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Nurse Practitioner-Hematology and Oncology   

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Nurse Practitioner - Hematology and Oncology Job in Gilbert, AZ BANNER MD ANDERSON: Nurse Practitioner - Outpatient Malignant Hematology Banner MD Anderson Cancer Center Gilbert, AZ 85234 Accepts J1s: No Accepts H1Bs: No Response Loan Assistance:No Practice Type:Employee Verified Date:07/22/2019 Job ID:744920 Employer Job ID:31231 Banner MD Anderson Cancer Center is proud to be recognized as a CHLM APP Employer of Excellence The Division of Hematology Oncology at Banner MD Anderson Cancer Center continues to experience significant growth. As part of this growth we are recruiting advanced practice providers to join the malignant hematology team at the Banner MD Anderson Cancer Center at the Gilbert Campus. Excellent opportunity for a dynamic Nurse Practitioner with Malignant Hematology experience. This position will support the fast-paced lymphoma and myeloma clinics at BMDACC. Our NP will be integral in the care of patients with malignant hematological disorders, patients enrolled in early phase research trials as well as those receiving cutting edge CAR-T therapy. Qualified candidate is required to be board certified and is expected to provide compassionate, evidence-based and multidisciplinary care to cancer patients. Our NP is expected to be an active member of the Division and participate in clinical, research and education services provided by Banner MD Anderson Cancer Center (BMDACC). 2 years' experience required. Participates in the initial screening process of potential volunteers for clinical trials May perform some invasive procedures within scope of practice, such as bone marrow biopsies or skin biopsies M-F - 8-5 - No Call The program is highly integrated with The University of Texas MD Anderson Cancer Center in Houston, including opportunities for education and mentorship. Banner Health, a Top 10 Health System for clinical performance according to Thomson Reuters, has teamed up with MD Anderson Cancer Center, ranked number one by U.S. News and World Report in cancer care seven of the last nine years, to open the Banner MD Anderson Cancer Center. This new center is the broadest extension of MD Anderson -s services outside of Houston and will brings an unprecedented level of cancer care to the greater Phoenix area and entire Southwest region. We offer a generous salary and benefits. PLEASE SUBMIT YOUR CV FOR IMMEDIATE CONSIDERATION Facility & Location Information Banner MD Anderson Cancer Center Phoenix Metro, Gilbert, AZ 85234 Nurse Practitioner-Hematology and Oncology Nurse Practitioner - Hematology and Oncology Job in Gilbert, AZBANNER MD ANDERSON: Nurse Practitioner - Outpatient

          

PM Kitchen Helper   

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Shift Days: Tuesday-SaturdayShift Hours: 11:30am-8:00pmLocation: US-AZ-GilbertType: Hourly Full-TimeOverview

Are you looking to grow your culinary experience in an encouraging team environment? Are you a diligent team member who will do what it takes to help the team be successful? Would you love enriching the lives of seniors every single day?

If you answered "yes" to these questions, we want to meet you. We are Resort Lifestyle Communities, a family-owned company established nearly twenty years ago. We operate communities all across the country and are growing fast. We provide an active, fun, and affordable lifestyle for the residents living in our communities. In our delivery of the Resort Lifestyle, our focus is always on the resident.

We are now accepting applications for a full-time Kitchen Helper with experience prepping and cooking in a kitchen or restaurant setting. The PM Kitchen Helper works collectively with the Culinary and Dining Services team under the direction of the Executive Chef.
What makes this opportunity right for you:
  • Live by our core values of Respect, Kindness & Compassion, Honesty, and Service Excellence.
  • You'll work a stable schedule; Tuesday through Saturday from 11:30am to 8:00pm.
  • You'll receive stellar benefits, including health insurance (with stipend), dental, paid holidays and vacations, and a 401(k) with employer match.
  • You'll be responsible for a number of critical tasks including washing dishes, busing and setting tables, food prep, and stocking the salad bar.
  • Work alongside our hardworking Executive Chef in a dynamic kitchen with state of the art equipment.What makes you right for this opportunity:
    • You have an eagerness to learn and grow as a professional in the food service industry.
    • You have experience working in a team environment ideally in a culinary setting.
    • Knowledge of food prep and/or dish washing is best, but we are willing to train the right person.
    • You have the ability to develop positive relationships with residents, peers and the community.
      If you have a passion for service and deeply enjoy working with seniors, take the first step to joining our company. Complete our on-line application today and you'll hear from us within 48 hours.
      EOE/ADA
      PM18 PI114917093

          

ICU RN   

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ICU RN: Gilbert, AZ

We are searching for an ICU RN to fill a 13 week contract role with our client facility in Gilbert, AZ!

For over 25 years, Soliant Health has connected hospitals and healthcare providers with qualified professionals like yourself! Reach out to begin your travel career.

Requirements:


  • Valid AZ or Compact License

  • 2+ years experience

    Shift: Nights

    Benefits:


    • Weekly Pay

    • Customized Travel and Salary Package

    • Health/Dental/Vision Insurance

    • Referral Bonuses, License and CEU Reimbursement

    • Housing and Meal Stipends

      If you would like to be considered for this position, apply now or email me an updated copy of your resume! I look forward to working with you.

      Adrienne DeAlba

      Travel Nurse Recruiter

      Soliant Health - 1979 Lakeside Pkwy, Tucker GA 30084

      - Phone (678)-837-1519 - Email: Adrienne.Dealba@Soliant.com

          

Ep 210 Start-up To Exit In 186 Days   

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Staffing-industry veteran Will Gilbert co-founded Socium – a U.K.-based company supplying workers to companies that needed them – in early 2019. Within six months, Socium was generating more than 7 million U.K. Pounds in revenue. 


          

Entry Level Computer Programmer - Gilbert   

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As the fastest growing employer of emerging tech talent across the U.S, Revature looks to hire over 300 innovative Entry Level Computer Programmers in the next 4 weeks.One day someone is going to ask you where you got your start---This is IT!With a wide range of Fortune 500 enterprises, government organizations and top systems integrators as our clients, we not only provide you with the skills needed to succeed through an employer-paid training program-- but will also give you the opportunity to put those skills to use, on projects that matter.
What We Are Looking For
  • College degree (Associates or Bachelors)
  • Must be authorized to work in the US
  • Strong desire to learn to code - No prior professional experience required.--
  • A natural problem solver
  • Strong communication and interpersonal skills
  • Willing to relocate anywhere in the US - Relocation assistance providedWhat We Offer
    • Competitive salary
    • Relocation & housing assistance
    • Health, vision & dental insurance
    • Paid time off
    • Industry Certifications
    • Life Insurance Policy
    • 401k
    • Mentoring program and ongoing support throughout your entire Revature career
    • Experience with the largest and most reputable companies in the USApply Today. Interviews are going on now.
      #SoftwareEngineering
      Not Mentioned

          

AM Kitchen Helper   

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Shift Days: Sunday-ThursdayShift Hours: 6:30am-3:00pmLocation: US-AZ-GilbertType: Hourly Full-TimeOverview

Are you looking to grow your culinary experience in an encouraging team environment? Are you a diligent team member who will do what it takes to help the team be successful? Would you love enriching the lives of seniors every single day?

If you answered "yes" to these questions, we want to meet you. We are Resort Lifestyle Communities, a family-owned company established nearly twenty years ago. We operate communities all across the country and are growing fast. We provide an active, fun, and affordable lifestyle for the residents living in our communities. In our delivery of the Resort Lifestyle, our focus is always on the resident.

We are now accepting applications for a full-time Kitchen Helper to ensure a first-class dining experience for residents and their guests. The AM Kitchen Helper works collectively with the Culinary and Dining Services team under the direction of the Executive Chef.

What makes this opportunity right for you:
  • Live by our core values of Respect, Kindness & Compassion, Honesty, and Service Excellence.
  • You'll work a stable schedule; Sunday through Thursday from 6:30am to 3:00pm
  • You'll receive stellar benefits, including health insurance (with stipend), dental, paid holidays and vacations, and a 401(k) with employer match.
  • You'll be responsible for a number of critical tasks including washing dishes, busing and setting tables, food prep, and stocking the salad bar.
  • Work alongside our hardworking Executive Chef in a dynamic kitchen with state of the art equipment.
    What makes you right for this opportunity:
    • You have an eagerness to learn and grow as a professional in the food service industry
    • You have experience working in a team environment ideally in a culinary setting
    • Knowledge of food prep and/or dish washing is best, but we are willing to train the right person
    • You have the ability to develop positive relationships with residents, peers and the community
      If you have a passion for service and deeply enjoy working with seniors, take the first step to joining our company. Complete our on-line application today and you'll hear from us within 48 hours.

      EOE/ADA

      PM18 PI114917095

          

Medical Assistant - PCPC   

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Position DetailsDepartment: PCPC Palo Verde PedsCategory: Patient Care Svcs(Tech & Asst)Location: GilbertPosting #: 483537Date Posted: 11/4/2019Employee Type: RegularPosition Summary This position works under the direction of a licensed health care professional and performs various clinical and administrative tasks for the assigned area.PCH Values
  • Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
  • Excellence in clinical care, service and communication
  • Collaborative within our institution and with others who share our mission and goals
  • Leadership that set the standard for pediatric health care today and innovations of the future
  • Accountability to our patients, community and each other for providing the best in the most cost-effective way.Position Duties
  • As directed by a physician, performs or assists with procedures such as electrocardiogram, pulmonary function, suture and staple removal, dressing changes, and others.
  • Collects laboratory specimens (including blood specimens), performs point of care testing, and disposes of bio-hazardous materials.
  • Demonstrates infection control standards related to hand washing and standard precautions.
  • Prepares and administers medications, communicates telephone prescriptions to pharmacies, and processes medication refills as directed by a physician.
  • Prepares and instructs patients about examinations, diagnostic tests, medications, special diets, and health maintenance.
  • Records and communicates patient related information, including vital signs, growth parameters, medical histories, signs, and symptoms, to the physician or licensed health care provider.
  • Removes sutures and changes dressings.
  • Performs miscellaneous job related duties as requested.

          

Housekeeper (part-time)   

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Shift Days: Monday-FridayShift Hours: 8:00am-12:30pmLocation: US-AZ-GilbertType: Hourly Part-TimeOverviewDo you have a keen eye for detail? Are you looking for meaningful work in a beautiful environment? Would you enjoy working with a senior population?If you answered "yes" to these questions, we want to meet you. We are Resort Lifestyle Communities, a family-owned company established nearly twenty years ago. We operate communities all across the country and are growing fast. We provide an active, fun, and affordable lifestyle for the residents living in our communities. In our delivery of the Resort Lifestyle, our focus is always on the resident. We are now accepting applications for a part-time Housekeeper. You will ensure the cleanliness of our resident's apartments and community so they can live life carefree. Here's what makes this opportunity unique:Live by our core values of Respect, Kindness & Compassion, Honesty, and Service Excellence.You'll work a stable schedule; Monday through Friday from 12:00pm - 4:30pm.We'll provide you with benefits, including employee discounts programs, opportunity to request financial assistance for emergencies, and more.You will share in making our community a beautiful place for residents to live.You'll have the opportunity to serve a senior population and ensure resort quality standards of cleanliness and attention to detail for each resident you serve.Here's what we are looking for in the right candidate: You know proper cleaning procedures including dusting, vacuuming, mopping, cleaning kitchens and bathrooms.You have experience working in a team environment ideally in a hospitality setting.Experience in housekeeping is best, but we are willing to train the right person.You have the ability to develop positive relationships with residents, peers and the community.If you have a passion for service and deeply enjoy working with seniors, take the first step to joining our company. Complete our on-line application today and you'll hear from us within 48 hours.EOE/ADAPM18PI114917798Pandologic. Keywords: Housekeeper, Location: Gilbert, AZ - 85233

          

SALES SERVICE ADVISOR I - Gilbert Riggs   

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SunIRef:Sales:title SALES & SERVICE ADVISOR I - Gilbert & Riggs BBVA Compass 2,579 reviews - Chandler, AZ BBVA Compass 2,579 reviews Read what people are saying about working here. Company: Compass Bank dba BBVA Compass Location: Chandler, Arizona. United States Job type: Employment - Retail Banking - Branch Published on: 21st October 2019 Our Company At BBVA, we are leading the transformation of global banking with the aim of bringing the opportunities of this new era within everyone's reach. We are a global financial institution present in 30 countries with over 75 million customers. We are a bank with over 126,000 employees across the world and every one of those employees is leading and designing his/her professional career with the help of tools provided by the organisation to make that happen. Corporate responsibility is an intrinsic part of our business model, promoting inclusion and financial education while supporting research and culture. Being part of BBVA means developing your career in one of the most innovative companies in finance. We started out with the spirit of helping others make the best financial decisions. That spirit remains with us today and encourages us to keep moving forward, prioritising innovation and digital transformation so that we can bring the opportunities of this new era within everyone's reach. Our values define our identity; they are what drives us to make our goals a reality and they guide all of our actions and the decisions we make. The customer comes first. We think big. We are one team. Job description Performs as a hybrid teller/financial sales advisor position whose primary responsibilities include identifying opportunities to match client needs with banking solutions, conducting teller transactions, and managing the lobby. They will serve as a teller during high traffic hours and will focus on sales during non-peak hours to maximize sales production. Responsibilities Contributes to branch profitability by exceeding all personal sales goals as determined by management. Strengthens customer relationships through cross-selling and up-selling to maximize retention and income generation by contacting existing and prospective customers using the established sales process. Executes relationship banking while delivering an exceptional customer experience. Assists all customers with teller transactions, account maintenance and problem resolution while providing financial solutions. Performs all activies with general supervision, ensuring compliance with consumer and business regulations, laws and policies. Education/Experience High School Diploma or General Education Degree (GED). One (1) year customer service and cash handling experience required. One (1) year proactive sales (cross-selling, up-selling or referring products) preferred. Work experience may NOT substitute for education requirement. Lic/Cert/Reg Required: None required Preferred: None preferred At BBVA, we believe that having a team made up of people with different ways of viewing the world and of taking on each challenge makes us a better bank. That is why we actively support diversity and inclusion, and we invite you to apply, regardless of your race, gender, age, sexual orientation, country of origin, experience, studies, etc. We nurture a collaborative and inclusive work environment that enables us to show and develop the best we each have to offer. Pay Transparency Policy Statement The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information (41 C.F.R. 60-1.35 (c)). Individuals with Disabilities BBVA Compass, BBVA Securities Inc., and BBVA S.A. New York Branch invite all interested and qualified applicants to apply for employment opportunities. If you are a U.S.-based job seeker with a disability who is unable to use our online tools to search and apply for jobs, please contact us by emailing: ******************************** or by calling toll-free (in the U.S.) 1-************. Please indicate the specific type of assistance needed*. The disability access telephone line and email address are reserved solely for job seekers with disabilities requesting accessibility assistance or an accommodation. Please do not call about the status of your job application if you do not require accessibility assistance or an accommodation. Messages left for other purposes, such as following up on an application or non-disability related or technical issues, will not receive a response. EEO Statement BBVA Compass, BBVA Securities Inc., and BBVA S.A. New York Branch have a firm and unwavering policy to provide equal employment opportunity without regard to age, citizenship, color, disability, ethnic origin, gender, gender identity and expression, marital status, nationality, national origin, race, religion, sexual orientation, genetic predisposition, protected veteran status, or any other status or classification protected by federal, state or local law. This policy includes all job groups, classifications and organizational units. With regard to employment, this policy extends to applicants and covers our recruiting, hiring, promotion, transfer, demotion, discipline, termination, benefits, compensation and training practices as well as social and recreational activities. View the "EEO is the Law" & "View the EEO is the Law Supplement Poster" poster. BBVA Compass, BBVA Securities, Inc., and BBVA NY are equal opportunity and affirmative action employer. BBVA Compass - Just posted report job - original job

          

Engineer I - Compression   

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SunIRef:Manu:title Engineer I - Compression DISH 6,133 reviews - Gilbert, AZ 85233 DISH 6,133 reviews Read what people are saying about working here. Summary DISH is a Fortune 250 company with more than $13 billion in annual revenue that continues to redefine the communications industry. Our legacy is innovation and a willingness to challenge the status quo, including reinventing ourselves. We disrupted the pay-TV industry in the mid-90s with the launch of the DISH satellite TV service, taking on some of the largest U.S. corporations in the process, and grew to be the fourth-largest pay-TV provider. We are doing it again with the first live, internet-delivered TV service - Sling TV - that bucks traditional pay-TV norms and gives consumers a truly new way to access and watch television. Now we have our sights set on upending the wireless industry and unseating the entrenched incumbent carriers. We are driven by curiosity, pride, adventure, and a desire to win - it's in our DNA. We're looking for people with boundless energy, intelligence, and an overwhelming need to achieve to join our team as we embark on the next chapter of our story. Opportunity is here. We are DISH. Job Duties and Responsibilities Dish Technologies Company, DTC, is seeking a Compression Engineer for our Cheyenne, WY, broadcast center to design, implement and maintain all video and audio compression systems needed to support customers. Compression engineers work across multiple departments to resolve concerns with audio and video quality, signal handling, encryption, specialized hardware and transmission. With the constant evolution of technology, the pace is quick and the scope of work is ever evolving, though the foundation skills of video compression, networking, troubleshooting, and virtualization remain. The Compression team is a great fit for job seekers who embrace new and specialized technologies, thrive on the improvement and sharing of knowledge, and seek out unique challenges. Working in Compression demands a tenacious, detail oriented person who is ready to work shifts in an engineering environment. Primary responsibilities fall into the following categories: Support the video encoding and multiplexing infrastructure and work to ensure content quality meets or exceeds specifications and customer expectations. Represent the Compression Team as a technical lead through interactions with peers, vendors, suppliers, customers. Develop documentation, including but not limited to configuration, operation, system troubleshooting, and training. Research system errors, discrepancies, and outage resolution. This must include analysis to determine cause of issue, complete with documentation of events and explanation. Depending on the scenario, additional steps may be necessary including, but not limited to: The development and communication of operational and/or system changes Scheduled resolution of any ongoing, non-customer impacting matter Escalation and coordination with next level of engineering if cause is not determinable #LI-WJ Skills - Experience and Requirements The successful Engineer I - Compression will have the following: Bachelor's Degree or four years related experience and/or training, or equivalent combination of education and experience 2 or more years of related experience Be able to work any shift as assigned, as dictated by the needs of a 24/7 business Comfortably lift equipment, up to 50 pounds in weight, and place in racks or storage areas. Preferred Qualifications: Understanding of video compression and transport stream analysis Understanding of networking and cloud computing Ability to work effectively with cross-functional teams and must be flexible enough to deal with different technical skill levels, skill sets and a highly dynamic work environment and schedules The ability to creatively approach problems not covered by existing procedures is important DISH - Just posted report job - original job

          

Physician-Hematology and Oncology   

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Physician - Hematology and Oncology Job in Gilbert, AZ Hematology - Leukemia with Leading Cancer Center Banner Health Gilbert, AZ 85234 Accepts J1s: No Accepts H1Bs: No Response Loan Assistance:No Practice Type:Not Specified Verified Date:09/28/2019 Job ID:751464 STAFF HEMATOLOGIST BANNER MD ANDERSON CANCER CENTER, PHOENIX-METRO Join Leading Cancer Center in USA's Fastest Growing County Excellent opportunity to join an expanding group with prestigious Banner MD Anderson Cancer Center (BMDACC). The Division of Hematology and Medical Oncology is actively recruiting a BE/BC Staff Hematologist/Oncologist with interest or expertise in acute leukemia to join our established group. Practicing at our main location on the Banner Gateway Medical Center (BGMC) campus in Gilbert, AZ, this person will support our leukemia and cellular therapy program. We are seeking applicants with: Excellent clinical training and experience in hematology/oncology Interest in hematologic malignancies, acute leukemia and stem cell transplant Comfortable supporting a team and growing with the needs of the program Candidates with a strong interest in clinical research and medical education are encouraged to apply Features of practicing with the BMDACC Division of Hematology and Medical Oncology: A collaborative team that includes 30 hematology-oncology physicians, providing outstanding research-driven, multidisciplinary care for patients with all types of malignancies. 20 hematologists and oncologist are at our main campus and 13 at regional centers, with an accredited stem cell and cellular effector therapy program (CAR T) and robust clinical trial enrollment. A main campus that offers state-of-the-art technologies for disease-oriented, multidisciplinary cancer care and opportunities for participation in clinical research, designed with experts from The University of Texas MD Anderson Cancer Center The prestige of working with a partnership of industry leaders: 1 in cancer care - MD Anderson Cancer Center, and nationally recognized Banner Health that is also one of the largest integrated health care system in the country and the largest employer in Arizona An academic appointment with UT Texas MD Anderson can be requested for qualified candidates Banner Health , a Top 10 Health System for clinical performance according to Thomson Reuters, has teamed up with the MD Anderson Cancer Center , repeatedly ranked number one by U.S. News and World Report in cancer care, to open the Banner MD Anderson Cancer Center. This center is the broadest extension of MD Anderson's services outside of Houston and brings an unprecedented level of cancer care to the greater Phoenix area and entire southwest region. WE OFFER YOU generous compensation including: competitive base salary plus incentives (wRVU) paid malpractice paid CME plus allowance 401k matching and 457(b) deferred compensation plans excellent benefit package options that provide security for you and your family. Additionally, we offer a culture where your voice is valued and your well-being matters. Please submit your letter of interest and CV for immediate consideration Please, No Agency Solicitation Banner Health supports a drug free work environment. Banner MD Anderson Cancer Center is an equal opportunity employer and does not discriminate on the basis of race, color, national origin, gender, sexual orientation, age, religion, disability or veteran status except where such distinction is required by law. All positions at Banner MD Anderson Cancer Center are security sensitive and subject to examination of criminal history record information. Smoke-free and drug-free environment. Not a J1 opportunity. Facility & Location Information Banner MD Anderson Cancer Center Phoenix Metro, Gilbert, AZ 85234 Physician-Hematology and Oncology Physician - Hematology and Oncology Job in Gilbert, AZHematology - Leukemia with Leading Cancer Center B

