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ES0-004 - RES PowerFuse 2010 Basic - BrainDump Information

Vendor Name : RES
Exam Code : ES0-004
Exam Name : RES PowerFuse 2010 Basic
Questions and Answers : 102 Q & A
Updated On : December 13, 2018
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ES0-004 exam Dumps Source : RES PowerFuse 2010 Basic

Test Code : ES0-004
Test Name : RES PowerFuse 2010 Basic
Vendor Name : RES
Q&A : 102 Real Questions

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RES RES PowerFuse 2010 Basic

Newsday Names RES enterprise a Winner of the big apple 2018 appropriate workplaces Award | killexams.com Real Questions and Pass4sure dumps

This put up become contributed by means of a community member.

BOHEMIA, ny  October 25, 2018 – RES enterprise has been awarded a 2018 precise workplaces honor by way of Newsday. The list is based mostly fully on employee remarks gathered through a third-party survey administered by research associate Energage, LLC (formerly WorkplaceDynamics), a leading provider of know-how-based mostly worker engagement equipment. The nameless survey measures a number of points of office subculture, together with alignment, execution, and connection, just to identify a number of.

“true places of work is more than just awareness,” spoke of Doug Claffey, CEO of Energage. “Our research shows corporations that earn the award appeal to greater skill, experience lessen turnover, and are greater outfitted to carry backside-line outcomes. Their leaders prioritize and punctiliously craft a healthy office lifestyle that helps employee engagement.”

"Being chosen as certainly one of Newsday's 2018 exact workplaces is a wonderful achievement for RES business. What makes it so particular is that the remarks from our employees allowed us to win this honor!  We proceed to work tough daily for our purchasers, to aid them in becoming extra independent, and it's so fine to take a second to honor the agency that permits us to do such astounding work," talked about Jodi Repperger, vp of RES business.  

One staff member pointed out, "I even have my household, and i have my RES family unit.  it is such a very good feeling to know that we are all working together to support our consumers achieve independence within the group.” a different pointed out, "It’s such a very good feeling to be a part of RES and understanding that we're all in it collectively.”

“becoming a desirable office isn’t whatever companies can buy,” Claffey noted. “It’s an achievement groups have labored for and a big difference that offers them a aggressive potential. It’s a huge deal.”

About RES business

Dr. Joseph Vollaro, Neuropsychologist, is the owner and founder of RES enterprise.  “RES company, Inc. changed into headquartered in 2000 with a simple tenet.  The purpose was to supply excessive nice community services to survivors of traumatic brain injury on big apple that have been offered during the ny State branch of fitness’s Medicaid Waiver software.  As RES entered the area of the Medicaid Waiver, the intent was to emphasize moral features that have been according to one of the crucial simple tenets of the emerging field of neuroscience.  RES company is committed to offering a continuum of functions to these people in want.  We try to permit these people the ability to keep their lives within the community, while offering a secure and supportive groundwork.” 

About Energage, LLC

Headquartered in Exton, Pa., Energage (formerly referred to as WorkplaceDynamics) is a number one company of technology-primarily based worker engagement equipment that support leaders to liberate advantage, encourage efficiency, and obtain stunning consequences inside their companies. The research partner behind the correct places of work program, Energage has surveyed more than forty seven,000 businesses representing well over 16 million employees in the united states.


The correct forty iPhone Apps of 2010 | killexams.com Real Questions and Pass4sure dumps

Editor’s note: This guest post is written by means of Alex Ahlund, the previous CEO and founder of AppVee and AndroidApps, that have been bought via mobile utility directory Appolicious. that you could study his outdated iPhone app picks right here and right here

The iTunes App shop is huge. greater than 300,000 apps huge. I’ve watched this monster delivery from nothing and switch into a billion-dollar trade in only a few short years. We’ve been coming near this element for some time now, nonetheless it’s extra apparent than ever that app publicity is of important value. A suit majority of iOS app clients find new applications without delay from their device as hostile to the usage of iTunes. if you seem especially on the iPhone, the volume of real estate for discovery is barely attainable to a extremely small percentage of the entire apps.

There are at present 20 average classes, with games providing an further 20 subcategories. each and every subcategory is damaged into three lists and shows a max of one hundred apps on the iPhone. Throw in a small quantity from the appropriate 25 and Featured lists and you finish up with roughly 12,000 apps being shown at one time. This works out to best about four% of all apps that receive visibility. you possibly can browse past this quantity on iTunes, however that immediately turns into an awesome, laborious assignment.

The expectation is that the market will dictate an app’s value, but it surely doesn’t always work out that means. in case you seem to be at the true lists, they're suffering from clones, low cost knockoffs and impulse grabs. Ninety-9 cent buys are only too tempting. devoid of relevant publicity (and potentially more acceptable pricing schemes), many in reality exceptional apps by no means see the light of day.

With that stated, I’ve compiled what I trust to be the top of the line apps which have come out this 12 months. Some obtained genuinely-earned publicity, while others were misplaced in the shuffle. The elaborate a part of assembling a “best of” record is spectacular a steadiness between apps with mainstream appeal and people with true innovation. There are a couple of elements that took area within the preference (such as the merits of an app itself, no longer simply the usefulness of an established provider it makes use of) and never each first rate app may make the reduce.

I existing the exact apps of 2010:

appropriate iPhone apps:

1. Instagram: Take a photo or opt for one from your library, apply a visible effect to it after which post it to facebook, Twitter, Flickr, Tumblr, or Foursquare. whereas there are loads of image filter applications obtainable, Instagram stands apart because of how easy it is to get a unique and skilled effect. Indie styling devoid of the want for a antique camera or Photoshop talents.

2. Chase cellular: whereas I don’t use Chase for banking, this app deserves some serious awareness. For an industry that isn’t widely used for pushing the technology envelope, Chase did something fairly cool here. as an alternative of going to a banking middle or ATM, that you can with no trouble take a picture of the front and back of a examine and the quantity is deposited into your account. Beats riding to a financial institution.

3. cost determine with the aid of Amazon: bound, there are several barscanning apps out there. Some work more desirable than others, but expense examine is well-nigh flawless. considering that I buy almost every thing from Amazon (from nutrition to electronics), I may well be somewhat biased. however regardless, this app offers a straightforward, effective way to assess the fee of physical goods in a store to look if you can get it more cost-effective on-line.

four. discover My iPhone: This turned into an excellent flow by means of Apple to release the locate My iPhone feature without requiring a paid MobileMe account. With this, that you can see where your cell is on a map, monitor a message, lock the phone or absolutely wipe it.

