multiply. This theological policy is impractical from a public policy point of view because higher population means more people to feed, shelter, educate not to mention that the resources needed to support overpopulation can take its toll to our already degraded environment. Such, the secular state is conceived to avoid this problem. According to Laborde, â€Å"the secular state is not a state committed to substantive atheism or to the marginalisation of religion from public and social life. It is, rather, a state in which citizens share a language – a secular language – for discussing political matters. So, religious believers can be secularists and secularists can also be religious believers†. Baggini mentioned that secular state is â€Å"neutral with regards comprehensive world-views at its core, but relaxed about the expression of such views in the public square†. It meant that citizens can freely elect their mode of worship but cannot impose its theological belief on policies which concerns public life and government. Secular state can also prevent branding of certain religions. If there is a sectarian state which could be Catholics or
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