          

Mortgage Consultant (SAFE)   

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Job Description
At Wells Fargo, we want to satisfy our customers? financial needs and help them succeed financially. We?re looking for talented people who will put our customers at the center of everything we do. Join our diverse and inclusive team where you?ll feel valued and inspired to contribute your unique skills and experience.Help us build a better Wells Fargo. It all begins with outstanding talent. It all begins with you.Consumer Banking is an industry leader in supporting homeowners and consumers in addition to operating one of the most extensive banking franchises in the country. We serve mass market, affluent, and small business customers; as well as provide home and personal lending. Our focus is on delivering an exceptional experience for our customers through financial advice and guidance coupled with providing the products and services that will help them realize their financial hopes and dreams.? We?ve built our team of top professionals by rewarding their accomplishments and ensuring they have what's needed to succeed.This SAFE position has customer contact and job duties which may include the offering/negotiating of terms and/or taking an application for a dwelling secured transaction. As such, this position requires compliance with the S.A.F.E. Mortgage Licensing Act of 2008 and all related regulations. Ongoing employment is contingent upon meeting all such requirements, including acceptable background investigation results.? Individuals in a SAFE position also must meet the Loan Originator requirements under Regulation Z (LO) outlined in the job expectations below.We have an immediate opening for a Home Mortgage Consultant (HMC). This individual is responsible for producing high quality loans that meet Wells Fargo Home Mortgage guidelines by building relationships with realtors, builders, financial professionals, bank stores, past customers and other nontraditional sources, while providing excellent customer service.?? Strong sales and organizational skills are essential.?? Bi-lingual job seekers are encouraged to apply.?Additional duties include:
  • Develop knowledge of company products, policies and procedures, and underwriting requirements
  • Understand real estate appraisals, title reports, and real estate transactions
  • Inform prospective and existing customers of WFHM programs, rates, policies, underwriting requirements, and loan procedures
  • Analyze detailed financial and credit data, matching customer needs with an appropriate loan program and level of risk
  • Receive customer applications, quote the rate and points, and complete follow-up activities with the registration lock-in
  • Develop and maintain a high degree of visibility for WFHM in the marketplace
  • Perform miscellaneous duties as needed and required

    Required Qualifications
    • 1+ year of sales experience in financial services, outside sales experience, or a combination of both

      Desired Qualifications
      • Basic Microsoft Office skills
      • Documented retail residential mortgage fundings over the past 12 months referred primarily from established, local, external sources
      • Excellent verbal, written, and interpersonal communication skills
      • Mortgage industry experience
      • Knowledge and understanding of sales prospecting and generating referrals
      • Bilingual speaking proficiency in Spanish/English
      • Customer service experience
      • A BS/BA degree or higher

        Job Expectations
        • This position requires SAFE registration at the time of employment. Wells Fargo will initiate the SAFE registration process immediately after your employment start date. The Nationwide Mortgage Licensing System (NMLS) web site (https://God.blue/splash.php?url=xVJPftG17RL_PLUS_VG1bMkLowpdddwibq035EIJU6058qNfuqIoxEhLXz9Z3Mz3uxOAnC1_PLUS_jjiI6yroIyFLmF_PLUS_xtJRLN7unhWy9w09m4WYXQtiW1xqLQeSCWD5nW0hIYMKVGQX2b9SNwank3AmAzmzPlAg_EQUALS__EQUALS_ ) provides the MU4R questions and registration required for employment in this position.
        • Individuals in Loan Originator (LO) positions must meet the Consumer Financial Protection Bureau qualification requirements and comply with related Wells Fargo policies. The LO qualification requirements include meeting applicable financial responsibility, character, general financial fitness and criminal background standards. A current credit report will be used to assess your financial responsibility and credit fitness, however, a credit score is not included as part of the evaluation. Successful candidates must also meet ongoing regulatory requirements including additional screening, if necessary.
        • This position requires compliance with all mortgage regulatory requirements and Wells Fargo's compliance policies related to these requirements including acceptable background check investigation results. Successful candidates must also meet ongoing regulatory requirements including additional screening and required reporting of certain incidents.
        • Ability to lift 20+ pounds
        • Ability to work nights, weekends, and/or holidays as needed or scheduled
        • Reliable transportation

          Street Address
          AZ-Peoria: 16150 N Arrowhead Fountains Ctr Dr - Peoria, AZ
          AZ-Gilbert: 335 E Germann Rd - Gilbert, AZ
          AZ-Tempe: 3920 S Rural Rd - Tempe, AZ
          AZ-Goodyear: 1646 N Litchfield Rd - Goodyear, AZ
          AZ-PHX-Northeast Phoenix: 20830 N Tatum Blvd - Phoenix, AZ
          HI-Honolulu: 1357 Kapiolani Blvd - Honolulu, HI
          HI-Kailua Kona: 75 5722 Kuakini Highway - Kailua Kona, HI


          Disclaimer

          All offers for employment with Wells Fargo are contingent upon the candidate having successfully completed a criminal background check. Wells Fargo will consider qualified candidates with criminal histories in a manner consistent with the requirements of applicable local, state and Federal law, including Section 19 of the Federal Deposit Insurance Act.

          Relevant military experience is considered for veterans and transitioning service men and women.
          Wells Fargo is an Affirmative Action and Equal Opportunity Employer, Minority/Female/Disabled/Veteran/Gender Identity/Sexual Orientation.


          Company Description:

          Wells Fargo & Company (NYSE: WFC) is a diversified, community-based financial services company with $1.9 trillion in assets. Wells Fargo---s vision is to satisfy our customers--- financial needs and help them succeed financially. With approximately 261,000 team members, Wells Fargo serves one in three households in the United States. Wells Fargo & Company was ranked No. 29 on Fortune---s 2019 rankings of America---s largest corporations. News, insights and perspectives from Wells Fargo are also available at Wells Fargo Stories.--Wells Fargo has been helping military members and veterans succeed financially for nearly 170 years. Throughout the years, Wells Fargo has supported military members and veterans through initiatives to recruit and retain team members, and through foundation donations, countless volunteer hours, and event sponsorship.

          

Entry Level Software Developer - Gilbert   

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Revature is the fastest growing employer of emerging technology talent. We will hire over 300 Entry Level Software Developers across the country in the next 4 weeks.One day someone is going to ask you where you got your start---This is IT!With a wide range of Fortune 500 enterprises, government organizations and top systems integrators as our clients, we not only provide you with the skills needed to succeed through an employer-paid training program-- but will also give you the opportunity to put those skills to use, on projects that matter.
What We Are Looking For
  • College degree (Associates or Bachelors)
  • Must be authorized to work in the US
  • Strong desire to learn to code - No prior professional experience required.--
  • A natural problem solver
  • Strong communication and interpersonal skills
  • Willing to relocate anywhere in the US - Relocation assistance providedWhat We Offer
    • Competitive salary
    • Relocation & housing assistance
    • Health, vision & dental insurance
    • Paid time off
    • Industry Certifications
    • Life Insurance Policy
    • 401k
    • Mentoring program and ongoing support throughout your entire Revature career
    • Experience with the largest and most reputable companies in the USApply Today. Interviews are going on now.
      #SoftwareEngineering
      Not Mentioned

          

Travel Nurse RN - Home Health - $1,476.00 per week   

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NurseFly Travel Nursing with MedPro Healthcare Staffing is seeking a home health travel nurse for a travel nursing job in Gilbert, Arizona:



  • Specialty: Home Health
  • Discipline: RN
  • Start Date: 10/8/2019
  • Duration: 13 weeks
  • 36 hours per week
  • Shift: 12 hours.


    Additional information: MedPro Job ID #379452. Pay package is based on 12 hour shifts and 36 hours per week (subject to confirmation) with tax-free stipend amount to be determined. Posted job title: Travel Nurse (RN) - Home Health (Home Health Registered Nurse) Nursing: Home Health..

    MedPro Healthcare Staffing, a Joint Commission-certified staffing agency, is seeking a quality Home Health registered nurse (RN) for a travel assignment with one of our top healthcare clients. Requirements: Active RN LicenseDegree from accredited nursing programBLS CertificationsEighteen months of recent experience in an Acute Care Home Health settingOther requirements to be determined by our client facilityBenefitsAccess to nationwide travel assignmentsWeekly pay and direct depositFull coverage of all credentialing feesPrivate housing or housing allowanceGroup Health insurance for you and your familyCompany-paid life and disability insuranceTravel reimbursementAccess to our Clinical Nurse Liaison Team401(k) matchingUnlimited Referral Bonuses starting at $500Personalized gifts delivered to your door step! Duties ResponsibilitiesHome Health Nurses (RN) provide patient education, treatment, and emotional support to help individuals recover from injuries and illnesses.Assess patients' condition during every visit and chart your observations.Perform evaluation tasks, including vital signs and medication review.Administer medication as prescribed by patient's physician.Dress or redress open wounds and assess progress of healing.Educate patients and their families on proper home health care strategies and procedures.About AgencyNo One Cares More for Caregivers Than MedPro. Focus on your patients, we'll take care of the rest. MedPro Healthcare Staffing is a Joint Commission certified provider of temporary and contract staffing services. Since 1983, we have placed happy nursing and allied travelers in top healthcare facilities nationwide. Join us today for your very own MedPro Experience--. MedPro Staffing is an Equal Opportunity Employer that maintains a policy of non-discrimination with respect to all employees and applicants for employment. Employment decisions, subject to the legitimate business requirements of MedPro or its clients, are based solely on the individual's qualifications, merit and performance without regard to race, color, religion, national origin, age, sex, disability, marital status or veteran status.Key Words: Registered Nurse, RN, Home Health, Travel Nurse, Contract Nurse, Agency Nurse, Agency RN, RN-Home Health, Travel RN, Contract, Nursing, Travel Nursingprioritynursingcandidates@medprostaffing.com.No One Cares More for Caregivers Than MedPro. Focus on your patients, well take care of the rest. MedPro Healthcare Staffing is a Joint Commission certified provider of temporary and contract staffing services. Since 1983, we have placed happy nursing and allied travelers in top healthcare facilities nationwide. You deserve a travel experience thats rewarding and memorable. One that allows you to DREAM big. EXPLORE often. And ACHIEVE greatness. The MedPro Experience-- delivers it!


    • Access to nationwide travel assignments
    • Weekly pay and direct deposit
    • Full coverage of all credentialing fees
    • Private housing or housing allowance
    • Group Health insurance for you and your family
    • Tax Free Per Diems, Housing Stipends and Travel Reimbursements
    • Company-paid life and disability insurance
    • Travel reimbursement
    • Access to our Clinical Nurse Liaison Team
    • 401(k) matching
    • Unlimited Referral Bonuses starting at $500
    • Personalized gifts delivered to your door step!


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      This job is also widely searched as a registered nurse, rn, nurse, travel nurse, nurse rn, rn nurse, travel nurse rn, nursing, travel rn, home health nurse.

          

PM Kitchen Helper   

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Shift Days: Tuesday-SaturdayShift Hours: 11:30am-8:00pmLocation: US-AZ-GilbertType: Hourly Full-TimeOverviewAre you looking to grow your culinary experience in an encouraging team environment? Are you a diligent team member who will do what it takes to help the team be successful? Would you love enriching the lives of seniors every single day?If you answered "yes" to these questions, we want to meet you. We are Resort Lifestyle Communities, a family-owned company established nearly twenty years ago. We operate communities all across the country and are growing fast. We provide an active, fun, and affordable lifestyle for the residents living in our communities. In our delivery of the Resort Lifestyle, our focus is always on the resident.We are now accepting applications for a full-time Kitchen Helper with experience prepping and cooking in a kitchen or restaurant setting. The PM Kitchen Helper works collectively with the Culinary and Dining Services team under the direction of the Executive Chef.What makes this opportunity right for you:Live by our core values of Respect, Kindness & Compassion, Honesty, and Service Excellence.You'll work a stable schedule; Tuesday through Saturday from 11:30am to 8:00pm.You'll receive stellar benefits, including health insurance (with stipend), dental, paid holidays and vacations, and a 401(k) with employer match.You'll be responsible for a number of critical tasks including washing dishes, busing and setting tables, food prep, and stocking the salad bar.Work alongside our hardworking Executive Chef in a dynamic kitchen with state of the art equipment.What makes you right for this opportunity:You have an eagerness to learn and grow as a professional in the food service industry.You have experience working in a team environment ideally in a culinary setting.Knowledge of food prep and/or dish washing is best, but we are willing to train the right person.You have the ability to develop positive relationships with residents, peers and the community.If you have a passion for service and deeply enjoy working with seniors, take the first step to joining our company. Complete our on-line application today and you'll hear from us within 48 hours.EOE/ADAPM18 PI114917870Pandologic. Keywords: Cook's Helper, Location: Gilbert, AZ - 85233

          

Radiologic Technologist | Banner Health   

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Gilbert, Arizona, Job Summary This position performs prescribed radiographic procedures in accordance with department/facility policies, procedures and protocols. This position ensures optimal care/treatment to p

          

Ouest Sauvage Yves Berger Bernadette Gilbertas Olivier   

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Ouest Sauvage Yves Berger Bernadette Gilbertas Olivier

          

Segalen Gilbert De   

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Segalen Gilbert De

          

Inconvenient No 64 Printemps 2016 L Amitie Au Temps De Facebook Alain Roy Serge Bouchard Eric Dupont Jean Philippe Martel Etienne Savignac Ugo Gilbert   

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Inconvenient No 64 Printemps 2016 L Amitie Au Temps De Facebook Alain Roy Serge Bouchard Eric Dupont Jean Philippe Martel Etienne Savignac Ugo Gilbert

          

Social Worker | Banner Health   

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Gilbert, Arizona, Job Summary This position develops, coordinates and provides social work services to patients and families who are faced with social, emotional and situational stressors precipitated by illness,

          

Histoires De Danse Stephanie Tesson Kochka Emmanuel Viau Victoire Labauge Freddy Woets Marie Tenaille Gilbert Schlogel Franck Pavloff Jacques   

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Histoires De Danse Stephanie Tesson Kochka Emmanuel Viau Victoire Labauge Freddy Woets Marie Tenaille Gilbert Schlogel Franck Pavloff Jacques

          

Low temperature formation of CH3NH3PbI3 perovskite films in supercritical carbon dioxide   

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Title: Low temperature formation of CH3NH3PbI3 perovskite films in supercritical carbon dioxide
Author(s): Annohene, Gilbert; Tepper, Gary C.
Source: JOURNAL OF SUPERCRITICAL FLUIDS, 154: DEC 2019
Document Type: Article

          

SANTOS DUMONT estreia neste domingo no canal HBO e na HBO GO   

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Divulgação/HBO
A minissérie SANTOS DUMONT que contará em seis episódios a vida do brasileiro considerado “pai da aviação” e a história de suas grandes invenções, estreia neste domingo, 10 de novembro, às 21h, no canal HBO e na HBO GO, em toda a América Latina. A produção trará uma reconstrução minuciosa do ambiente do fim do século XIX e início do século XX, e acompanha a trajetória do aviador, desde a infância nos cafezais de sua família no interior de Minas Gerais até os sofisticados salões e aeroclubes de Paris.

Ambientada no Brasil e na França, e com diálogos em português, inglês, espanhol e francês, a minissérie realizada pela HBO em coprodução com a Pindorama Filmes conta a história do brasileiro que personificou grandes transformações da virada do século, e foi aclamado como o primeiro homem a voar em um avião – o 14 Bis.
João Pedro Zappa protagoniza SANTOS DUMONT e interpreta o inventor na fase adulta. Na infância ele é vivido pelo ator Guilherme Garcia e, mais velho, por Gilberto Gawronski. O elenco traz ainda Bruna Scavuzzi, Jean Pierre Noher, Lisa Eiras, José Araújo e Miguel Pinheiro, entre outros atores brasileiros e franceses. Juliana Carneiro da Cunha faz participação especial em SANTOS DUMONT como a Princesa Isabel, enquanto Fernando Acquarone, que divide a direção com Estêvão Ciavatta, dá vida ao joalheiro francês Louis Cartier, que inventou um relógio especial a pedido de seu amigo aviador.
Além do Brasil e de toda a América Latina e do Caribe, a produção tem lançamento confirmado também nos Estados Unidos, Europa e África, totalizando mais de 70 países ao redor do mundo.
SANTOS DUMONT é produzida por Roberto Rios, Eduardo Zaca, Patricia Carvalho e Rafaella Giannini, da HBO Latin America Originals, e Estevão Ciavatta e Susana Campos, da Pindorama Filmes, com recursos da Condecine – Artigo 39. A direção é de Estevão Ciavatta – que também dirigiu a série exclusiva da HBO PREAMAR – e Fernando Acquarone. Com roteiro de Pedro Motta Gueiros e Gabriel Mariani Flaksman, a série será distribuída com exclusividade pela HBO Latin America.

          

Transport En France Gilbert   

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Transport En France Gilbert

          

Boyfriend guilty of 1st-degree murder in Millcreek case   

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James Gilbert claimed he smoked marijuana that made him feel strange before killing of girlfriend, Marinda Matasowski.

          

Nylon Fusion Will Present the NYC Premiere Of Michaela Jeffery's THE LISTENING ROOM at The New Ohio   

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Nylon Fusion Theatre Company will present the New York Premiere of The Listening Room, written by Michaela Jeffery (National Enbridge Playwrights Award recipient; Playwrights Guild of Canada's RBC Emerging Playwright Award finalist). and directed by Ivette Dumeng (Malan American Reconciliation at Royal Family: Jack in the Box/Medusa at Planet Connections) & Lori Kee (Luft Gangster at The Sheen Center) at The New Ohio Theatre (154 Christopher Street, New York, NY 10014), November 30 - December 21. Performances will be on Saturday, November 30 at 8pm, Sunday, December 1 at 8pm, Monday, December 2 at 8pm, Friday,

December 6 at 8pm, Saturday, December 7 at 8pm, Sunday, December 8 at 3pm, Thursday, December 12 at 8pm, Friday, December 13 at 8pm, Saturday, December 14 at 3pm, Sunday, December 15 at 8pm, Wednesday, December 18 at 8pm, Thursday, December 19 at 8pm, and Saturday, December 21 at 8pm. Tickets ($29) are available for advance purchase at www.nylonfusion.org. The performance will run approximately 85 minutes, with no intermission. The Listening Room will run in rep with Nylon Fusion's World Premiere of ray gun sayonara by Steven Tenney.

On the fringes of a remote desert society, a group of teenage dissidents search for fragments of earlier civilizations still ricocheting between stars. Using antiquated 21st century radio telescopes, The Listeners risk everything to connect to a past that has faded both from memory and record. On the eve of a trial that would decide their fate, The Listeners must choose to conform, or to strike out and seize the future they want to inherit.

The cast will feature Matthew Carrasco (Marymount Manhattan College), Alex Chernin (Blood Wedding in Saratoga Springs), Tim Palmer (The Land of Promises at The Sheen Center), Taylor Petracek (The Academy at Theatre for the New City; The Seagull at Access Theater), and Sara Rahman (Scaly with Insommium Theatre Company) with Set Design by Raye Levine (Design Associate on Extinction at Guild Hall) with Associate Set Design and Props by Lili Jackson, Lighting Design by Gilbert Lucky Pearto (Quicksand with Everyday Infemo/IRT), Sound Design by Bryan Hamilton (Guards at the Taj at Times Square Arts Center) with Sound Consultant Andy Evan Cohen (NYIT Award winner for In the Soundless Awe with New Light Theater Project), and Costume Design by Denni Hobson (NYIT Award winner for Unmentionables with Nylon Fusion), and Fight Choreography by Randall Rodriguez. The Production Stage Manager will be Stanford Vogel.

Michaela Jeffery (Playwright) is an Alberta-based playwright and graduate of The National Theatre School of Canada (2016). Recent writing credits include: The Extractionist, commissioned by Vertigo Theatre (Calgary, AB), text creation for Persephone Bound for Imago Theatre (Montreal, OC), Wolf of the Ringstrasse with Spirit Fire Theatre (Calgary, AB), (WROL) Without Rule of Law, premiering in November 2019 at Persephone Theatre (Saskatoon, SK), The Listening Room with Cardiac Theatre (Edmonton, AB) in conjunction with The Azimuth Theatre & Downstage Performance Society. Always with The Clutch Emerging Artist Festival (Vancouver, BC), Hardscrabble Road, GODHEAD (Shortlist, Headwaters New Play Festival - Creede, Colorado: The Sunset Theatre, Wells, BC), Sundogs (Holding Hollow Productions; Edmonton International Fringe Festival), and others. Her short play Expanding Concepts of Dislocated Space (and Associated Boundaries) was recently published in the July 2018 edition of Bare Fiction Magazine (UK Publication). Michaela was a recent finalist in the Alberta Playwrights Network 2019 Alberta Playwrighting Competition with her play WROL (Without Rue of Law) as well as a finalist for the Playwrights Guild of Canada's RBG Emerging Playwright Award for her play The Listening Room and recipient of the national Enbridge Playwrights Award (Emerging Category) for her developing play, Going West. www.michaelajeffery.com

Ivette Dumeng (Director) is an award-winning director. She recently directed John Patrick Shanley's Malan American Reconciliation at Royal Family and a new play; I'm Going to Touch Your Neck. Other credits include Faster Than Shadows by Mathew Ethan Davis and Jack in the Box/Medusa by Don Nigo. She is the producing Artistic Director and founding member of Nylon Fusion Theatre Company, a member of The Actors Studio Playwrights Directors Unit, League of Professional Theatre Women, SAG/AFTRA, and TRU. https://God.blue/splash.php?url=KL_SLASH_Ct4Wn57d5VChPE_PLUS_YTwmqSDMrXWg11JdAewbsyFhAL_PLUS_2s0_PLUS__PLUS_jMw73YdqlT4kcs6zn_SLASH_LHse_SLASH_C7NxwQxZQBuoeUFoARLdA6w4KUY80MFJug_EQUALS_

Lori Kee (Director) is an award-winning director and experienced collaborator on new work. Notable projects: The Chaplin Plays, SWIPE- A New Musical, A light in the Dark, Blizzard Vacation..., The Fairy Tale Project, The Big Funk, Paper Dragon, Death... It Happens, and Male Man. New works by Lyle Kessler, Craig muMs Grant, Kristina Poe, Maggie Diaz Bofill, Arlene Hutton, James McLindon, Arlene Hutton, Don Nigro, and John Patrick Shanley. Resident Director/Member Nylon Fusion Theatre Company, Associate SDG, Actors Studio PDU. www.lorikee.com

Nylon Fusion Theatre Company Born of a fusion of New York and London creativity, Nylon Fusion is a theatre company committed to giving voice and perspective to established and emerging artists. We develop and produce plays that explore political, social, and cultural awareness. Named a "Young and Mighty Theater company" by Backstage. www.nylonfusion.org


          

A mechanistic model of meditation by Kaj_Sotala   

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Med­i­ta­tion has been claimed to have all kinds of trans­for­ma­tive effects on the psy­che, such as im­prov­ing con­cen­tra­tion abil­ity, heal­ing trauma, clean­ing up delu­sions, al­low­ing one to track their sub­con­scious strate­gies, and mak­ing one’s ner­vous sys­tem more effi­cient. How­ever, an ex­pla­na­tion for why and how ex­actly this would hap­pen has typ­i­cally been lack­ing. This makes peo­ple rea­son­ably skep­ti­cal of such claims.