5. Google Voice: lengthy awaited, Google Voice has been in approval limbo for a long time. i believed it could by no means see the easy of day (due perhaps to objections from AT&T) however to most individuals’s surprise, it was authorized. With Google Voice, which you can replace your calling plan with a different quantity that includes dialing, texting, voicemail, and message transcription.

6. Twitter: After acquiring Tweetie, Twitter relaunched this as the reliable Twitter app for the iPhone. It remains the regular bearer. How time and again a day do you pull down to refresh?

7. Dropbox: I’m a large proponent of the digital nomad way of life, so I always reside backed up on the cloud. I need to be capable of access, view, retrieve and share any of my data whether I have my desktop with me or not, and the Dropbox app helps me do this. It does require a Dropbox account, but its free for up to 2gb of storage.

eight. SpringPad: whereas the Evernote app is outstanding (i take advantage of it to catalog most of my notes and concepts), SpringPad really steps up cellular notetaking. you can write a brief memo, take a photograph, scan a barcode of an item to remember, or have the app search neighborhood stores and restaurants to add. There are much more alternate options than Evernote and it looks a bit of swifter to right away sell off a notion.

9. Foursquare: ok, this one didn’t come out this year, however any most suitable iPhone Apps list could be incomplete without it. Checking in, which appeared so quirky a 12 months ago, is now an obsession with tens of millions of people, and that they can thank Foursquare. inform individuals where you are, get mayorships, badges, and perhaps some other rewards. The newest update simply delivered comments and photo checkin capabilities. (Gowalla continues to be searching good too).

10. Skyfire net Browser: I haven’t met any one yet who doesn’t hate the undeniable fact that the iPhone lacks Flash help. whereas Skyfire is with the aid of no capability a perfect solution, it offers us a method to watch Flash video clips from the web on our iPhone. unluckily, it does not help Flash games and never all websites with Flash video are supported.

11. Kindle: I’m a type of people who prefers analyzing off an e-ink Kindle to an lcd iPad. For the tens of millions like me, the Kindle app makes a perfect accomplice. however, while I don’t take my Kindle everywhere, I all the time have my cellphone. simply boot up the app and you'll continue reading from the place you last left off.

12. word Lens: notice Lens is likely one of the few apps that definitely indicates the advantage of the iPhone. aim your cell at the rest with average printed writing on it in yet another language (a sign, newspaper, and so forth.) and notice Lens will substitute it with translated copy. The marvelous aspect is that it'll do it in realtime. currently it only helps English to Spanish translations (and visa versa), but stronger language help is on the way. It has just a few quirks, but the pace and accuracy is terribly awesome.

13. Groupon: here is an outstanding partner app to the day by day-deal provider Groupon, which presents up a deeply discounted product or service for a confined time. The app makes the manner less complicated to manipulate with out the want of the web site. There are a number of ancillary facets like discussion, but the actual purpose to keep it round is to with no trouble check out the every day offers.

14. Hashable: if you're a heavy networker or just like introducing americans, Hashable is the app for you. It allows you to introduce americans by means of Twitter or e-mail and annotate your entire meetings with hashtags like #lunch or #justmet so so that you can go back later and search through them. You additionally get “Hashcred” every time you employ the app, which pushes you up the leaderboard. here's a business app, however it feels fun.

top amusement Apps:

15. Netflix: I’m a big fan of Netflix streaming and this app is an excellent approach to observe streamed content appropriate for your iPhone. i was expecting film streaming to be gradual over 3G but become shocked to look that after a brief loading duration, it became extremely smooth. great settings are decreased depending on the connection, but all in all, it really works terrific.

sixteen. Hulu: i used to be on the fence about the Hulu app considering Netflix covers so a lot of my media wants. This app requires you to subscribe to the Hulu Plus carrier, which is a similar fee as a Netflix streaming account. however, Hulu includes lots of wonderful tv content so that it will fill in lots of of the holes left through Netflix. The app itself feels solid and the streaming exceptional looks to be on par with Netflix in terms of looks and pace.

17. TuneIn Radio: The issue with information superhighway radio has been that despite being magnificent, it hasn’t allowed entry to local radio. TuneIn Radio permits you to eavesdrop on heaps of real radio stations throughout the nation. With a bunch of elements just like the ability to pause and rewind live radio, it makes a good addition next to Pandora and Slacker.

18. Rhapsody: Rhapsody is an all-you-can-devour song listening provider. For the longest time, iPhone/iPod Rhapsody clients have been not noted in the bloodless in the event that they desired to take their songs with them. however now, with the Rhapsody app, you can hearken to as a lot music from the service as you love without desiring an active web connection.

19. TextPics: Emoji are fun to add to text messages to different iPhone clients—the issue is that your iPhone-much less chums can’t see them. TextPics tries to solve this concern by using providing you with a bunch of ASCII “drawings” so you might text or include in emails. The best part is that they are made of usual text characters, so anybody can acquire them on any machine.

excellent iPhone video games:

20. angry Birds: It’s not effortless to disregard irritated Birds—you’ll continually find it putting out at that #1 true spot. It’s probably the most first phenomenons to come out of the iPhone world, spawning seasonal versions, toys and even a film deal. I doubt it even wants an outline, so if for some purpose you’re just now crawling out from under a rock, go and download indignant Birds.

21. vegetation vs Zombies: I got here from the casual video games business so I’ve been keen on PopCap for a very long time. PvZ is a streamlined, linear tower protection video game. Your aim is to preserve your home from a swarm of zombies the use of a number of distinctive plants from standard pea shooters to exploding landmine plants. With a simple, fast paced system for incomes cash to upgrade your defenses, this game is an exciting mix of action, method and zombies.

22. trade nations: here is one in every of my favourite freemium video games on the iPhone. In some ways, it plays like a cooperative precise-time strategy video game. You region homes to create workers, develop timber yards to herald lumber, harvest wheat for food, and many others. It’s a rewarding adventure top-rated performed in short, productive bursts. each action takes time, so it’s at all times interesting to sign in and do a bit management throughout a break.

23. Gun Bros: Most duel-stick survival shooters on the iPhone are primary, shallow experiences. Gun Bros. takes the style to the subsequent level through offering a freemium improve device, a special visible style and a robust leveling mechanic. if you’re keen on fast moving accurate-down shooters, here is the one to seize.

