Cook essentials pressure cooker manual pdf
2011.06.20 21:57 Hamsterdam Pressure Cooking!
2023.06.06 01:17 jkool702 Could use some help/guidance for setting up a soda dispenser I found at a yard sale for home use
So, last weekend I came across a commercial restaurant-grade soda dispenser machine at a yard sale that, despite being way
more than we needed, was such an unbelievably good deal ($150 for everything) that I'd have been a fool to pass it up. here is an Imgur album with pics of the hardware
. As best as I can tell, we have:
- an 8-valve SV-175i soda dispenser (SKU 2705555)
- a McCann 7H carbonator deck pump
- (10x) BIB pumps + 2 pressure controllers on a rack for the syrup "bags in a box"
- a 20 lb CO2 tank
- Various cut off tubes + tubing connectors
Supposedly everything works and has only been used for ~1 month to provide drinks for the people setting up a restaurant (I didnt get the whole story, but it sounded like the lady I purchased this from and her husband were in the process of opening a restaurant when her husband was killed in a car accident and now she just wanted it gone).
Ive been able to find a few manuals (e.g., this
) for various revisions of the machine (though none that specifically list SKU 2705555), as well as this
technician's guide, though Im not looking forward to having to sift through 250+ pages of manuals to figure out how to put this thing together. So, If anyone who knows how can give a general overview or point me towards a good concise guide that would be awesome.
A few initial questions from what Ive seen browsing through these manuals:
- I was told that the only things missing were a) an (optional) ice maker and b) the syrup - does this seem to be correct?
- The diagrams in the manual showing how to connect things indicate some sort of secondary carbonator tank...I have the carbonator deck pump, but not a 2nd take (unless it is integrated into this pump)...Do I need one or will the deck pump I have do the carbonating all on its own?
- In the manuals Ive seen the "i" (in SV-175i) indicated as meaning "internal carbonator" as well as "inteli-carb". Internal carbonator I get, but could someone explain intelli-carb?
- Will this cool the soda it dispenses? Or would I need to rig up something like a small water tank in a mini-fridge that feeds it?
- I know it doesnt make ice, but if I dump ice in will it keep it cold for sustained periods of time?
Thanks in advance!
submitted by jkool702
to restaurant [link] [comments]
2023.06.06 00:05 Old_Researcher_9129 List of everything you need to setup your kitchen
This is for my fellow interns / New joinees who have just moved in to a new city and have no clue what all things you should get for FULLY setting up a kitchen:
Cutlery: Plates, bowls (keep a set of two for each person) Spoons and forks Glasses
Cookware: Pressure cooker kadai Tawa Non stick Frying pan Knife Cutting board Handi/ that cylindrical dish where you cook rice mixer grinder (optional) Peeler 2 Spatulas (wooden ones, don't go for plastic) Grater lighter chimta strainer
Groceries: Rice (Search for Sona Mussoorie, that would do) Toor Dal Butter Refined sunflower oil Onions Potato Garlic Ginger Red chilli powder (I use Tikha Lal) turmeric Powder Black pepper powder Garam Masala Cumin powder Coriander powder Cinnamon Jeera Cardamom Bay leaves Green chilli Tomato ketchup Soy Sauce Vinegar
Again, you can stick to basics if this is too long. This is preferably for people who want a complete kitchen setup. Redditors, you can add something if I must have missed out 🙂
submitted by Old_Researcher_9129
to bangalore [link] [comments]
2023.06.06 00:03 Old_Researcher_9129 A List of everything you need to setup your kitchen
This is for my fellow interns / New joinees who have just moved in to a new city and have no clue what all things you should get for FULLY setting up a kitchen:
Cutlery: Plates, bowls (keep a set of two for each person) Spoons and forks Glasses
Cookware: Pressure cooker kadai Tawa Non stick Frying pan Knife Cutting board Handi/ that cylindrical dish where you cook rice mixer grinder (optional) Peeler 2 Spatulas (wooden ones, don't go for plastic) Grater lighter chimta strainer
Groceries: Rice (Search for Sona Mussoorie, that would do) Toor Dal Butter Refined sunflower oil Onions Potato Garlic Ginger Red chilli powder (I use Tikha Lal) turmeric Powder Black pepper powder Garam Masala Cumin powder Coriander powder Cinnamon Jeera Cardamom Bay leaves Green chilli Tomato ketchup Soy Sauce Vinegar
Again, you can stick to basics if this is too long. This is preferably for people who want a complete kitchen setup. Redditors, you can add something if I must have missed out 🙂
submitted by Old_Researcher_9129
to hyderabad [link] [comments]
2023.06.05 20:42 st3vehuff A Guide to Getting Started with UPSC CSE 2024
I hope everybody is doing well. This post has been long-due from my end. Let's get right into it. Introduction
In life, there are challenges that test our mettle, push our limits, and demand unwavering dedication. Among such trials, there exists a realm that holds the power to shape destinies; the "Civil Services Examination
" a fiercely demanding examination conducted by the Union Public Service Commission that stands as a testament to resilience, intellect, and perseverance. This post delves into the domain of a truly arduous yet immensely fulfilling endeavor—the journey of UPSC CSE 2024. Disclaimer
Under no pretense, I promise that following the advice mentioned in this post will guarantee selection. However, if you pay attention to these valuable insights it will make your journey far less daunting and more enjoyable.
Table of Content
- Understanding UPSC CSE
- Deciding to Pursue UPSC CSE
- Exam Preparation Strategy
- Preliminary Exam
- Main Exam
- Personality Test (Interview)
- Developing Skills and Qualities
- Additional Preparation Resources
- Exam-Day Strategies and Tips
- Post-Exam and Result Analysis
- Frequently Asked Questions (FAQs)
1. Understanding UPSC CSE & Role of Civil Servants
UPSC CSE is of significant importance in shaping governance and administration. It recruits capable candidates for administrative, police, and diplomatic roles, crucial for nation-building. Civil servants formulate and implement policies, manage resources, and ensure effective governance. They address social issues, uplift marginalized communities, improve public services, and strive for inclusive growth. They work with policymakers, addressing challenges like poverty, education, healthcare, infrastructure, and sustainability. Civil services also include foreign services, fostering diplomacy and global cooperation. UPSC follows a rigorous, merit-based selection process, ensuring competent and ethical candidates. Civil servants are accountable, acting with transparency and integrity. It offers growth opportunities, diverse roles, training, and exposure, enhancing skills and leadership abilities.
You should check the official notification
- Eligibility criteria
- Services offered through UPSC CSE
2. Deciding to Pursue UPSC CSE
Deciding whether UPSC CSE is the right path for you requires careful consideration and self-reflection using C-A-R S-E-T. Consider
if you have a genuine desire to serve the nation, make a positive impact on society, and contribute to the betterment of the country through public service. Assess
your strengths, skills, and aptitudes. Consider if you possess the necessary qualities for civil services, such as analytical thinking, leadership abilities, effective communication, problem-solving skills, and the ability to work under pressure. Reflect
on whether you are willing to invest the time, effort, and dedication needed for extensive and rigorous preparation. Consider your study habits, ability to handle vast amounts of information, and commitment to continuous learning. Seek Guidance and Advice
Speak to current or former civil servants, mentors, or individuals who have attempted UPSC CSE; or are/were in service. Seek their guidance and insights into the challenges, rewards, and realities of a career in civil services. Their experiences can help you gain a deeper understanding of what to expect. Evaluate Alternative Paths
Consider if there are alternative career paths that align with your interests, skills, and aspirations. Explore other avenues that allow you to make a positive impact on society and contribute to public service. [Checkout my previous post for more details] Trust Your Intuition
Listen to your inner voice and trust your instincts. Consider your passion, enthusiasm, and dedication toward public service. If you genuinely feel drawn to the purpose and challenges associated with civil services, it may be an indication that UPSC CSE is the right path for you.
3. Exam Preparation Strategy 3.1 Creating a study plan and Timeline
Develop a realistic and organized study plan that covers all the subjects and topics within the given time frame. Allocate specific time slots for each subject, revision, and practice. Here is one sample you can take inspiration
3.2 Understanding the Syllabus and exam pattern
|Month ||MonthSubject/Theme ||Action |
|June 2023 ||Syllabus and Exam Pattern Analyse ||Syllabus - Word by-word breakdown; Check out PYQs for both Prelims and Mains |
|July 2023 ||Polity/Economy ||Cover the important chapters, Make Notes |
|August 2023 ||History/Art and Culture ||Cover the important chapters, Make Notes |
|September 2023 ||Geography/Environment ||Cover the important chapters, Make Notes |
|October 2023 ||The Optional ||Based on your interest in the past 4 months decide optional and study the PYQs. |
|November 2023 ||The Optional ||If you have to alter the subject this is the time. Else Continue to study. |
|December 2023 ||S&T, IR, Social Issues, CSAT ||Consolidate Current Affairs of the last 6 months. CSAT prep begins here. |
|Jan 2024 ||Core Subjects, Answer Writing, Test Series ||Revise Core Subjects and Practice Test Series and Write at least 1 answer daily from GSI-IV. |
|Feb 2024 ||Core Subjects, Answer Writing, Test Series, Optional Revision ||Revise Core Subjects and Practice Test Series and Write at least 1 answer daily from GSI-IV. Revisit Optional once. |
|March 2024 ||Prelims ||Revise keeping prelims in mind. |
|April 2024 ||Prelims ||70:30 focus on Static: Current. |
|May 2024 ||Prelims, Exam *26 May 2024 ||Final Revision in 3 weeks. |
|June 2024 ||Essay + Ethics+Optional ||Prepare pointers for Essay and Ethics, Revise Paper 1 optional. |
|July 2024 ||GSIII, GS1, GSII ||Mains Answer writing |
|August 2024 ||GS I-IV, Optional ||Mains Answer writing |
|September 2024 ||Mains Exam ||Stay Healthy and Revise concepts from your one-pager notes. |
Check out the Points 4 and 5. 3.3 Recommended Books and study materials
Make use of NCERT textbooks for various subjects (especially for foundational knowledge). At least one standard book per subject we need. So here are some suggestions.
General Studies (Prelims and Mains):
- Indian Polity by M. Laxmikanth
- Indian Economy by Ramesh Singh
- History of Modern India by Bipan Chandra (or)
- Spectrum A Brief History of Modern India By Rajiv Ahir
- India's Struggle for Independence by Bipan Chandra
- Certificate Physical and Human Geography by G.C. Leong
- General Studies Paper I Manual by Tata McGraw-Hill
- General Studies Paper II Manual by MHE (McGraw-Hill Education)
- The Wonder that was India by A.L. Basham
- Indian Art and Culture by Nitin Singhania
- Environment for Civil Services Prelims and Mains by Khuller
- CSAT - Topic-wise Solved Papers by Disha Experts
Current Affairs and Newspapers:
- The Hindu or The Indian Express (Newspapers) (Just one)
- Yojana and Kurukshetra magazines
- Monthly Compilation of Current Affairs.
- Manorama Yearbook
Apart from books, regularly following reliable online platforms, UPSC preparation websites, and educational resources like PIB (Press Information Bureau), PRS (PRS Legislative Research), and the government's official websites can provide valuable insights and updates.
[Moved to 8. Additional Preparation Resources] 3.4 Effective note-making techniques
- Keep it concise: Focus on capturing the key points and essential information. Avoid lengthy sentences and unnecessary details. Use bullet points, headings, and subheadings to structure your notes and make them easy to scan and review.
- Use abbreviations and symbols: Develop a set of abbreviations and symbols to represent commonly used words or phrases. This saves time and space while taking notes. For example, use arrows (→) for "leads to," abbreviations like "govt" for government, or "&" for "and."
- Highlight and underline: Use highlighters or underline important keywords, phrases, or facts to draw attention to critical information. This makes it easier to quickly review and revise key points.
- Draw diagrams and flowcharts: Visual representations like diagrams, flowcharts, or mind maps can help in understanding and retaining complex concepts. Use arrows, boxes, and connectors to illustrate relationships between different ideas or components.
- Use colors and different fonts: Incorporate colors or different fonts to visually differentiate between headings, subheadings, and content. This makes your notes more visually appealing and aids in organization and quick reference.
- Summarize and rephrase: Instead of copying content verbatim, try to summarize and rephrase information in your own words. This process enhances understanding and retention. Focus on capturing the essence of the content rather than every single detail.
- Include examples and case studies: Supplement your notes with relevant examples, case studies, and illustrations. This helps in better comprehension and application of concepts during revision and while answering exam questions.
- Create separate sections for different subjects/topics: Maintain separate notebooks or sections for each subject or topic. This helps in keeping your notes organized and easily accessible. It also allows you to review specific subjects independently.
- Use headings and subheadings: Use clear headings and subheadings to categorize and structure your notes. This makes it easier to locate specific information and navigate through your notes during revision.
- Regularly review and revise your notes: Set aside regular time for revisiting and updating your notes. Reviewing your notes frequently ensures that the information stays fresh in your memory and helps you identify areas that need further clarification or revision.
Remember, note-making is a personal process, and you should develop a system that works best for you. Experiment with different techniques (Cornell, Outlining, Mapping, Charting, Sentence), formats, and organization methods to find what suits your learning style and aids your comprehension and revision process.
4. Preliminary Exam
The Preliminary exam is the first stage of the selection process. It consists of two papers: General Studies Paper-I (GS Paper-I) and General Studies Paper-II (CSAT Paper-II). Here is an overview of the Prelims exam: 1. General Studies Paper-I (GS Paper-I):
Duration: 2 hours
Total marks: 200 marks
Number of questions: 100 questions
1/3rd Negative Marking
Nature of questions: Multiple-choice questions (MCQs)
Syllabus: a. History: Ancient, Medieval, Art and Culture, Modern History of India, Indian National Movement. (not world history) b. Geography: Indian Geography, Physical Geography, Economic Geography, Environmental Geography. c. Polity and Governance: Indian Polity, Constitution, Public Administration, Panchayati Raj, Rights Issues, and Governance. d. Economy: Indian Economy, Economic Development, Sustainable Development, Social Sector Initiatives, Poverty, Inclusion, and Demographics. e. Science and Technology: General Science, Space Technology, IT, Biotechnology, and Environmental Science. f. Environment and Ecology: Environmental Ecology, environmental Legislation, Biodiversity, Climate Change, and Conservation. g. Current Affairs: National and International Events, Government Schemes, Sports, Policies, etc. Not including key important topics as that will put a bias on your initial preparation. 2. General Studies Paper-II (CSAT Paper-II):
Duration: 2 hours
Total marks: 200 marks
Number of questions: 80 questions
1/3rd Negative Marking
Nature of questions: Multiple-choice questions (MCQs)
Syllabus: The CSAT Paper-II focuses on testing the aptitude and analytical abilities of the candidates, including areas such as comprehension, logical reasoning, analytical ability, decision-making, problem-solving, and general mental ability.