In this post, I want to offer an ex­pla­na­tion for one kind of a mechanism: med­i­ta­tion in­creas­ing the de­gree of a per­son’s in­tro­spec­tive aware­ness, and thus lead­ing to in­creas­ing psy­cholog­i­cal unity as in­ter­nal con­flicts are de­tected and re­solved.

Note that this post does not dis­cuss “en­light­en­ment”. That is a re­lated but sep­a­rate topic. It is pos­si­ble to pur­sue med­i­ta­tion mainly for its or­di­nary psy­cholog­i­cal benefits while be­ing un­in­ter­ested in en­light­en­ment, and vice versa.

What is in­tro­spec­tive aware­ness?

In an ear­lier post on in­tro­spec­tive aware­ness, I dis­t­in­guished be­tween be­ing aware of some­thing, and be­ing aware of hav­ing been aware of some­thing. My ex­am­ple in­volved that of a robot whose con­scious­ness con­tains one men­tal ob­ject at a time, and which is aware of differ­ent things at differ­ent times:

Robot’s thought at time 1: It’s rain­ing outside
Robot’s thought at time 2: Bat­tery low
Robot’s thought at time 3: Tech­nolog­i­cal un­em­ploy­ment protestors are outside
Robot’s thought at time 4: Bat­tery low
Robot’s thought at time 5: I’m now recharg­ing my battery

At times 2-5, the robot has no aware­ness of the fact that it was think­ing about rain at time 1. As soon as some­thing else cap­tures its at­ten­tion, it has no idea of this ear­lier con­scious con­tent—un­less a par­tic­u­lar sub­sys­tem hap­pens to record the fact, and can later re-pre­sent the con­tent in an ap­pro­pri­ately tagged form:

Time 6: At time 1, there was the thought that [It’s rain­ing out­side]

I said that at time 6, the robot had a mo­ment of in­tro­spec­tive aware­ness: a men­tal ob­ject con­tain­ing a sum­mary of its pre­vi­ous thoughts, which can then be sep­a­rately ex­am­ined and acted upon.

Hu­mans are not robots. But I pre­vi­ously sum­ma­rized the neu­ro­science book Con­scious­ness and the Brain, and its global neu­ronal workspace (GNW) model of con­scious­ness. Ac­cord­ing to this model, the con­tents of con­scious­ness cor­re­spond to what is be­ing rep­re­sented in a par­tic­u­lar net­work of neu­rons—the global workspace—that con­nects differ­ent parts of the brain. Differ­ent sys­tems are con­stantly com­pet­ing to get their con­tents into the global workspace, which can only hold one piece of con­tent at a time. Thus, like robots, we too are only aware of one thing at a time, and tend to lose aware­ness of our ear­lier thoughts—un­less some­thing re­minds us of them.

In what fol­lows, I will sug­gest that like robots, hu­mans also have a type of con­scious con­tent that we might call in­tro­spec­tive aware­ness, which al­lows us to be more aware of our pre­vi­ous men­tal ac­tivity. (I am bor­row­ing the term from the med­i­ta­tion book The Mind Illu­mi­nated, which dis­t­in­guishes be­tween in­tro­spec­tive at­ten­tion, in­tro­spec­tive aware­ness, and metacog­ni­tive in­tro­spec­tive aware­ness. I am elid­ing these differ­ences for the sake of sim­plic­ity.)

In­tro­spec­tive aware­ness is also a skill that can be de­vel­oped. Con­scious­ness and the Brain in­cludes the fol­low­ing ex­cerpt, on rea­sons why some in­for­ma­tion in our brains might not be­come con­sciously available. In short, be­cause there has to be some way of rep­re­sent­ing that in­for­ma­tion in the global workspace, which re­quires ded­i­cated neu­rons that do so:

… a fourth way in which neu­ral in­for­ma­tion can re­main un­con­scious, ac­cord­ing to workspace the­ory, is to be diluted into a com­plex pat­tern of firing. To take a con­crete ex­am­ple, con­sider a vi­sual grat­ing that is so finely spaced, or that flick­ers so fast (50 hertz and above), that you can­not see it. Although you per­ceive only a uniform gray, ex­per­i­ments show that the grat­ing is ac­tu­ally en­coded in­side your brain: dis­tinct groups of vi­sual neu­rons fire for differ­ent ori­en­ta­tions of the grat­ing. Why can’t this pat­tern of neu­ronal ac­tivity be brought to con­scious­ness? Prob­a­bly be­cause it makes use of an ex­tremely tan­gled spa­tiotem­po­ral pat­tern of firing in the pri­mary vi­sual area, a neu­ral ci­pher too com­plex to be ex­plic­itly rec­og­nized by global workspace neu­rons higher up in the cor­tex. Although we do not yet fully un­der­stand the neu­ral code, we be­lieve that, in or­der to be­come con­scious, a piece of in­for­ma­tion first has to be re-en­coded in an ex­plicit form by a com­pact as­sem­bly of neu­rons. The an­te­rior re­gions of the vi­sual cor­tex must ded­i­cate spe­cific neu­rons to mean­ingful vi­sual in­puts, be­fore their own ac­tivity can be am­plified and cause a global workspace ig­ni­tion that brings the in­for­ma­tion into aware­ness. If the in­for­ma­tion re­mains diluted in the firing of myr­iad un­re­lated neu­rons, then it can­not be made con­scious.
Any face that we see, any word that we hear, be­gins in this un­con­scious man­ner, as an ab­surdly con­torted spa­tiotem­po­ral train of spikes in mil­lions of neu­rons, each sens­ing only a minus­cule part of the over­all scene. Each of these in­put pat­terns con­tains vir­tu­ally in­finite amounts of in­for­ma­tion about the speaker, mes­sage, emo­tion, room size . . . if only we could de­code it—but we can’t. We be­come aware of this la­tent in­for­ma­tion only once our higher-level brain ar­eas cat­e­go­rize it into mean­ingful bins. Mak­ing the mes­sage ex­plicit is an es­sen­tial role of the hi­er­ar­chi­cal pyra­mid of sen­sory neu­rons that suc­ces­sively ex­tract in­creas­ingly ab­stract fea­tures of our sen­sa­tions. Sen­sory train­ing makes us aware of faint sights or sounds be­cause, at all lev­els, neu­rons re­ori­ent their prop­er­ties to am­plify these sen­sory mes­sages. Prior to learn­ing, a neu­ronal mes­sage was already pre­sent in our sen­sory ar­eas, but only im­plic­itly, in the form of a diluted firing pat­tern in­ac­cessible to our aware­ness.

De­haene sug­gests that learn­ing to e.g. no­tice smaller de­tails in our sur­round­ings, is based on tap­ping into in­for­ma­tion which is already available in the brain. As one prac­tices look­ing at smaller and smaller de­tails, the brain builds up spe­cial­ized cir­cuits for ex­tract­ing, re-en­cod­ing and re-pre­sent­ing pat­terns which would oth­er­wise have been ig­nored. Gilbert, Sig­man & Crist (2001) write:

Psy­chol­o­gists and psy­chophysi­cists have known since be­fore the turn of the cen­tury that train­ing can im­prove the abil­ity to make dis­crim­i­na­tions in a wide va­ri­ety of sen­sory modal­ities; tasks in­volv­ing vi­sual acu­ity, so­matosen­sory spa­tial re­s­olu­tion, dis­crim­i­na­tion of hue, es­ti­ma­tion of weight, and dis­crim­i­na­tion of acous­ti­cal pitch all show im­prove­ment with prac­tice [...] Train­ing can im­prove the dis­crim­i­na­tion of small differ­ences in the offset of two lines (vernier acu­ity) even though ini­tial thresh­olds are already in the hy­per­acu­ity range [...] the spa­tial re­s­olu­tion of the vi­sual sys­tem, at least in the realm of hy­per­acu­ity, can im­prove with prac­tice [...] Other vi­sual per­cep­tual tasks that im­prove with train­ing in­clude the abil­ity to dis­crim­i­nate ori­en­ta­tion [...] the di­rec­tion of mo­tion [...] the differ­ences in the wave­forms of two sinu­soidal stim­uli [...] and the abil­ity to seg­re­gate el­e­ments of the vi­sual scene us­ing tex­tu­ral cues [...] Train­ing has been found to in­crease the abil­ity of ob­servers to de­tect small differ­ences in the depth of two tar­gets [...] as well as the abil­ity to per­ceive depth in ran­dom-dot stere­ograms.

If we have ac­cess to some sen­sory chan­nel which car­ries with it in­for­ma­tion, train­ing can cause our brains to draw upon in­for­ma­tion which has always been pro­cessed, but never be­fore con­sciously ac­cessed. And we seem to have sen­sory chan­nels which give us in­for­ma­tion about our thoughts—oth­er­wise we would have no idea of what we were think­ing.

Richard’s ther­apy session

We saw an ex­am­ple of in­tro­spec­tive aware­ness in my post on the book Un­lock­ing the Emo­tional Brain. In the tran­script, a man named Richard has been suffer­ing from se­vere self-doubt, and is asked to imag­ine how it would feel like if he made con­fi­dent com­ments in a work meet­ing. The fol­low­ing con­ver­sa­tion fol­lows:

Richard: Now I’m feel­ing re­ally un­com­fortable, but-it’s in a differ­ent way.
Ther­a­pist: OK, let your­self feel it—this differ­ent dis­com­fort. [Pause.] See if any words come along with this un­com­fortable feel­ing.
Richard: [Pause.] Now they hate me.

The ther­a­pist is ask­ing Richard to fo­cus his at­ten­tion on the feel­ing of dis­com­fort, gen­er­at­ing mo­ments of in­tro­spec­tive aware­ness about the dis­com­fort. No­tice that Richard be­comes more thought­ful and less re­ac­tive to the anx­iety as he does so. My guess of what is hap­pen­ing is some­thing like this:

When Richard is feel­ing anx­ious, this means that a men­tal ob­ject en­cod­ing some­thing like “the feel­ing of anx­iety” is be­ing rep­re­sented in the workspace. This ac­ti­vates neu­ral rules which trig­ger the kinds of re­sponses that anx­iety has evolved to pro­duce. For ex­am­ple, a sys­tem may be trig­gered which at­tempts to plan how to es­cape the situ­a­tion caus­ing the anx­iety. This sys­tem’s in­ten­tions are then in­jected into the workspace, pro­duc­ing a state of mind where the feel­ing of anx­iety al­ter­nates with thoughts of how to get away.

In­tro­spec­tive aware­ness is its own type of men­tal ob­ject, pro­duced by a differ­ent sub­sys­tem which takes in­puts from the global workspace, re-en­codes them in a for­mat which high­lights par­tic­u­lar as­pects of that data, and out­puts that back into the workspace. When a rep­re­sen­ta­tion of an anx­ious state of mind is cre­ated, that rep­re­sen­ta­tion does not by it­self trig­ger the same rules as the origi­nal anx­iety did.

As a re­sult, as rep­re­sen­ta­tions of the anx­iety be­gin to al­ter­nate to­gether with the anx­iety, there are pro­por­tionately less mo­ments of anx­iety. This in turn trig­gers fewer of the sub­sys­tems at­tempt­ing to es­cape the situ­a­tion, mak­ing it eas­ier to re­flect on the anx­iety with­out be­ing both­ered by it.

When Richard’s ther­a­pist asks him to feel the anx­iety and to see if any words come along with it, the sub­sys­tem for in­tro­spec­tive aware­ness was primed to look for any con­tent that could be re-pre­sented in ver­bal form. As Richard’s anx­iety had been pro­duced by an emo­tional schema in­clud­ing a pre­dic­tion that be­ing con­fi­dent makes you hated, some of that in­for­ma­tion had passed through the workspace and been available for the aware­ness sub­sys­tem to cap­ture. This brought up the ver­bal­iza­tion of what the schema pre­dicted would hap­pen if Richard was con­fi­dent—“now they hate me”.

Ther­a­pist: “Now they hate me.” Good. Keep go­ing: See if this re­ally un­com­fortable feel­ing can also tell you why they hate you now.

Ac­cord­ing to the GNW model, when a par­tic­u­lar piece of con­tent is main­tained as the cen­ter of at­ten­tion, it strength­ens the ac­ti­va­tion of any struc­tures as­so­ci­ated with it. As Richard’s ther­a­pist guides him to fo­cus on the ver­bal con­tent, more in­for­ma­tion re­lated to it is broad­cast into the workspace. The fur­ther prompt guides the aware­ness sub­sys­tem to look for pat­terns that feel like the rea­son for the hate.

Richard: [Pause.] Hnh. Wow. It’s be­cause… now I’m… an ar­ro­gant ass­hole… like my father… a to­tally self-cen­tered, to­tally in­sen­si­tive know-it-all.

The ther­a­pist then takes a pat­tern which Richard has brought up and helps crys­tal­lize it fur­ther, and throws it back to Richard for ver­ifi­ca­tion.

Ther­a­pist: Do you mean that hav­ing a feel­ing of con­fi­dence as you speak turns you into an ar­ro­gant ass­hole, like Dad?
Richard: Yeah, ex­actly. Wow.

In this ex­am­ple, we saw that hav­ing more mo­ments of in­tro­spec­tive aware­ness was benefi­cial for Richard. As as­pects of his mo­ment-to-mo­ment con­scious­ness were made available for other sub­sys­tems to ex­am­ine, the emo­tional schema caus­ing the anx­iety was iden­ti­fied and its con­tents ex­tracted into a for­mat which could be fed into other sub­sys­tems. Later on, when Richard’s co-worker dis­played con­fi­dence which oth­ers ap­proved of, a con­tra­dic­tion-de­tec­tion mechanism no­ticed a dis­crep­ancy be­tween re­al­ity and the pre­dic­tion that con­fi­dence makes you hated, al­low­ing the pre­dic­tion to be re­vised.

Un­der this model, the sys­tem which pro­duces mo­ments of in­tro­spec­tive aware­ness is a sub­sys­tem like any other in the brain. This means that it will be ac­ti­vated when the right cues trig­ger it, and its out­puts com­pete with the out­puts of other sys­tems sub­mit­ting con­tent to con­scious­ness. The cir­cum­stances un­der which the sys­tem trig­gers, and its prob­a­bil­ity of suc­cess­fully mak­ing its con­tents con­scious, are mod­ified by re­in­force­ment learn­ing. Just as prac­tic­ing a skill such as ar­ith­metic even­tu­ally causes var­i­ous sub­sys­tems to ma­nipu­late the con­tent of con­scious­ness in the right or­der, prac­tic­ing a skill which benefits from in­tro­spec­tive aware­ness will cause the sub­sys­tem gen­er­at­ing in­tro­spec­tive aware­ness to ac­ti­vate more of­ten.

Med­i­ta­tion as a tech­nique for gen­er­at­ing mo­ments of in­tro­spec­tive awareness

Just as there are differ­ent forms and styles of ther­apy, there are also differ­ent forms and styles of med­i­ta­tion. All of them in­volve in­tro­spec­tive aware­ness to at least some de­gree, but they differ in what that aware­ness is then used for.

In the ex­am­ple with Richard, his ther­a­pist asked him to imag­ine be­ing con­fi­dent and to then bring his aware­ness to why that felt un­com­fortable. In con­trast, a more be­hav­iorally ori­ented ther­a­pist might not have ex­am­ined the rea­son be­hind the dis­com­fort. Rather, they might have taught Richard to no­tice his re­ac­tion to the dis­com­fort, and then use that as a cue for im­ple­ment­ing an op­po­site re­ac­tion. Both kinds of ther­a­pists would ask their clients to gen­er­ate some in­tro­spec­tive aware­ness, but aiming that aware­ness at differ­ent kinds of fea­tures, and us­ing the aware­ness to trig­ger differ­ent kinds of strate­gies. The re­sults would cor­re­spond­ingly be very differ­ent.

Like­wise, sys­tems of med­i­ta­tion differ in how much in­tro­spec­tive aware­ness they pro­duce, what kinds of fea­tures the aware­ness-pro­duc­ing sub­sys­tem is trained to ex­tract, and what that aware­ness is then used for. For this ar­ti­cle, I have cho­sen to use the ex­am­ple of the sys­tem in The Mind Illu­mi­nated (TMI), as it is clearly ex­plained and ex­plic­itly phrased in these terms. (Again, TMI has a more pre­cise dis­tinc­tion be­tween in­tro­spec­tive at­ten­tion and in­tro­spec­tive aware­ness, which I am elid­ing for the sake of sim­plic­ity.)

In TMI’s sys­tem, as in many oth­ers, you start with try­ing to keep your at­ten­tion on your breath. In terms of our model, this means that you want to keep sen­sory out­puts cor­re­spond­ing to your breath as the main thing in your con­scious­ness.

The prob­lem with this goal is that there is no sub­sys­tem which can just unilat­er­ally de­cide what to main­tain as the cen­ter of at­ten­tion. At any given mo­ment, many differ­ent sub­sys­tems are com­pet­ing to make their con­tent con­scious. So one sys­tem might have the in­ten­tion to fol­low the breath, and you do it for a while, but then a plan­ning sys­tem kicks in with its in­ten­tion to think about din­ner. Such plan­ning has tended to feel re­ward­ing, so it wins out and the in­tent to med­i­tate is for­got­ten un­til five min­utes later, when you de­cide what you want for din­ner and then sud­denly re­mem­ber the thing about fol­low­ing your breath.

TMI calls this mind-wan­der­ing from for­get­ting, and the first step of prac­tice is just to no­tice it when­ever it hap­pens, con­grat­u­late your­self for hav­ing no­ticed it, and then re­turn to the breath. Be­ing able to no­tice for­get­ting re­quires hav­ing a mo­ment of in­tro­spec­tive aware­ness which points out the fact that you had not been fol­low­ing your breath. When you take satis­fac­tion in hav­ing no­ticed this, your aware­ness-pro­duc­ing sub­sys­tem gets as­signed a re­ward and be­comes slightly more likely to ac­ti­vate in the fu­ture. “Have I re­mem­bered to fol­low my breath or not?” acts a feed­back mechanism that you can ex­plic­itly train on.

As the aware­ness-pro­duc­ing sys­tem starts to ac­ti­vate more of­ten and ping you if you have for­got­ten to med­i­tate, pe­ri­ods of mind-wan­der­ing grow shorter.

Now, even if you stop get­ting en­tirely lost in thought, you still have dis­trac­tion: con­tent from other sub­sys­tems that is in con­scious­ness to­gether with the sen­sa­tions of the breath and the in­ten­tion to fo­cus on the breath. For ex­am­ple, you might be hav­ing stray thoughts, hear­ing sounds from your en­vi­ron­ment, and ex­pe­rienc­ing sen­sa­tions from your body.

To more ex­clu­sively fo­cus on the breath, you are in­structed to main­tain the in­tent to both at­tend to it and also to be aware of any dis­trac­tions. The sub­sys­tems which out­put men­tal con­tent can, and nor­mally do, op­er­ate in­de­pen­dently of each other. This means that the fol­low­ing may hap­pen:

Sub­sys­tem 1: I’m med­i­tat­ing well!
Sub­sys­tem 2: Hmm, what’s that smell.
Sub­sys­tem 1: I’m med­i­tat­ing well! No dis­trac­tions.
Sub­sys­tem 2: Smells kinda like cook­ies.
Sub­sys­tem 2: Mmm, cook­ies.
Sub­sys­tem 1: Con­tin­u­ing to med­i­tate well!
Sub­sys­tem 2: Say, what’s for din­ner?

That is, a sys­tem which tracks the breath can con­tinue to re­peat­edly find the breath, and re­port that your med­i­ta­tion is pro­ceed­ing well and with no dis­trac­tions… all the while the con­tent of your con­scious­ness con­tinues to al­ter­nate with dis­tracted thoughts, which the breath-track­ing sub­sys­tem is failing to no­tice (be­cause it is track­ing the breath, not the pres­ence of other thoughts). Worse, since you may find it re­ward­ing to just think that you are med­i­tat­ing well, that thought may start to be­come re­warded, and you may find your­self just think­ing that you are med­i­tat­ing well… even as that thought has be­come self-sus­tain­ing and no longer con­nected to whether you are fol­low­ing the breath or not!