24. Grand Theft Auto: Chinatown Wars: I’m generally no longer a fan of ports but this time it turned into carried out right. GTA: CW is a devoted translation of its Nintendo DS counterpart. The game is introduced in a 3D overhead viewpoint, combining points from the normal GTA and GTA four. regardless of having an appearance similar to the previous, it basically plays greater just like the latter and those customary with Liberty city will discover themselves appropriate at domestic right here.

25. N.O.V.A 2: if you’ve ever wanted to play Halo on the iPhone, this is the closest you’ll get for now. just like the long-established, you combat your means through a lush Sci-Fi atmosphere whereas applying a huge arsenal of futuristic weaponry and powers, like the capacity to slow down time. With better pix, more expansive environments, unique video game components like piloting cars, and an array of visual results, N.O.V.A 2 is certain to provide enthusiasts of the normal, as well as beginners, with an engrossing adventure.

26. Puzzle Agent: this is why i admire doing these lists. video games like Puzzle Agent deserve attention for stepping backyard the container and delivering an engrossing journey. You play as an FBI agent from the Puzzle Investigation Division in a game that mixes points of basic adventure video games with notion-upsetting puzzles. along side quirky art and good voice performing, here's one to try out.

27. Rhythm Spirit: Rhythm Spirit is the sleeper hit of the yr. It was cherished through critics, but flew beneath the radar for many iPhone gamers. The game is a rhythm-based combating game that includes a rich storyline according to japanese folklore. inventive characters, interesting gameplay and a actually extraordinary techno-zen soundtrack make Rhythm Spirit essential for each fighting and rhythm game enthusiasts.

28. Ragdoll Blaster 2: Trajectory video games had been all of the rage for the iPhone. And whereas the genre has viewed a lot of beneath regular apps, Ragdoll Blaster 2 stands out from the group. With whimsical, steampunk-inspired pictures and hundreds diversity in stage design and background art, RB2 is a deep and profitable puzzler.

29. Spiderman: total Mayhem: the world of Spiderman makes for probably the most top-quality gaming environments, regardless of the combined consequences of many past makes an attempt. complete Mayhem for the iPhone succeeds in offering up a very pleasing, incredibly playable web-slinging journey. This strong beat-em-up offers you all of Spidey’s capabilities as you swing through cityscapes, net-up unhealthy guys, and engage in some decent ol’ fashion fisticuffs. complete Mayhem is visually amazing and contours actually impressive fighting mechanics.

30. mirror’s aspect: I’ve been occupied with parkour ever given that the film Yamakazis came out. I even signed up to instruct in it with extra or less unfortunate results. So for now, reflect’s side is the closest I’ll get to spending my weekends leaping from rooftops. i used to be a big fan of the online game on consoles, so I firstly approached this iPhone adaptation warily. besides the fact that children, I rapidly found out that this version is tremendously capable with intuitive controls and a pretty good, device-friendly side-scrolling viewpoint. clean, flowing animation and fantastically sharp 3D pix evocative of the normal console version contributes to the uniquely pleasing, running and leaping journey.

31. reduce the Rope: I didn’t wish to like this video game. It shot up to the #1 place on the App shop after simplest a day. i thought there certainly had to be some foul play at work. however the truth is, in spite of whether or no longer “artistic” advertising methods were used, the video game is pretty damn enjoyable. The objective is to get a bit of sweet, dangling from a rope, into a cute monster’s mouth. It’s now not as easy because it sounds. quite a lot of obstacles get on your approach and earlier than lengthy, you’ll end up completely addicted to assisting the little man get his sugary fix.

32. Fruit Ninja: Some video games are just enjoyable for their sheer senseless simplicity – Fruit Ninja is a kind of video games. As 3D fruits hop into view, you run your finger across the reveal to reduce them in half—primary as that. Slice up the countless onslaught of fruit while averting the game-ending bombs. every session starts at a slow, steady pace with the action gradually becoming greater extreme and frantic as you development.

33. Osmos: there's a definite zen-like delight you get from taking part in Osmos. You control an amoeba-like blob that have to devour smaller entities to develop, after which expel them to circulate. You’ve bought to be alert to retain this careful balancing act, but the meditative lull of Osmos’ ambiance creates a uniquely relaxing, trancey event.

34. Smurfs’ Village: When it comes to freemium administration games presently attainable on the App shop, the event is too often shallow and predictable. This isn’t the case with Smurf’s Village. whereas the objective is still to construct and improve your village, the game is jam packed with initiatives, mini-games and even a unfastened narrative. Smurf’s Village features exquisite track and fabulous, hi-res photos which are sure to instill a warm sense of nostalgia to anyone who spent the eighty’s observing Saturday morning cartoons.

desirable Technical fulfillment video games:

The iPhone has come a long manner in terms of processing vigour and developers are starting to figure out a way to get essentially the most out of the hardware. right here video games are in reality surprising examples of what the iPhone is capable of:

35. contemporary fight 2: Black Pegasus: It’s no primary project to convey a console-satisfactory first-person shooter to a device the measurement of your hand. It’s a careful stability of processing, belongings, and usefulness. fortunately, up to date fight does a extremely commendable job of pulling it off. excessive-res pictures, fabulous visual results, and special environments give contemporary fight 2 more than sufficient purpose to be considered a technical fulfillment this 12 months.

36. megastar Wars Arcade: Falcon Gunner: you are going to are looking to play this gam ein a swivel chair. The 360-diploma pictures take capabilities of the iPhone’s gyroscope to permit you to swivel around and shoot TIE opponents from the Millenium Falcon’s gun turret. The gameplay is pretty simple, but the 360-impact and 3D photos put you in the action like no other video game. that you could also play in augmented truth mode which switches the heritage to your digital camera view, making it seem like the TIE combatants are in your room or flying through the air.

37. Samurai 2: Vengeance: i like video games that in fact push fashion and persona, and Samurai 2: Vengeance does just that. Visually, the game looks like it can be a more youthful sibling of Capcom’s console gem, Okami. The artwork is like a combination of eastern brush portray and anime, giving Vengeance an amazingly prosperous and distinct style. Thick outlines, flat colorations and exaggerated movement create a different manga look that boldly stands out within the App save.