It's important to note that the marks obtained in the Prelims exam are considered for qualifying purposes only. The score of the Prelims is not added to the final merit list. The objective of the Prelims is to shortlist candidates for the Main examination based on a predetermined cutoff. How to prepare
- Familiarize yourself with the exam pattern and syllabus of both GS Paper-I and Paper-II. Understand the weightage of each topic and the type of questions asked in the exam.
- Go through PYQs to understand the trends, the difficulty level, and the areas that are frequently asked. This will give you insights into the exam pattern and help you identify important topics.
- Develop a study plan that covers the entire syllabus, allocating sufficient time to each subject and topic. Make a timetable and stick to it, ensuring regular and consistent study hours.
- Choose reliable and comprehensive study materials for each subject. Refer to textbooks, NCERT books, and other recommended resources.
Importance of PYQs and Mock Tests (PYQs >> Mocks)
Solving mock tests and previous years' question papers allows you to evaluate your exam readiness. Mock tests and PYQs provide valuable insights into the exam pattern, structure, and types of questions asked in the UPSC CSE Prelims.
Mock tests help you assess your knowledge and skills. By analyzing your performance, you can identify your strengths and weaknesses in different subjects and topics. This helps you focus your preparation on areas that need improvement, optimizing your study plan.
By solving these papers, you become familiar with the format of the exam and gain confidence in tackling different question styles. It also helps in time management. It won't be an exaggeration if we say that PYQs can help you clear prelims with ease.
5. Main Examination
The Main examination consists of a written exam comprising nine papers, out of which two are qualifying in nature, and the remaining seven are considered for the ranking. Here is the structure and syllabus of the Main exam:
- Paper-A: One of the Indian languages (qualifying in nature) This paper tests your proficiency in one of the scheduled languages mentioned in the 8th Schedule of the Indian Constitution. You need to choose one language from the given list.
- Paper-B: English (qualifying in nature) This paper tests your understanding of English language and comprehension skills.
- Essay (Paper-I): You are required to write two essays, each consisting of 1,000-1,200 words. The topics are given from a wide range of subjects and require analytical and critical thinking.
- General Studies I (Paper-II): Indian Heritage and Culture, History, and Geography of the World and Society.
- General Studies II (Paper-III): Governance, Constitution, Polity, Social Justice, and International Relations.
- General Studies III (Paper-IV): Technology, Economic Development, Bio-diversity, Environment, Security, and Disaster Management.
- General Studies IV (Paper-V): Ethics, Integrity, and Aptitude.
- Optional Subject - Paper I (Paper-VI): You have to choose one optional subject from the list provided by UPSC. Each subject has two papers (Paper I and Paper II).
- Optional Subject - Paper II (Paper-VII): The second paper of the chosen optional subject.
In order to adequately prepare for your studies, it is crucial to refer to the specific wording and content outlined in the syllabus. Let's take an example from the UPSC GS-1 syllabus, which includes the topic "Effects of globalization on Indian society." This particular aspect of the syllabus encompasses various dimensions such as the impact of globalization on women, children, older individuals, culture, and crime in India. Therefore, it is essential to thoroughly prepare for this section by exploring all possible dimensions mentioned. To ensure you cover the required topics, it is advisable to keep a copy of the syllabus for reference. Ethics
broadly comprise two parts. Section A ( Theory) and Section B ( Case studies)
Section A of the General Studies IV (Paper-V) in the UPSC Main examination focuses on theoretical aspects related to fundamental values and concepts. It explores the meaning of various words such as integrity, ethics, morality, beliefs, and value systems.
An important subsection within Section A is "foundational values for civil services." This part delves into the core values expected from civil servants, including integrity, impartiality, neutrality, objectivity, dedication to public service, empathy, tolerance, and compassion towards marginalized sections of society.
This section holds immense significance in the syllabus, not only for Section A and case studies but also for your future career as a civil servant. It is crucial to prepare this portion thoroughly as it forms the basis of your ethical conduct and professional responsibilities once you are selected for civil services. Tips for essay writing and answer presentation
Subject-wise preparation strategies for General Studies papers
- Understand the Question: Carefully read and understand the essay or question prompt. Identify the key themes, arguments, or perspectives that need to be addressed.
- Plan and Structure: Devote some time to brainstorming and outlining your essay or answer. Create a clear and logical structure with an introduction, body paragraphs, and a conclusion. Outline the main points and arguments you want to include.
- Introduction: Start with a compelling introduction that sets the context and provides a clear thesis statement or main argument. Engage the reader from the beginning and establish the purpose of your essay or answer.
- Main Body: Present your arguments and ideas coherently in the main body. Each paragraph should focus on a specific point or sub-topic. Use logical transitions to connect your ideas and ensure a smooth flow of information.
- Use Evidence and Examples: Support your arguments with relevant evidence, facts, and examples. This demonstrates your understanding of the topic and adds credibility to your essay or answer. Use real-life examples, case studies, and current affairs to strengthen your points.
- Be Clear and Concise: Use clear and concise language to express your ideas. Avoid unnecessary jargon or complex terminology. Present your thoughts in a straightforward and understandable manner.
- Balance Perspectives: While presenting arguments, consider multiple perspectives and provide a balanced view. Acknowledge counterarguments and address them effectively. This showcases your analytical thinking and ability to critically evaluate different viewpoints.
- Time Management: Manage your time effectively during the exam. Allocate sufficient time to each question or essay and stick to the time limit. Prioritize answering the questions you are most confident about, but ensure that you answer all questions.
- Language and Grammar: Pay attention to your language and grammar. Use proper punctuation, sentence structure, and vocabulary. Proofread your answers for any errors or typos before submitting.
- Practice and Review: Practice writing essays and answering mock questions regularly. Review and analyze your answers to identify areas for improvement. Seek feedback from mentors, teachers, or peers to enhance your writing skills.
It is essential to have a subject-wise approach to cover the vast syllabus effectively. Here are some subject-wise preparation strategies for the GS papers: History
- Start by familiarizing yourself with the major periods, events, and personalities in Indian and world history.
- Focus on understanding the causes, consequences, and significance of important historical events.
- Make a timeline or chronology of events to aid in better retention and visualization.
Polity and Governance
- Study physical, human, and economic geography at the global, regional, and national levels.
- Understand the concepts of physical features, climate, vegetation, population, resources, and their impact on society and economy.
- Use maps, diagrams, and atlases to enhance your understanding of geographical phenomena.
- Stay updated with current events related to geography, such as environmental issues, climate change, and regional conflicts.
- Read the Indian Constitution thoroughly, focusing on fundamental rights, duties, and the structure of the government.
- Understand the working of various institutions like the President, Parliament, Judiciary, and the Election Commission.
- Keep track of recent developments in the field of politics, governance, and constitutional amendments.
- Study the basic principles of public administration and governance in India.
Science and Technology
- Gain a conceptual understanding of the Indian economy, including the various sectors, economic policies, and challenges.
- Study topics like economic planning, budgeting, taxation, banking, and financial institutions.
- Keep track of current economic affairs, government schemes, and initiatives related to the economy.
- Refer to economic survey reports, budget documents, and standard textbooks to develop a strong foundation.
Environment and Ecology
- Cover the basic concepts of physics, chemistry, biology, and environmental science.
- Focus on contemporary issues in science and technology, such as space exploration, biotechnology, information technology, and innovations.
- Stay updated with scientific advancements, breakthroughs, and their implications for society and the environment.
- Understand the ethical, social, and economic aspects of science and technology in the Indian context.
- Study environmental concepts, ecological balance, biodiversity, climate change, and conservation strategies.
- Understand the impact of human activities on the environment and the need for sustainable development.
- Keep track of environmental policies, initiatives, and international agreements.
- Familiarize yourself with important national parks, wildlife sanctuaries, and biosphere reserves in India.
- Stay updated with current affairs by reading newspapers, magazines, and reliable online sources.
- Focus on national and international events, government policies, reports, and developments related to various subjects.
- Make notes on important current affairs topics and their relevance to the GS papers.
- Analyze the impact of current affairs on society, governance, economy, and international relations.
Remember to practice answer writing, solve previous years' question papers, and take mock tests to assess your preparation and improve your answer presentation skills for each subject. Optional subject selection and preparation
Some tips for selecting and preparing for an optional subject:
- Interest and Aptitude: Choose a subject that genuinely interests you and aligns with your strengths and aptitude. Having a natural inclination towards the subject will make the preparation process more enjoyable and easier to grasp.
- Syllabus and Availability of Study Material: Review the syllabus of each optional subject and assess the availability of relevant study materials, books, and resources. Opt for a subject with a well-defined syllabus and ample study materials to aid your preparation.
- Previous Knowledge and Background: Consider your educational background and previous knowledge in a particular subject. If you have prior knowledge or academic expertise in a specific area, it can give you an advantage and make the learning process smoother.
- Scoring Potential: Research and analyze the scoring potential of different optional subjects. Look at the past trends and the success rate of candidates in each subject. However, keep in mind that scoring in the optional subject is not the sole determinant of success in the exam.
- Coaching and Guidance: Evaluate the availability of coaching institutes and guidance for your chosen optional subject. Coaching can provide structured guidance, study materials, and access to experienced faculty who can help you navigate the subject effectively.
- Time and Effort: Assess the time and effort required for the preparation of each optional subject. Consider the overlap of the optional subject with the General Studies papers and choose a subject that allows you to manage your time and efforts effectively.
- Consistency and Revision: Once you have selected an optional subject, maintain consistency in your preparation. Allocate dedicated time for studying the subject regularly. Revise the concepts, practice answer writing, and solve previous years' question papers to strengthen your understanding and retention.
6. Personality Test (Interview)
The Personality Test is the final hurdle in the selection process. After the Main examination results are announced, candidates who qualify for the interview stage receive a call letter with details about the interview date, time, and venue. Virtual Tour of Museum
- Duration and Panel: The interview generally lasts around 30 minutes. A panel of experienced and knowledgeable members, including UPSC officials and subject matter experts, conducts the interview.
- Evaluation Criteria: The interview assesses the candidate's personality traits, communication skills, critical thinking abilities, problem-solving skills, general awareness, and suitability for a career in civil services.
- Topics Covered: The interview can cover a wide range of topics, including current affairs, national and international events, social issues, government policies, the candidate's background, hobbies, academic achievements, and optional subject knowledge.
- Approach: The interview is not a knowledge test but an evaluation of the candidate's personality. Be confident, honest, and composed. Listen carefully to the questions and provide well-thought-out responses.
- Preparation: To prepare for the interview, stay updated with current affairs and recent developments. Review your DAF (Detailed Application Form) thoroughly, as the panel may ask questions based on the information provided. Practice mock interviews and seek feedback from mentors or seniors.
- Body Language and Communication: Pay attention to your body language, maintain eye contact, sit upright, and speak clearly and confidently. Use appropriate language and be respectful to the panel members.
- Honesty and Integrity: Be truthful in your responses. If you are unsure about an answer, it is better to admit it rather than provide incorrect information. The panel values honesty and integrity.
- Positive Attitude: Maintain a positive and optimistic attitude throughout the interview. Do not get flustered by challenging questions or interruptions. Stay composed and present your thoughts logically.
- Post-Interview Analysis: After the interview, reflect on your performance. Identify areas where you can improve and learn from the experience. Stay positive and prepare for the next steps in the selection process.
Remember, the interview is an opportunity to showcase your personality, confidence, and suitability for civil services. Be well-prepared, stay calm, and present your best self during the interview. More on DAF
Do not include unnecessary hobbies without realizing the consequences. As a result, You have to spend a lot of time preparing answers for irrelevant information, which could have potentially put you in trouble during the interview.
It is crucial to consult a senior or someone experienced before filling your DAF. More often than not, a significant portion of your interview is based on the information provided in the DAF. You will be asked numerous questions on specific aspects of your DAF that the panel found interesting.
Being honest is essential, but it is equally important to be smart. Include only those details that can be easily prepared from an interview point of view. Focus on adding things you are confident about and have thoroughly prepared. Not being able to answer something from your DAF can create a wrong impression.
If possible, consider filling out a rough DAF at the beginning of your UPSC preparation and then develop your hobbies and personality accordingly throughout the course of your preparation.
Even if something goes wrong during the interview, it is crucial to stay calm. Remember that everyone makes mistakes. Gather yourself, remain confident, and maintain a polite demeanor.
7. Developing Skills and Qualities
Read Newspapers: Develop a habit of reading newspapers daily. Focus on national, international, and regional news. Pay attention to editorials, opinion pieces, and articles related to governance, politics, economy, and social issues. You read the newspaper not only for knowledge but as a good habit building. Regularly visit government websites at the national, state, and local levels to stay updated on policy announcements, initiatives, reports, and official statements. Join study groups or discussion forums where aspirants and experts exchange knowledge and insights on current affairs. Engaging in meaningful discussions with fellow aspirants can enhance your understanding. Don't waste time listening to rants. Regularly practice answer writing on current affairs topics. This helps you develop a structured approach, improve your articulation skills, and reinforce your knowledge. Improving writing and communication skills
Reading extensively exposes you to different writing styles, vocabulary, and ideas. Read a variety of materials such as books, newspapers, magazines, and online articles to improve your language skills and broaden your knowledge. Set aside time each day for writing practice. Start with short exercises like journaling, writing reflections, or summarizing articles. Gradually progress to longer pieces such as essays or opinion pieces. Focus on clarity, coherence, and grammar. Organize your thoughts before writing. Create an outline or mind map to establish a logical flow and structure for your writing. This helps convey your ideas effectively and ensures coherence in your written work. Develop your oral communication skills by seeking opportunities for public speaking. Join debate clubs, participate in group discussions, or deliver presentations. Practice articulating your thoughts clearly and engaging with your audience effectively. Effective time management
Stress management techniques
- Prioritize Tasks: Identify the most important and urgent tasks and prioritize them. Make a to-do list or use a planner to organize your tasks based on their importance and deadlines.
- Set SMART Goals: Set Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) goals for your study sessions. Breaking down your goals into smaller, manageable tasks helps you stay focused and motivated.
- Create a Study Schedule: Develop a study schedule that suits your preferences and aligns with your daily routine. Allocate specific time slots for different subjects, revision, and practice. Stick to the schedule as much as possible to maintain consistency.