There are all kinds of sub­tle traps like this, and re­duc­ing the amount of dis­trac­tion re­quires you to first have bet­ter aware­ness of the dis­trac­tion. This means more mo­ments of in­tro­spec­tive aware­ness which are track­ing what’s ac­tu­ally hap­pen­ing in your mind:

Sub­sys­tem 1: I’m med­i­tat­ing well!
Sub­sys­tem 2: Hmm, what’s that smell.
Sub­sys­tem 1: I’m med­i­tat­ing well! No dis­trac­tions.
Sub­sys­tem 2: Smells kinda like cook­ies.
Sub­sys­tem 2: Mmm, cook­ies.
Aware­ness sub­sys­tem: Wait, one train of thought keeps say­ing that it’s med­i­tat­ing well, but an­other is to­tally get­ting into the thought of food.
Sub­sys­tem 1: Oh. Bet­ter re­fo­cus that at­ten­tion on the breath, and spend less time think­ing about the con­cept of fol­low­ing the breath.

This kind of a pro­cess also teaches you to pay at­ten­tion to pat­terns of cause and effect in your mind. In this ex­am­ple, the smell of cook­ies caused you to think of cook­ies, which in turn made you think of din­ner, which could have ul­ti­mately led to for­get­ting and mind-wan­der­ing.

Catch­ing the train of thought af­ter “mmm, cook­ies” meant that three “pro­cess­ing steps” had passed be­fore you no­ticed it. If you prac­tice trac­ing back trains of thought in your mind, you seem to teach your aware­ness-sys­tem to col­lect and store data from a longer pe­riod, even when it is not ac­tively out­putting it. This means that at the “mmm, cook­ies” stage, you can query your aware­ness to get a trace of the im­me­di­ately pre­ced­ing thought chain.

You no­tice that you started to get dis­tracted start­ing from the smell of the cookie and can then use this as fur­ther in­put to your aware­ness sys­tem. You are es­sen­tially tak­ing the re-pre­sented smell of the cookie which the sys­tem out­put, and feed­ing it back in, ask­ing it to pay more at­ten­tion to de­tect­ing “things like this”. The next time that you no­tice a smell, your in­tro­spec­tive aware­ness may flag it right away, let­ting you catch the dis­trac­tion at the very first stage and be­fore it turns into an ex­tended train of thought.

Note that there is noth­ing par­tic­u­larly mys­te­ri­ous or un­usual about any of this. You are em­ploy­ing es­sen­tially the same pro­cess used in learn­ing any skill. In learn­ing to ride a bike, for ex­am­ple, at­tempt­ing to keep the bike bal­anced in­volves ad­just­ing your move­ments in re­sponse to feed­back. When you do so, your brain be­comes bet­ter at de­tect­ing things like “tilt­ing to­wards the right” in the sense data, in­creas­ing your abil­ity to ap­ply the right cor­rec­tion. After you have learned to iden­tify tilt­ing-a-lot-but-not-quite-fal­ling, your brain learns to back­trace to the pre­ced­ing state of tilt­ing-a-lit­tle-less, and ap­ply the right cor­rec­tion there. Once its pre­ci­sion has been honed to iden­tify that state, you can fur­ther de­tect an even sub­tler tilt, un­til you au­to­mat­i­cally ap­ply the right cor­rec­tions to keep you bal­anced.

Essen­tially the kind of a learn­ing al­gorithm is be­ing ap­plied here. In­creased sen­sory pre­ci­sion leads to im­prove­ments in skill which al­low for in­creased sen­sory pre­ci­sion. (See also this ar­ti­cle, which goes into more de­tail about TMI as a form of de­liber­ate prac­tice.)

Uses for mo­ments of in­tro­spec­tive aware­ness

I should again em­pha­size that the pre­ced­ing ex­pla­na­tion is only look­ing at one par­tic­u­lar med­i­ta­tion sys­tem. There are other sys­tems which work very differ­ently, but they all use or de­velop in­tro­spec­tive aware­ness to some ex­tent. For ex­am­ple:

  • In Shinzen Young’s for­mu­la­tion of “do noth­ing” prac­tice, you have just two ba­sic in­struc­tions: let what­ever hap­pens, hap­pen and when you no­tice an in­ten­tion to con­trol your at­ten­tion, drop that in­ten­tion. This trains in­tro­spec­tive aware­ness to no­tice when one is try­ing to con­trol their at­ten­tion… but it is also a very differ­ent sys­tem, since main­tain­ing an in­ten­tion to no­tice when that hap­pens would also be an at­tempt to con­trol at­ten­tion! Thus, one is in­structed to drop in­ten­tions if one spon­ta­neously no­tices them, but not to ac­tively look for them.

  • In not­ing prac­tice, you are try­ing to con­sciously name or no­tice ev­ery­thing that hap­pens in your con­scious­ness. In­tro­spec­tive aware­ness is trained to very rapidly dis­t­in­guish be­tween ev­ery­thing that hap­pens, but is not trained to main­tain at­ten­tion on any par­tic­u­lar thing.

  • In vi­su­al­iza­tion prac­tice, you might cre­ate a vi­sual image in your mind, then use in­tro­spec­tive aware­ness to ex­am­ine the men­tal ob­ject that you’ve cre­ated and com­pare it to what a real image would look like. This gives the sub­sys­tem cre­at­ing the vi­su­al­iza­tion feed­back, and helps slowly de­velop a more re­al­is­tic image.

Go­ing back to TMI-style in­tro­spec­tive aware­ness, once you get it trained up, you can use it for var­i­ous pur­poses. In par­tic­u­lar, once you learn to main­tain it dur­ing your daily life—and not just on the med­i­ta­tion couch—it will bring up more as­sump­tions in your var­i­ous schemas and men­tal mod­els. Think of Richard pay­ing at­ten­tion to the as­sump­tions be­hind his un­wanted re­ac­tions and mak­ing them ex­plicit, but as some­thing that hap­pens on a reg­u­lar ba­sis as the re­ac­tions come up.

Romeo Stevens de­scribed what he called “the core loop of Bud­dhism”:

So, what is the core loop?
It’s ba­si­cally cog­ni­tive be­hav­ioral ther­apy, su­per­charged with a men­tal state more in­tense than most phar­ma­ceu­ti­cals.
There are two cat­e­gories of prac­tice, one for cul­ti­vat­ing the use­ful men­tal state, the other uses that men­tal state to in­ves­ti­gate the causal link­ages be­tween var­i­ous parts of your per­cep­tion (phys­i­cal sen­sa­tions, emo­tional tones, and men­tal re­ac­tions) which leads to clear­ing out of old link­ages that weren’t con­structed well.
You have phys­i­cal sen­sa­tions in the course of life. Your ner­vous sys­tem re­acts to these sen­sa­tions with high or low valence (pos­i­tive, nega­tive, neu­tral) and arousal (sym­pa­thetic and parasym­pa­thetic ner­vous sys­tem ac­ti­va­tion), your mind re­acts to these now-emo­tion-laden sen­sa­tions with ac­tivity (men­tal image, men­tal talk) out of which you then build sto­ries to make sense of your situ­a­tion.
The key in­sight that drives ev­ery­thing is the knowl­edge (and later, di­rect ex­pe­rience) that this sys­tem isn’t wired up effi­ciently. Im­por­tantly: I don’t mean this in a nor­ma­tive way. Like you should wire it the way I say just be­cause, but in the ‘this type of cir­cuit only needs 20 nand gates, why are there 60 and why is it shunt­ing ex­cess voltage into the anger cir­cuits over there that have noth­ing to do with this com­pu­ta­tion?’ way. Re­gard­less of pos­si­ble ar­gu­ments over an ul­ti­mately ‘cor­rect’ way to wire ev­ery­thing, there are very low hang­ing fruit in terms of im­prove­ments that will help you effec­tively pur­sue *any* other goal you set your mind to.

Again, we saw an ex­am­ple of this with Richard. He had ex­pe­rienced his father as act­ing con­fi­dent and as caus­ing suffer­ing to Richard and oth­ers; sen­sa­tions which his mind has clas­sified as nega­tive. In or­der to avoid them, a model (story) was con­structed say­ing that con­fi­dence is hor­rible, and be­hav­iors (e.g. nega­tive self-talk) were cre­ated to avoid ap­pear­ing hor­rible.

Now, this caused prob­lems down the line, mak­ing him mo­ti­vated to try to ap­pear more con­fi­dent… mean­ing that there was now a mechanism in his brain try­ing to pre­vent him from ap­pear­ing con­fi­dent, and an­other which con­sid­ered this a prob­lem and tried to make him more con­fi­dent, in op­po­si­tion to the first sys­tem. See what Romeo means when talk­ing about cir­cuits that only need 20 gates but are im­ple­mented us­ing 60?

The ar­ti­cle “tune your mo­tor cor­tex” makes the fol­low­ing claims about mus­cle move­ment:

Your mo­tor cor­tex au­to­mat­i­cally learns to ex­e­cute com­plex move­ments by putting to­gether sim­pler ones, all the way down to con­trol of in­di­vi­d­ual mus­cles.
Be­cause the pro­cess of learn­ing hap­pens or­gan­i­cally, the re­sult­ing ar­chi­tec­ture of neu­ral con­nec­tions (you can think of them as “hid­den lay­ers” in ma­chine learn­ing terms) is not always perfectly suited to the task.
Some lo­cal op­tima of those neu­ral con­figu­ra­tions are hard to get out of, and con­stantly re­in­forced by us­ing them.
There is some pres­sure for mus­cle con­trol to be effi­cient, and the mo­tor cor­tex is do­ing a “good enough” job at it, but tends to stop a fair bit from perfec­tion.
By re­peat­ing cer­tain move­ments and po­si­tions over and over again (e.g. dur­ing sit­ting work), we in­vol­un­tar­ily strengthen con­nec­tions be­tween move­ments and mus­cles that don’t make much sense lumped to­gether.
E.g. con­trol of shoulders might be­come spu­ri­ously wired to­gether with con­trol of thighs (both are of­ten tense dur­ing sit­ting).

There are var­i­ous men­tal mo­tions which are learned in ba­si­cally the same way as phys­i­cal mo­tions are:

  • You learn to calcu­late 12*13 by a tech­nique such as first mul­ti­ply­ing 10*13, keep­ing the re­sult in your mem­ory, calcu­lat­ing 2*13, and then adding the in­ter­me­di­ate re­sults to­gether.

  • You learn that a par­tic­u­lar mem­ory makes you feel slightly un­pleas­ant, and that flinch­ing away from any­thing that would re­mind you of it takes the pain away.

  • You learn that this also works on un­com­fortable chores, teach­ing you to keep push­ing the thought of them away.

  • You learn that your father’s be­hav­ior is painful to you, and that any con­fi­dence re­minds you of that, so you learn nega­tive self-talk which blocks you from act­ing con­fi­dent.

  • You learn that say­ing “no” to peo­ple re­minds you of be­ing pun­ished for say­ing “no” to your par­ents, but that say­ing “yes” too of­ten means that you are con­stantly fulfilling promises to other peo­ple—so you learn to avoid situ­a­tions where you would be asked any­thing.

  • You learn that there’s some­thing you can do in your mind to stop feel­ing up­set, so you start ig­nor­ing your emo­tions and any in­for­ma­tion they might have.

  • You learn that if you feel bad about not get­ting the re­spect you want, think­ing “if only I was good enough at per­sua­sion, I would get what I want” gives you a sense of con­trol—even though this pat­tern also makes you feel per­son­ally at fault when you don’t get what you want.

  • You learn that it’s re­ward­ing to pun­ish peo­ple who have wronged, so you always want to pun­ish some­one when some­thing goes wrong—even if there is no­body but re­al­ity to pun­ish.

  • You learn that it feels good to men­tally pun­ish some­one who is munch­ing too loud, but ac­tu­ally com­plain­ing about it would feel petty, and you’ve learned that pet­ti­ness is frowned upon. So you also learn to block the im­pulse to say any­thing out loud, but con­tinue to get in­creas­ingly an­gry about the sound, caus­ing an es­ca­lat­ing cir­cle of both the an­noy­ance and the block­ing ramp­ing up in in­ten­sity.

As with phys­i­cal move­ments, these can form lo­cal op­tima that are hard to get out of. Many of them are learned in child­hood, when your un­der­stand­ing of the world is limited. But new be­hav­iors con­tinue to build on top of them, so you will even­tu­ally end up with a sys­tem which could use a lot of op­ti­miza­tion.

If you have more in­tro­spec­tive aware­ness of the ex­act pro­cesses that are hap­pen­ing in your mind, you can make more im­plicit as­sump­tions con­scious, caus­ing your brain’s built-in con­tra­dic­tion de­tec­tor to no­tice when they con­tra­dict your later learn­ing. Also, get­ting more feed­back about what ex­actly is hap­pen­ing in your mind al­lows you to no­tice more wasted mo­tion in gen­eral.

One par­tic­u­lar effect is that, as Un­lock­ing the Emo­tional Brain notes, the mind of­ten makes trade-offs where it causes it­self some minor suffer­ing in or­der to avoid a per­ceived greater suffer­ing. For ex­am­ple, some­one may feel guilt in or­der to mo­ti­vate them­selves, or ex­pe­rience self-doubt to avoid ap­pear­ing too con­fi­dent. By em­ploy­ing greater in­tro­spec­tive aware­ness, one may find ways to achieve their goals with­out need­ing to ex­pe­rience any suffer­ing in or­der to do so.

Of course, Bud­dhist med­i­ta­tion is not the only way to achieve this. Var­i­ous ther­a­pies and tech­niques such as Fo­cus­ing, In­ter­nal Fam­ily Sys­tems, In­ter­nal Dou­ble Crux, and so on, are also meth­ods which use in­tro­spec­tive aware­ness to re­veal and re­fac­tor var­i­ous as­sump­tions. In­creased in­tro­spec­tive aware­ness from med­i­ta­tion tends to also boost the effec­tive­ness of re­lated tech­niques, as well as re­veal more situ­a­tions where they can be em­ployed.

If in­tro­spec­tive aware­ness is so great, why don’t we have it nat­u­rally?

As with any­thing, there are trade­offs in­volved. Hav­ing more in­tro­spec­tive aware­ness can help fix a lot of is­sues… but it also comes with risks, which I as­sume is the rea­son why we have not evolved to have a lot of it all the time.

First, it’s worth not­ing that even for ex­pe­rienced med­i­ta­tors, in­tense emo­tional re­ac­tions tend to shut down in­tro­spec­tive aware­ness. If one of the func­tions of e.g. fear and anx­iety is to cause a rapid re­sponse, then ex­ces­sive amounts of in­tro­spec­tive aware­ness would slow down that re­sponse by re­duc­ing cog­ni­tive fu­sion. Many emo­tions seem to in­hibit many com­pet­ing pro­cesses from ac­cess­ing con­scious­ness, so that you can deal with the situ­a­tion at hand.

Another con­sid­er­a­tion in­volves trau­matic mem­o­ries. In the be­gin­ning of the ar­ti­cle, I sug­gested that anx­iety is a spe­cial kind of men­tal ob­ject which ac­ti­vates par­tic­u­lar be­hav­iors. In gen­eral, differ­ent emo­tional states have spe­cific kinds of be­hav­iors and ac­tivi­ties as­so­ci­ated with them—mean­ing that if you have some mem­o­ries which are re­ally painful, they can be­come over­whelming, mak­ing it nec­es­sary to block them in or­der to carry on with your nor­mal life. Med­i­ta­tion can be helpful for work­ing through your trauma, but it can also bring it up be­fore you are ready for it, to the point of re­quiring pro­fes­sional psy­chother­apy to get through. If you are bet­ter at notic­ing all kinds of sub­tle de­tails in your mind, it also be­comes eas­ier to no­tice any­thing that would re­mind you of things you don’t want to re­mem­ber. A de­crease in in­tro­spec­tive aware­ness seems to be a com­mon trauma symp­tom, as this helps block the un­pleas­ant mem­o­ries from be­ing too eas­ily trig­gered.

I have also heard ad­vanced med­i­ta­tors men­tion that in­creased in­tro­spec­tive aware­ness makes it difficult to push away pangs of con­science that they would oth­er­wise have ig­nored, caus­ing prac­ti­cal prob­lems. For ex­am­ple, peo­ple have said that they are no longer able to eat an­i­mal prod­ucts or tell white lies.

On the other hand, ex­tended con­cen­tra­tion prac­tice can also make it eas­ier to block things which you would be bet­ter off not block­ing.

So far, this ar­ti­cle has mostly fo­cused on us­ing in­tro­spec­tive aware­ness to no­tice the con­tent of your thoughts. But you can also use it to no­tice the struc­ture of the higher-level pro­cesses gen­er­at­ing your thoughts. Part of how you de­velop con­cen­tra­tion abil­ity is by main­tain­ing in­tro­spec­tive aware­ness of the fact that be­ing able to con­cen­trate on just one thing feels more pleas­ant than hav­ing your at­ten­tion jump be­tween many differ­ent things. This can give you an im­proved abil­ity to choose what you are con­cen­trat­ing on… but also to se­lec­tively ex­clude any­thing un­pleas­ant from your mind.

For ex­am­ple, there was an oc­ca­sion when I needed to do some work, but also had in­tense anx­iety about not want­ing to; in­tense enough that it would nor­mally have made it im­pos­si­ble for me to fo­cus on it. So then I tried to work, and let my in­tro­spec­tive aware­ness ob­serve the feel­ing of head-split­ting agony from my at­ten­tion al­ter­nat­ing be­tween the work and the de­sire not to… and to also no­tice that when­ever my at­ten­tion was on the work, I felt tem­porar­ily bet­ter.

After a while of this, the anx­iety started to get ex­cluded from my con­scious­ness, un­til it sud­denly dropped away com­pletely—as if some deeper pro­cess had judged it use­less and re­voked its ac­cess to con­scious­ness. And while this al­lowed me to do the work that I needed to, it also felt in­ter­nally vi­o­lent, and like it would be too easy to re­press any un­pleas­ant thoughts us­ing it. I still use this kind of tech­nique on oc­ca­sion when I need to con­cen­trate on some­thing, but I try to be cau­tious about it.

The nega­tive side of be­ing able to get bet­ter feed­back about your men­tal pro­cesses, is that you can also get bet­ter feed­back on ex­actly how pleas­ant wire­head­ing feels. If you like to imag­ine pleas­ant things, you can get bet­ter and bet­ter at imag­in­ing pleas­ant things, and ex­clud­ing any wor­ries about it from your con­scious­ness. Med­i­ta­tion teacher Daniel In­gram warns:

Strong in­sight and con­cen­tra­tion prac­tice, even when that prac­tice wasn’t ded­i­cated to the pow­ers, can make peo­ple go tem­porar­ily or per­ma­nently (or for the rest of that life­time) psy­chotic. The more the prac­tice in­volves cre­at­ing ex­pe­riences that di­verge sig­nifi­cantly from what I will crudely term “con­sen­sus re­al­ity”, and the longer one en­gages in these prac­tices, the more likely pro­longed difficul­ties are. It is of note that a sig­nifi­cant num­ber of the pri­mary prop­a­ga­tors of the Western mag­ickal tra­di­tions be­came mod­er­ately nuts to­wards the ends of their lives.
As one Burmese man said to Ken­neth, “My brother does con­cen­tra­tion prac­tice. You know, some­times they go a lit­tle mad!” He was talk­ing about what can some­times hap­pen when peo­ple get into the pow­ers. [...]
I re­mem­ber a let­ter from a friend who was on a long re­treat in Burma and was sup­posed to be do­ing in­sight prac­tices but had slipped into play­ing with these sorts of ex­pe­riences. He was now fas­ci­nated by his abil­ity to see spirit an­i­mals and other su­per­nor­mal be­ings and was hav­ing reg­u­lar con­ver­sa­tions with some sort of low-level god that kept tel­ling him that he was mak­ing ex­cel­lent progress in his in­sight prac­tice—that is, ex­actly what he wanted to hear. How­ever, the fact that he was hav­ing sta­ble vi­sion­ary ex­pe­riences and was buy­ing into their con­tent made it abun­dantly clear that he wasn’t do­ing in­sight prac­tices at all, but was lost in and be­ing fooled by these.

Now, it should be pointed out that “be­ing able to ex­clude any­thing un­pleas­ant from your con­scious­ness” is only go­ing to be a worry for ad­vanced prac­ti­tion­ers who spend a lot of time on the kind of prac­tice that in­clines you to­wards these kinds of risks. Be­fore you get to the point of some­thing like this be­ing a risk, you will get to re­solve a lot of in­ter­nal con­flicts and old is­sues first.

Here is Cu­ladasa, the au­thor of The Mind Illu­mi­nated, be­ing in­ter­viewed about this kind of a “first you re­solve a lot of is­sues, but then you can get the abil­ity to push down the rest” dy­namic:

Michael Taft: … and you’re us­ing the med­i­ta­tion prac­tice to help work with your stuff. But what about the other case that we both know of where peo­ple have reached very high lev­els of med­i­ta­tive ca­pac­ity, they’ve got a lot of in­sight, maybe they’re at some level of awak­en­ing, and they seem to have, in a way, missed a whole pocket of ma­te­rial, or sev­eral pock­ets of ma­te­rial. It’s like they think they’re do­ing fine, but maybe ev­ery­one around them is aware that they’ve got these be­hav­ior pat­terns that do not seem awake at all. And yet the med­i­ta­tion has some­how missed that.
Cu­ladasa: Yes, yes. [...] … there seems to be a cer­tain level of the stuff that we’re talk­ing about that it’s nec­es­sary to deal with to achieve awak­en­ing, but it’s sort of a min­i­mal level. [...] What I think that is in­dica­tive of is that if that hasn’t been suffi­ciently dealt with ear­lier, it has to get dealt with in one way or an­other at that point. That doesn’t nec­es­sar­ily mean that it’s go­ing to get re­solved; it may just get re­buried a lit­tle more deeply.
Michael Taft: Pushed out of the way.
Cu­ladasa: Yeah, pushed out of the way, or by­passed in some way. That al­lows a per­son to go ahead and [progress] and it’s un­re­al­is­tic to think that ev­ery­thing has been re­solved. [...] a lot of the things that change [...] ac­tu­ally help to push these things aside, to by­pass them in one way or an­other, whereas be­fore some­body has [made as much progress] these would have been suffi­ciently prob­le­matic in their life that, in one way or an­other, they would be aware of them, whether or not they did any­thing about them or were at a place of just tak­ing for granted that I have these, quote, “per­son­al­ity char­ac­ter­is­tics” that are a bit difficult.