38. precise Racing 2: the first real Racing took the App save through storm when it turned into released final yr. It become one of the crucial few apps that showed what the iPhone was truly able to. real Racing 2 doesn’t disappoint in keeping that way of life alive. RR2 is the premier looking racing game purchasable for the iPhone. From the detailed tracks and environments, to the specific licensed vehicles themselves, this can be certain to galvanize even probably the most cynical of using sim lovers. while actual Racing 2 has packed in much more play modes, multiplayer alternate options and automobiles, it still uses the near flawless manage scheme alternate options of its predecessor.

39. Rage HD: I generally dislike the “on-rails” mechanic for any video game. If I completely had to play an on-rails shooter, I’d greater probably head on all the way down to the coin laundry and play some Operation Wolf. however that doesn't shrink the proven fact that Rage HD is currently one of the two gold standard looking video games within the App save nowadays. Sharp textures, dynamic lighting, and excessive poly rendering make this an mind-blowing feat. Now if they would simply pry us off these rails we might have a seriously magnificent shooter on our fingers.

40. Infinity Blade: Infinity Blade is via a long way the most beneficial searching online game ever to appear on the iPhone. Developed by means of Epic using the same engine that powered the surprising tech demo, Epic fortress, it is not any surprise that Infinity Blade is visually on par with up to date console games. The gameplay contains tapping and swiping the reveal in a spread swashbuckling maneuvers as you combat towards a succession of guards attempting to stay away from you from accomplishing the God King. moreover the combat, the game additionally facets some pleasing RPG elements and a purposeful storyline to deliver context for all the mayhem. And though it doesn’t present the deepest or premier gameplay, Infinity Blade succeeds in ushering within the new visible benchmark for top-conclusion iPhone gaming.

inform us which apps you could possibly placed on this checklist.


China prisoners of moral sense rally urges Congress to stand in solidarity for human rights | killexams.com Real Questions and Pass4sure dumps

twelve months in the past today, Liu Xiaobo, the 2010 Nobel Peace Prize Laureate, died whereas in detention in China. His spouse Liu Xia, who was not ever charged with against the law, changed into launched this week after spending eight years under house arrest. “For decades Liu Xaobo fought without charge expression, justice and liberty in China and he is still an impressive symbol for all those that combat for general human rights,” spoke of Francisco Bencosme of Amnesty international, speakme at yesterday’s rally on the US Capitol to honor Liu Xiaobo and to deliver consideration to Prisoners of sense of right and wrong in China and all over.

participants of Congress, human rights leaders and representatives from impacted communities challenged americans and fellow participants of Congress to now not forget, to no longer ignore the injustice of these falsely accused and to no longer let human rights defenders stand alone. unluckily, there are tens of thousands of people unjustly imprisoned in China because of their peaceful expression of political, spiritual or different conscientiously held beliefs.

“america has a moral duty to talk out in opposition t China’s brazen push aside for basic freedoms,” spoke of Congresswoman Nancy Pelosi. “essentially the most excruciating torture to those in penal complex is to tell prisoners that no one remembers them or why they're in reformatory. We understand you are there. We salute your braveness. We pray to your security and we hope we will shorten the time unless you're free.”

each Reps.Tom McGovern (D-Mass.) and Randy Hultgren (R-unwell.), co-chairs of the Tom Lantos Human Rights commission, spoke on the rally. This commission created the Defending Freedom venture in 2012, in partnership with six civil society businesses, to motivate participants of Congress to select and suggest for a specific prisoner of sense of right and wrong. additionally, McGovern and Hultgren lately added H.Res.750, a bipartisan resolution that calls to set up a Prisoners of conscience Day.

Former Congressman Frank Wolf of 21Wilberforce issued a clarion call. “it's essential that we support prisoners of moral sense. i'd ask each workplace within the Senate and the apartment to undertake a prisoner of moral sense. Write to them. Write to their families. And to my fellow americans, write to your Senator or Congressman and express guide for H.Res.750.”

different speakers that inspired the gang to stand for human rights included Senator Ted Cruz (R-TX), Dr. Tenzin Dorjee, Chair of the USA fee on international religious Freedom, Carl Gershman, President of countrywide Endowment for Democracy, Sophie Richardson of Human Rights Watch, Pastor Wang Dao representing China help, and Elyse Anderson speaking on behalf of Sen. Rubio (R-FL).

To be taught more about prisoners of conscience, the Defending Freedom assignment orH.Res.750, contact any of the rally sponsors: 21Wilberforce, Amnesty overseas,the Lantos groundwork for Human Rights and Justice, Freedom apartment and China aid.

TAKE motion here

###

Contact:Lou Ann Sabatier[email protected](703) 216-2941

This story is accessible for republication.


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Early Subspecialization in Orthopedic Surgery Training | killexams.com real questions and Pass4sure dumps

Orthopedic surgeons in the United States have increasingly become subspecialized.1,2 From 1990 to 2006, the proportion of practicing orthopedic generalists decreased from 44.2% to 28.7%.3 As of 2008, more than 90% of graduating residents were pursuing fellowship training,4 and a more recent study reported that the percentage of fellowship-trained applicants taking the American Board of Orthopaedic Surgery (ABOS) Part II examination increased from 76% to 90% from 2003 to 2013.2 The same study found that 78% of the procedures performed by all applicants were within their subspecialty, with that percentage increasing to 85% for applicants trained in hand or spine surgery.2

This increasing subspecialization in orthopedics may begin as early as residency training. Currently, the ABOS requirements for orthopedic training allow some flexibility for trainees to tailor their education to specific areas of interest, although these opportunities would likely require program approval.5 The ABOS specifies requirements for 12 months of adult orthopedics, 12 months of fractures and trauma, 6 months of pediatric orthopedics, and 6 months of basic or clinical specialties after the intern year.5 Thus, 12 months are left to the discretion of the programs. Furthermore, although the Accreditation Council for Graduate Medical Education specifies minimum case numbers for graduation, these minimum numbers are fairly small and would not interfere with resident subspecialization.6

Several studies of orthopedic resident case logs have shown dramatic variability in the number of procedures different residents perform in different fields.7–10 Daniels et al7 found a 5.5-fold difference between the top and bottom 10% of orthopedic residents in the number of spine procedures logged. Gil et al10 found a 5-fold difference in the number of shoulder arthroscopy procedures, a 3.4-fold difference in the number of knee arthroscopy procedures,10 and a 3.9-fold difference in the number of peripheral nerve procedures.8 Although some of this variability is likely due to differences in institutional case volume, it is possible that residents are using the freedom allowed by the ABOS and Accreditation Council for Graduate Medical Education requirements to acquire additional experience in their area of interest.