- Avoid Procrastination: Procrastination can lead to unnecessary stress and time pressure. Break tasks into smaller parts set deadlines, and practice self-discipline to avoid procrastinating. Start with the most challenging or important tasks to build momentum.
- Minimize Distractions: Identify and minimize distractions during study hours. Turn off notifications on your phone or keep it away from your study area. Create a quiet and dedicated study space to help you concentrate better.
- Use Productivity Techniques: Explore productivity techniques like the Pomodoro Technique, where you work for a set time (e.g., 25 minutes) and take short breaks in between. This helps maintain focus and improves productivity.
- Practice Relaxation Techniques: Engage in relaxation techniques like deep breathing, meditation, or yoga to calm your mind and reduce stress. Regular practice helps manage anxiety and promotes overall well-being.
- Take Breaks: Give yourself regular breaks during study sessions. Short breaks can help refresh your mind, improve focus, and prevent burnout. Use these breaks to engage in activities you enjoy or to stretch and relax.
- Maintain a Healthy Lifestyle: Prioritize your physical and mental well-being. Get enough sleep, eat nutritious meals, and exercise regularly. Taking care of your body and mind helps you manage stress better.
- Seek Support: Reach out to friends, family, or fellow aspirants for support. Discuss your concerns, share your experiences, and seek advice when needed. Joining study groups or online communities can provide a support network.
- Stay Positive and Motivated: Maintain a positive mindset and stay motivated throughout your preparation. Celebrate small victories, remind yourself of your goals, and focus on your progress. Surround yourself with positive influences and motivational resources.
8. Additional Preparation Resources Pros of Coaching institutes
Cons of Coaching Institutes:
- Structured Guidance: Coaching institutes provide a structured approach to preparation. They offer a well-defined curriculum, study materials, and a schedule that can help aspirants stay organized and focused.
- Experienced Faculty: Coaching institutes often have experienced faculty members who are well-versed in the UPSC exam pattern and syllabus. They can provide valuable insights, tips, and strategies to tackle different subjects and stages of the exam.
- Peer Learning and Competition: Joining a coaching institute allows you to interact with like-minded aspirants. Group discussions, mock tests, and peer interactions can create a competitive environment that motivates and challenges you to improve your performance.
- Test Series and Mock Exams: Coaching institutes usually conduct regular test series and mock exams, which help in assessing your preparation level and identifying areas that need improvement. These simulated exams also provide a real exam-like experience and help you develop exam-taking skills.
- Personalized Guidance and Doubt Clearing: Many coaching institutes offer personalized guidance and doubt-clearing sessions. You can seek clarification on difficult topics, get feedback on your performance, and receive guidance on exam strategy from expert mentors.
- Cost: Joining a coaching institute can be expensive. Tuition fees, study materials, and other expenses can put a strain on your budget. It is essential to consider the financial aspect before enrolling in a coaching institute. These days online resources can be pretty useful. It requires more digging and some unethical means.
- Time Constraints: Coaching classes have fixed schedules, and you may need to adjust your daily routine accordingly. This can be challenging for working professionals or individuals with other commitments.
- Teaching Style and Compatibility: The teaching style of the faculty and the institute's approach may not always match your learning preferences. Some individuals may find it difficult to adapt to the teaching methods used in coaching institutes.
- Dependency: Over-reliance on coaching institutes can sometimes hinder self-study and independent thinking. It is important to strike a balance between self-study and coaching institute guidance to develop a holistic understanding of the subjects.
- Quality Variation: The quality of coaching institutes can vary. While some institutes have highly qualified and experienced faculty, others may not meet the same standards. It is crucial to research and choose reputable institutes with a proven track record.
Ultimately, the decision to join a coaching institute for UPSC CSE preparation depends on your individual learning style, financial capacity, and availability of time. It is possible to crack the exam without coaching, but if you believe that structured guidance, peer learning, and personalized support would benefit you, joining a coaching institute can be a viable option.
Here are some popular institutes:
Popular Individual faculty for UPSC CSE preparation
- Vajiram and Ravi is a reputed offline coaching institute that also offers online courses for UPSC CSE preparation. Their online platform provides video lectures, study materials, and test series.
- IASbaba is an online platform that offers a range of free and paid courses for UPSC CSE preparation. It provides daily current affairs, study materials, test series, and guidance from experienced mentors.
- ForumIAS is a popular online community for UPSC aspirants. It offers a platform for discussion, doubt-solving, and peer interaction. It also provides study materials, current affairs updates, and guidance from experts.
- InsightsIAS is known for its comprehensive study materials, test series, and current affairs analysis. It provides free resources as well as paid courses for UPSC CSE preparation.
- Vision IAS emphasizes current affairs preparation, considering its significance in the UPSC CSE. They provide monthly magazines, daily news analyses, and other resources to help aspirants stay updated on current events.
Mr. Mrunal Patel [Economy]
Mr. Pratik Nayak [History]
Mr Siddharth Arora [Polity]
Mr Anudeep Durishetty [Essay]
Mr Praveen Kishore [sociology]
More on this later. Self-Motivation and Discipline
Self-study requires self-motivation and discipline. It helps you cultivate these essential qualities, which are crucial for success in the exam. By setting goals, managing your time effectively, and staying focused, you develop a strong work ethic that prepares you for the challenges ahead. When you engage in self-study, you have the opportunity to dive deep into concepts and develop a thorough understanding. You can spend more time on complex topics, explore different resources, and seek clarification when needed. This promotes a strong foundation of knowledge and enhances your conceptual clarity. Regular self-evaluation allows you to assess your progress, identify areas of improvement, and fine-tune your study approach.
9. Exam-Day Strategies and Tips Dos on the day of the exam
- Get a good night's sleep
- Eat a healthy breakfast
- Arrive early at the exam center
- Carry essential documents
- Stay calm and positive
- Read instructions carefully
Don'ts on the day of the exam:
Time management during the exam
- Don't study new topics
- Don't discuss the exam with others
- Don't panic over difficult questions
- Don't rush through the exam
- Don't carry prohibited items
- Don't compare yourself to others
Quickly skim through the entire question paper to get an overview of the questions and their difficulty level. This will help you prioritize and allocate time accordingly.
Divide the available time among different sections based on their weightage and your comfort level. Allocate more time to sections that carry more marks or where you are stronger.
Assign specific time limits to each question or set of questions based on their complexity and marks. This will help you stay on track and avoid spending too much time on a single question.
If you encounter a particularly difficult question or one that is taking up too much time, it's okay to skip it and come back to it later if you have time remaining. Focus on answering the questions you can handle efficiently first.
There are breaks scheduled during the exam, use them wisely. Take a quick mental and physical break, but avoid engaging in lengthy discussions or distractions that may consume precious time. Dealing with exam anxiety and stress
One of the best ways to alleviate exam anxiety is to be well-prepared. Maintain a consistent study routine, cover the syllabus comprehensively, and revise thoroughly. Confidence in your preparation can significantly reduce anxiety. Break it down: Rather than getting overwhelmed by the entire syllabus, break it down into smaller, manageable portions. Create a study plan and set realistic goals for each study session. Focusing on one topic at a time can help reduce anxiety. Deep breathing exercises, meditation, yoga, or listening to calming music can help you relax and reduce anxiety levels. Ensure you prioritize self-care. Get enough sleep, eat nutritious meals, and engage in physical activity. A healthy body and mind can better handle stress and anxiety. Develop a study schedule that allows for regular breaks and leisure activities. Effective time management can help reduce the pressure of last-minute cramming and provide a better balance in your routine.
10. Post-Exam and Result Analysis Preliminary Exam Result:
After the UPSC CSE Preliminary Exam, the result is usually declared within a few weeks. The result is published on the official UPSC website. It includes a list of candidates who have qualified for the Main Exam based on the cutoff marks set by the UPSC. Main Exam Result:
Once the Main Exam is conducted, the result is declared after a few months. The result is published on the UPSC website and includes the roll numbers of candidates who have qualified for the next stage, which is the Interview or Personality Test. Final Result:
The final result is declared after the completion of the Interview/Personality Test. It includes the names and ranks of candidates who have successfully cleared all the stages of the exam. The final result is published on the UPSC website and may also be published in leading newspapers. Merit List:
The final result is based on the total marks obtained by candidates in the Main Exam and the Interview/Personality Test. A merit list is prepared based on the overall performance, and candidates are ranked accordingly. The allotment of services is done based on the candidate's rank and preference. Analyzing performance and identifying areas for improvement
Start by reviewing your exam scores and marks obtained in each section. Identify the areas where you performed well and areas where you struggled or scored lower. This will give you an initial understanding of your strengths and weaknesses. Based on your analysis, create a study plan that addresses your weak areas while also reinforcing your strengths. Allocate more time and effort to topics or subjects that need improvement. Break down your study plan into smaller, achievable targets to ensure consistent progress. Strategies for preparing for subsequent attempts
Analyze your strengths and weaknesses, and use this self-assessment as a foundation for your subsequent preparation. Based on your analysis, pinpoint the subjects, topics, or specific areas where you need improvement. It could be conceptual understanding, answer writing, time management, or current affairs. Prioritize these areas and develop a targeted strategy to enhance your knowledge and skills. Reinforce your foundational knowledge by revisiting the basic concepts and fundamentals of each subject. Assess your time management skills and identify areas where you can improve. Consult mentors, teachers, or successful candidates who can provide guidance and valuable insights. Take care of your physical and mental well-being.
11. Frequently Asked Questions (FAQs) Is coaching necessary for UPSC CSE preparation?
Coaching is not mandatory, but it can provide structured guidance, study materials, and mock tests. It can be helpful, especially for those who require additional support or prefer a classroom learning environment. However, self-study with the right resources and self-discipline can also lead to success. What are the best books for UPSC CSE preparation?
The choice of books may vary depending on the subject and individual preferences. Some popular books for UPSC CSE include NCERT textbooks, standard reference books by authors like Laxmikanth, M. Laxmikanth, Ramesh Singh, and Bipan Chandra, and newspapers like The Hindu for current affairs. Can working professionals prepare for UPSC CSE?
Yes, working professionals can prepare for UPSC CSE by managing their time effectively, creating a study plan, and dedicating focused hours to preparation. Utilize weekends, early mornings, and evenings for study. Balance work commitments with consistent preparation.
Clarifying misconceptions and providing guidance
Misconception: Only candidates from prestigious educational backgrounds can crack UPSC CSE. →
UPSC CSE is open to candidates from diverse educational backgrounds. It is the knowledge, aptitude, and dedication that matter more than the educational institution. With the right strategy, study materials, and consistent effort, anyone can succeed in the exam.
Misconception: UPSC CSE can be cleared on the first attempt without much preparation. →
UPSC CSE is a highly competitive exam that requires thorough preparation and dedication. While a few exceptional candidates may clear it on their first attempt, most aspirants require multiple attempts. Developing a long-term preparation strategy and consistent effort is key to success.
Misconception: Coaching institutes guarantee success in UPSC CSE. →
Coaching institutes can provide guidance, study materials, and mock tests, but they do not guarantee success. Success in UPSC CSE depends on individual effort, self-study, and consistent practice. Many candidates have cleared the exam without formal coaching. It's important to choose the right resources and adopt a disciplined approach to self-study.
Misconception: Memorizing information is enough for UPSC CSE. →
UPSC CSE tests conceptual understanding, analytical abilities, and application of knowledge. Mere memorization of facts and information is not enough. Focus on understanding concepts, connecting topics, and developing critical thinking skills. Practice answer writing and analyze previous years' question papers to enhance your application-based approach.
Misconception: Studying for long hours guarantees success. →
Study hours alone do not determine success. Quality of study matters more than quantity. Focus on effective time management, breaking down topics into manageable chunks, and setting realistic goals. Take regular breaks, maintain a healthy lifestyle, and prioritize self-care to ensure sustained productivity.
Misconception: English proficiency is mandatory for UPSC CSE. →
While UPSC CSE is conducted in English and Hindi, candidates do not need exceptional fluency in English. Basic proficiency in English is sufficient to understand and communicate effectively. Focus on improving language skills through reading, writing, and practicing answer writing.
Misconception: The optional subject is the key to success in UPSC CSE. →
The optional subject plays a significant role in the Main Examination, but it is not the sole determinant of success. A well-rounded preparation, including General Studies papers, current affairs, and essay writing, is equally important. Choose the optional subject based on your interest, aptitude, and availability of study materials.
Misconception: UPSC CSE is all about hard work, and luck plays no role. →
Hard work is essential for UPSC CSE, but luck can also play a role in certain aspects like question patterns, options in multiple-choice questions, etc. However, luck alone cannot guarantee success. Focus on consistent effort, smart preparation, and improving your skills and knowledge to maximize your chances of success.
We have covered a wide range of topics related to UPSC CSE preparation. We discussed the importance of this exam and its eligibility criteria, exam stages, and services offered. We explored various strategies for exam preparation, including recommended books, note-making techniques, and time management. We also delved into specific subjects, optional subject selection, and interview processes. Furthermore, we addressed common queries, clarified misconceptions, and provided guidance. Throughout the discussion, we emphasized the significance of self-study, self-evaluation, and continuous improvement. We highlighted the value of mock tests, previous years' question papers, and analyzing performance. Lastly, we discussed the importance of motivation, encouragement, and perseverance on this challenging yet rewarding journey. Remember, with dedication, strategic planning, and the right mindset, you can overcome obstacles and achieve success in UPSC CSE. Good luck! Encouragement and motivation for sticklers
Some motivational movies centered around society and its betterment. You should watch it when you have time :)
Dead Poets Society, Remember the Titans, The Pursuit of Happyness, October Sky, Hidden Figures, A Beautiful Mind, Freedom Writers, The Blind Side, Gandhi, Invictus, Freedom Writers, The Help 2011, The Great Debaters, The Pursuit of Equality, Milk 2008, Selma, Norma Rae, Kaala 2018, Peranbu, Mahatma, Drishyam, Swades, Rang De Basanti and many more.
"The future belongs to those who believe in the beauty of their dreams.
" - Eleanor Roosevelt
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2023.06.05 18:38 AvailableLake8727 How To Stay Secure In Hotels In Nigeria: Advice For Travelers
In recent times, there have been several cases of mysterious deaths occurring in hotels in Nigeria. These incidents have led to a lot of fear and anxiety among hotel lodgers, and it is important to take steps to protect oneself from such incidents. In this article, NigeriaCrime will provide you with some essential security tips that can help keep you safe while lodging in a hotel in Nigeria.
The increasing rate of mysterious deaths in hotels in Nigeria is a cause for concern. There have been several cases of lodgers who suddenly died in their hotel rooms, with some cases ending up in court, while others were covered up. The need for hotel lodgers to take necessary precautions to stay safe cannot be overemphasized. It is essential to be aware of the risks involved in lodging in a hotel and take necessary measures to ensure personal safety.