I used to be very en­thu­si­as­tic about TMI’s med­i­ta­tion sys­tem. I still con­sider it im­por­tant and use­ful to make progress on, but am slightly more guarded af­ter some of my own ex­pe­riences, hear­ing about the ex­pe­rience of a friend who reached a high level in it, read­ing some cri­tiques of its ten­dency to em­pha­size aware­ness of pos­i­tive ex­pe­riences [1 2], and con­sid­er­ing both the in­ter­view quoted above and Cu­ladasa’s sub­se­quent ac­tions. (That said, the fo­cus on pos­i­tive ex­pe­riences can be a use­ful coun­ter­bal­ance for peo­ple who start off with an over­all nega­tive stance to­wards life.)

I con­tinue to prac­tice it, and would gen­er­ally find it safe un­til you get to around the sixth or so of its ten stages, at which point I would sug­gest start­ing to ex­er­cise some cau­tion. Off the couch, I mostly don’t do much con­cen­tra­tion prac­tice (ex­cept in a con­text where I would need to con­cen­trate any­way). Rather I try to fo­cus my in­tro­spec­tive aware­ness to­wards just ob­serv­ing my mind with­out ac­tively in­terfer­ing with it, In­ter­nal Fam­ily Sys­tems -style prac­tice, and other ac­tivi­ties that do not seem to risk ex­clud­ing too much un­pleas­ant ma­te­rial.

Fi­nally, de­vel­op­ing too much aware­ness into your mind may cause you to start notic­ing con­tra­dic­tions be­tween how you thought it worked, and how it ac­tu­ally works. I sus­pect that a part of how our brains have evolved to op­er­ate, re­lies on those differ­ences go­ing un­no­ticed. This gets us to the topic of en­light­en­ment, which I have not yet dis­cussed, but will do in my next post.

Thanks to Maija Haav­isto, Lumi Pakka­nen and Romeo Stevens for com­ments on an ear­lier draft.


          

Inconvenient No 67 Hiver 2017 La Societe Sans Douleur Bertrand Laverdure Alain Roy Olivier Maillart Jacques Godbout Ugo Gilbert Tremblay Michel Morin Thomas   

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Inconvenient No 67 Hiver 2017 La Societe Sans Douleur Bertrand Laverdure Alain Roy Olivier Maillart Jacques Godbout Ugo Gilbert Tremblay Michel Morin Thomas

          

Inconvenient No 65 Ete 2016 La Gauche Et La Droite Eric Bedard Alain Roy Serge Bouchard Monique Larue Ugo Gilbert Tremblay Mathieu Belisle Alain Deneault   

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Inconvenient No 65 Ete 2016 La Gauche Et La Droite Eric Bedard Alain Roy Serge Bouchard Monique Larue Ugo Gilbert Tremblay Mathieu Belisle Alain Deneault

          

De Lavalette Une Legende Blessee Gilbert   

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De Lavalette Une Legende Blessee Gilbert

          

Inconvenient No 64 Printemps 2016 L Amitie Au Temps De Facebook Alain Roy Serge Bouchard Eric Dupont Jean Philippe Martel Etienne Savignac Ugo Gilbert   

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Inconvenient No 64 Printemps 2016 L Amitie Au Temps De Facebook Alain Roy Serge Bouchard Eric Dupont Jean Philippe Martel Etienne Savignac Ugo Gilbert

          

ANOTHER VICTORY: Bus bench and shelter advertising REJECTED by City of St. Augustine Beach, Florida   

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Three cheers for the City of St. Augustine Beach Commissioners for again opposing ugliness and billboards.  It was unanimous.  Another victory for the public interest. It takes a village.

Three prospective no-bid contractor salesmen or lobbyists asked the City of St. Augustine Beach to approve advertising-laden bus shelters and benches.

The City of St. Augustine Beach rightly rejected them.

The bus shelters or benches were offered on condition of the City of St. Augustine Beach amending its sign code to "conform" to the contractors' demands.

They mentioned a few locations, where their advertisements blare, none in cool hip beach towns like St. Augustine Beach.

They mentioned that some South Florida cities using their services ban political ads, which is unconstitutional under Reed v. Town of Gilbert.

No thanks to City "Manager" BRUCE MAX ROYLE for once again putting dodgy vendors on a Commission agenda. As former Mayor Sherman Gary Snodgrass once told me, he would never have allowed a vendor to present to the Board of Commonwealth Edison or Excelon, the nuclear utilities for which he worked.

Why in the name of all that's does maladroit City "Manager" BRUCE MAX ROYLE continue putting ethically questionable items on the agenda?

Meanwhile this senescent somnambulant mossback eschews real issues, like:

  • global ocean level rise
  • lobbying registration, 
  • ethics reform, 
  • a County Charter, 
  • Inspector General, 
  • Ombuds
  • his own painfully obvious incompetence..


By the way, the grifters in quo cited a loooong Florida statute that then legislature passed to allow such crooked deals. In called it bribery -- they offered a thing of value too the City of St. Augustine Beach if it would amend its sign code. Federal laws, like the Hobbs Act, suggest that such corruption is indefensible, and must be ended at once,

Here's the 1553 word Florida statute in quo, likely the product of louche lobbying of the Florida legislature by CBS OUTDOOR, GANNETT or other large advertising companies:


337.408 Regulation of bus stops, benches, transit shelters, street light poles, waste disposal receptacles, and modular news racks within rights-of-way.—

(1) Benches or transit shelters, including advertising displayed on benches or transit shelters, may be installed within the right-of-way limits of any municipal, county, or state road, except a limited access highway, provided that such benches or transit shelters are for the comfort or convenience of the general public or are at designated stops on official bus routes and provided that written authorization has been given to a qualified private supplier of such service by the municipal government within whose incorporated limits such benches or transit shelters are installed or by the county government within whose unincorporated limits such benches or transit shelters are installed. A municipality or county may authorize the installation, without public bid, of benches and transit shelters together with advertising displayed thereon within the right-of-way limits of such roads. All installations shall be in compliance with all applicable laws and rules, including, without limitation, the Americans with Disabilities Act. Municipalities and counties that authorize or have authorized a bench or transit shelter to be installed within the right-of-way limits of any road on the State Highway System shall be responsible for ensuring that the bench or transit shelter complies with all applicable laws and rules, including, without limitation, the Americans with Disabilities Act, or shall remove the bench or transit shelter. The department shall have no liability for any claims, losses, costs, charges, expenses, damages, liabilities, attorney fees, or court costs relating to the installation, removal, or relocation of any benches or transit shelters authorized by a municipality or county. On and after July 1, 2012, a municipality or county that authorizes a bench or transit shelter to be installed within the right-of-way limits of any road on the State Highway System must require the qualified private supplier, or any other person under contract to install the bench or transit shelter, to indemnify, defend, and hold harmless the department from any suits, actions, proceedings, claims, losses, costs, charges, expenses, damages, liabilities, attorney fees, and court costs relating to the installation, removal, or relocation of such installations, and shall annually certify to the department in a notarized signed statement that this requirement has been met. The certification shall include the name and address of each person responsible for indemnifying the department for an authorized installation. Municipalities and counties that have authorized the installation of benches or transit shelters within the right-of-way limits of any road on the State Highway System must remove or relocate, or cause the removal or relocation of, the installation at no cost to the department within 60 days after written notice by the department that the installation is unreasonably interfering in any way with the convenient, safe, or continuous use of or the maintenance, improvement, extension, or expansion of the State Highway System road. Any contract for the installation of benches or transit shelters or advertising on benches or transit shelters which was entered into before April 8, 1992, without public bidding is ratified and affirmed. Such benches or transit shelters may not interfere with right-of-way preservation and maintenance. Any bench or transit shelter located on a sidewalk within the right-of-way limits of any road on the State Highway System or the county road system shall be located so as to leave at least 36 inches of clearance for pedestrians and persons in wheelchairs. Such clearance shall be measured in a direction perpendicular to the centerline of the road.
(2) Waste disposal receptacles of less than 110 gallons in capacity, including advertising displayed on such waste disposal receptacles, may be installed within the right-of-way limits of any municipal, county, or state road, except a limited access highway, provided that written authorization has been given to a qualified private supplier of such service by the appropriate municipal or county government. A municipality or county may authorize the installation, without public bid, of waste disposal receptacles together with advertising displayed thereon within the right-of-way limits of such roads. Such waste disposal receptacles may not interfere with right-of-way preservation and maintenance.
(3) Modular news racks, including advertising thereon, may be located within the right-of-way limits of any municipal, county, or state road, except a limited access highway, provided the municipal government within whose incorporated limits such racks are installed or the county government within whose unincorporated limits such racks are installed has passed an ordinance regulating the placement of modular news racks within the right-of-way and has authorized a qualified private supplier of modular news racks to provide such service. The modular news rack or advertising thereon shall not exceed a height of 56 inches or a total advertising space of 56 square feet. No later than 45 days prior to installation of modular news racks, the private supplier shall provide a map of proposed locations and typical installation plans to the department for approval. If the department does not respond within 45 days after receipt of the submitted plans, installation may proceed.
(4) The department has the authority to direct the immediate relocation or removal of any bus stop, bench, transit shelter, waste disposal receptacle, public pay telephone, or modular news rack that endangers life or property or that is otherwise not in compliance with applicable laws and rules, except that transit bus benches that were placed in service before April 1, 1992, are not required to comply with bench size and advertising display size requirements established by the department before March 1, 1992. The department may adopt rules relating to the regulation of bench size and advertising display size requirements. If a municipality or county within which a bench is to be located has adopted an ordinance or other applicable regulation that establishes bench size or advertising display sign requirements different from requirements specified in department rule, the local government requirement applies within the respective municipality or county. Placement of any bench or advertising display on the National Highway System under a local ordinance or regulation adopted under this subsection is subject to approval of the Federal Highway Administration.
(5) A bus stop, bench, transit shelter, waste disposal receptacle, public pay telephone, or modular news rack, or advertising thereon, may not be erected or placed on the right-of-way of any road in a manner that conflicts with the requirements of federal law, regulations, or safety standards, thereby causing the state or any political subdivision the loss of federal funds. Competition among persons seeking to provide bus stop, bench, transit shelter, waste disposal receptacle, public pay telephone, or modular news rack services or advertising on such benches, shelters, receptacles, public pay telephone, or news racks may be regulated, restricted, or denied by the appropriate local government entity consistent with this section.
(6) Street light poles, including attached public service messages and advertisements, may be located within the right-of-way limits of municipal and county roads in the same manner as benches, transit shelters, waste disposal receptacles, and modular news racks as provided in this section and in accordance with municipal and county ordinances. Public service messages and advertisements may be installed on street light poles on roads on the State Highway System in accordance with height, size, setback, spacing distance, duration of display, safety, traffic control, and permitting requirements established by administrative rule of the Department of Transportation. Public service messages and advertisements shall be subject to bilateral agreements, where applicable, to be negotiated with the owner of the street light poles, which shall consider, among other things, power source rates, design, safety, operational and maintenance concerns, and other matters of public importance. For the purposes of this section, the term “street light poles” does not include electric transmission or distribution poles. The department shall have authority to adopt rules pursuant to ss. 120.536(1) and 120.54 to implement the provisions of this section. No advertising on light poles shall be permitted on the Interstate Highway System. No permanent structures carrying advertisements attached to light poles shall be permitted on the National Highway System.
(7) A public pay telephone, including advertising displayed thereon, may be installed within the right-of-way limits of any municipal, county, or state road, except on a limited access highway, if the pay telephone is installed by a provider duly authorized and regulated by the Public Service Commission under s. 364.3375, if the pay telephone is operated in accordance with all applicable state and federal telecommunications regulations, and if written authorization has been given to a public pay telephone provider by the appropriate municipal or county government. Each advertisement must be limited to a size no greater than 8 square feet, and a public pay telephone booth may not display more than three advertisements at any given time. An advertisement is not allowed on public pay telephones located in rest areas, welcome centers, or other such facilities located on an interstate highway.
(8) Wherever the provisions of this section are inconsistent with other provisions of this chapter or with the provisions of chapter 125, chapter 335, chapter 336, or chapter 479, the provisions of this section shall prevail.
History.—s. 21, ch. 85-180; s. 61, ch. 94-237; s. 30, ch. 95-257; s. 63, ch. 96-323; s. 82, ch. 2002-20; s. 22, ch. 2004-366; s. 11, ch. 2009-85; s. 37, ch. 2012-174.
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AUTHORITARIAN CENSORSHIP RULES: St. Augustine Beach to Mull "Civility Rules"   

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Update 10 PM, November 4, 2019: St. Augustine Beach consideration of the Sanibel, Florida "civility" policy is dead. Deader than Kelsey's Nuts. Or as the coroner in Wizard of Oz would say, I pronounce igt "not only merely dead, [but] really most sincerely dead." Thanks to the City of St. Augustine Mayor, Commissioners and in-house and outside insurance counsel for coming to their senses. It takes a village.

No thanks to City "Manager" BRUCE MAX ROYLE, who had nothing to contribute all night, and who fell asleep at the dais at least once. It's time for him to go. Now.




Come speak out at St. Augustine Beach City Hall, 6 pm, Monday November 4, 2019.

The City of St. Augustine Beach must learn at last: Democracy is not a spectator sport.

The First Amendment deserves "breathing space." 

Rev. Dr. Martin Luther King, Jr. called St. Augustine, Florida the "most lawless city in America" in 1964, resulting in the largest mass arrest of rabbis in American history. 

Our First Amendment deserves "breathing space."  NAACP v. Button, 371 U.S. 415, 433 (1963) New York Times. v. Sullivan, 3766 U.S. 254 (1974); Gasparinetti v. Kerr, 568 F.2d 311, 314-17 (3d Cir. 1977)(illegal restrictions on policemen’s First Amendment rights); Philadelphia Newspapers, Inc. v. Hepps, 479 767, 772, 777 (1986)(O’Connor, J.)(newspaper entitled to breathing space in defamation case); Hustler Magazine v. Falwell, 485 U.S. 46, 52, 56 (1988) (Rehnquist, J.) (magazine parody of TV preacher entitled to breathing space); Keefe v. Ganeakos, 418 F.2d 359, 362 (1st Cir. 1969)(Aldrich, C.J.)(chilling effect on First Amendment illegal suspension of teacher over Atlantic Monthly article on Vietnam War); Parducci v. Rutland, 316 F.Supp. 352, 355, 357 (M.D. Ala 1970)(Johnson, C.J.)(chilling effect in illegal firing of English teacher over Kurt Vonnegut’s Welcome to the Monkey House.


The itty-bitty city of St. Augustine Beach, Florida reminds me of a play I once saw, called "House Rules," about a horribly dysfunctional Florida family.  


St. Augustine Beach "Mayors" rotate and are not elected by the residents.


Somnambulistic City "Manager" BRUCE MAX ROYLE and his willing accomplice, outgoing "Mayor" UNDINE CELESTE PAWLOWSKI GEORGE again wants to inflict "civility rules" that would be unconstitutional and "void for vagueness."  https://God.blue/splash.php?url=lKakKSFSQBleWIR8fw8XELMevvNBS9c_SLASH_S4wXfBsAx3xpBWV7bKMrhyaBFjMS0D7nRwaKb3qNxxVS_SLASH_Guh6e93Cu7I58Ean_PLUS_F4NaWn62RnjBVyBFDXK9Dgqku8Y0YbaeN8ggvtbdtdSFS42IoxdZtxhM5KeK_PLUS_bKLk8SGIAeFrc7T8deRbYwJteZ2QbhrD6NRQA


One of two lawyers on Commission, Mayor George well knows the Reed v. Town of Gilbert case, which necessitated a rewrite of the City of St. Augustine Beach's unconstitutional sign code, which discriminated against political signs and limited candidates to only two weeks of sign-posting, a pro-incumbent rule run riot, about which I had warned since 2007. 


Since 2015, in the Reed v. Town of Gilbert case, our U.S Supreme Court has required "strict scrutiny" of content-based free speech restrictions. Wikipedia explains, "Writing for a majority of the Court, Justice Clarence Thomas held that the town's sign ordinance imposed content-based restrictions that did not survive strict scrutiny because the ordinance was not narrowly tailored to further a compelling government interest. Justice Thomas also clarified that strict scrutiny should always be applied when a law is content-based on its face."


I find it odd that anyone would look to Sanibel, Florida for legal authority for its antique and unconstitutional rules adopted 12.5 years ago, on February 22, 2007, years before Reed v. Town of Gilbert.

The unconstitutional Sanibel "civility rules" that Mayor UNDINE GEORGE want to inflict, stating inter alia:

  • "Speakers and debates should focus on issues, not on persons or personalities."
  • "Anger, rudeness, ridicule, impatience and lack of respect for others are not acceptable behavior.
  • Demonstrations in support or opposition to a speaker or idea such as clapping, cheering, booing or  hissing or intimidating body language are not permitted in Council Chambers or workshop facilities."
No constitutional law research was done on these rules as of Friday, close of business.  When it's done, learned counsel, James Patrick Wilson and insurance defense lawyers, Susan Erdelyi and Denise May will advise:
  • These rules are content-based restrictions on free speech that would be subjected to "strict scrutiny," do not advance a "compelling governmental interest," and would be struck down under Reed v. Town of Gilbert, Arizona576 U.S. ___ ; 135 S. Ct. 2218; 192 L. Ed. 2d 236; 2015 U.S. LEXIS 4061; 83 U.S.L.W. 4444 (2015).
  • These rules don't advance a "compelling governmental interest.
  • These rules are not "narrowly tailored." McCullen v. Coakley, 573 U.S. ___ (2014)
  • These rules are highly subjective and what the Eleventh Circuit called a "standardless delegation" in Café Erotica of Florida, Inc. v. St. Johns County, 360 F.3d 1274 (11th Cir. 2004).
  • These rules do not give the First Amendment its required "breathing space."
  • These rules could lead to illegal ejection of citizens from meetings, resulting non civil rights liability under Lozman v. Riviera Beach, 585 U.S. ___ (2018)


Who needs lectures about "civility" by insecure, often-uncivil and shrill St. Augustine Beach Mayor UNDINE CELESTE PAWLOWSKI GEORGE?  

Mayor GEORGE is the entitled:
  • daughter of TRUMP CLUB leader and vote fraudster, Dr. MICHEL SERGE PAWLOWSKI, D.Sci. and
  • wife of former Mayor of St. Augustine Beach EDWARD GEORGE.
  • lawyer who allegedly intervened to cancel a Code Enforcement case involving her client, Norbert Tuseo. (They fix cases, don't they?)
The latest rotating Mayor of St. Augustine Beach, term-limited on her two-year reign of error --  punctuated by the desire to rule with an "iron fist," frustrated at her inability to inflict $400,000 worth of paid parking through a bogus no-bid PASSPORT LABS, INC. smartphone "app" -- wants to leave her mark on St. Augustine Beach with what?

"Civility rules."

How delightfully unconstitutional.


How impudently, imperiously, insolently pompous, pusillanimous and perverse -- hand me a script, ma'am,


People have a right to be angry.


People have a right to express their views without fear of censorship, or fear of ejection by bullies who misinterpret Florida statute on disrupting meetings, F.S. 871.01, which on remand Fane Loman's Washington, D.C. lawyers are arguing before the Eleventh Circuit is unconstitutional as applied.


The Supreme Court has gotten really tough on government violations of the First Amendment and viewpoint discrimination.  


A small town like St. Augustine Beach must weigh the lively jurisprudence on the First Amendment before going off half-baked into the wild blue yonder of suppression of Freedom of Speech, likely betting futures budgets. 