In this study, the authors used case log data from 5 large academic centers to determine whether resident interest in spine surgery, hand surgery, sports medicine, total joint arthroplasty, and foot and ankle surgery impacted case volume. The authors hypothesized that residents pursuing careers in these fields would have significantly increased associated case volume relative to their peers.

Materials and Methods

The chosen fellowships of all residents who graduated from the Brown University program from 2002 to 2016, the Drexel University program from 2005 to 2015, the University of Iowa program from 2009 to 2015, the Oregon Health Sciences University program from 2010 to 2015, and the Tufts University program from 2005 to 2015 were reviewed. Additionally, all current senior residents graduating from Brown University in 2017 were surveyed to determine their future subspecialty fellowship.

Accreditation Council for Graduate Medical Education case logs for all of these residents were then reviewed. Case logs were analyzed for the number of individual cases in spine surgery, hand surgery, sports medicine, total joint arthroplasty, and foot and ankle surgery, as the case log formats allow searching by these fields for all included years. The total number of cases was reported. Multiple procedure codes applied to a single case were not considered separate cases because residents differed substantially on how they logged cases with more than one Current Procedural Terminology code.

Spine cases included any procedure on the cervical, thoracic, or lumbar spine. Hand cases included any procedure on the hand, wrist, or forearm. Sports medicine cases were defined as any arthroscopic procedure on the shoulder or knee. Hip arthroscopy was not included because Accreditation Council for Graduate Medical Education case logs did not include codes for hip arthroscopy until 2012. Additionally, residents after 2012 reported small numbers of hip arthroscopy cases. Total joint arthroplasty cases included total hip replacements, total knee replacements, and hip and knee revisions. Foot and ankle cases included any procedure performed on the foot and ankle; nailing for tibia fractures was excluded.

For each subspecialty, the number of cases logged by residents who chose a fellowship in that subspecialty was compared with the number of cases logged by all residents who chose other subspecialties. Comparisons were made within graduating classes to control for year in training to reduce the effect of institutional variation during the course of the study. For each subspecialty, comparisons were made within each program and as a pooled total. Two-tailed Student';s t tests were performed with Excel (Microsoft Corporation, Redmond, Washington), with P<.05 being considered statistically significant.

Results

The case logs of 231 residents graduating from 5 different orthopedic residency programs from 2002 to 2017 were reviewed. In total, 50 (21.6%) chose sports medicine, 44 (19.0%) chose hand surgery, 26 (11.3%) chose foot and ankle surgery, 25 (10.8%) chose spine surgery, and 21 (9.1%) chose adult reconstruction for fellowship training.

The mean number of spine surgery, hand surgery, sports medicine, total joint arthroplasty, and foot/ankle cases were 83.0±59.6, 208.0±85.2, 244.6±100.1, 270.6±108.4, and 198.8±78.2, respectively.

For residents who chose spine surgery, the mean number of spine cases was 108.4±50.7, which was significantly greater than the mean number of spine cases for residents who did not choose spine surgery (74.4±60.2; 1.5-fold difference; P<.01) (Table 1). Although individually this difference in case numbers reached significance only at programs 1 and 5, residents who chose spine surgery at programs 2 and 4 also performed 1.5 or more times the number of spine procedures when compared with their colleagues (Table 1).

Case Comparisons for Spine Surgery

Table 1:

Case Comparisons for Spine Surgery

Similarly, for residents who chose hand surgery, the mean number of hand surgery cases was 242.2±92.9, which was significantly greater than the mean number of hand surgery cases for residents who did not choose hand surgery (194.3±78.2; 1.2-fold difference; P<.01) (Table 2). Residents who chose hand surgery performed more hand surgeries than their colleagues at all evaluated programs, although individually this was significant only at program 5 (Table 2).

Case Comparisons for Hand Surgery

Table 2:

Case Comparisons for Hand Surgery

For residents who chose sports medicine, the mean number of knee or shoulder arthroplasty cases was 278.5±105.8, which was significantly greater than the mean number of knee or shoulder arthroplasty cases for residents who did not choose sports medicine (229.0±93.9; 1.2-fold difference; P<.01) (Table 3). Residents only at programs 3 and 5 showed significant differences in case numbers between residents who chose sports medicine and those who did not, although residents at programs 1 and 2 who chose sports medicine logged more cases than their colleagues.

Case Comparisons for Sports Medicine

Table 3:

Case Comparisons for Sports Medicine

In contrast, the mean number of total joint arthroplasty cases for residents who chose adult reconstruction was 300.0±115.7, which was not significantly different from the mean number of cases for residents who did not choose total joint arthroplasty (260.7±105.1; 1.2-fold difference; P=.18) (Table 4). Residents at program 2 who chose total joint arthroplasty performed significantly more procedures than their colleagues (P=.02), but this difference did not occur at other programs. Of note, only 12 residents in the dataset at programs 1, 3, 4, and 5 chose total joint arthroplasty.

Case Comparisons for Total Joint Arthroplasty

Table 4:

Case Comparisons for Total Joint Arthroplasty

Similarly, for residents who chose foot and ankle surgery, the mean number of cases was 163.4±46.8, and the mean number of cases for residents who did not choose foot and ankle surgery was 164.5±51.4 (P=.46). There were no significant differences at any individual program.

A subanalysis was performed of the total joint arthroplasty data excluding program 5 because the residents at that program performed a mean of 546.0±80.0 total joint procedures, whereas the mean number of total joint procedures performed by all other residents was 241.6±58.9. Excluding the program 5 residents, the mean number of total joint cases for residents who chose adult reconstruction was 271.2±67.5, which was significantly greater than the mean number of total joint cases for residents who did not choose adult reconstruction (231.7±51.8; 1.2-fold difference; P=.03).

Discussion

Technological advancements and surgical innovations have rapidly broadened the range of approaches and procedures available to orthopedic surgeons. Recent studies have shown that orthopedic surgeons are both pursuing more subspecialty training and performing a higher percentage of procedures within their subspecialty.1,2 Still, the model for training surgeons has remained essentially unchanged for the past 30 years. This study revealed that orthopedic trainees who plan careers in spine surgery, hand surgery, and sports medicine are already seeking more subspecialty exposure during residency, and the analysis by individual program suggests that this early subspecialization is occurring across the country.