The Need to Stay Safe While Lodging in a Hotel in Nigeria:
Staying safe while lodging in a hotel should be a top priority for everyone. Regardless of the reason for lodging in a hotel, it is crucial to take necessary precautions to avoid being a victim of theft, assault, or any other criminal activity. Here are some tips to stay safe while lodging in a hotel:
Know Your Hotel:
Before making a reservation, it is essential to research the hotel thoroughly. Do not rely solely on the pictures on the hotel’s website or the description of the hotel. Take the time to read reviews from other guests who have stayed at the hotel. Check online reviews and ratings to get an idea of the hotel’s reputation. Look out for any red flags, such as complaints of poor security, theft, or other criminal activities. Also, check the hotel’s location and proximity to known unsafe areas.
Once you have chosen a hotel and checked in, it is essential to ensure your room is secure. Use deadbolts and security chains to keep intruders out. If there is a safe in the room, keep your valuables in it or with the hotel management. Look around the room and check for any hidden cameras or other surveillance devices that could compromise your privacy.
While lodging in a hotel, be cautious about sharing your personal information with strangers. Avoid giving out information about your room number, travel plans, or any other personal details to strangers. When using hotel facilities, such as the gym or pool, be aware of your surroundings and any potential risks. Also, be wary of unsolicited visitors to your room, and always ask for identification before opening the door.
Emergency Preparedness In hotels in Nigeria:
In case of an emergency, it is important to be prepared and to know what to do. When staying in a hotel, there are some specific steps you can take to ensure your safety in case of an emergency.
Know the emergency exit routes
One of the most important things to do when you check into a hotel is to familiarize yourself with the emergency exit routes. Find the closest fire exits and know how to use them in case of a fire or other emergency. Knowing the emergency exit routes can help you evacuate the hotel quickly and safely.
Familiarize yourself with the emergency procedures of the hotel
Each hotel has its own emergency procedures, and it’s important to be familiar with them. Take a few minutes to read the emergency procedures manual in your room, and ask the hotel staff if you have any questions or concerns. Knowing the emergency procedures can help you stay calm and respond appropriately in case of an emergency.
Have emergency numbers on hand
Keep a list of emergency numbers on hand, including the hotel’s front desk, local emergency services, and your embassy or consulate. Make sure your mobile phone is fully charged and keep it close to you at all times.
Hotel staff members are there to assist you and ensure your comfort and safety. It is important to treat them with respect and report any suspicious behavior to the hotel management. Additionally, don’t leave staff entrance doors open as this can compromise the hotel’s security.
When accessing the internet in a hotel, it’s important to take extra precautions to protect your personal information. Use a virtual private network (VPN) when accessing the internet in the hotel, as this will encrypt your data and protect it from hackers. Don’t use public Wi-Fi networks for sensitive transactions, such as online banking or shopping, as these networks can be easily compromised. Also, avoid clicking on suspicious links or emails as they may contain malware or viruses.
Food and Drink Safety
Food and drink safety is another important aspect to consider when staying in a hotel. Be cautious of street food vendors near the hotel, as their food may not be properly prepared or stored. Avoid consuming expired or suspicious food items, and be careful when ordering drinks in bars or clubs. Always keep an eye on your drink, and don’t accept drinks from strangers.
When traveling to Nigeria, it’s important to respect the local customs and traditions. Dress appropriately for the location and occasion, and avoid offending the local people. Research the local customs and etiquette before you travel, and be mindful of your behavior and actions.
Staying safe while lodging in a hotels in Nigeria requires a combination of awareness, preparation, and caution. By following the tips provided in this article, you can help ensure your safety and security during your stay.
What should I do if I feel unsafe in my hotel room?
If you feel unsafe in your hotel room, immediately contact hotel management and report the situation. If you feel that your life is in danger, call the police.
Can I trust the hotel staff?
While most hotel staff are trustworthy, it is important to exercise caution and not share personal information with strangers. If you notice any suspicious behavior, report it to hotel management.
What should I do in case of a fire or other emergency?
Familiarize yourself with the emergency procedures of the hotel and know the emergency exit routes. Have emergency numbers on hand and follow the instructions of hotel staff in case of an emergency.
Can I eat street food near my hotels in Nigeria?
While it is best to avoid street food vendors near hotels, if you must consume street food, be cautious and ensure that the food is properly cooked and not expired.
What are the consequences of ignoring hotel safety precautions?
Ignoring hotel safety precautions can lead to serious consequences, including loss of valuables, physical harm, and even death.
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2023.06.05 18:06 Gloryinwar Creating a military doctrine that encourages soldiers to "Fight Dirty" and use every trick in the book to win victories.
As the title says I wanted to try creating a military doctrine that teaches soldiers to fight the enemy as though they were in a "brawl" Soldiers in this doctrine are taught and even encouraged to fight dirty and to use every trick at their disposal to fight the enemy. A doctrine where conventional warfare is not utilized until the conditions for a sure victory (Or a moderately successful chance at it.) has been achieved.
This is for a science fantasy world of mine.
You see, this is the Doctrine for the army of the Skovi Federation.
And it has been their doctrine for a very long time, only seeing minor reforms and changes but otherwise still telling the soldiers to not fight fair and to use every advantage they have.
You see what this doctrine entails is that regular infantry and other light forces will be the ones to carry out the "Brawling fight" as it is officially known. This essentially entails that the Infantry does everything and anything to gain an advantage... They will lay traps, use snipers, call in harassing artillery and constant air strikes, lay ambushes, perform lighting-fast raids meant to cripple enemy supplies, etc.
In this context, the role of the Infantry is to engage in hit-and-run tactics, fighting mostly as platoon-sized units and companies, rather than anything larger than that.
Their role is to make the enemy lose many men, supplies, and vehicles through constant ambushes, sniper attacks, raids, traps that were set in place, etc.
As the manual says "Fight dirty like in a Bar brawl. Never engage the enemy in conventional warfare unless victory is either certain or has a reasonable chance of success."
While soldiers still fight with their typical organization, Squads, companies, etc. Companies and even smaller platoons were granted high degrees of autonomy and were accustomed to functioning as smaller units, only combining back into larger formations for major operations.
And all this time, the heavier forces such as the Armor and Tripods (Analogous to 40k's Titans.) and other heavy units are typically kept in reserve, either to respond to rapidly developing situations or simply waiting for the next grand offensives.
The whole idea is that the Federation can use its "endless ocean" of Infantry to weaken, blunt, or even halt enemy offensives and keep the enemy distracted and pressured as the Federation Infantry does everything to make life as hard as possible.
From snipers to constant air and artillery strikes, to the small and large scale raids and ambushes, the Infantry is there to bleed the enemy out, playing dirty to cut them in a million different places.
Enough that when the counter attack begins, the enemy will have been weakened or at least suffered significantly.
Draining enemy supplies and manpower while preserving the heavy hitters.
Yeah just wanted to share this.
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2023.06.05 17:13 lustyjusty69 Presto 15psi vs Electric 12psi pressure cooker
Just a quick one. So due to regulations in my country we can only get up to 12psi levels on new pressure cookers and it's damn hard to find anything that cooks up to (or above) 15.
I have a decent electric cooker already (12.3 psi max) but I've seen the crème of the crop in a presto 23 quart 20 psi cooker unused in a pawn shop here for about 130 dollars.
My question is - is the 3 psi going to make enough of a difference for the investment?
Thanks for the help!
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2023.06.05 14:46 Ricosss Combination of triheptanoin with the ketogenic diet in Glucose transporter type 1 deficiency (G1D). (Pub Date: 2023-06-02)
Fuel influx and metabolism replenish carbon lost during normal neural activity. Ketogenic diets studied in epilepsy, dementia and other disorders do not sustain such replenishment because their ketone body derivatives contain four carbon atoms and are thus devoid of this anaplerotic or net carbon donor capacity. Yet, in these diseases carbon depletion is often inferred from cerebral fluorodeoxyglucose-positron emission tomography. Further, ketogenic diets may prove incompletely therapeutic. These deficiencies provide the motivation for complementation with anaplerotic fuel. However, there are few anaplerotic precursors consumable in clinically sufficient quantities besides those that supply glucose. Five-carbon ketones, stemming from metabolism of the food supplement triheptanoin, are anaplerotic. Triheptanoin can favorably affect Glucose transporter type 1 deficiency (G1D), a carbon-deficiency encephalopathy. However, the triheptanoin constituent heptanoate can compete with ketogenic diet-derived octanoate for metabolism in animals. It can also fuel neoglucogenesis, thus preempting ketosis. These uncertainties can be further accentuated by individual variability in ketogenesis. Therefore, human investigation is essential. Consequently, we examined the compatibility of triheptanoin at maximum tolerable dose with the ketogenic diet in 10 G1D individuals using clinical and electroencephalographic analyses, glycemia, and four- and five-carbon ketosis. 4 of 8 of subjects with pre-triheptanoin beta-hydroxybutyrate levels greater than 2 mM demonstrated a significant reduction in ketosis after triheptanoin. Changes in this and the other measures allowed us to deem the two treatments compatible in the same number of individuals, or 50% of persons in significant beta-hydroxybutyrate ketosis. These results inform the development of individualized anaplerotic modifications to the ketogenic diet.ClinicalTrials.gov registration NCT03301532, first registration: 04/10/2017.
- Avila A
- Málaga I
- Sirsi D
- Kayani S
- Primeaux S
- Kathote GA
- Jakkamsetti V
- Kallem RR
- Putnam WC
- Park JY
- Shinnar S
- Pascual JM
------------------------------------------ Info ------------------------------------------
Open Access: True
Additional links: * https://doi.org/10.1038/s41598-023-36001-x
------------------------------------------ Open Access ------------------------------------------
If the paper is behind paywall, please consider uploading it to our google drive anonymously.
You'll have to log on to Google but none of your personal data is stored. I will manually add a link to the file in this post when received. Upload PDF
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2023.06.05 14:45 Ricosss New prebiotics by ketone donation. (Pub Date: 2023-06-02)
Integrity of the microbiome is an essential element for human gut health. 3-Hydroxybutyrate (3HB) secreted into the gut lumen has gained attention as a regulator of gut physiology, including stem cell expansion. In this opinion, I propose new prebiotics leading to gut health by use of a ketone (3HB) donor. When exogenous 3HB is supplied through ketone donation, it has the potential to markedly improve gut health by altering the gut microbiome and systemic metabolic status. Poly-hydroxybutyrate (PHB) donates 3HB and primarily influences microbiota, making it an effective prebiotic for improving the gut environment. Thus, exogenous 3HB donation to the lumen of the gut may aid gut health by maintaining the integrity of microbiome.
------------------------------------------ Info ------------------------------------------
Open Access: False
------------------------------------------ Open Access ------------------------------------------
If the paper is behind paywall, please consider uploading it to our google drive anonymously.
You'll have to log on to Google but none of your personal data is stored. I will manually add a link to the file in this post when received. Upload PDF
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to TheKetoScienceJournal [link] [comments]
2023.06.05 14:28 kitchenmusthaves Instant Essentials 4QT Air Fryer Oven 4 Quarts Air Fryer Oven Instan...
This Instant Essentials 4 Quarts Air Fryer Oven Is An Incredible And Versatile Appliance That Can Help You Cook Faster, Healthier And More Delicious Meals Every Day. Here Are Some Of The Amazing Benefits Of Owning This Fantastic Product: It Is From The Makers Of Instant Pot, The Trusted And Reliable Brand That Has Revolutionized Home Cooking With Its Innovative And User-Friendly Pressure Cookers. It Uses Evencrisp Technology To Deliver Crispy And Juicy Results With Up To 95% Less Oil And Fat Than Deep Frying. You Can Enjoy Your Favorite Fried Foods Without Guilt Or Mess. It Has 6 Smart Programs That Let You Air Fry, Roast, Bake, Broil, Reheat And Dehydrate A Variety Of Foods With One Touch. You Can Make Everything From Crispy Chicken Nuggets To Cheesy Pizza To Savory Jerky With Ease. It Has A Large 4-Quart Capacity That Can Fit Up To 2 Pounds Of Fries Or A Whole Chicken. You Can Cook For Your Family Or Entertain Your Guests With Plenty Of Food. It Has A Nonstick And Dishwasher-Safe Basket That Makes Cleaning A Breeze. You Don't Have To Worry About Scrubbing Or Soaking The Basket After Use. It Comes With A Free App That Has Over 100 Recipes To Inspire You. You Can Access The App On Your Smartphone Or Tablet And Follow The Step-By-Step Instructions And Videos To Make Mouthwatering Dishes. Don't Miss This Opportunity To Get Your Own Instant Essentials 4 Quarts Air Fryer Oven Today And Enjoy Healthier And Tastier Food At Home.
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2023.06.05 10:49 betterinthesouth Masterchef double standards
I just finished watching yesterdays elimination episode and I feel so sorry for Robbie. What the judges did to him was unfair, how do you tell a contestant that there’s something wrong when there’s like 20 minutes left on the clock, what do you expect him to do?
And I also don’t like the double standards in masterchef. Curry is viewed as something that’s one dimensional - that if a person cooks it repeatedly then they’re repeating their dishes but it’s not true. There’s so many ways to make curries and just because they have the same colour does not mean it’s the same.
Also, if we look at curry in this way then we should view making pasta in the same light. Yes, there’s different types of pastas out there but at the end of the day it’s still pasta. Because that’s what they’re essentially saying when it comes to curries.
Anyway my rant is over but I just found it so unfair to Robbie that he was pressured into changing his sausage curry when he’s never made sausage curry in the kitchen before.
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2023.06.05 10:42 JadedIntention4960 Heart-Healthy Recipes That Are Easy and Yummy!
helps you have the right food and keeps a check on your heart health. It aids in weight loss, reduces cholesterol, inflammation, blood pressure, and other heart risks, and increases lifespan.
According to WHO, “cardiovascular diseases (CVDs) are the leading cause of death globally, taking an estimated 17.9 million lives each year”. One-third of these deaths occur prematurely in people under 70 years of age. Four out of five CVD deaths are due to heart attacks and strokes.
This definitely is a problem of concern and needs to be addressed soon. But as it’s said – “Prevention is better than cure” It’s always better we start to visualize the problem, spread awareness, and follow practices that help us. Altering our lifestyle and incorporating a healthy diet are the best ways to stay safe from heart risks. And our heart-healthy recipes could be a great choice to start with! Diet Changes that Can Eliminate the Risk of Heart Disease
Increase the intake of whole grains, veggies, fruits, and seeds in your regular diet. This makes a balanced diet and reduces heart problems.