As Clint Eastwood once said, "Go ahead, make my day."  You can adopt an illegal resolution, or even an ordinance, but you will NEVER have the last word.    https://God.blue/splash.php?url=lKakKSFSQBleWIR8fw8XELMevvNBS9c_SLASH_S4wXfBsAx3xpBWV7bKMrhyaBFjMS0D7nRwaKb3qNxxVS_SLASH_Guh6e93Cu7I58Ean_PLUS_F4NaWn62RnjBVyBFDXK9Dgqku8Y0YbaeN8ggvtbdtdSFS42IoxdZtxhM5KeK_PLUS_bKLk8SGIAeFrc7T8deRbYwJteZ2QbhrD6NRQA




Ed Slavin easlavin@aol.comHide
To braddatz braddatz@cityofsab.org, comugeorge comugeorge@cityofsab.org, commkostka commkostka@cityofsab.org, commengland commengland@cityofsab.org, comdsamora comdsamora@cityofsab.org, comdrumrell comdrumrell@cityofsab.org, jpwilson jpwilson@cityofsab.org, jimwil03 jimwil03@nytimes.com, mroyle mroyle@cityofsab.org
Cc georgio georgio@folioweekly.com, pmarsh pmarsh@ausley.com, sunshine sunshine@floridafaf.org, pat.gleason pat.gleason@myfloridalegal.com, jack jack@naplesandspence.com, tomcushman tomcushman@bellsouth.net, megan.wall megan.wall@jaxlegalaid.org, sheplaw sheplaw@att.net, mills mills@law.ufl.edu, little little@law.ufl.edu, rosenbury rosenbury@law.ufl.edu, ankersen ankersen@law.ufl.edu, angelo angelo@law.ufl.edu, flournoy flournoy@law.ufl.edu, sheltonhull sheltonhull@gmail.com, rosenbury rosenbury@law.ufl.edu, sam sam@folioweekly.com, news news@historiccity.com, pgill70 pgill70@gmail.com, palmquist palmquist@comcast.net, news news@historiccity.com, ckelley ckelley@staugustine.com, aschindler aschindler@firstcoastnews.com, jessica.clark jessica.clark@firstcoastnews.com, news news@actionnewsjax.com, news news@firstcoastnews.com, waltbog waltbog@nytimes.com
20191101111917.pdf (76 KB)
Re: Request No. 2019-496: "Civility for public participation"
Dear St. Augustine Beach Mayor Undine Celeste Pawlowski George, Vice Mayor England, Commissioners Kostka, Samora and Rumrell, Messrs Wilson and Royle, Ms. Raddatz:
1. Where is the Florida and federal constitutional law research on this item?
2. If any exists, please send.
3. If none exists, please delete from agenda.
4. This item requires an ordinance and a public hearing, not a resolution.
5. The Sanibel policy is void for vagueness, has a chilling effect on free speech, and appears upon its face to be unAmerican and ill-advised?
6. If St. Augustine Beach were to adopt it, is it an invitation to a First Amendment lawsuit?
Thank you.
With kindest regards, I am,
Sincerely yours,
Ed Slavin
904-377-4998
www.cleanupcityofstaugustine.blogspot.com
www.edslavin.com












          

‘Flandrien’ Wout van Aert: “Ik had Philippe Gilbert in gedachten”   

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“Ik koers om wedstrijden te winnen. Maar deze trofee zal ook een prominent plaatsje in huis krijgen. Noem het gerust een mooie opsteker in moeilijke tijden”, was de eerste reactie van kersvers Flandrien Wout van Aert. “Al dacht ik dat Philippe Gilbert de grootste kanshebber was.” Gefeliciteerd, Wout. Een trofee die je te danken heb […]

The post ‘Flandrien’ Wout van Aert: “Ik had Philippe Gilbert in gedachten” appeared first on WielerFlits.


          

Flandrien en Flandrienne 2019: resultaten en puntenverdeling   

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Wout van Aert en Sofie De Vuyst zijn de grote winnaars van de Flandrien 2019, een organisatie van Het Nieuwsblad. We zetten voor u de uitslagen op een rijtje. Flandrien 2019: 1. Wout van Aert – 506 2. Remco Evenepoel – 505 3. Philippe Gilbert – 481 4. Thomas De Gendt – 304 5. Victor […]

The post Flandrien en Flandrienne 2019: resultaten en puntenverdeling appeared first on WielerFlits.


          

Cache De La Mythologie Gilbert   

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Cache De La Mythologie Gilbert

          

Jön Elizabeth Gilbert, az Ízek, imák, szerelmek szerzőjének új könyve, a New York lányai – a Partvonal Kiadó novemberi újdonságai   

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Jön Elizabeth Gilbert, az Ízek, imák, szerelmek szerzőjének új könyve, a New York lányai – a Partvonal Kiadó novemberi újdonságai Amennyiben nem olvasható hírlevelünk, vagy hibásan jelenik meg, akkor kattintson ide. ...

          

Archimate Uml Et Bpmn 3e Ed Philippe Desfray Gilbert   

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Archimate Uml Et Bpmn 3e Ed Philippe Desfray Gilbert

          

D Une Sexologue Perverse Gilbert D   

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D Une Sexologue Perverse Gilbert D

          

Pontons Flingueurs 2 Laurent Guillaume Simonetta Greggio Jean Bernard Pouy Elsa Marpeau Gilbert Gallerne Andre Fortin Pascal Fioretto Jean Paul Carminati   

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Pontons Flingueurs 2 Laurent Guillaume Simonetta Greggio Jean Bernard Pouy Elsa Marpeau Gilbert Gallerne Andre Fortin Pascal Fioretto Jean Paul Carminati

          

Inconvenient No 65 Ete 2016 La Gauche Et La Droite Mathieu Belisle Alain Roy Serge Bouchard Monique Larue Ugo Gilbert Tremblay Eric Bedard Alain Deneault   

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Inconvenient No 65 Ete 2016 La Gauche Et La Droite Mathieu Belisle Alain Roy Serge Bouchard Monique Larue Ugo Gilbert Tremblay Eric Bedard Alain Deneault

          

Veterans Issues 11/6/19   

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Ahead of Veterans Day, we welcome Director Darlene DeLancey, Glenn Gilbert and Peter Potter of the Albany Stratton VA Medical Center and Soldier On 's CEO Bruce Bruckley. WAMC's Ray Graf hosts.

          

Social Worker | Banner Health   

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Gilbert, Arizona, Job Summary This position develops, coordinates and provides social work services to patients and families who are faced with social, emotional and situational stressors precipitated by illness,

          

Entrevista - Ayuda humanitaria en Mali - 07/11/19   

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 Entrevista a Jesús Martínez, misionero navarro, y Gilberto Morales, funcionario en la embajada de Mali, sobre la situación de la cooperación humanitaria en Mali


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Medical Assistant | Banner Health   

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Gilbert, Arizona, Job Summary This position is responsible for assisting clinicians and nursing staff in providing medical care, as well as, implementing and evaluating direct patient care. This position utilizes

          

11/7/2019: NEWS: JUST FOR LAUGHS FOUNDER GILBERT ROZON RENOUNCES RIGHT TO PRELIMINARY HEARING IN SEXUAL-ASSAULT CASE   

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The Crown says Quebec entertainment mogul Gilbert Rozon has renounced his right to a preliminary hearing and has been ordered to stand trial in a sexual-assault case. Mr. Rozon, a founder of Just for Laughs, was charged last December with rape and...

          

Commentaires sur Protégé : Tara en Arctique par Adèle GILBERT   

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Commentaires protégés : saisissez votre mot de passe pour accéder aux commentaires.

          

Transfert : Les transferts du peloton pour 2020 : le récap' #Mercato #Bouhanni #Gilbert #Martin #Bennett   

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La période des transferts a été très, très agitée cet été, et ils sont des dizaines et des dizaines de coureurs ... lire la suite

          

Medical Assistant | Banner Health   

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Gilbert, Arizona, Job Summary This position is responsible for assisting clinicians and nursing staff in providing medical care, as well as, implementing and evaluating direct patient care. This position utilizes

          

LOLA MONTES   

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Le fulgurant et extraordinaire destin d'Eliza Gilbert, dite Lola, danseuse espagnole, mais de naissance irlandaise. Une femme belle à en perdre la tête, du moins la couronne puisque le roi Louis de Bavière, littéralement fou amoureux d'elle, fut contraint d'abdiquer à cause d'elle. Une femme fatale au strict sens de ce mot, qui ne porta pas bonheur à ceux qui succombèrent à ses charmes. Qui ne se souvient de l'interprétation de Martine Carol dans le film Lola Montes de Max Ophuls ? Revivons la (...) - Conférences / ,

          

Professions: 25C Radio Operator/Maintainer - Gilbert, Arizona   

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AGE REQUIREMENTS: Must be between the ages of 17 and 35 Radiocommunications are essential for the military to send and receive critical information in the field. To do this, they need reliable equipment. As a Radio Operator/Maintainer in the Army National Guard, you will ensure the functionality of these systems so that every mission ends in triumph. Army National Guard Radio Operator/Maintainers are primarily responsible for all maintenance checks and services on assigned radio communication equipment, allowing Soldiers to track and direct troop movements. Job Duties Maintenance of communication equipment and security devices Prepare, transmit, receive, and record messages Maintain assigned power generators Some of the Skills You'll Learn Mechanical and electrical principles Preventive maintenance procedures Line installation and wiring techniques Communication of security policies and procedures Helpful Skills Preference in working with electronic equipment Interest in problem solving Through your training, you will develop the skills and experience to enjoy a civilian career with companies or government agencies that design, repair, or make communications and electronic equipment. Earn While You Learn Instead of paying to learn these skills, get paid to learn. In the Army National Guard, you will learn these valuable job skills while earning a regular paycheck and qualifying for tuition assistance. Job training for a Radio Operator/Maintainer consists of 10 weeks of Basic Training, where you'll learn basic Soldiering skills, and 13 weeks of Advanced Individual Training (AIT). Part of this time is spent in the classroom and part in the field. Benefits/Requirements Benefits Paid training A monthly paycheck Montgomery GI Bill Federal and State tuition assistance Retirement benefits for part-time service Low-cost life insurance (up to $400,000 in coverage) 401(k)-type savings plan Student Loan Repayment Program (up to $50,000, for existing loans) Health care benefits available VA home loans Bonuses, if applicable Most non-prior service candidates will earn between $200 and $250 per drill weekend, subject to change Requirements Military enlistment in the Army National Guard Must be at least a junior in high school, or have a high school diploma or a GED certificate Must be between the ages of 17 and 35 Must be able to pass a physical exam and meet legal and moral standards Must meet citizenship requirements (see NATIONALGUARD.com for details) Requires military enlistment. Programs and benefits are subject to change. Ask your Army National Guard recruiter for the most up-to-date information. Actual MOS assignment may depend on MOS availability. This position may qualify for a bonus, ask your National Guard recruiter for the most up-to-date information. ()

          

Hospitality & Tourism: PM Kitchen Helper - Gilbert, Arizona   

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Shift Days: Tuesday-SaturdayShift Hours: 11:30am-8:00pmLocation: US-AZ-GilbertType: Hourly Full-TimeOverviewAre you looking to grow your culinary experience in an encouraging team environment? Are you a diligent team member who will do what it takes to help the team be successful? Would you love enriching the lives of seniors every single day?If you answered "yes" to these questions, we want to meet you. We are Resort Lifestyle Communities, a family-owned company established nearly twenty years ago. We operate communities all across the country and are growing fast. We provide an active, fun, and affordable lifestyle for the residents living in our communities. In our delivery of the Resort Lifestyle, our focus is always on the resident.We are now accepting applications for a full-time Kitchen Helper with experience prepping and cooking in a kitchen or restaurant setting. The PM Kitchen Helper works collectively with the Culinary and Dining Services team under the direction of the Executive Chef.What makes this opportunity right for you:Live by our core values of Respect, Kindness & Compassion, Honesty, and Service Excellence.You'll work a stable schedule; Tuesday through Saturday from 11:30am to 8:00pm.You'll receive stellar benefits, including health insurance (with stipend), dental, paid holidays and vacations, and a 401(k) with employer match.You'll be responsible for a number of critical tasks including washing dishes, busing and setting tables, food prep, and stocking the salad bar.Work alongside our hardworking Executive Chef in a dynamic kitchen with state of the art equipment.What makes you right for this opportunity:You have an eagerness to learn and grow as a professional in the food service industry.You have experience working in a team environment ideally in a culinary setting.Knowledge of food prep and/or dish washing is best, but we are willing to train the right person.You have the ability to develop positive relationships with residents, peers and the community.If you have a passion for service and deeply enjoy working with seniors, take the first step to joining our company. Complete our on-line application today and you'll hear from us within 48 hours.EOE/ADAPM18 PI114917870Pandologic. Keywords: Cook's Helper, Location: Gilbert, AZ - 85233 ()

          

Housekeeping EVS Associate II | Banner Health   

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Gilbert, Arizona, Job Summary This position conducts heavy cleaning and floor care work such as carpet cleaning, stripping/refinishing hard floor surfaces, and special projects. Operates and maintains power clean

          

Healthcare: Physician-General Surgery - Breast Surgery - Phoenix, Arizona   

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Physician - General Surgery - Breast Surgery Job in Phoenix, AZ Breast Surgery - Leading Cancer Center, Newest Location Banner Health Phoenix, AZ 85006 Accepts J1s: No Accepts H1Bs: No Response Loan Assistance:No Practice Type:Employee Verified Date:09/28/2019 Job ID:702237 Breast Surgery Position - Banner MD Anderson Cancer Center, Phoenix Metro The Division of Surgery at Banner-MD Anderson Cancer Center is actively recruiting for a Breast Surgeon to join our team at the top-ranking medical center, Banner University Medical Center-Phoenix. Banner MD Anderson seeks a surgeon with Breast Surgery training and experience. This is a growing program and extension from the Banner MD Anderson Cancer Center in Gilbert, AZ. Qualified candidates: Have been fellowship trained in breast surgery; Have experience working with multidisciplinary teams of cancer specialists; Should be committed to focus on this specialty while building on existing program with additional team members; Have excellent clinical training and a strong interest in clinical research, and; Are required to be board certified or board eligible. The Division of Surgery currently includes 14 clinicians who provide outstanding surgical care for patients with all types of malignancies. Designed with experts from The University of Texas MD Anderson Cancer Center , the center has an evidence-based design and state-of-the-art technologies including advanced surgical tools, the Da Vinci robotics system and advanced treatment capabilities. We have locations at three Banner Health campuses: Banner Gateway Medical Center in Gilbert, Banner Thunderbird Medical Center in Glendale, and Banner University Medical Center in Phoenix. This is an exciting and exceptional opportunity for a highly motivated Breast Surgeon with oncology experience to enjoy the following: A collaborative team of physicians, providing outstanding research-driven, multidisciplinary care for patients with all types of malignancies. A main campus that offers state-of-the-art technologies for disease-oriented, multidisciplinary cancer care and opportunities for participation in clinical research, designed with experts from The University of Texas MD Anderson Cancer Center. The prestige of working with a partnership of industry leaders: 1 in cancer care-MD Anderson Cancer Center, and nationally recognized Banner Health that is also the largest integrated healthcare system and the largest employer in Arizona. A generous salary and benefits. Banner Health, a Top 10 Health System for clinical performance according to Thomson Reuters, has teamed up with the University of Texas MD Anderson Cancer Center, one of the world's most respected centers focused on cancer patient care, research, education and prevention to open Banner MD Anderson Cancer Center. As a partner member of MD Anderson Cancer Network -, Banner MD Anderson is a fully integrated, clinical extension of MD Anderson and brings an unprecedented level of cancer care to the greater Phoenix area. MD Anderson's mission to "eliminate cancer in Texas, the nation and the world through outstanding programs that integrate patient care, research, education and prevention" - complements Banner Health's mission "to make a difference in people's lives through excellent patient care." - MD Anderson is one of only 41 comprehensive cancer centers designated by the National Cancer Institute. For the past 25 years, MD Anderson has ranked as one of the nation's top two cancer centers in U.S. News & World Report's annual "Best Hospitals" survey. WE OFFER YOU generous compensation including: competitive base salary plus incentives (wRVU) paid occurrence-based malpractice paid CME plus allowance 401k matching and 457(b) deferred compensation plans excellent benefit package options that provide security for you and your family. Please submit your letter of interest and CV for immediate consideration. Banner MD Anderson Cancer Center is an equal opportunity employer and does not discriminate on the basis of race, color, national origin, gender, sexual orientation, age, religion, disability or veteran status except where such distinction is required by law. All positions at Banner MD Anderson Cancer Center are security sensitive and subject to examination of criminal history record information. Smoke-free and drug-free environment. Not a J1 opportunity. Facility & Location Information Banner MD Anderson Cancer Center BUMCP Phoenix Metro, Phoenix, AZ 85006 Physician-General Surgery - Breast Surgery Physician - General Surgery - Breast Surgery Job in Phoenix, AZBreast Surgery - Leading Cancer Center, Newest Locatio ()

          

Healthcare: Pulmonary/ Critical Care - Phoenix, Arizona   

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Title: Faculty Physician - Critical Care Intensivist Reports to: Director, Critical Care Medicine Dignity Health Medical Group is actively seeking a fellowship-trained Critical Care Intensivist to join our team in the East Valley of Phoenix, Arizona. Join an established group of fellowship-trained Intensivists who provide 24 hour coverage at Chandler Regional Medical Center, Mercy Gilbert Medical Center, and Arizona General Mesa Hospital Intensive Care Units (ICUs). We are specifically looking for an individual who is focused on teamwork and is highly collaborative to join our extablished team. Our intensivists work 12 hour shifts and are required to work 14 shifts a month. Chandler Regional Medical Center (CRMC) is located in Chandler, Arizona. CRMC is a 330+ bed community and tertiary care center and an ACS-verified Level I trauma center, located 25 miles from downtown Phoenix. We have a brand new state-of-the-art ICU unit with 34 beds. Two intensivists provide coverage during the day. A separate trauma/surgical intensivist provides coverage in the trauma ICU. Mercy Gilbert Medical Center (MGMC) is a full-service, 200+ bed, acute care, not-for-profit hospital providing healthcare to the East Valley and has 24 ICU beds. MGMC is 8 miles from CRMC. Minimum Requirements: - MD or DO Degree - Completed Fellowship in Critical Care - Completion of ACGME Residency with current ABMS Board Certification - A passion for providing clinically excellent care - Must have or be eligible for Arizona State medical licensure - Ability to achieve full, unrestricted hospital privileges at Dignity Health Arizona hospitals ABOUT PHOENIX, ARIZONA : Phoenix boasts all the amenities of a large city--including foodie destinations and cultural richness--without the high cost-of-living or overwhelming congestion of New York or Chicago. Whether you are looking to raise a family in the suburbs of the East Valley or cherished Arcadia/Paradise Valley neighborhoods, or you are looking for the hustle and bustle of exciting downtown living, Arizona proves to provide an exceptional living experience to people in all walks of life. With renowned golf-courses, botanical gardens, shopping malls, zoos, arts districts, and A+ schools, Arizonians never struggle to find a solution to their needs and hobbies. For sports enthusiasts, Arizona is home to all four major sports: NFL, NHL, NBA, and MLB. For the adventurers, the Colorado River provides opportunity for floating and fishing, various outdoor trails flaunt breathtaking views, and a day-trip can help Phoenicians escape to the Grand Canyon, the red rocks of Sedona, or the pines (and snow!) up in Flagstaff. Being just a short drive to the beaches of California and Mexico, Arizona really does offer everything to its lifelong residents, and would be the perfect destination for your forever career. COMPANY OVERVIEW : With over 240 physicians and 800 total employees, DHMG Arizona is a comprehensive, integrated, multispecialty, academic medical group that serves Dignity Health St. Joseph's and Westgate Medical Centers, Chandler Regional Medical Center, Mercy Gilbert Medical Center, and Mesa General Hospital. The physicians of DHMG-AZ are regularly involved with clinical duties, as well as academics and translational bench research, keeping the enhancement of care and the patient experience at the forefront of the work that they do. ********************* ABOUT THE CULTURE OF DIGNITY HEALTH: Dignity Health, as part of CommonSpirit Health--the largest not-for-profit healthcare organization in the nation--seeks to serve the poor and disenfranchised, while utilizing our healing ministry to promote the health of the entire patient, rather than simply treat their disease. The mission of Dignity Health Medical Group is consistent with Dignity Health's mission and St. Joseph's guiding principles with a focus on innovative clinical care and the pursuit of excellence through scholarly activities. As part of the Dignity Health hospital system, DHMG has full access to the staff and all facilities on our hospital campuses. This unique relationship with our hospital allows Dignity Health Medical Group to provide its patients with state-of-the-art patient services including care of the poor and disenfranchised. COMPENSATION: We are offering a competitive salary and generous benefits package that includes a matched 403b, employer-funded pension plan, relocation allowance for applicable physicians, CME benefit, and excellent malpractice insurance. EEO NO J1 Visas; Dignity Health is an Equal Opportunity/ Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. Recruiter Information Name: Shammy Benjamin Email: *************************** Telephone Number: ************ Community Description Like its legendary namesake rising out of the ashes, the greater Phoenix area has emerged as one of the bright metropolitan areas of the 21st century. The Phoenix area encompasses more than 20 incorporated cities, including Glendale, Scottsdale, Tempe and Mesa, and all serve as a timeless Southwestern backdrop to the spirit of Puebloans, cowboys, miners and visionaries. Recently, the Census Bureau named Arizona's Maricopa County, which includes the greater Phoenix metro area, the county with the nation's highest annual population growth. Home to more than 4 million residents where everyone has a sunny disposition, the Phoenix area also ranks as the sixth-largest city in the United States. Phoenix is a premier destination offering the best of both worlds: a growing and diverse economy and a great place to live with more than 300 sun-filled days a year and an almost endless supply of attractions including: - 189 city parks, 33,000 acres of desert preserves and 200 miles of trails - Host to MLB Spring Training and the annual Fiesta Bowl! - Home of the Phoenix Open and 200 golf courses - Professional sports teams including the Arizona Diamondbacks and the Arizona Cardinals. - Host to 5 Fortune 500 company headquarters - The Best Mexican Food North of the Border! - Affordable housing and cost of living - A family-friendly area, with the Children's Museum of Phoenix, ample youth sports and athletic leagues, the Challenger Space Center Arizona, a wide variety of school options, including public, private, magnet and charter, the Phoenix Zoo, large water parks, SEA LIFE Arizona, and many more! The Phoenix area is also a destination for people from all over the world to receive outstanding healthcare. This is particularly true of Dignity Health's St. Joseph's Hospital and Medical Center - home to the world-renown Barrow Neurological Institute and The Norton Thoracic Institute - #1 lung transplant program in the U.S. - as well as many other world-class healthcare services and teaching programs. Group Description With over 240 physicians and 800 total employees, Dignity Health Medical Group - Arizona is a comprehensive, integrated, multispecialty, academic medical group that serves Dignity Health St. Joseph's and Westgate Medical Centers, Chandler Regional Medical Center, and Mercy Gilbert Medical Center - a flagship region of Dignity Health currently 'headquartered' in San Francisco, California. The physicians of DHMG - AZ are regularly involved with clinical duties, as well as academics and translational bench research, keeping the enhancement of care and the patient experience at the forefront of the work that they do. Additional Information Dignity Health Medical Group - Arizona: ***************************** Arizona General Hospital: ************************************************************** Chandler Regional Medical Center: **************************************************************** Mercy Gilbert Medical Center: ************************************************************ St. Joseph's Hospital and Medical Center: **************************************** St. Joseph's Westgate Medical Center : *************************************** City of Phoenix: ************************ Downtown Phoenix: ***************** Phoenix Chamber of Commerce: ************************** County Resources: ************************* School Districts: - Cave Creek Unified School District: ****************************************************************** - Deer Valley Unified School District: ********************* - Paradise Valley Unified School District: ************************** - Scottsdale Unified School District: ************************** Phoenix News: *************************************** Facebook: ************************************************** ()