The reason for this self-selection within these subspecialties may reflect factors other than residents'; own self-assessments of their level of preparation. One possibility is that once residents have chosen their subspecialty, they may intentionally seek out those cases on the basis of personal interest. In addition, faculty may offer access to cases to residents with a demonstrated interest in their subspecialty. Further, co-residents entering other orthopedic subspecialties may be more willing to pass up spine, hand, or sports medicine cases.

Early subspecialization is not unique to orthopedic surgery; it has been increasingly formalized in general surgery and other surgical specialties.11,12 Although plastic surgery, vascular surgery, and cardiothoracic surgery traditionally followed most or all of a general surgery residency, integrated programs for all 3 specialties now exist in which residents train within the selected subspecialty for their entire residency.11 Additionally, the American Board of Surgery approved a flexibility in surgery training option in 2011 that allows general surgery residents 12 months of flexible rotations in residency to tailor their training to their subspecialty interest.12 For residents interested in truly general practice, particularly in rural communities, a training track focused on broad-based training was also developed.12

The question becomes: Is it possible to institute a well-designed, intentional early specialization in orthopedic residency training within the current regulations? Both the Accreditation Council for Graduate Medical Education and ABOS mandate 36 months of orthopedic surgery rotations in postgraduate years 2 to 5.5 The ABOS requirements further specify 12 months of adult orthopedics, 12 months of orthopedic trauma, 6 months of pediatric orthopedics, and 6 months of basic and/ or clinical specialties.5 Still, both sets of requirements leave 12 unspecified months to be used at the program';s discretion. These months could serve as a focused postgraduate year 5 specialty training year, with some ongoing general orthopedic training occurring concurrently.

Such a change is possible within the current requirement framework. However, it would necessitate extensive planning at the individual program level to accommodate resident service coverage and completion of all required rotations prior to postgraduate year 5. The specialized chief resident year would be designed to prepare trainees for subspecialty fellowship, with a comprehensive curriculum incorporating specialty-specific didactics and clinical rotations. Research rotations could additionally be included. Preparing for the year would require close mentorship from senior faculty at earlier stages in residency, and ongoing assessment of the year with follow-up survey data would be performed to determine its perceived utility by the trainees and fellowship directors.13 American Board of Orthopaedic Surgery Part I preparation and general orthopedic trauma call would also be continued to ensure that well-trained orthopedic surgeons would emerge from the year.

This study had several limitations. The data were limited to 5 centers and may not reflect the training environment nationwide. Furthermore, the sample sizes limited the impact of the analysis of individual programs, necessitating data pooling. The accuracy of the data also depended on the accuracy of the logging practices of the individual residents, which may have varied considerably. Thus, the data presented may not adequately reflect the true number of procedures performed. Case log data also did not account for the complexity of the procedures or outpatient experiences and did not allow for evaluation of residents who chose the subspecialties of trauma, shoulder and elbow surgery, pediatric orthopedics, and orthopedic oncology. Finally, it is possible that the fellowship training sought by the trainees did not reflect their actual practice. Despite these limitations, the data provide valuable insight into current orthopedic surgery training.

Conclusion

Orthopedic residents interested in spine surgery, hand surgery, and sports medicine are already tailoring their residency experience at an early stage in training. A specialized chief resident year incorporating a well-designed, specialty-specific curriculum may be considered to formalize this training. Further research is necessary to determine if the increase in cases results in better preparation for fellowship and beyond.

References
  • Sarmiento A. Subspecialization in orthopaedics: has it been all for the better?J Bone Joint Surg Am.2003;85(2):369–373. doi:10.2106/00004623-200302000-00028 [CrossRef]
  • Horst PK, Choo K, Bharucha N, Vail TP. Graduates of orthopaedic residency training are increasingly subspecialized: a review of the American Board of Orthopaedic Surgery Part II database. J Bone Joint Surg Am. 2015;97(10):869–875. doi:10.2106/JBJS.N.00995 [CrossRef]
  • Gaskill T, Cook C, Nunley J, Mather RC. The financial impact of orthopaedic fellowship training. J Bone Joint Surg Am. 2009;91(7):1814–1821. doi:10.2106/JBJS.H.01139 [CrossRef]
  • Salsberg ES, Grover A, Simon MA, Frick SL, Kuremsky MA, Goodman DC. An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90(5):1143–1159. doi:10.2106/JBJS.G.01305 [CrossRef]
  • Hurwitz SR. 2016 Rules and Procedures for Residency Education Part I and Part II Examinations, 2016. https://www.abos.org/media/13762/2016_rules_and_procedures_-_part_ii.pdf. Accessed May 10, 2017.
  • Accreditation Council for Graduate Medical Education. Orthopaedic surgery minimum numbers: Review Committee for Orthopaedic Surgery. http://www.acgme.org/Portals/0/PFAssets/ProgramResources/260_ORS_Case_Log_Minimum_Numbers.pdf. Accessed May 1, 2017.
  • Daniels AH, Ames CP, Smith JS, Hart RA. Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. J Bone Joint Surg Am. 2014;96(23):e196. doi:10.2106/JBJS.M.01562 [CrossRef]
  • Gil JA, Daniels AH, Akelman E. Resident exposure to peripheral nerve surgical procedures during residency training [retracted in: J Grad Med Educ. 2016;8(5):645]. J Grad Med Educ. 2016;8(2):173–179. doi:10.4300/JGME-D-15-00318.1 [CrossRef]
  • Gil JA, Daniels AH, Weiss A-PC. Variability in surgical case volume of orthopaedic surgery residents: 2007 to 2013. J Am Acad Orthop Surg. 2016;24(3):207–212. doi:10.5435/JAAOS-D-15-00461 [CrossRef]
  • Gil JA, Waryasz GR, Owens BD, Daniels AH. Variability of arthroscopy case volume in orthopaedic surgery residency. Arthroscopy. 2016;32(5):892–897. doi:10.1016/j.arthro.2016.01.018 [CrossRef]
  • Grant SB, Dixon JL, Glass NE, Sakran JV. Early surgical subspecialization: a new paradigm? Part I. Bull Am Coll Surg. 2013;98(8):38–42.
  • Kulaylat AN, Zheng F, Kuy S, Bittner JG IV, . Early surgical subspecialization: a new paradigm. Part II. Interviews with leaders in surgical education. Bull Am Coll Surg. 2013;98(8):43–49.
  • Daniels AH, McDonnell M, Born CT, et al. Critical analysis of a trauma fellowship-modeled, six-year orthopaedic surgery training program. J Bone Joint Surg Am. 2013;95(15):e108. doi:10.2106/JBJS.L.00988 [CrossRef]
  • Table 1