Limit your consumption of Sodium, saturated fats, and trans fats like sugary foods & drinks, fried food, and processed meat. Cook your meals at home. This ensures you eat healthy food regularly.
Complement these practices with regular exercise; quit smoking and alcohol consumption to prevent heart disease. Heart-Healthy Recipes You Need to Try Home-cooked-meals
don’t just fill your belly, you also become mindful of what you feed your body by selecting healthier ingredients and practicing portion control. Not to forget, home-cooked meals help us save money and bring our loved ones around the table.
Grab the chance and try out our heart-healthy recipes that are easy to make and extremely tasty. Our list has a combination of foods covering veggies to whole grains that keep you satiated until your next meal. Black Salmon with Roasted Vegetables
Salmon, rich in Omega-3-fatty acid, is a healthy fat. It can reduce cholesterol, control blood pressure, and is great for your heart and brain. When Salmon is paired with carrots, bell peppers, onions, or other veggies, it adds vital nutrients, making it a perfect dish that could make your heart crave for more.
This nutritious dish is a quick recipe that can be prepared within 30 minutes. You first need to preheat your oven to 400O F, place the salmon filets seasoned with salt and pepper on a baking sheet and roast the fish for up to 15 minutes. Now add the roasted vegetables seasoned with salt, pepper, and olive oil and transfer it to a platter along with the Salmon, and your delicious recipe is ready to taste! Slow Cooker Butternut Squash Soup
Butternut squash is a rich source of vitamins, Potassium, Magnesium, Manganese, and fiber. It is low in saturated fats and cholesterol and, thus, is an excellent heart-healthy appetizer.
Saute diced onions, carrot, and garlic, with butternut squash in olive oil for 5-10 minutes. Transfer this mixture to a slow cooker and add vegetable or chicken broth and coconut milk. Lastly, add your desired spices (salt, pepper, cumin, chili flakes, and curry powder) and cook on low. This heart-healthy soup is ready to serve after 6-8 hours and tastes like heaven. Lentil and Vegetable Stew
Lentils reduce the risk of heart disease by lowering cholesterol and blood pressure. They are a good source of plant protein and are rich in iron, Vitamin B1, and folate, which helps your heart be healthy. Additionally, the vegetables in this dish provide essential vitamins and minerals, making it a balanced diet.
Saute onions, garlic, celery, and carrots in the olive oil for 5 minutes. Add lentils, tomatoes, herbs, and vegetable broth and bring it to a boil. Add the seasoning, simmer the stew, and boil the lentils and vegetables until they are tender. Lastly, garnish the stew with parsley and serve it hot as is or with quinoa or brown rice. Grilled Chicken and Veggie Skewers
Unlike red meat, chicken is healthy as it is comparatively low in saturated fats and is a great food choice for non-vegetarians. And when you add your favorite veggies to it, don’t you think it’s a medley of rich flavors?
To make this incredible heart-healthy recipe
, cut the chicken breast into small pieces, marinate them in a mixture of olive oil, lime juice, spices, and herbs and add these chicken pieces to the skewers along with tomatoes, zucchini, onions, or bell pepper. Grill the skewers until the chicken is cooked. This dish can satisfy your taste buds and is something you would love to devour. Quinoa and Black Bean Salad
You can’t go wrong with this recipe when you are looking for a dish that is heart-friendly. Quinoa and black bean salad is a classic cuisine that is extremely healthy, with its main ingredients being Quinoa – a superfood high in amino acids and nutrients, and black bean – which is power-packed with proteins. This dish is delicious and can be made in a jiffy.
Cook the Quinoa as per the package instructions and add the canned black bean to it. Mix them with chopped bell peppers, tomatoes, onions, corn, and your desired spices, and serve them hot. Roasted Root Vegetable Salad
Root veggies can protect you from heart diseases as they are low in calories and sodium and have higher amounts of potassium and fiber. Thus, they curb your hunger pranks and are healthy.
To make this salad, dice your favorite veggies, and sprinkle salt, pepper, and olive oil. Now spread these veggies on a baking sheet and roast them in the preheated oven for up to 35-40 minutes. Add the roasted vegetables to a bowl of greens, walnuts, crumbled cheese, and vinaigrette; toss them with the dressing, and voila! You got a healthy and yummy salad to savor.
In conclusion, incorporating heart-healthy recipes into your diet can help reduce the risk of heart disease and keep you healthy. These recipes are easy to make and delicious, making it easier to stick to a healthy diet. Remember to also complement these dietary changes with regular exercise and other healthy lifestyle choices.
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2023.06.05 10:28 preacherhummus Can't seem to get dried beans right
I did my second attempt at cooking dried beans today. Here
was my first.
I still can't seem to get them right.
I cooked butter beans, and online sources said they need about an hour. Following Deborah Madison's advice in her big Vegetarian Cooking for Everyone
book, I boiled for 10 mins and then simmered for the rest of the time.
After about 40 mins simmering though, ended up with burst, quite mushy beans. https://imgur.com/a/pP9rCsr
The only thing I can think of is that the water came to the boil briefly at one point during simmer. (I find it very difficult to keep a covered pan consistently at a simmer without every boiling, tbh). Also confused about why it took so much less time than predicted for them to cook. Is it normal for butter beans to be kind of over-cooked after 50 mins total cooking time?
I'm starting to wonder if getting a pressure cooker would be a good idea for better results.
Any advice appreciated.
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to Cooking [link] [comments]
2023.06.05 09:11 luoyang-judian Unraveling the Wonders of Wire Rod Mills: From Raw Material to High-Quality Wire Products
| || | submitted by luoyang-judian to u/luoyang-judian [link] [comments]
A wire rod mill
is a type of industrial plant used for the production of high-quality wire products from raw materials such as billets, blooms, or scrap metal. The process of wire rod production involves several stages, including heating, rolling, and cooling, which are carried out on specialized equipment in the mill.
During the heating stage, the raw material is heated to a specific temperature in a furnace, which makes it malleable and easier to shape. The heated material is then passed through a series of rollers in the rolling stage, which gradually reduces its diameter to the desired size. The rollers can be arranged in various configurations, depending on the type of product being produced. https://preview.redd.it/hhbit5q8g54b1.jpg?width=600&format=pjpg&auto=webp&s=c714c31d5b61eca69dd3680d294cea82ae7ac332
Once the wire has been rolled to the right size, it is cooled to room temperature in the cooling stage and then coiled onto a spool or reel. The resulting wire product can be used in a wide range of applications, from construction and manufacturing to electrical wiring and jewelry making.
Advantages of Wire Rod Mill Control Systems
Modern wire rod mills use advanced control systems that monitor and control the entire production process. These systems use sensors and other instruments to track various parameters such as temperature, pressure, and speed, and adjust the process parameters in real time to optimize the production process. Roll Design
The design of the rolls used in wire rod mills has improved significantly, with the development of rolls that are more wear-resistant and have longer lifetimes. This reduces the frequency of roll changes, which leads to less downtime and higher productivity. Digital Modeling and Simulation
Wire rod mills now use digital modeling and simulation tools that allow engineers to simulate the production process and test different scenarios before implementing changes. This reduces the risk of errors and helps optimize the production process for maximum efficiency. Robotics and Automation
Many wire rod mills now use robotics and automation to perform tasks such as loading and unloading materials, handling finished products, and performing routine maintenance tasks. This reduces the need for manual labor and increases productivity while reducing the risk of accidents. Energy Efficiency
Modern wire rod mills are designed to be more energy-efficient, with improved insulation, better control systems, and advanced equipment such as regenerative burners that recover waste heat and use it to preheat incoming materials. This reduces energy consumption and lowers operating costs.
Wire rod mills are essential components of the metalworking industry, and their products are used in countless applications around the world. With advances in technology and automation, wire rod mills have become increasingly efficient and versatile, allowing manufacturers to produce a wide range of wire products with exceptional quality and precision.
2023.06.05 09:11 mk2k01 [For Sale] Mix of Genres: Rome Streetz, Cousin Feo, Mid Air Thief, Slightly Stoopid, VMP, etc!
Items will be listed below the lowest discogs price (for the condition), shipped in high quality whiplash mailer ($4 for shipping), and will be graded properly, I will do free shipping on orders of 2 or more.
Posting early version, will add more throughout the day...
- Al.divino - Facemelt 2 - Purple/Green - Sealed/Mint - $50
- Al Green - Gets Next to You - Green (VMP) - Sealed/Mint - $40
- Ambrose Akinmusire - On the Tender Spot... - Smoke Brown 180g (VMP) - Sealed/NM - $20
- BadBadNotGood x Ghostface - Sour Soul (Lex Records) - Sealed/Mint - $20
- Cookin' Soul - Diggin' Stories - Standard - Sealed/Mint - $40
- Cousin Feo - Patat - Orange - Sealed/Mint - $40
- Daniel Son x Futurewave - Pressure Cooker - OBI - Unsealed/NM - $75
- Dreddy Kruger - Presents... Think Differently Two - OBI/Clear - Unsealed/Mint - $50
- Earl Sweatshirt - Feet of Clay - Tan - Sealed/Mint - $25
Earl Sweatshirt - SICK! - Brown/White (VMP) - Sealed/Mint - $35 SOLD
- El Camino x 38 Spesh - Sacred Palms - Blue - Sealed/Mint - $60
- Kev Brown x J Scienide - Stray from the Pack - Red/Green Split - Sealed/Mint - $50
- Marlon Craft - Funhouse Mirrors - Black - Sealed/Mint - $75
- Mid Air Thief - Crumbling - Purple in Blue Sky Galaxy - Unsealed/NM (never spun) - $80
- Mooch x Giallo Point - Dopanese - Red/White Split - Sealed/Mint - $40
- The Marias - Superclean 1/2 - Trans Red - Sealed/Mint - $40
- Ransom x Nicholas Craven - Deleted Scenes - Freddy Variant - Unsealed/VG - $50
- Corner ding from OG shipment, never played
- Rigz x Mooch - No Way Out - Seafoam Blue - Unsealed/NM (never spun) - $60
- Rome Streetz x The Artivist - Joyeria - Gold - Sealed/NM - $150
- Scientifik - Criminal (de Rap Winkel) - Blue - Unsealed/NM (never spun) - $50
- Slightly Stoopid - Everything You Need - Black - Sealed/VG - $30
- Corner semi bent from shitty packing when originally sent, still sealed though
- Slightly Stoopid - The Longest Barrel Ride - Blue Trans 180g - Sealed/Mint - $25
- Steve & Teresa - Catching A Wave - Blue Swirl (VMP) - Unsealed/Mint - $25
- Stove God Cooks - Reasonable Drought - Black - Sealed/Mint - $60
- Surfing - Deep Fantasy - Seafoam Splash - Sealed/Mint - $40
- Sven Wunder - Eastern Flowers - Repress - Unsealed/NM (spun once) - $40
submitted by mk2k01
to VinylCollectors [link] [comments]
2023.06.05 08:58 nilkanthenggworks Cement Silo: A Key Component for Efficient Concrete Storage and Delivery
In the world of construction, the storage and management of cement play a vital role in ensuring the success of concrete-related projects. Cement silos are essential structures designed specifically for the storage and controlled discharge of cement. In this blog post, we will delve into the importance of cement silo
, their functionalities, and how they contribute to efficient concrete storage and delivery.
- Understanding Cement Silos:
Cement silos are tall, cylindrical structures typically made of steel, designed to store large quantities of cement. They are equipped with various components such as filling and discharge systems, level indicators, and safety devices to facilitate the storage and controlled distribution of cement.
- Types of Cement Silos:
· Vertical Cement Silos: These silos have a vertical design and are commonly used in construction sites where space is limited. They offer a smaller footprint and are suitable for storing cement in smaller quantities.
· Horizontal Cement Silos: Horizontal silos have a horizontal orientation and are often used in larger construction projects. They offer higher storage capacity and are efficient for bulk cement storage.
· Mobile Cement Silos: Mobile silos are designed for easy transportation and on-site mobility. They can be transported to different construction sites, providing flexibility and convenience.
- Benefits and Features of Cement Silos:
· Efficient Storage: Cement silos provide a secure and protected environment for cement storage, protecting it from moisture, air, and other external factors that could compromise its quality.
· Controlled Discharge: Cement silos are equipped with discharge systems that allow for precise control over the amount of cement released, ensuring accurate batching and minimizing wastage.
· Improved Workflow: With cement silos, construction sites can have a continuous supply of cement, reducing downtime and improving overall workflow efficiency.
· Enhanced Safety: Cement silos are designed with safety features such as pressure relief valves, level indicators, and alarms to ensure safe and reliable operation.
· Customization Options: Cement silos can be customized to meet specific project requirements, including capacity, material of construction, and additional features like dust collectors or pneumatic conveying systems.
- The Role of Cement Silos in Concrete Production:
· Continuous Supply: Cement silos ensure a continuous and reliable supply of cement, enabling uninterrupted concrete production and reducing the risk of project delays.
· Batch Accuracy: The controlled discharge from cement silos allows for accurate batching of cement, ensuring consistent and high-quality concrete mixtures.
· On-Demand Cement Delivery: Cement silos enable the delivery of cement in the required quantities at the right time, eliminating the need for manual handling and reducing the chances of contamination or waste.
- Choosing the Right Cement Silo:
· Consider Capacity: Evaluate the storage requirements and choose a cement silo with an appropriate capacity to meet the project’s needs without excessive downtime or space limitations.
· Quality and Durability: Opt for a cement silo constructed with high-quality materials to ensure longevity, protection against corrosion, and structural stability.
· Advanced Features: Look for additional features like level indicators, pressure relief valves, and dust collection systems that enhance safety, efficiency, and ease of operation.
Cement silos play a critical role in the efficient storage and delivery of cement, a key component in concrete production. Nilkanth Engineering Works
providing secure storage, controlled discharge, and a continuous supply of cement, these silos contribute to improved workflow, batch accuracy, and overall project efficiency. When selecting a cement silo, it is important to consider capacity, quality, and advanced features that align with specific project requirements. Embrace the benefits of cement silo Manufacturers
and ensure smooth concrete production and delivery for successful construction projects.