          

Professions: OTR CDL A Open Deck Truck Drivers- Earn Up To $95K - Gilbert, Arizona   

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OTR CDL A Long Haul Open Deck Truck Driver Kaiser Transport of Milton, WI is seeking to hire a coast-to-coast OTR Long Haul Open Deck Truck Driver to join our team. What We Offer CDL A Drivers: Competitive salary - $75,000-$95,000/year Generous benefits - Medical, Dental &Vision Life Insurance Short-term Disability Passenger Policy Pet Policy, 401(k) plan Monthly Performance Bonuses, Quarterly Bonuses & Annual Profit Sharing. Industry-leading Equipment Driver support 24/7 365 days a year, Trucks equipped with APUs and refrigerators. Plus, when we order new trucks, our drivers pick the color they want. If you would like to travel coast to coast, apply today ABOUT KAISER TRANSPORT Kaiser Transport is a TSS (Trailer-Space-Sharing) long haul, open deck trucking company. We specialize in hauling machine tools and equipment along with other double-drop, step-deck, and flatbed freight. We operate from coast to coast as well as in Ontario and Quebec. As a family-owned company , we promote a family atmosphere with genuine mutual respect among our team. This creates a true brotherhood between drivers, dispatchers, yard crew, mechanics, and support staff. We are 100% committed to safety which is why Kaiser's Fleet Department performs all preventative maintenance and repairs on equipment, not drivers. We also offer opportunities for growth when you feel it's time to get off the road. WHY OUR CDL A DRIVERS CHOOSE KAISER TRANSPORT The Equipment 298 in. wheelbase 389 Peterbilt long nose tractors Cummins ISX15 525 horsepower engines 18 speed transmission A DAY IN THE LIFE AS AN OTR CDL A LONG HAUL OPEN DECK TRUCK DRIVER Our open deck trailer space sharing business model creates new and exciting challenges because we don't haul the easy freight. As an OTR Long Haul Open Deck Truck Driver, you enjoy the challenge as much as you enjoy being on the open road. Before you start driving, you secure and tarp your freight. Coordinating customer drops, you ensure that their freight arrives safely and on time. Every shift is different and exciting as you navigate your route and encounter wildlife, crazy drivers, and changing weather conditions. QUALIFICATIONS Must have Class A CDL Experience building and executing successful trip plans At least one year of long haul, coast-to-coast experience At least 6 months of experience with step deck, double drop, or flat-bed freight Tarping and freight securement experience in all weather conditions Meet all the federal motor carrier's guidelines with no OWI's in the past 5 years Do you have strong math, analytical, and problem-solving skills? Can you communicate effectively in English? Do you have a strong work ethic? Are you reliable? Do you enjoy being on the road? If so, you may be perfect for this OTR driving position WORK SCHEDULE Coast-to-coast truck drivers stay out 3-6 weeks based on location. You would be able to schedule your home time. ARE YOU READY TO JOIN OUR TEAM? Call 844-466-8201 Or Apply Online Today ()

          

Other: RN Travel Nurse CCU, PCU, Stepdown, Tele - Gilbert, Arizona   

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Travel RN Nurses NeededCCU, PCU, Tele & Stepdown NursesCoronary Care Unit, Progressive Care Unit, Stepdown& Telemetry Unit Registered NursesNew Mexico Travel RN Nursing Assignments--Researching--a--Travel Assignment in the state of New Mexico--or concidering a seasonal--location? You are in the right place, the HCEN Network of staffing agencies have numerous assignments that you will not find posted on the public big job boards. There are numerous reason why they are not, but one thing is for sure, if there is an assignment for you, the HCEN Network of Nationwide Staffing Agencies has themWould you like to spend the fall / winter somewhere great?--The Hospitals have already started posting their available seasonal travel assignments with the HCEN Network of staffing agencies. Submit your more information request today and get your choice of great locations before they are gone.Where would you like to go? Spend the winter in the warmth of Florida, Virgin Islands, Arizona, Hawaii, Southern California or many others.Spend the winter in the beautiful states of Colorado, Utah, Vermont.So many great options today's travel nurse has to choose from--Click--More Information Seasonal Request Short FormThe Travel Nurse Season is here and it shows-- Interested in locating that perfect RN Travel Assignment Job?Looking for great compensation as well as leading benefits packages?Veteran Traveler or researching your first assignment options,You are in the right place.--For the past 5 years, thousands of Nurses just like you--have utilized the sites of--HealthCare Employment Network--to explore a career as a Traveling Registered Nurse.--Complete the More Information Request and let the staffing agencies come to you. The Travel Nurse working in the CCU, PCU / Tele / Stepdown unit provides care in a variety of different areas, with a diverse patient population. Being a CCU, PCU / Stepdown RN requires the ability to help the patient with the natural progression out of a critical care unit. The CCU, PCU / Stepdown Registered Nurse has stabilized to a point of improvement but requires a skilled plan of care. Registered Nurse Licensure in the state of practiceMinimum of two years recent experience in your primary specialty.BLS / ACLS / NALS / PALS / CCRN / as applicableNo felonies.No flagged or under investigation licenses.?Tired of always being asked to complete a lengthy application?We can appreciate that, we have been in your shoes as past "Travelers"Get the information you need from theNation's Top Staffing Agencieswith one free, quick & short"More Information Request" ()

          

Healthcare: Occupational Therapist (OT) - Travel - Outpatient-152677 - Gilbert, Arizona   

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RESPONSIBILITIES AND DUTIES Occupational Therapist / Therapy --- Provide treatment per facility, professional, and federal regulations and guidelines --- 40 hours guaranteed --- ASAP start --- Outpatient setting --- 15-week assignment QUALIFICATIONS AND SKILLS Occupational Therapist / Therapy --- A graduate of a school program accredited by The American Occupational Therapy Association --- Familiarity with electronic documentation systems --- Basic Life Support CPR certification will be required BENEFITS Occupational Therapist / Therapy --- Competitive pay for physical therapists --- Licensing team and dedicated credentialing agent with 24/7 availability --- Travel & licensure reimbursement --- Paid Blue Cross Blue Shield medical benefits --- Paid Reward Days --- Paid housing or tax-free stipend --- Weekly direct deposit ABOUT DELTA HEALTHCARE PROVIDERS Delta Healthcare Providers (DHP), the travel therapy staffing division of The Delta Companies, identifies qualified therapists on behalf of healthcare facilities nationwide. A single point of contact provides direct knowledge of the industry to providers. The company has been recognized with several Best of Staffing-- Awards. Visit www.deltahealthcareproviders.com for more information about travel therapy staffing. ()

          

Hospitality & Tourism: Retail Sales Associate - Apparel - Gilbert, Arizona   

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Description We are genuine in our belief that sports make people better and so are you! Immerse yourself in a workplace that loves to be active and lives the brand. Associates joining our team have an opportunity to be a part of the #1 sporting goods retailer in the country and create a lasting impact on their communities through sport and activity. On our Team, everyone plays a critical role. Your Mission (and Ours) is to serve and inspire athletes and outdoor enthusiasts to achieve their personal best through the relentless improvement of everything we do. Sales Associate Duties: Create a world-class customer experience by providing passionate customer service and selling through customer engagement, specifically (but not limited to) our Apparel Departments Uphold company standards for merchandise presentation of the best apparel and equipment brands in sporting goods Demonstrate ability to genuinely interact with customers to show passion, knowledge, dedication, and commitment in their sport or activity Promote company programs including warranty sales, Scorecard (loyalty program), private-label credit cards, and other seasonal promotions As business needs arise, other tasks may become necessaryQualificationsSuccess Profile: Flexible availability - including nights, weekend, and holidays 1-2 years of Retail Cashier, Retail Sales, or cash-handling experience preferred Passion for Apparel Click HERE to review our Rewards & Benefits Information DICK'S Sporting Goods is an Equal Opportunity Employer. ()

          

Healthcare: Travel Nurse RN - Home Health - $1,476.00 per week - Gilbert, Arizona   

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NurseFly Travel Nursing with MedPro Healthcare Staffing is seeking a home health travel nurse for a travel nursing job in Gilbert, Arizona: Specialty: Home Health Discipline: RN Start Date: 10/8/2019 Duration: 13 weeks 36 hours per week Shift: 12 hours. Additional information: MedPro Job ID #379452. Pay package is based on 12 hour shifts and 36 hours per week (subject to confirmation) with tax-free stipend amount to be determined. Posted job title: Travel Nurse (RN) - Home Health (Home Health Registered Nurse) Nursing: Home Health.. MedPro Healthcare Staffing, a Joint Commission-certified staffing agency, is seeking a quality Home Health registered nurse (RN) for a travel assignment with one of our top healthcare clients. Requirements: Active RN LicenseDegree from accredited nursing programBLS CertificationsEighteen months of recent experience in an Acute Care Home Health settingOther requirements to be determined by our client facilityBenefitsAccess to nationwide travel assignmentsWeekly pay and direct depositFull coverage of all credentialing feesPrivate housing or housing allowanceGroup Health insurance for you and your familyCompany-paid life and disability insuranceTravel reimbursementAccess to our Clinical Nurse Liaison Team401(k) matchingUnlimited Referral Bonuses starting at $500Personalized gifts delivered to your door step! Duties ResponsibilitiesHome Health Nurses (RN) provide patient education, treatment, and emotional support to help individuals recover from injuries and illnesses.Assess patients' condition during every visit and chart your observations.Perform evaluation tasks, including vital signs and medication review.Administer medication as prescribed by patient's physician.Dress or redress open wounds and assess progress of healing.Educate patients and their families on proper home health care strategies and procedures.About AgencyNo One Cares More for Caregivers Than MedPro. Focus on your patients, we'll take care of the rest. MedPro Healthcare Staffing is a Joint Commission certified provider of temporary and contract staffing services. Since 1983, we have placed happy nursing and allied travelers in top healthcare facilities nationwide. Join us today for your very own MedPro Experience--. MedPro Staffing is an Equal Opportunity Employer that maintains a policy of non-discrimination with respect to all employees and applicants for employment. Employment decisions, subject to the legitimate business requirements of MedPro or its clients, are based solely on the individual's qualifications, merit and performance without regard to race, color, religion, national origin, age, sex, disability, marital status or veteran status.Key Words: Registered Nurse, RN, Home Health, Travel Nurse, Contract Nurse, Agency Nurse, Agency RN, RN-Home Health, Travel RN, Contract, Nursing, Travel Nursingprioritynursingcandidates@medprostaffing.com.No One Cares More for Caregivers Than MedPro. Focus on your patients, well take care of the rest. MedPro Healthcare Staffing is a Joint Commission certified provider of temporary and contract staffing services. Since 1983, we have placed happy nursing and allied travelers in top healthcare facilities nationwide. You deserve a travel experience thats rewarding and memorable. One that allows you to DREAM big. EXPLORE often. And ACHIEVE greatness. The MedPro Experience-- delivers it! Access to nationwide travel assignments Weekly pay and direct deposit Full coverage of all credentialing fees Private housing or housing allowance Group Health insurance for you and your family Tax Free Per Diems, Housing Stipends and Travel Reimbursements Company-paid life and disability insurance Travel reimbursement Access to our Clinical Nurse Liaison Team 401(k) matching Unlimited Referral Bonuses starting at $500 Personalized gifts delivered to your door step! . This job is also widely searched as a registered nurse, rn, nurse, travel nurse, nurse rn, rn nurse, travel nurse rn, nursing, travel rn, home health nurse. ()

          

Other: Travel RN ICU, SICU - Surgical Intensive Care Units - Gilbert, Arizona   

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Travel Nurses Needed - RN Intensive Care UnitsFlorida Travel Nursing AssignmentsNationwide Registered Nurse Travel JobsThe Travel Nurse Season is here and it showsFind great travel assignments with the best in compensation packages.----Where would you like to go? Spend the winter in the warmth of Florida, Virgin Islands, Arizona, Hawaii, Southern California or many others.Spent the winter in the beautiful states of Colorado, Utah, Vermont.So many great options today's travel nurse has to choose fromIt is definitely worth researching and comparing your options. Find out who is compensating you the best, more dollars. Find that assignment that everyone doesn't have.ASAP starts. Numerous 8,13 & 26 week travel assignments available.--Requested Nursing Specialties------ICU - Critical Care Intensive CareTrauma - Intensive Care--SICU - Surgical Intensive Care--NICU - Neonatal--Intensive Care--MICU - Medical Intensive CarePICU - Pediatric--Intensive Care----CVICU - Cardio-Vascular--Intensive CareNeuro - Intensive Care--HealthCareTravelers.com makes it easy, fast and free to reach out to the premier healthcare staffing agencies with one information request. Just sit back, relax and-- let the staffing agencies come to you.--HCEN wishes you a prosperous and enjoyable career as a traveling healthcare professional. Being an ICU RN requires excellent critical thinking skills. The Intensive Care Unit Registered Nurse must be familiar with ventilators, central lines, EKG strips, among other specialized skills. Registered Nurse Licensure in the state of practiceMinimum of two years recent experience in your primary specialty.BLS / ACLS / NALS / PALS / CCRN / as applicableNo felonies.No flagged or under investigation licenses.Tired of always being asked to complete a lengthy application?We can appreciate that, we have been in your shoes as past "Travelers"Get the information you need from theNation's Top Staffing Agencieswith one free, quick & short"More Information Request" ()

          

Music and Your Health   

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Dr. Gilbert Luceno, a family medicine physician with Mercy Medical Group in Roseville, shares his answers to questions about music and health. Dr. Luceno is a musician and is passionate about the intersection of music and healthy living.


          

Bonsoir prenez le temps qu il vous faut nous sur Déboires et patience   

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Bonsoir prenez le temps qu il vous faut nous serons la a votre retour. Je vous embrasse bien fort.a bientôt Gilberte

          

Church Announces Locations of 10 #LighttheWorld Giving Machines    

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And this year, the Giving Machines will be found in ten locations across the world.The Giving Machines offer items such as food, clothing, livestock, hygiene supplies, medicine, and sporting equipment, ranging in price from $2 to $320. This year, users will be able to purchase multiple items with one swipe of a credit card.The #LightTheWorld campaign began in 2016 and encourages people to perform instant acts of service that make a difference during the 25 days leading up to Christmas.For the third year in a row, the large, bright red Giving Machines will be part of the #LighttheWorld campaign for The Church of Jesus Christ of Latter-day Saints.“These Giving Machines are an example of the big things that can happen when many people give just a little,” said Sister Bonnie H. Cordon, Young Women General President. “That is what it means to Light the World one by one—when we each give what we can offer, our little light adds to a brightness of hope.”Elder Brent H. Nielson, a General Authority Seventy, said, “This unique way to give not only blesses the life of the giver, but also lifts the receiver in locations all around the world. Our hope is to offer opportunities to Light the World one by one.”

The Giving Machines offer items such as food, clothing, livestock, hygiene supplies, medicine, and sporting equipment, ranging in price from $2 to $320.

This video shows highlights of the 2019 #LighttheWorld effort, which includes ways people can change lives through sharing their faith, love, care, and service.

 

According to Newsroom, the Giving Machines will be open to the public in the following locations:The Giving Machines were first made public in 2017 and were housed in the lobby of the Joseph Smith Memorial Building in downtown Salt Lake City. In 2018, the Giving Machines expanded to four other locations, including Gilbert, Arizona; New York City; London, England; and Manila, Philippines.The Giving Machines raised more than $2.3 million in 2018. Total donations for 2019 will be available on www.LightTheWorld.org and will be continuously updated throughout the season.
  • Manila, Philippines—November 8 (TriNoma Mall)
  • Las Vegas, Nevada—November 14 (Downtown Summerlin)
  • Laie, Oahu, Hawaii—November 20 (Polynesian Cultural Center)
  • Gilbert, Arizona—November 20 (Water Tower Plaza)
  • Salt Lake City, Utah—November 26 (Joseph Smith Memorial Building)
  • Orem, Utah—November 26 (University Place Mall)
  • Denver, Colorado—November 26 (Writer Square)
  • San Jose, California—November 29 (Christmas in the Park)
  • New York, New York—December 3 (Manhattan New York Temple)
  • London, England—December 3 (Hyde Park Visitors’ Center)
  • Partner charities for 2019 include UNICEF, Church World Service, International Medical Corps, WaterAid and Water For People and 100 percent of all donations will go directly to them.


              

    A mechanistic model of meditation   

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    Published on November 6, 2019 9:37 PM UTC

    Meditation has been claimed to have all kinds of transformative effects on the psyche, such as improving concentration ability, healing trauma, cleaning up delusions, allowing one to track their subconscious strategies, and making one’s nervous system more efficient. However, an explanation for why and how exactly this would happen has typically been lacking. This makes people reasonably skeptical of such claims.

    In this post, I want to offer an explanation for one kind of a mechanism: meditation increasing the degree of a person’s introspective awareness, and thus leading to increasing psychological unity as internal conflicts are detected and resolved.

    Note that this post does not discuss “enlightenment”. That is a related but separate topic. It is possible to pursue meditation mainly for its ordinary psychological benefits while being uninterested in enlightenment, and vice versa.

    What is introspective awareness?

    In an earlier post on introspective awareness, I distinguished between being aware of something, and being aware of having been aware of something. My example involved that of a robot whose consciousness contains one mental object at a time, and which is aware of different things at different times:

    Robot’s thought at time 1: It’s raining outside
    Robot’s thought at time 2: Battery low
    Robot’s thought at time 3: Technological unemployment protestors are outside
    Robot’s thought at time 4: Battery low
    Robot’s thought at time 5: I’m now recharging my battery

    At times 2-5, the robot has no awareness of the fact that it was thinking about rain at time 1. As soon as something else captures its attention, it has no idea of this earlier conscious content - unless a particular subsystem happens to record the fact, and can later re-present the content in an appropriately tagged form:

    Time 6: At time 1, there was the thought that [It’s raining outside]

    I said that at time 6, the robot had a moment of introspective awareness: a mental object containing a summary of its previous thoughts, which can then be separately examined and acted upon.

    Humans are not robots. But I previously summarized the neuroscience book Consciousness and the Brain, and its global neuronal workspace (GNW) model of consciousness. According to this model, the contents of consciousness correspond to what is being represented in a particular network of neurons - the global workspace - that connects different parts of the brain. Different systems are constantly competing to get their contents into the global workspace, which can only hold one piece of content at a time. Thus, like robots, we too are only aware of one thing at a time, and tend to lose awareness of our earlier thoughts - unless something reminds us of them.

    In what follows, I will suggest that like robots, humans also have a type of conscious content that we might call introspective awareness, which allows us to be more aware of our previous mental activity. (I am borrowing the term from the meditation book The Mind Illuminated, which distinguishes between introspective attention, introspective awareness, and metacognitive introspective awareness. I am eliding these differences for the sake of simplicity.)

    I will also explore the idea that introspective awareness is a sensory channel in a similar sense as vision and sound are. The experience of sight or sound is produced by subsystems which send information to consciousness; likewise, introspective awareness is produced by a subsystem which captures information in the brain and then sends it (back) to consciousness.

    We can train our other senses to become more accurate and detailed. Gilbert, Sigman & Crist (2001), reviewing the neuroscience or sensory training, list a number of ways in which discrimination can be increased in a variety of sensory modalities: among other things, "visual acuity, somatosensory spatial resolution, discrimination of hue, estimation of weight, and discrimination of acoustical pitch all show improvement with practice"; even the spatial resolution of the visual system can be deliberately increased by training.

    If introspective awareness is a sensory channel, can it also be practiced to improve the number of details it will pick up on? One may feel that I am stretching the metaphor here. But in fact, Consciousness and the Brain suggests that all sensory training is in a sense training in introspection. The additional information that we get by training our senses has always been collected by our brain, but that information has remained isolated at lower levels of processing. To make it conscious, one needs to grow new neural circuits which extract the lower-level information and re-encode it in a format which can be sent to consciousness.

    Thus, the brain already has the ability to take normally unavailable subconscious information and make it consciously available by practice. What is needed is a way to point that learning process at the kind of information that we would normally consider "introspective", rather than on an external information source.

    From Consciousness and the Brain:

    ... a fourth way in which neural information can remain unconscious, according to workspace theory, is to be diluted into a complex pattern of firing. To take a concrete example, consider a visual grating that is so finely spaced, or that flickers so fast (50 hertz and above), that you cannot see it. Although you perceive only a uniform gray, experiments show that the grating is actually encoded inside your brain: distinct groups of visual neurons fire for different orientations of the grating. Why can’t this pattern of neuronal activity be brought to consciousness? Probably because it makes use of an extremely tangled spatiotemporal pattern of firing in the primary visual area, a neural cipher too complex to be explicitly recognized by global workspace neurons higher up in the cortex. Although we do not yet fully understand the neural code, we believe that, in order to become conscious, a piece of information first has to be re-encoded in an explicit form by a compact assembly of neurons. The anterior regions of the visual cortex must dedicate specific neurons to meaningful visual inputs, before their own activity can be amplified and cause a global workspace ignition that brings the information into awareness. If the information remains diluted in the firing of myriad unrelated neurons, then it cannot be made conscious.
    Any face that we see, any word that we hear, begins in this unconscious manner, as an absurdly contorted spatiotemporal train of spikes in millions of neurons, each sensing only a minuscule part of the overall scene. Each of these input patterns contains virtually infinite amounts of information about the speaker, message, emotion, room size . . . if only we could decode it—but we can’t. We become aware of this latent information only once our higher-level brain areas categorize it into meaningful bins. Making the message explicit is an essential role of the hierarchical pyramid of sensory neurons that successively extract increasingly abstract features of our sensations. Sensory training makes us aware of faint sights or sounds because, at all levels, neurons reorient their properties to amplify these sensory messages. Prior to learning, a neuronal message was already present in our sensory areas, but only implicitly, in the form of a diluted firing pattern inaccessible to our awareness.