    Case Comparisons for Spine Surgery

    ProgramNo. of Residents Who Chose Spine (% of Program)Mean±SDDifferencePNo. of Cases for Residents Who Chose SpineNo. of Cases for Residents Who Chose Other Specialties113 (15.3)76.3±28.845.7±17.61.7-fold<.0124 (9.1)138.0±51.291.2±43.61.5-fold.1632 (8.3)194.5±50.2223.0±39.3NA.5942 (4.8)135.5±70.065.8±12.92.1-fold.4054 (11.1)126.8±25.052.0±16.62.4-fold<.01Pooled25108.4±50.774.4±60.21.5-fold<.01Table 2

    Case Comparisons for Hand Surgery

    ProgramNo. of Residents Who Chose Hand (% of Program)Mean±SDDifferencePNo. of Cases for Residents Who Chose HandNo. of Cases for Residents Who Chose Other Specialties119 (22.4)271.9±112.6231.2±95.61.2-fold.1825 (11.4)245.6±71.2185.6±53.91.3-fold.1433 (12.5)231.0±56.3195.6±45.61.2-fold.4148 (19.0)159.6±73.9139.1±46.41.1-fold.4859 (25.0)254.8±25.7177.7±36.31.4-fold<.01Pooled44242.2±92.9194.3±78.21.2-fold<.01Table 3

    Case Comparisons for Sports Medicine

    ProgramNo. of Residents Who Chose Sports (% of Program)Mean±SDDifferencePNo. of Cases for Residents Who Chose SportsNo. of Cases for Residents Who Chose Other Specialties117 (20.0)290.6±66.4259.9±75.31.1-fold.1328 (18.2)225.4±149.2204.3±156.21.1-fold.7536 (25.0)314.3±58.1249.1±75.01.3-fold<.0547 (16.7)170.4±56.4171.4±51.8NA.97514 (38.9)332.8±108.4237.6±84.61.4-fold.01Pooled52278.5±105.8229.0±93.91.2-fold<.01Table 4

    Case Comparisons for Total Joint Arthroplasty

    ProgramNo. of Residents Who Chose Joints (% of Program)Mean±SDDifferencePNo. of Cases for Residents Who Chose JointsNo. of Cases for Residents Who Chose Other Specialties16 (7.1)212.7±53.8199.0±42.3NA.5829 (20.5)298.4±56.0242.7±48.01.2-fold.0233 (12.5)313.3±68.9259.1±52.31.2-fold.3141 (2.4)251.0±00.0286.4±34.8NANA52 (5.6)574.0±140.0536.7±68.01.1-fold.78Pooled21300.0±115.7260.7±105.11.2-fold.18

    How To Make Your Workplace Ready For Gen Z | killexams.com real questions and Pass4sure dumps

    Photo credit: Getty Royalty FreeGetty

    Generation Z is about to change the face of the workforce.

    These new workers don’t remember a world without the internet and smartphones. They’ve witnessed hard times for their parents during the Great Recession. They’re coming of age in the era of #MeToo. And no, they’re not Millennials.

    The older members of this substantial group — more than 61 million individuals in the U.S. alone, often defined as the generation born between 1996 and 2010 — are now breaking into the labor force and should make up one-fifth of it by 2021. Gen Z brings expectations and aspirations that differ from its Millennial predecessors.

    While Millennials (also known as Generation Y) have sought work with a purpose, Gen Zers, driven by the fear of experiencing another recession, place a premium on a stable paycheck and a secure job. Shaped also by the #MeToo era, these upcoming workers expect authenticity and transparency from management. And where Millennials eschew linear advancement in favor of their own path of development, this new generation seems eager to pursue an upward route.

    These and many other distinctions raise key questions for your workplace. The culture you create, the tools (read: tech) you provide, and the general environment you establish can go a long way in attracting the best of young workers. If you want to be well-prepared for the new wave, consider three critical Gen Z traits and how they can help your company evolve.

    1. Tinker with your tech.

    You’re preparing your workplace for the first generation of digital natives. They’re not merely comfortable with technology, they live and breathe it. Yet many managers are still surprisingly oblivious to the fact that their offices aren’t delivering a truly digital environment.

    Forward-thinking organizations like PwC are making digital fitness (as they call it) a business imperative. Half of the new recruits that PwC hired last year were recent college graduates and other half were people with experience in the workforce. So they will be welcoming a lot of Gen Zers into their workforce in the coming years. To show the organization just how important digital is, they created a new leadership position – Chief Digital Officer – and appointed senior partner Joe Atkinson to the role. He says “My role is to be ‘a constructive disrupter.’ My mission is to enhance digital fitness throughout the organization and put in place the learning and technology necessary to get the entire organization comfortable with the language and concepts that are driving digital innovation.”

    “For many companies, outdated technology is just the result of the business itself,” says Saagar Govil, CEO of Cemtrex, a company that develops fully integrated “smart” office products. “You can get so focused on the day-to-day operations that you lose sight of the resources available to make things run that much smoother.”

    As a result, many executives simply remain unaware of current trends in technology and the basic assumptions that digital natives will bring to the workplace — namely, that devices should be connected, and resources shouldn’t be wasted. These presumptions might prompt changes as obvious as going paperless or adding more screens to increase productivity. Or they may lead you to utilize fresh software such as Jamboard for brainstorm sessions or Vidyard for internal communications. Anything that could reduce the friction of getting work done or smooth workflow is fair game for an upgrade.

    2. Instigate competition.

    Yes, you’ve already cultivated a collaborative culture for your Millennial teams. You’ve migrated to Slack, knocked down the office walls, and assigned teamwork. But Gen Zers are fiercely independent and competitive, boasting a “do-it-myself” attitude. They’re not afraid to go head-to-head with their teammates to prove their mettle.