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to u/nilkanthenggworks [link] [comments]
2023.06.05 07:57 cookOki01 multi function pressure cooker - Okicook.com
- A multi function pressure cooker may completely transform your culinary experience. This appliance saves you time, space, and effort by combining various cooking tasks into one unit.
submitted by cookOki01
to u/cookOki01 [link] [comments]
2023.06.05 01:15 Selkcahs Red Deck Wins (RDW) - A Burn/Kuldotha Comprehensive Primer
| || |Red Deck Wins (RDW) - A Burn/Kuldotha Comprehensive Primer Image by Rhystic Studies https://www.youtube.com/@RhysticStudies submitted by Selkcahs to Pauper [link] [comments]
Hi guys, my name is Selkcahs (https://twitter.com/selkcahs
) and I’m an Argentinian MTG/MTGO Grinder that has played competitive Magic for the last 10 years and enjoys writing MTG Primers. While i have dabled myself in a multitude of formats, I've been always pulled back to Pauper due to it’s unique qualities and characteristics.
I’ve also played a lot of Archetypes but I've had modestly successful results in the competitive scene with the infamous Red Deck Wins (https://www.mtggoldfish.com/deck/300634#paper
). While a great many players see themselves above the simplicity of playing Red Aggro, choosing more complex and colorful options; I've always respected the core idea behind it: finding the faster and most efficient way to kill your opponent. “A harmony of mathematical precision” - The Architect expressing his thoughts about the efficiency of Red Deck Wins.
That being said, i think it was about time for me to immerse into what is the most dominant Red Aggro Archetype that has ever been seen in the Format; so I hope you enjoy the reading as much as I've enjoyed the writing.
A bit of history first... https://preview.redd.it/yqjlp8z1234b1.png?width=306&format=png&auto=webp&s=a7ab53a48760f5b2937c4cc28fb34d6895a08a33
A long time ago, when extra Mana in the Pool burned you and Combat Damage used the Stack, a man made history and revolutionized the whole idea of Deckbuilding in Magic forever. That man was called Paul Sligh, who made 2nd Place in the Atlanta PTQ in 1996 with a deck that by all standards (old and new) seems lackluster and not suited for competitive play. https://www.mtggoldfish.com/deck/3858668#paper
The deck itself wasn’t fancy at all and it didn’t play the best cards of his time (it even broke the Golden rule in Magic, to not play more than 60 cards), but it did 1 thing particulary well: It curved with Creatures and Spells from Turn 1, which allowed it to maintain the Tempo advantage with early board presence and pressure. This game plan was helped by Red damage spells that served both as Removals to control the board and Burn to damage directly the opponent’s life totals.
The results obtained by Paul in the tournament were so impactful in the Magic competitive scene that from that point on the new decks that followed the same game plan were named “Sligh” in honour of the man that started a new era of building and playing Aggro strategies (even if the original deck idea was designed by another famous player, Jay Schneider).
While we have come a long road from that 1996 Atlanta PTQ, the core concepts of that first Mono Red Archetype sticked trough almost all formats: efficient and cheap creatures, combined with Burn spells that focused on closing the game as fast as possible, was a perfectly sound plan to achieve victory in the game of Magic.
The Red Menace https://preview.redd.it/l8ab9ma9234b1.png?width=292&format=png&auto=webp&s=3f08c5509b657256786bcf14c936a048d42b38d7
Since the beginning of the Pauper format, the Red Aggro Archetype has existed because the best Burn spells in the game are commons (Fireblast, Lightning Bolt, Chain Lightning and all the subsequent and weaker iterations). Despite that, Red Aggro in Pauper historically lacked cheap and efficient creatures to complement their game plan, which meant that it existed as a 2nd Tier deck at most that could only achieve good results sporadically.
But that is the past brother, because in the year 2022 Wizards released Double Masters; an expansion focused on reprints that made the fatal mistake of downgrading to common one of the best Red creatures ever printed: She’s beautiful, isn’t she?
The moment Monastery was legal on Pauper the entire metagame warped around it, classic Burn decks started playing very similarly to their Legacy counterpart thanks to now having an efficient and hard-to-answer creature. In a few weeks, the format gave birth to a new iteration of Red Aggro called Hot Dogs; which used Monastery, Kiln Fiend and Festival Crasher; paired with various cheap and “free” spells, to deliver One Turn Kills before Turn 4.
- Hot Dogs: https://www.mtggoldfish.com/deck/5058490#paper
When the meta adapted and started efficiently countering the fragile game plan of deploying few early creatures and going all-in for the OTK, Red Mages commited themselves to explore other nefarious ways to abuse their new Prowess girlfriend until someone hit the jackpot when he realized that a combination of Red/Colorless Artifacts allowed you to play Kuldotha Rebirth in a Red Aggro shell with few concessions thanks to cards like Great Furnace, Chromatic Star, Implement of Combustion and Experimental Synthetizer.
The most important of those Artifact cards was Synthethizer because it provided something that was unkown to most Burn players until then: Card Advantage. Since that first Sligh deck, Monored has caracterized itself for being all about the Tempo advantage, trading at most 1 for 1 while abusing the early game pressure to nullify the extra cards that your opponent would have in hand until you managed to kill them.
With the adition of Synthetizer players started searching other Red cards that provided some sort of Card Advantage when they realized that effects like Reckless Impulse were essentially “Draw 2 cards” when you have that many cheap spells that can be easily deployed during the course of 2 Turns. And thus, the abomination was given birth:
- Kuldotha Red: https://www.mtggoldfish.com/deck/5094195#paper
When the deck was in its apogee, Wizards decided it was a good idea to print another Reckless Impulse; this time named Wrenn’s Resolve. This meant that while Kuldotha continued as a perfectly consistent game plan, Red Decks now had enough card advantage to not even need to play the board with small creatures and focus on more Burn Spells and “Ping” creatures that, if left unanswered, will usually mean a swift and violent death.
- Mono Red Burn: https://www.mtggoldfish.com/deck/5626897#online
The Primer itself
Okay, this storytelling until now has been nice and fun, but i promised you a Primer (which usually means an explanation in depth of the Archetype itself) and so i shall deliver:
- The Rations https://preview.redd.it/v6u6islg234b1.png?width=576&format=png&auto=webp&s=b1c7bdab8de4144d9a4c64e441f9ea02fae1f540
Yeah you guessed it, we will be playing the best lands a Red Aggro deck can wish for: untapped Basic Mountains. While the most important thing about that beautiful Red mana generator is that it comes Untapped, the Mountain Type is extremely important whenever you are playing cards like Fireblast or Lava Dart. In adittion to those, we also have some more interesting options at our disposal for different purposes:
- Mountain: Everything we really need to be honest.
- Great Furnace: Oh boy do i wish i could play 18 of this bad boys, but being able to use 4 in any interation of Burn that abuses Artifacts is good enough.
- The Autonomous Furnace: the only tapped land that we can afford to play because it allows us to increase our chances of not getting screwed in the early game while also cycling itself in the Mid/Late stages of the match. You will usually see it as a 1-of and sometimes as a 2-of.
- Forgotten Cave: A card no longer used in most lists because it can’t be cycled when revealed with “exile” effects.
- The Troops https://preview.redd.it/uqodj32m234b1.png?width=576&format=png&auto=webp&s=9bbbb2bb0f2378f004316c2b8dc5b8675f462f58
As we already discussed, a fundamental part of RDW is having efficient creatures to put pressure in the early game, and this are the best options avalaible right now:
- Monastery Swiftspear: Nuff said, it’s so good that its played in any format it’s legal. While to the inexpert eye it may not seem that oppressive, you will soon realize that Prowess triggers with EVERYTHING that is not a creature and that it’s almost impossible to safely block because it can always be pumped in various ways during the Combat Phase. In all intents and purposes, a busted card.
- Voldaren Epicuren: a seemingly inoffensive 1/1 that does A LOT of things, which are dealing direct damage when it ETB and giving you a token Artifact that allows you to cycle useless cards (usually extra Lands). While the card is good by itself, it will always be played in iterations of the deck that can abuse the Artifact Blood Token in various ways.
- Goblin Blast-Runner: A new 1-drop that can deal a lot of damage when you can consistently sacrifice permanents each turn.
- Kuldotha Rebirth: While Kuldotha is a Sorcery, it represents three 1/1 Creatures for 1 mana as long as you can easily get an artifact to sacrifice. While it may seem not that broken, anyone that has played with or against it knows how much of a powerhouse it is.
- Goblin Bushwacker: A monster of a card that multiplies the damage of your board unexpectedly, allowing you to deal massive amounts of damage; used specifically to abuse Kuldotha Rebirth.
- Dwarven Forge-Chanter: The best Red Prowess card besides Monastery, having to deal 2 damage to kill it with a spot removal makes it feel like a common Eidolon of the Great Rebel sometimes.
- Kessig Flamebreather: A “Ping” creature utilized in more Burn focused lists.
- Thermo-Alchemist: Another “Ping” creature like Kessig, used to complement it.
- Burning-Tree Emissary: Another beast of an infrequent downgraded to common. Multiple copies of her in the early game can give you an unfair Tempo advantage while also being decent in the Midgame when combined with other cards.
- Underworld Rage-Hound: A creature that has seen little use but that has a lot of potential in grindy matchups.
- Burning Prophet: A card that has seen little use mainly due to how inconsistent the Scry value usually is in redundant Aggro decks.
- The Guns https://preview.redd.it/g7ueg5go234b1.png?width=576&format=png&auto=webp&s=ab14856d22b9c98071ae03d4bdcc750a9f5b5544
One fundamental component of Red Aggro is playing cards that deal direct damage to the opponent, to their creatures or both; here are the best options in today’s Pauper:
- Lightning Bolt: The best red damage spell ever printed, period.
- Chain Lightning: The next best thing after Lightning Bolt, a bit tricky to play against decks with easy access to double Red.
- Galvanic Blast: An extremely powerful burn spell as long as you can consistently have Metalcraft; in the worst cases it works as a Shock which usually gets the job done.
- Lava Dart: The bane of Faires and most 1 thoughness Creatures while also providing 2 triggers in 1 card of Prowess/Ping. A monster of a card in the right situation.
- Fireblast: 0 mana for 4 damage? Well yes we’ll take it. The small detail of having 2 sacrifice 2 Mountains is usually little relevant in the Mid/Late game.
- Searing Blaze: An historic 2x1 card for Burn. While it usually shines in formats with Fetchlands, it’s still good enough when played on your turn with the natural landrop.
- Lava Spike: 1 mana for 3 damage to the face is usually all you really need when playing a list focused on burning your opponent directly.
- Rift Bolt: One of the “worst” 1 mana burn spell due to having to wait 1 turn to work or costing 3 (which is sub-optimal to say the least).
- Skewer the Critics: The least used “Bolt” of the pack due to how hard can it be to cast for 1 mana in a lot of situations.
- Firebolt: A sorcery Shock with an expensive Flashback, rarely used.
- Seal of Fire: Another niche card that has it uses when you want to use Trigger effects while saving the “shock” for later.
- Needle Drop: A tool from another time when Red Burn decks didn’t had any real access to card advantage, rarely used this days.
- Goblin Grenade: A niche option for decks that heavily use Goblins creatures.
- Shock: Just don’t play this, please.
- Curse of the Pierced Heart: If i find you playing this card we gonna have problems okay? This is from a bygone era when Burn was desperate for a way to maintain damage-over-time; this is no longer the case now that we have access to card advantage mechanisms.
- The Ammo https://preview.redd.it/543ymqgq234b1.png?width=576&format=png&auto=webp&s=bae5401eaef1bdba7f21cd988bb362ed3908a34b
While for classic Burn players the adittion of non-land cards that don’t efficiently deal direct damage or inmediatly increase the board presence may seem strange, they are the sole reason why Burn stopped being a Tier 2/3 deck and become the undisputed master of the format.
- Reckless Impulse/Wrenn’s Resolve: Both cards do exactly the same effect, they exile 2 cards until the end of your next turn; for all intents are purposes, in a low curve Burn deck, this effectively is “2 mana, draw 2 cards”. This type of card advantage allows Burn to not be afraid of play the value game and it’s common nowadays seeing Red Aggro outgrinding their opponents thanks to this kind of tools.
- Experimental Syntethizer: An absolute beast of an Artifact, when correctly played it represents a 3x1 card advantage that is extremely hard to deal with. Do take in mind that the card exiled must be played the same turn or it will be lost; but then again, this is usually an easy endeavour in a low curve deck.
- Chromatic Star: A card that cycles itself while providing an Artifact. Usually used by lists with Kuldotha Rebirth.
- Implement of Combustion: A cousin of Chromatic Star, it deals damage when being manually cycled but it doesn’t provide mana. Depending on your approach to the Archetype you may sometimes find more value in the extra point of damage instead of regaining the invested mana when cycling with Star.
- Mutagenic Growth: A “free” pump spell specially useful in Prowess based lists.
- Manamorphse: A card that allows “free” triggers of Ping and Prowess creatures.
- The Garrison https://preview.redd.it/0tv0hldt234b1.png?width=576&format=png&auto=webp&s=4c4448c2a93da17b3f04d439941c84898d47e05f
Sometimes people don’t like being burned to death, so they will try to employ strategies to prevent us from doing that; and while when choosing between only Red card our Sideboaes options may seem limited, we have more than enough tools against most decks in the format.
- End the Festivities: It allows us to deal with 1 thougness creatures for 1 mana while also doing a bit of damage to the opponent. An extremely efficient sweeper that is sometimes Mainborded.
- Electrickery: Instant sweeper that can very relevant against Faeries or Bushwacker + Kuldotha.
- Pyroblast/Red Elemental Blast: The anti-Blue hate cards by default, they come in handy specially to counter opposing Hydroblast/Blue Elemental Blast. You will always find youself using Pyroblast over REB (unless you want more than 4 copies) because Pyro can be played against any permanent/spell even if it’s not Blue, thus allowing us to get a Prowess/Ping trigger if needed.
- Gorilla Shaman: A monkey that hates Affinity almost as much as you, while useless against Bridges it can get a lot of value against normal Artfifact Lands and other pesky permanents. Ironically, it can be sided in sometimes against Kuldotha based lists trying to punish their heavy Artifact use.
- Smash to Smithereens: Destroying an artfact and dealing 3 damage? You are playing Burn, what else do you really need?
- Shattering Blow: In a format plagued by indestructible Bridges, Shattering Blow can win some games by itself in the right situations.
- Relic of Progenitus: The best Graveyard hate in the format, as long as you are not heavily depending on your own Graveyard to play.
- Raze: We will usually have far more Lands that we need to comfortly operate, which allows us to trade 1x2 to destroy powerful enemy Lands like Bouncelands, Basilisk Gate and Lands enchanted with Utopia Sprawl/Abundant Growth.
- Molten Rain: Paying 3 mana to destroy a Land is a lot for us, you are probably better with Raze in most situations.
- Flaring Pain: A great way to bypass effects that prevent damage, specially against cards like Prismatic Strands.
- Flame Slash: 1 mana for 4 damage to a creature is great way to clear the board and keep swinging our boys sideways.
- Mine Collapse: A “free” removal spells that can take out most creatures in the format.
- Martyr of Ashes: An old card no longer used due to how hard it is to get good value out of it.
- The Battle Plan Von Moltke after he casted 3 Lightning Bolts to the face and the opponent responded with a Weather the Storm.
“A game plan for Burn? Isn’t as easy as just targeting all our spells to the opponent’s face while we swing with our creatures?”
Oh my sweet summer child, you couldn’t be more wrong. While Aggro decks in general (specially Red ones) have a straightforward strategy of killing the opponent as fast as possible, and sometimes you will encounter yourself with “automatic” hands where the road to victory is extremely clear; this also means that the slightest mistake can put you in a position where you lack the resources needed to close the game. Countless games of Magic have been lost because the opponent stayed at 1 life away of lethal only for you to realize that you missed that 1 point of damage in a seemingly unimportant missplay some turns before.
So the central point is: you will probably have to take a lot less decisions when playing Red Aggro than other more “complicated” Archetypes, so you better think things through really well because having few decisions means that the smallest innacuracy will often have dire consequences.
“Okay, okay, Got it. Just don’t fuck up and point everything to the face then?”
Wrong again, probably the worst play Monored can do today is Turn 1: Mountain, Bolt to the face. While more classic iterations of the Archetype focus on incinerating the opponent’s life total as fast as possible, we have learnt better. While Red Aggro’s goal is to maximize the damage dealt to the opponent, usually the most efficient way to do this is by sticking a few good Threats into the board and using our damage spells to control it and consistently deal damage over time; a plan that is helped by our newfound access to Card Advantage that will keep Creatures and Burn spells flowing turn after turn. Thus, we will only point our Bolts directly to the face when they will allow us to close the game in the immeadiate future.
While in the 2 current iterations of RDW we will see a propensity of Kuldotha caring more on maintaining board control and Ping Burn more focused on burning directly the opponent, neither of this decks can afford to mindlessly waste their Bolts.
“So you mean that i have to THINK when playing Monored?”
Sadly yes, besides the nut draw where you will win the match effortlessly you will need to find the right balance between board development, card advantage and burning the fuck out of your opponent’s creatures/life points. Playing correctly will usually allows us to neutralize the few ways our adversary has to counter us:
- Did the opponent chained 2/3 Weather the Storm and went up to 60 lifes?
No problem mate, they have just lost those cards because we will be grinding them out with card advantage and our creatures will eventually drain their life attacking, even if it takes a good couple of turns.
- Is the opponent holding multiple Blue mana open with potential Counterspell effects?
Easy peasy lemon squeezy. If they are leaving a lot of mana open and unused, they probably won’t be able to advance their game plan either, we can just gather our cheap resources and play them all together baiting their responses. If we play something and it resolves, we call it a win and continue to let them waste their Tempo; if they do decide to user their Countermagic, we then have an opening to resolve a potentially more powerful spell, which should be something that provides card advantage that would then allows to happily trade one of those extra resources to their Counterspells later.
- Are they killing each and every creature we put on the Board?
Well after all we are called Burn for something and while we do like to use our creatures to push damage, we are more than happy to go the incendiary route when needed. Also, as long as you don’t walk into a sweeper situation that allows the opponent to trade 1 big removal for several of our resources, we should be able to eventually utilize our card advantage to put into play more threats than the amount of removals spells our opponent have.
- Is the opponent drawing a lot of cards, gaining life and also pressuring us?
Well give me a break, you can’t win them all. Sadly sometimes you will lose no matter what you do, specially if the opponent is well prepared and teched against Burn. With all the positives we have discussed here, in some situations playing a Monocolor Aggro deck that everyone is expecting is not the smartest choice; but even then, current RDW is so powerful that with a bit of luck you can even get good results against the harshest of matchups.
Burn samples: https://www.mtggoldfish.com/deck/5654255#paper https://www.mtggoldfish.com/deck/5654242#paper
Kuldotha samples: https://www.mtggoldfish.com/deck/5654243#paper https://www.mtggoldfish.com/deck/5641081#paper
Okay, that’s been a long one for me and i hope that everyone that read it had a good time. As of June 2023, and since the release of the Lady in Red in June 2022, we have experienced an undisputed dominance of the different variants of Red Deck Wins that shaped the format around it; basically, if you are playing a deck that is too slow to withstand an early Monastery/Kuldotha opening you are setting yourself up for a rough time in Pauper. This have forced the players to choose between 3 main option if they decide to play the format competitively:
- Play a Burn variant.
- Play an anti-Burn Archetype.
- Play a “Combo” deck that tries to ignore being set on fire while it does it’s own thing.
As the Pauper Format Panel (PFP), who’s in charge of monitoring the “health” of the metagame, has stated multiple times that they think there are no changes needed in the format; we are left with the only option of basking in ther infinite knowledge and enjoy being constantly burned to death if we want to continue playing Pauper in the foreseable future.
If you enjoyed the reading be sure to check my other Primers: https://www.reddit.com/Paupecomments/w5td9k/faeries_primer_a_comprehensive_guide/ https://www.reddit.com/Paupecomments/wxzd8e/uw_cawgate_prime
I also have a Patreon that, while mainly focused on the UW Caw-Gate Archetype right now, provides anything related to the Pauper format; including decks discussion, metagame analysis and coaching services.
2023.06.04 20:29 dnew My Firmament Critique (heavy spoilers for all Cyan games)
Before I dump on the game, let me mention a few of the places that were actually clever:
- The bit with Camelus where you had to raise the bridge and shoot into it from below.
- Figuring out there was a path under the bridge that the ice block blocked.
- Figuring out that you could get up on the ice block from the other end of the crane.
I found the game to be disappointing and frustrating, all down to three reasons:
- The lack of interaction modes. Everything is a doorknob.
- The lack of characters, plot, conflict, and motivation.
- An inability to suspend disbelief, made even more absurd by the ending.
Let's look at these, along with contrasting to early Cyan games, and notice how combining all three together makes for a poor experience.
Essentially, the only mode of interaction available is turning a knob. While this is not necessarily a game killer (Myst, for example, only has clicking something) in Firmament it is completely treated as turning a knob. That is, every time you use the adjunct, you're interacting with a manufactured bit of machinery to control power to one or the other function of what you're connecting to. This leads to a sparse range of puzzles that can be included, essentially none of which progress the narrative. And it leads to the requirement for a technical instruction manual at the start of the game.
There's no "let the water out of the chest then close the knob again so it'll float when you fill the pool." There's no compass rose or turning mirrors. There's no locks to find the combination to (fortunately, given the plot). There's no sorting of singing monkeys. There's no tempting of birds with seed pods. There's no catching of Squees. There's no summoning of Wharks. The steam generator and pipes to fill the Voltaic airship actually work logically, and there's a reason they're puzzling, unlike the steam pipes in Curievale. (I had to actually look up which world the steam pipes were in just now, which shows you how well-integrated that puzzle is.) Also, each puzzle is independent of all the others; there's no foreshadowing of what you need to know, nor cleverness of relating one puzzle to another, as was common all through Exile for example.
Almost all the puzzles (including the most frustrating) involve trying to find the next doorknob to turn; or, having found it, trying to figure out how to reach it with the one and only tool available. Occasionally there's the "let's see if I can find the hidden pathway." Almost none of them involve figuring something out based on the environment or the world building. When stuck, I found myself walking around with the adjunct out looking for some hidden doorknob to light up, or wandering into unobvious corners and walking around the edge of the playable area seeing if I missed a hidden pathway. This is compounded by the huge amount of nonsensical consistency-busting designs. (Watch any first-time playthrough and you'll see the player running all over the place looking for the next clue.)
Granted, once you figured out the solution, it was often clear in hindsight what you were supposed to have been doing.
- You could realize the conservatory is symmetrical and has rubble blocking the way so you need to climb across the planters.
- You could figure out that there were controls under the sulfur you couldn't see the first time by looking at the diagram, if you could figure out what the diagram was saying without extensive exploring to start with.
- You could figure out that the goal in the battery field was to connect the one wire to the other (and not stringing batteries from the outside inwards) once you realize there's exactly two wires leading out from the lake and the error is "no connection".
- You could figure out what order the sockets get concatenated in by looking at their orientations. (Granted, they tried to teach you that during "verification.")
- Once you've drained the first reservoir, it becomes clear the odd structures sticking up were walkways.
- Often you progress a ways through a puzzle and then you can see the exit.
The lack of characters, living people, conflict, narrative, etc also left the game feeling lacking. There's nobody you can interact with, almost no direction is provided as to what you should do (and no, just saying "start the Embrace" doesn't help given you have no memory of what that means), and no motivation for doing it other than some ghost tells you. The real reason you work at it is you know you're playing a game. The fact that the world is terribly inconsistent with the story, and the mentor wants you to do things she won't reveal, just compounds the problem.
- One of the first things she tells you is she'll lie to you, which kind of gave away the "you are Turner" ending.
- You're the only person alive/awake, you're vital to the completion of the project, and your mentor can tell you what to do, but she doesn't.
- In Myst, Riven, Exile, you're given ongoing plot, and you know your motivation from the start, and why there's nobody helping you.
- The ending is an unsatisfying info dump. The beginning is the same. There really wasn't a sense of accomplishment, especially since "Hey, you got to the end, no go away, everything else is automated."
The entire time I was playing, I was saying to myself "Why would this be like this?" It made the entire experience tremendously gamey. Myst and Riven didn't make you think "why would anyone do this?" Exile and Portal both had reasons for being full of puzzles, as well as a motivation for your opponent to be setting up the puzzles and
for making them solvable. But Firmament should have been 10x as easy to navigate, except that wouldn't make a good game, so artificial barriers that make no sense are set in your way. This, for me, destroyed the suspension of disbelief. Especially when the ending reveals that even the things you might have thought were accidental were designed that way. Even the constructed places were designed like puzzles rather than somewhere you want your workers to be effective at working.
- Why would your mentor set things up that you needed to work so hard to make happen what she wanted?
- Why are there even locks on the doors, given only keepers and crew are there?
- Why would any giant door only have a doorknob on one side, especially when there are other doors you can enter?
- Why wouldn't there be a path around the skiff engine so you could couple either side?
- Why is there even a cargo skiff stuck to the side of a building that has stairs at the top and bottom of its range? That's like making a handicap elevator that opens onto a staircase landing. What are you moving on the skiff?
- Why would you install steam pipes zig-zagging all over under the water?
- Why would you install the gangways zig-zagging all over under the water?
- Why would you install steam valves that block the path when turned on? Why not turn that bit so they stick out over space?
- What does turning on the steam even do, other than clearing the way to the spire? It's not powering anything at the exit. Why are the pipes and heaters even there except to make a puzzle?
- Why do the electric heaters need steam power?
- Why do pressurized steam pipes glow green, except to make the puzzle possible? Why are electric lights shining out from inside the steam pipes?
- Why wouldn't you provide all the modes of running the crane on top of the crane? Why can't you raise the hook from on top of the crane?
- How is Juleston the only place that needs special electricity? Where do the other realms get their electricity that this realm couldn't?
- Why does the conservatory have collapsed columns blocking the way that aren't anywhere else in the building? There's no place for them to have fallen from. They're not symmetrical with the other half of the building.
- Why wouldn't the walkways around planters go all the way around? How are you supposed to care for or harvest the contents on the sides without walkways?
- Why wouldn't the controls for rotating the planters be more easily accessible? There's 6 or so controls to raise and lower each planter, and one control to rotate them that you wouldn't even be able to access on foot.
- Why do you need to ride the ice block to get to the factory? Did OSHA approve that? How come the protective gear described on the sign isn't available?
- Why did the walkway in the ice processing center that the moving bridge fills collapse, and where did the collapsed floor go? There are no broken plates on the floor.
- Why is there even a movable room in the ice processing center? Why not just finish building the bridges and walkways?
- How did whoever put the moving bridge there leave? You can only reach it standing on top of an ice block.
- Why is the green pipe valve hidden behind a bunker? Wouldn't it be easier to build stairs?
- Why wouldn't you build stairs all the way to the ground instead of having to walk along the crane to an ice block to reach the stairs?
- Why are there blocks of ice all over outside the processing center?
- How did all the ice blocks get around the base of the crane? Why not grind those up instead?
- How did the block of ice block the pathway, then the bridge get closed, except intentionally?
- Why not put all the controls for the sulfur mixer in one socket?
- Why is there a giant door requiring three sockets to get connected? The tracks don't go through, and there's nothing to be moved from one side to the other, and no vehicle nearby. Why is it there, and who closed it for that matter?
- Who would build a vehicle where the part you need to line up can't be seen from the steering wheel? Camelus' back door is not visible from the steering wheel. The first ice crane has to be automated at each end because you can't see what's happening. The alignment of the second ice crane is invisible from inside the crane, requiring the platform out the side.
you get to the end, and it becomes even more absurd, given that everything you've seen was intentionally designed and built.
- Why would the crane be constructed to run into the cliff? Put it farther out like the bubble car, or don't put rocks jutting out to block its path.
- Why would the sulfur need to be mined? It's not really a planet. Why not stacks of sulfur bricks? Why are there geysers in space?
- Why would you build the bubble car rails where they'd get frozen by ice? There's no seasonal run-off making waterfalls so you had to know that would happen.
- Why pretend you're mining coal? Why launch your coal supply from the ground in rocks instead of extracting it on Earth?
- Why are you wasting coal melting ice anyway? Just use the water before you freeze it. Why build the heat-powered power plant in the coldest realm?
- Why not build the steam furnace downhill from piles of coal and a big pool of water?
- What were you planning to do with a bunch of mountains in orbit when you got to your destination?
- Lots of puzzles block you from turning them off once solved. Why? And how'd they even get in that state in the first place? Nobody is working against you, and nobody has more authority to make changes than you do.
And many more I don't remember the details of.
Given Cyan's track record, one might ponder some of the inconsistencies in implementation and wonder whether they have a deeper meaning. I
couldn't find any.
- The first double-bridge you come to, you have to navigate around to cross; the second double-bridge you can just reach the adjunct across; the bubble car there (I think) is positioned in a way that the last person to leave couldn't set up.of mentor dialog or books or something.
- Only one bunker has an alternate exit.
- Only one bunker has a hibernation bed. Did she drag that there? Her monologue doesn't sound like it.
- It seems like a bad idea to have the Juleston bunker close you in when the power goes off.
- Places blocked by rubble have nowhere above for the rubble to have come from.