    That’s not to say both workplace attitudes can’t coexist. Beyond initiating contests or other in-house competitions among your staff, technology again provides a creative solution. The recent surge in gamification software offers a unique way to engage this competitive spirit. Used primarily in training programs, the software facilitates competition (and fun) by making training into a game replete with points, badges, and leaderboards.

    Whatever methods or tools you use, fanning Gen Zers’ competitive flame may prove critical for the workplace of the decades ahead.

    3. Design your space to balance the social and the solitary.

    While these new workers may be competitive, they nonetheless value the chance to be part of a team. In fact, striking the right social-solitary balance in the workspace, along with other aspects of your office’s physical design, is vital to creating a healthy working environment for this up-and-coming cohort.

    Much has been said about the startlingly high levels of loneliness within Generation Z, which topped the UCLA Loneliness Scale with a score of 48.3 in a recent Cigna study. Still other research reveals high levels of anxiety and distrust among Gen Zers. Designing a space that encourages collaboration and openness, yet still allows for needed breakaway work, may prove pivotal in their success.

    Millennials and Gen Zers do share many traits, and your office design can incorporate that common ground. Whether it be incorporating multifunctional furniture, vibrant colors, or plenty of sunlight and plant life into the office space, both generations prefer a thoughtfully designed space that is aesthetically pleasing, not just functional.

    Over the past two decades, Millennials have clearly reshaped the culture of the modern workplace, but their younger coworkers are poised to reshape it yet again. Enhancing your office’s tech, fostering a culture of healthy competition, and rethinking your workplace design are but a few ways you can invite the unique contributions of Gen Z into your company. Adapting to the new workforce’s expectations sooner rather than later will give your company a competitive edge. What is your organization doing to attract the next generation?

    William Arruda is the cofounder of CareerBlast and creator of the complete LinkedIn quiz that helps you evaluate your LinkedIn profile and networking strategy.


    How to prepare for a wildfire | killexams.com real questions and Pass4sure dumps

     

    On Nov. 8, the Camp Fire, which started that morning in rural Butte County, California, about 90 miles north of Sacramento, exploded. Within hours, it engulfed the small town of Paradise. As flames spread, harried evacuations choked busy streets with traffic, trapping people in their cars and homes. As of Nov. 14, the official death count is 48 people, but with more than 200 missing, that number is expected to rise. 

    The Camp Fire, which broke out on the same day as massive fires in Southern California that have claimed two lives, is the latest disaster to test the preparedness of communities living on the edge of forests and shrublands. As climate change worsens drought conditions and ongoing fire suppression leaves behind fire-prone forests and chaparral, the threats to communities are only getting worse. 

    Communities are increasingly grappling with how to keep residents safe and get ready for fire season. While there are not always ways to prevent tragedies like the Camp Fire, preparation is essential. Here are five steps to take to protect yourself during a wildfire:

    Determine if you live in a fire-prone area

    The areas where communities meet forests and shrublands are known as the Wildland Urban Interface and often called by the acronym WUI. These areas are at higher risk of wildfire, because there is an increased likelihood of human ignited fires. They are also harder to defend because controlled burns are unpopular near human settlement, and protecting homes and lives is more difficult there than in uninhabited areas like remote commercial timberlands and national forests.

    Even as the risk of extreme wildfires rises, more people are choosing to live in harm’s way. The number of homes across the country built in WUI areas increased by 41 percent between 1990 and 2010, according to US Forest Service research headed by the University of Wisconsin Madison’s SILVIS Lab. While living away from bustling cities and closer to undeveloped landscapes has an appeal for many homeowners, it carries an inherent set of risks.

    Are you unsure if you live in a WUI area? Click here for a map and use the search box in the right hand corner to look up your address and see WUI areas near you. 

    Get ready before the fire hits

    Fire preparation falls into two broad categories: long-term planning and short-term response. 

    In areas prone to wildfire, long-term preparation is about reducing the likelihood a fire will consume your house and making sure you know what to do when a fire is coming. One of the most important steps any homeowner can do to protect themself from wildfires is creating defensible space around their home. Clearing brush and flammable materials and designing landscapes that are less fire-prone saves houses and aids firefighters in structure protection. A good primer on the basics of defensible space can be found here.

    Know your plan for getting out 

    Short-term fire preparation involves making a plan for evacuating your home and communicating that plan within your family and throughout your neighborhood. Last October, Melissa Lely was on her Sonoma County farm when the Nuns Fire, one of more than a dozen to engulf California’s wine country last year, broke out. “It was the scariest night of our lives,” she said. “We didn’t have an evacuation plan.” 

    Now, just over a year later, Lely and her husband have a plan for evacuating themselves and their farm animals, and has rebuilt their farm with a focus on defensible space and fire preparation.

    Fires often move faster than emergency services can be dispatched, which means “you, your family and your neighbors are your own rescuers,” said Michele Steinberg, the division director for wildfire at the National Fire Protection Association. Steinberg recommends having a written plan for evacuating during a fire and preparing supplies when hazardous fire weather conditions, like high winds and low humidity, are predicted. One of the most important ways to prepare for a fire is knowing the evacuation routes out of your community. “People don’t realize how little time they have,” she said. “Being prepared buys you time.” 

    As you evacuate, think of the first responders

    As fires near and evacuation warnings are put in place, there are a few last minute steps that help firefighters and reduce the likelihood your house will burn down. If you have time, turn off any gas lines to the house, move flammable materials like patio furniture cushions and propane tanks inside the house, and close all windows and doors to reduce the chance that embers ignite and burn your house. Also, attaching and leaving out any outdoor hoses you have can aid firefighters in structure protection. But these measures come with an important caveat: If it is time to evacuate, leaving should be your first priority, Steinberg said. And when you leave, stick with your family or group.

    Prepare to be cut off

    Two modern essentials that are some of the first to go when fires break out are cell phone service and electricity. Losing either or both poses challenges that require planning ahead. 

    Losing cell service often means losing GPS and the maps applications many of us use for driving directions. Designating and practicing evacuation routes before an emergency strikes can help reduce reliance on cell phones in an emergency situation. 

    Electrical lines pose a great fire risk and are often taken out of service during fires and extreme fire weather. One of the most serious problems posed by power outages are automatic garage doors, said Steinberg. If you store your car in a garage that relies solely on an electric motor, it is best to keep a vehicle outside during times of high fire risk.

    Carl Segerstrom is an editorial fellow for High Country News. Email him at [email protected] or submit a letter to the editor. 

    Read more More from Wildfire


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