- Collapsed floors that need to be bridged have no broken flooring or rubble under them, nor is there any reason for them to have collapsed.
- The first double-bridge you come to, you have to naviate around to cross; the second double-bridge you can just reach the adjunct across; the bubble car there (I think) is positioned in a way that the last person to leave couldn't set up.
- The moving bridge near the ice grinder for sure could not have been left that way (unless someone got ground up). Otherwise riding the ice wouldn't be a puzzle.
- The first place you need to connect three sockets, and there's only one order they connect in.
- The second place needs four sockets connected, but still shows "1/3" when you do the first one.
- When there's some option not currently available for a socket, you're not given that option. Or maybe it goes "Doink". Or maybe just nothing happens. Or maybe it's dimmed out. Or maybe it starts and then immediately reverts.
Compare to Myst: Myst was surreal, magical. It's expected in such situations that there will be weirdness. Nevertheless, essentially every puzzle was reasonable in its environment and grounded and somewhat predictable. Things like getting the key to the lighthouse was grounded in basic physics; things like resetting the spaceship after a mistake, or figuring out how to deduce the stoneship symbols, or raising the channelwood tree, were based on wide-spread cultural references. Where there were other puzzles, the end-goal was shown in advance, with you almost always running across the lock before being presented with the keys. The rare maze allowed you to (mostly) see where you were going several steps ahead and also told you the destination before you found it. The pointers to the story were left in conspicuous places (the note on the grass, the blue and red books). Also, the weird crap was explained in extensive world-building (heh) books in the library. Nothing (almost) was hidden just to make a puzzle harder. The solution to each puzzle was presented while you're in the puzzle trying to figure out the solution, if only you were clever or observant enough to understand it. If you wanted to get into the spaceship, you followed the wires. The elevator trick in Mechanical Age wasn't hidden; you just had to think about why the elevator didn't start right away. The most hidden thing there was the secret panels, which were secret, but still had a target drawn on them. Every place you were stymied by a lock, the lock was intentionally put there to keep natives of the land away from the books, or to keep others from using the books on Myst Island (i.e., the places of protection).
Contrast with (say) the greenhouse puzzle: first you have to figure how to get to the entrance riding the skiff, because that made so much more sense than another flight of stairs or a ladder; thank goodness the vines didn't quite
close off every
path. Then you have to figure out that the place you're trying to go is the other side of the planters on the same level (and not to the thing that looks like a lift or ladder), even though you can't see the other side. Then you ride the things around a while, trying to see the walkways above and below you, before realizing there's another doorknob down at the bottom; good thing they all have distinctive lights on them, eh? That doorknob can only be reached from where you're far from your goal, and from a limited number of puzzle states, then you have to work your way all the way back up, and then if you're lucky you'll have figured out how to turn the planters so you can dodge across. Sometimes you can cross on the diagonal, sometimes it's a fraction too far. And your knees don't bend, so you can't get over the foot-high plank lying on the floor. Or look at the steam pipes and heaters. You need to turn them on, and oh goody, they light up when you do. But some of the doorknobs don't glow; other sockets on the pipes aren't doorknobs they just look that way. Some of the pipes go above the surface, and you can't tell where they come back down. You then can turn on electric heaters using steam, somehow. You have to go down to turn one on, then melt some ice, then coming back up requires turning that off again. Several times you have to turn it on, then turn it off again because the valve was installed in a way that blocks the walkway. There's a valve hidden behind a grate for some reason, but fortunately your other tool can go through grates and the walkway passes by quite close. Then you have to turn on a valve, loop around to go two levels down, turn on the second valve that you can't get to because the steampunk builders thought it was a good idea to install valves that block the pathway, come back up far enough to turn on the third valve, go back down to turn on the heater, come back up and turn off
the first valve, then you can progress. And when you've worked the steam power all the way to the end, what do you get? A steam-powered machine? No, just the same electric lift as in every other realm. Good thing, because you had to turn the steam off again to get to the other side of the path. The only reason for the steam pipes is to make a puzzle that somehow runs electric heaters off steam pressure, with electricity at both ends of the path already. Oh, and there's a hundred meters of gangway in loops and ramps in the water, instead of, you know, a path from one side to the other.
Compare to Riven: Riven is grounded like Firmament. It's not particularly supernatural. The stuff is mechanical, not magical. If someone disappears from a one-door room, there's probably a hidden switch. Granted, "fire marbles" aren't explained, and why there would even need to be clues to get into Tay is unclear story-wise, but OK, combinations to locks need to be written where you can find them. And the mine cart going under water was just Rule Of Cool. Everything else
makes sense. Secret passages are only secret from one side. Doors are locked between where Ghen moves and where natives move, and locked on the side where Ghen is. When there's a "hidden" passage that's hard to see, the people who created it leave a pointer (usually a dagger). When there's a hidden door, you can see into the adjacent room so you know to look for the door. There's no case of "wander all over the level holding the 'show me interaction points' control, trying to figure out if there's a button that enables some other part of the level to work." There's no wondering whether you need an upgrade to even start working on this puzzle. If there's a hidden button to make something work, you can follow the wire to it (the fan), or see the pathway over there, or see the room through the window (book assembly island dome), or notice from where you start there's only one other path of many open (the lake sub), or etc. Look at the design of the wood pulp boiler vs the sulphur mixer. And again, the reason for all the locks are explained in-game. Riven is a masterclass in adventure game design because the puzzles all make sense in the context and story of the game, all of which we see before we need to know it, and there's almost nothing arbitrary
about the puzzles.
Contrast with Firmament: Firmament looks
realistic, but is surreal in detail. The entire place acts like one giant puzzle, with a dozen unintuitive steps to get from each place to the next. It has knobs that can control things remotely, but uses that capability to put things out of reach instead of making things easier, even tho the only people with adjuncts would be people who are supposed to be working the machines. It has machinery on rails constructed too close to other features to let the cars pass (like the first crane blocked by rocks, the second crane blocked by ice, the bubble car blocked by the ice, etc), which is even more silly when you find out the cliffs aren't natural either. It uses complex machinery of all different kinds to accomplish the same ends; the skiff vs the first crane vs the second crane vs the sulfur trains; the conveyance pods vs the bubble cars vs (cripes) riding blocks of ice and hopping off hopefully before you reach the shredder blades. There are places where simple stairs or bridges could be built, but instead there's a half dozen baroque processes to get from one place to another place a literal stone's throw away (see "riding blocks of ice" as well as the pointless skiff and the pointless steam pipes and ....). There's several kinds of power supplies which have to be turned on, each of which powers only the bits of puzzle blocking your way. There are innumerable doorknobs placed in cages where you have to be at the right angle to fire them with no obvious reason for the cage walls to be blocking you from there (see "riding blocks of ice"). Even at the end you have to walk entirely around the axis twice to unlock a door you're 20 feet from when you come out into space.
Compare to Exile: Exile is surreal, but this time it's intentionally designed by its creator to be surreal. Each age has a purpose and a theme, and it looks
designed (unlike Myst's ages). The design of each Age gives you clues to the solutions of the puzzles, and then plays into the endgame. You have an ongoing story that tells you the motivations of the people involved. You have a reason you're suddenly thrown into the situation alone. (As in Myst and Riven, for that matter.) No need for the cliche loss of memory or untrustworthy narrator (both features of Firmament, both described in the opening monologue). There's a reason the puzzles are more difficult than you'd think necessary. The same reason is why there are clues how to solve them scattered about. And you're shown the ways in which the puzzles were made more difficult, which helps tell the story; nothing is randomly broken by accident. When you solve an age, you get a beautiful reward of getting to see the age laid out before you to admire. The ending is fulfilling, and in your hands, left to you to figure out how to bring about some solution or the best solution.
Contrast with Firmament: No setup other than a monologue telling you "you remember nothing, I might lie, go do puzzles I mean maintenance work." The puzzles are arbitrary-progress-blockage puzzles. There's very little where you have to think about what the world is like to make things work. The ages don't feel any different from each other, because every one is "figure out where the path is, where the goal is, and then try to find where you can reach the doorknob from." There's no puzzle having to do with ice on Curievale (other than the heaters, which are just different forms of doors). There's no puzzle having to do with plants on St. Andrew. Even places where you might have figured it out, it was tedious rather than clever; for example, the batteries were painted colors. Imagine how it would have been if you could see into the water and each post had a different number of batteries wired to it? I don't really want to spend time doing linear algebra to figure out puzzles during my gaming hour. And when you do solve a puzzle, half the time you're inside a building or vehicle where you can't see what's happening; the shutters only open once, the bubble cars obscure most of the view, engaging the Embrace doesn't make it obvious the doors are opening in the spire, etc.
How could I have done better? Well, I don't design games for a living, but I've been playing adventure games since they were coded in FORTRAN and printed their text on paper. There are a few obvious places the puzzles could have been made more enjoyable.
- Make the batteries in Juleston visible through the water, with different pylons having different numbers of batteries visibly connected. Then you don't have to do linear algebra and experiments to figure out what's going on, and the fact that the final step is also providing power would be obvious. This would leave open the possibility for the people who want to do linear algebra. (Sort of like how the sound direction clues in Mechanical Age let you navigate in Selentic Age even though there were adequate clues if you went to Selentic first.)
- Keep the steam pipes underwater, so you can follow where the next valve is.
- Actually require the player to mix the sulfur with the sulfur mixer, just for realism. And don't just have the computer tell the user what the next step is. "Door crusted." "Too much acid." "Pool full." Show, don't tell, like with the crusted lock at the start. Maybe make it so you can look into the pool before you add sulfur and see that there are controls down there, and locking lugs, and crusty stuff.
- When a machine finally turns on, make it obvious why you needed that machine in the first place. The whole "turn on steam" in Curievale was there to clear the way of ice in your way (with electric heaters, no less), while the builders could have just put a walkway over or straight through the water there. They could have made the lift at the end obviously running on steam pressure, which might have even made sense in the context of the steampunk origin story. The whole "turn on the batteries" in Juleston was there to power a half dozen machines while other machines all over already had power. Why does the Juleston bunker (you know, the place holding all the maintenance supplies) need battery power to be accessible and the others don't? (Oh, that's right, achievements.) Why did you have to send power to the bunker in order to open the giant doors? And again, the sulfur didn't need mixing (can you tell I'm traumatized?).
- Put some puzzles in that have to do with the age. Require a puzzle where you have to know ice floats, like drop a giant floating ice cube in the resevoir to get across. Require a puzzle where you have to fertilize or poison (with sulfur?) or electrocute (after powering up Juleston?) plants to progress through St Andrew. Let the player pick up a battery to locally power puzzles in Juleston (due to broken wires?) instead of just declaring that this lift lacks power but that lift works fine.
Anyway, that's my
rambling rant. Hope you enjoyed. :)
P.S., what it reminds me most, thinking on it, is all the knock-off adventure games that came out right after Myst became a world-wide success. Except refined and moved into the 2020s.
submitted by dnew
to FirmamentGame [link] [comments]
2023.06.04 18:27 mushlove79 Its all gone to shit
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My mushroom journey is going downhill fast!!! I cannot even seem to make a bag of substrate anymore 😕 the bags either burst in the pressure cooker or it swells so much its all mistapen or ends up with little puncture holes in them what the hell am i doing wtong i am ready to pack it all in or have i just been sold shitty bags.. i have tried sealing the bags prior cooking and after all with the same shitty results submitted by mushlove79 to MagicMushrooms [link] [comments]
2023.06.04 15:02 TheGoldminor Wouldn't be suprised if some fans don't think pokemon will move to the nintendo's next gen console, for long.
For clarity's sake, there is not based on any leak information or whatever about pokemon moving to nintendo's next gen consoles or even what the new system of sorts, atleast that i am not aware off.
I Just feel like sharing a pattern i saw since pokemon kinda start being more talk about on the internet in like late 2008s to now, atleast on my personal time perspective.
But typically during this waiting period between new nintendo console, it always feel like every nintendo fan is super excited of the ideas of what nintendo can cook based on of the next gen console upgrades we gonna get, an average nintendo fan in 2012 will be like "the wii U is like a HD wii with ps3 and xbox 360 graphics, imagine the potential mario game we are gonna get with this new system" whereas many pokemon fans during the jump to a next gen console, almost majority is like "no way pokemon is moving to this console"
Before the series jump to the 3ds during the 2013s, the argument against it is like "but the DS sold 150 million, no way TPC is gonna abandon us" or "3D graphics will never fit for mainline series"
Then in 2017, seen majority reason why it will NEVER debut on switch like "but it's a home console", "the double screen is essential", "the 3ds has more install base than the switch (this is 2017)"
That being said, I say the actual possibility is just purely based on if nintendo's next console is still handheld, if it is in some way portable then absolutely is inevitable, but can still likely be if nintendo pressured tpc enough to have pokemon clout for their next gen systems regardless if it fit the brand name
submitted by TheGoldminor
to TruePokemon [link] [comments]
2023.06.04 14:34 Dirtclodkoolaid AMA RESOLUTION 235
| || | submitted by Dirtclodkoolaid to ChronicPain [link] [comments]
AMA RESOLUTION 235 November 2018 INAPPROPRIATE USE OF CDC Guidelines FOR PRESCRIBING OPIOIDS (Entire Document)
“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients” https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted. https://www.cdc.gov/injury/pdfs/bsc/NCIPC_BSC_OpioidPrescribingEstimatesWorkgroupReport_December-12_2018-508.pdf
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multimillion dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with CocaCola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research) https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline. https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/LT-CDC-OpioidGuideline011516.pdf
The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee and the Centers for Disease Control and Prevention Guideline Committee) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief https://www.medscape.com/viewarticle/863477_2
Actual Study https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-article-JPR
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:
“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.”
Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.
- “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?
Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.
"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”
Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:
- I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”
Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”
No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute: https://legislature.maine.gov/statutes/22/title22sec1726.html?fbclid=IwAR0dhlwEh56VgZI9HYczdjdyYoJGpMdA9TuuJLlQrO3AsSljIZZG0RICFZc
January 23, 2019
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:
- Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
- Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
- Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
- Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
- If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
AS 08.80.261 DISCIPLINARY ACTIONS
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
12 AAC 52.920 DISCIPLINARY GUIDELINES
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Professionally, Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests: https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm630847.htm
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(D) (1) WHEN A PATIENT IS PRESCRIBED AN OPIOID UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE OPIOID.
(2) WHEN A PATIENT IS CO–PRESCRIBED A BENZODIAZEPINE WITH AN OPIOID THAT IS PRESCRIBED UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE BENZODIAZEPINE AND THE CO–PRESCRIPTION OF THE BENZODIAZEPINE. (E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.