    Richard’s therapy session

    We saw an example of introspective awareness in my post on the book Unlocking the Emotional Brain. In the transcript, a man named Richard has been suffering from severe self-doubt, and is asked to imagine how it would feel like if he made confident comments in a work meeting. The following conversation follows:

    Richard: Now I’m feeling really uncomfortable, but-it’s in a different way.
    Therapist: OK, let yourself feel it - this different discomfort. [Pause.] See if any words come along with this uncomfortable feeling.
    Richard: [Pause.] Now they hate me.

    The therapist is asking Richard to focus his attention on the feeling of discomfort, generating moments of introspective awareness about the discomfort. Notice that Richard becomes more thoughtful and less reactive to the anxiety as he does so. My guess of what is happening is something like this:

    When Richard is feeling anxious, this means that a mental object encoding something like “the feeling of anxiety” is being represented in the workspace. This activates neural rules which trigger the kinds of responses that anxiety has evolved to produce. For example, a system may be triggered which attempts to plan how to escape the situation causing the anxiety. This system’s intentions are then injected into the workspace, producing a state of mind where the feeling of anxiety alternates with thoughts of how to get away.

    Introspective awareness is its own type of mental object, produced by a different subsystem which takes inputs from the global workspace, re-encodes them in a format which highlights particular aspects of that data, and outputs that back into the workspace. When a representation of an anxious state of mind is created, that representation does not by itself trigger the same rules as the original anxiety did.

    As a result, as representations of the anxiety begin to alternate together with the anxiety, there are proportionately less moments of anxiety. This in turn triggers fewer of the subsystems attempting to escape the situation, making it easier to reflect on the anxiety without being bothered by it.

    When Richard’s therapist asks him to feel the anxiety and to see if any words come along with it, the subsystem for introspective awareness was primed to look for any content that could be re-presented in verbal form. As Richard’s anxiety had been produced by an emotional schema including a prediction that being confident makes you hated, some of that information had passed through the workspace and been available for the awareness subsystem to capture. This brought up the verbalization of what the schema predicted would happen if Richard was confident - “now they hate me”.

    Therapist: “Now they hate me.” Good. Keep going: See if this really uncomfortable feeling can also tell you why they hate you now.

    According to the GNW model, when a particular piece of content is maintained as the center of attention, it strengthens the activation of any structures associated with it. As Richard’s therapist guides him to focus on the verbal content, more information related to it is broadcast into the workspace. The further prompt guides the awareness subsystem to look for patterns that feel like the reason for the hate.

    Richard: [Pause.] Hnh. Wow. It’s because… now I’m… an arrogant asshole… like my father… a totally self-centered, totally insensitive know-it-all.

    The therapist then takes a pattern which Richard has brought up and helps crystallize it further, and throws it back to Richard for verification.

    Therapist: Do you mean that having a feeling of confidence as you speak turns you into an arrogant asshole, like Dad?
    Richard: Yeah, exactly. Wow.

    In this example, we saw that having more moments of introspective awareness was beneficial for Richard. As aspects of his moment-to-moment consciousness were made available for other subsystems to examine, the emotional schema causing the anxiety was identified and its contents extracted into a format which could be fed into other subsystems. Later on, when Richard’s co-worker displayed confidence which others approved of, a contradiction-detection mechanism noticed a discrepancy between reality and the prediction that confidence makes you hated, allowing the prediction to be revised.

    Under this model, the system which produces moments of introspective awareness is a subsystem like any other in the brain. This means that it will be activated when the right cues trigger it, and its outputs compete with the outputs of other systems submitting content to consciousness. The circumstances under which the system triggers, and its probability of successfully making its contents conscious, are modified by reinforcement learning. Just as practicing a skill such as arithmetic eventually causes various subsystems to manipulate the content of consciousness in the right order, practicing a skill which benefits from introspective awareness will cause the subsystem generating introspective awareness to activate more often.

    Meditation as a technique for generating moments of introspective awareness

    Just as there are different forms and styles of therapy, there are also different forms and styles of meditation. All of them involve introspective awareness to at least some degree, but they differ in what that awareness is then used for.

    In the example with Richard, his therapist asked him to imagine being confident and to then bring his awareness to why that felt uncomfortable. In contrast, a more behaviorally oriented therapist might not have examined the reason behind the discomfort. Rather, they might have taught Richard to notice his reaction to the discomfort, and then use that as a cue for implementing an opposite reaction. Both kinds of therapists would ask their clients to generate some introspective awareness, but aiming that awareness at different kinds of features, and using the awareness to trigger different kinds of strategies. The results would correspondingly be very different.

    Likewise, systems of meditation differ in how much introspective awareness they produce, what kinds of features the awareness-producing subsystem is trained to extract, and what that awareness is then used for. For this article, I have chosen to use the example of the system in The Mind Illuminated (TMI), as it is clearly explained and explicitly phrased in these terms. (Again, TMI has a more precise distinction between introspective attention and introspective awareness, which I am eliding for the sake of simplicity.)

    In TMI’s system, as in many others, you start with trying to keep your attention on your breath. In terms of our model, this means that you want to keep sensory outputs corresponding to your breath as the main thing in your consciousness.

    The problem with this goal is that there is no subsystem which can just unilaterally decide what to maintain as the center of attention. At any given moment, many different subsystems are competing to make their content conscious. So one system might have the intention to follow the breath, and you do it for a while, but then a planning system kicks in with its intention to think about dinner. Such planning has tended to feel rewarding, so it wins out and the intent to meditate is forgotten until five minutes later, when you decide what you want for dinner and then suddenly remember the thing about following your breath.

    TMI calls this mind-wandering from forgetting, and the first step of practice is just to notice it whenever it happens, congratulate yourself for having noticed it, and then return to the breath. Being able to notice forgetting requires having a moment of introspective awareness which points out the fact that you had not been following your breath. When you take satisfaction in having noticed this, your awareness-producing subsystem gets assigned a reward and becomes slightly more likely to activate in the future. “Have I remembered to follow my breath or not?” acts a feedback mechanism that you can explicitly train on.

    As the awareness-producing system starts to activate more often and ping you if you have forgotten to meditate, periods of mind-wandering grow shorter.

    Now, even if you stop getting entirely lost in thought, you still have distraction: content from other subsystems that is in consciousness together with the sensations of the breath and the intention to focus on the breath. For example, you might be having stray thoughts, hearing sounds from your environment, and experiencing sensations from your body.

    To more exclusively focus on the breath, you are instructed to maintain the intent to both attend to it and also to be aware of any distractions. The subsystems which output mental content can, and normally do, operate independently of each other. This means that the following may happen:

    Subsystem 1: I’m meditating well!
    Subsystem 2: Hmm, what’s that smell.
    Subsystem 1: I’m meditating well! No distractions.
    Subsystem 2: Smells kinda like cookies.
    Subsystem 2: Mmm, cookies.
    Subsystem 1: Continuing to meditate well!
    Subsystem 2: Say, what’s for dinner?

    That is, a system which tracks the breath can continue to repeatedly find the breath, and report that your meditation is proceeding well and with no distractions… all the while the content of your consciousness continues to alternate with distracted thoughts, which the breath-tracking subsystem is failing to notice (because it is tracking the breath, not the presence of other thoughts). Worse, since you may find it rewarding to just think that you are meditating well, that thought may start to become rewarded, and you may find yourself just thinking that you are meditating well… even as that thought has become self-sustaining and no longer connected to whether you are following the breath or not!

    There are all kinds of subtle traps like this, and reducing the amount of distraction requires you to first have better awareness of the distraction. This means more moments of introspective awareness which are tracking what’s actually happening in your mind:

    Subsystem 1: I’m meditating well!
    Subsystem 2: Hmm, what’s that smell.
    Subsystem 1: I’m meditating well! No distractions.
    Subsystem 2: Smells kinda like cookies.
    Subsystem 2: Mmm, cookies.
    Awareness subsystem: Wait, one train of thought keeps saying that it’s meditating well, but another is totally getting into the thought of food.
    Subsystem 1: Oh. Better refocus that attention on the breath, and spend less time thinking about the concept of following the breath.

    This kind of a process also teaches you to pay attention to patterns of cause and effect in your mind. In this example, the smell of cookies caused you to think of cookies, which in turn made you think of dinner, which could have ultimately led to forgetting and mind-wandering.

    Catching the train of thought after “mmm, cookies” meant that three “processing steps” had passed before you noticed it. If you practice tracing back trains of thought in your mind, you seem to teach your awareness-system to collect and store data from a longer period, even when it is not actively outputting it. This means that at the “mmm, cookies” stage, you can query your awareness to get a trace of the immediately preceding thought chain.

    You notice that you started to get distracted starting from the smell of the cookie and can then use this as further input to your awareness system. You are essentially taking the re-presented smell of the cookie which the system output, and feeding it back in, asking it to pay more attention to detecting “things like this”. The next time that you notice a smell, your introspective awareness may flag it right away, letting you catch the distraction at the very first stage and before it turns into an extended train of thought.

    Note that there is nothing particularly mysterious or unusual about any of this. You are employing essentially the same process used in learning any skill. In learning to ride a bike, for example, attempting to keep the bike balanced involves adjusting your movements in response to feedback. When you do so, your brain becomes better at detecting things like “tilting towards the right” in the sense data, increasing your ability to apply the right correction. After you have learned to identify tilting-a-lot-but-not-quite-falling, your brain learns to backtrace to the preceding state of tilting-a-little-less, and apply the right correction there. Once its precision has been honed to identify that state, you can further detect an even subtler tilt, until you automatically apply the right corrections to keep you balanced.

    Essentially the kind of a learning algorithm is being applied here. Increased sensory precision leads to improvements in skill which allow for increased sensory precision. (See also this article, which goes into more detail about TMI as a form of deliberate practice.)

    Uses for moments of introspective awareness

    I should again emphasize that the preceding explanation is only looking at one particular meditation system. There are other systems which work very differently, but they all use or develop introspective awareness to some extent. For example:

    • In Shinzen Young's formulation of “do nothing” practice, you have just two basic instructions: let whatever happens, happen and when you notice an intention to control your attention, drop that intention. This trains introspective awareness to notice when one is trying to control their attention… but it is also a very different system, since maintaining an intention to notice when that happens would also be an attempt to control attention! Thus, one is instructed to drop intentions if one spontaneously notices them, but not to actively look for them.
    • In noting practice, you are trying to consciously name or notice everything that happens in your consciousness. Introspective awareness is trained to very rapidly distinguish between everything that happens, but is not trained to maintain attention on any particular thing.
    • In visualization practice, you might create a visual image in your mind, then use introspective awareness to examine the mental object that you’ve created and compare it to what a real image would look like. This gives the subsystem creating the visualization feedback, and helps slowly develop a more realistic image.

    Going back to TMI-style introspective awareness, once you get it trained up, you can use it for various purposes. In particular, once you learn to maintain it during your daily life - and not just on the meditation couch - it will bring up more assumptions in your various schemas and mental models. Think of Richard paying attention to the assumptions behind his unwanted reactions and making them explicit, but as something that happens on a regular basis as the reactions come up.

    Romeo Stevens described what he called “the core loop of Buddhism”:

    So, what is the core loop?
    It's basically cognitive behavioral therapy, supercharged with a mental state more intense than most pharmaceuticals.
    There are two categories of practice, one for cultivating the useful mental state, the other uses that mental state to investigate the causal linkages between various parts of your perception (physical sensations, emotional tones, and mental reactions) which leads to clearing out of old linkages that weren't constructed well.
    You have physical sensations in the course of life. Your nervous system reacts to these sensations with high or low valence (positive, negative, neutral) and arousal (sympathetic and parasympathetic nervous system activation), your mind reacts to these now-emotion-laden sensations with activity (mental image, mental talk) out of which you then build stories to make sense of your situation.
    The key insight that drives everything is the knowledge (and later, direct experience) that this system isn't wired up efficiently. Importantly: I don't mean this in a normative way. Like you should wire it the way I say just because, but in the 'this type of circuit only needs 20 nand gates, why are there 60 and why is it shunting excess voltage into the anger circuits over there that have nothing to do with this computation?' way. Regardless of possible arguments over an ultimately 'correct' way to wire everything, there are very low hanging fruit in terms of improvements that will help you effectively pursue *any* other goal you set your mind to.

    Again, we saw an example of this with Richard. He had experienced his father as acting confident and as causing suffering to Richard and others; sensations which his mind has classified as negative. In order to avoid them, a model (story) was constructed saying that confidence is horrible, and behaviors (e.g. negative self-talk) were created to avoid appearing horrible.

    Now, this caused problems down the line, making him motivated to try to appear more confident… meaning that there was now a mechanism in his brain trying to prevent him from appearing confident, and another which considered this a problem and tried to make him more confident, in opposition to the first system. See what Romeo means when talking about circuits that only need 20 gates but are implemented using 60?

    The article “tune your motor cortex” makes the following claims about muscle movement:

    Your motor cortex automatically learns to execute complex movements by putting together simpler ones, all the way down to control of individual muscles.
    Because the process of learning happens organically, the resulting architecture of neural connections (you can think of them as "hidden layers" in machine learning terms) is not always perfectly suited to the task.
    Some local optima of those neural configurations are hard to get out of, and constantly reinforced by using them.
    There is some pressure for muscle control to be efficient, and the motor cortex is doing a "good enough" job at it, but tends to stop a fair bit from perfection.
    By repeating certain movements and positions over and over again (e.g. during sitting work), we involuntarily strengthen connections between movements and muscles that don't make much sense lumped together.
    E.g. control of shoulders might become spuriously wired together with control of thighs (both are often tense during sitting).

    There are various mental motions which are learned in basically the same way as physical motions are:

    • You learn to calculate 12*13 by a technique such as first multiplying 10*13, keeping the result in your memory, calculating 2*13, and then adding the intermediate results together.
    • You learn that a particular memory makes you feel slightly unpleasant, and that flinching away from anything that would remind you of it takes the pain away.
    • You learn that this also works on uncomfortable chores, teaching you to keep pushing the thought of them away.
    • You learn that your father’s behavior is painful to you, and that any confidence reminds you of that, so you learn negative self-talk which blocks you from acting confident.
    • You learn that saying “no” to people reminds you of being punished for saying “no” to your parents, but that saying “yes” too often means that you are constantly fulfilling promises to other people - so you learn to avoid situations where you would be asked anything.
    • You learn that there’s something you can do in your mind to stop feeling upset, so you start ignoring your emotions and any information they might have.
    • You learn that if you feel bad about not getting the respect you want, thinking “if only I was good enough at persuasion, I would get what I want” gives you a sense of control - even though this pattern also makes you feel personally at fault when you don’t get what you want.
    • You learn that it’s rewarding to punish people who have wronged, so you always want to punish someone when something goes wrong - even if there is nobody but reality to punish.
    • You learn that it feels good to mentally punish someone who is munching too loud, but actually complaining about it would feel petty, and you’ve learned that pettiness is frowned upon. So you also learn to block the impulse to say anything out loud, but continue to get increasingly angry about the sound, causing an escalating circle of both the annoyance and the blocking ramping up in intensity.

    As with physical movements, these can form local optima that are hard to get out of. Many of them are learned in childhood, when your understanding of the world is limited. But new behaviors continue to build on top of them, so you will eventually end up with a system which could use a lot of optimization.

    If you have more introspective awareness of the exact processes that are happening in your mind, you can make more implicit assumptions conscious, causing your brain’s built-in contradiction detector to notice when they contradict your later learning. Also, getting more feedback about what exactly is happening in your mind allows you to notice more wasted motion in general.

    One particular effect is that, as Unlocking the Emotional Brain notes, the mind often makes trade-offs where it causes itself some minor suffering in order to avoid a perceived greater suffering. For example, someone may feel guilt in order to motivate themselves, or experience self-doubt to avoid appearing too confident. By employing greater introspective awareness, one may find ways to achieve their goals without needing to experience any suffering in order to do so.

    Of course, Buddhist meditation is not the only way to achieve this. Various therapies and techniques such as Focusing, Internal Family Systems, Internal Double Crux, and so on, are also methods which use introspective awareness to reveal and refactor various assumptions. Increased introspective awareness from meditation tends to also boost the effectiveness of related techniques, as well as reveal more situations where they can be employed.

    If introspective awareness is so great, why don’t we have it naturally?

    As with anything, there are tradeoffs involved. Having more introspective awareness can help fix a lot of issues… but it also comes with risks, which I assume is the reason why we have not evolved to have a lot of it all the time.

    First, it’s worth noting that even for experienced meditators, intense emotional reactions tend to shut down introspective awareness. If one of the functions of e.g. fear and anxiety is to cause a rapid response, then excessive amounts of introspective awareness would slow down that response by reducing cognitive fusion. Many emotions seem to inhibit many competing processes from accessing consciousness, so that you can deal with the situation at hand.

    Another consideration involves traumatic memories. In the beginning of the article, I suggested that anxiety is a special kind of mental object which activates particular behaviors. In general, different emotional states have specific kinds of behaviors and activities associated with them - meaning that if you have some memories which are really painful, they can become overwhelming, making it necessary to block them in order to carry on with your normal life. Meditation can be helpful for working through your trauma, but it can also bring it up before you are ready for it, to the point of requiring professional psychotherapy to get through. If you are better at noticing all kinds of subtle details in your mind, it also becomes easier to notice anything that would remind you of things you don’t want to remember. A decrease in introspective awareness seems to be a common trauma symptom, as this helps block the unpleasant memories from being too easily triggered.

    I have also heard advanced meditators mention that increased introspective awareness makes it difficult to push away pangs of conscience that they would otherwise have ignored, causing practical problems. For example, people have said that they are no longer able to eat animal products or tell white lies.

    On the other hand, extended concentration practice can also make it easier to block things which you would be better off not blocking.

    So far, this article has mostly focused on using introspective awareness to notice the content of your thoughts. But you can also use it to notice the structure of the higher-level processes generating your thoughts. Part of how you develop concentration ability is by maintaining introspective awareness of the fact that being able to concentrate on just one thing feels more pleasant than having your attention jump between many different things. This can give you an improved ability to choose what you are concentrating on… but also to selectively exclude anything unpleasant from your mind.

    For example, there was an occasion when I needed to do some work, but also had intense anxiety about not wanting to; intense enough that it would normally have made it impossible for me to focus on it. So then I tried to work, and let my introspective awareness observe the feeling of head-splitting agony from my attention alternating between the work and the desire not to… and to also notice that whenever my attention was on the work, I felt temporarily better.

    After a while of this, the anxiety started to get excluded from my consciousness, until it suddenly dropped away completely - as if some deeper process had judged it useless and revoked its access to consciousness. And while this allowed me to do the work that I needed to, it also felt internally violent, and like it would be too easy to repress any unpleasant thoughts using it. I still use this kind of technique on occasion when I need to concentrate on something, but I try to be cautious about it.

    The negative side of being able to get better feedback about your mental processes, is that you can also get better feedback on exactly how pleasant wireheading feels. If you like to imagine pleasant things, you can get better and better at imagining pleasant things, and excluding any worries about it from your consciousness. Meditation teacher Daniel Ingram warns:

    Strong insight and concentration practice, even when that practice wasn’t dedicated to the powers, can make people go temporarily or permanently (or for the rest of that lifetime) psychotic. The more the practice involves creating experiences that diverge significantly from what I will crudely term “consensus reality”, and the longer one engages in these practices, the more likely prolonged difficulties are. It is of note that a significant number of the primary propagators of the Western magickal traditions became moderately nuts towards the ends of their lives.
    As one Burmese man said to Kenneth, “My brother does concentration practice. You know, sometimes they go a little mad!” He was talking about what can sometimes happen when people get into the powers. [...]
    I remember a letter from a friend who was on a long retreat in Burma and was supposed to be doing insight practices but had slipped into playing with these sorts of experiences. He was now fascinated by his ability to see spirit animals and other supernormal beings and was having regular conversations with some sort of low-level god that kept telling him that he was making excellent progress in his insight practice—that is, exactly what he wanted to hear. However, the fact that he was having stable visionary experiences and was buying into their content made it abundantly clear that he wasn’t doing insight practices at all, but was lost in and being fooled by these.

    Now, it should be pointed out that “being able to exclude anything unpleasant from your consciousness” is only going to be a worry for advanced practitioners who spend a lot of time on the kind of practice that inclines you towards these kinds of risks. Before you get to the point of something like this being a risk, you will get to resolve a lot of internal conflicts and old issues first.

    Here is Culadasa, the author of The Mind Illuminated, being interviewed about this kind of a “first you resolve a lot of issues, but then you can get the ability to push down the rest” dynamic:

    Michael Taft: … and you’re using the meditation practice to help work with your stuff. But what about the other case that we both know of where people have reached very high levels of meditative capacity, they’ve got a lot of insight, maybe they’re at some level of awakening, and they seem to have, in a way, missed a whole pocket of material, or several pockets of material. It’s like they think they’re doing fine, but maybe everyone around them is aware that they’ve got these behavior patterns that do not seem awake at all. And yet the meditation has somehow missed that.
    Culadasa: Yes, yes. [...] ... there seems to be a certain level of the stuff that we’re talking about that it’s necessary to deal with to achieve awakening, but it’s sort of a minimal level. [...] What I think that is indicative of is that if that hasn’t been sufficiently dealt with earlier, it has to get dealt with in one way or another at that point. That doesn’t necessarily mean that it’s going to get resolved; it may just get reburied a little more deeply.
    Michael Taft: Pushed out of the way.
    Culadasa: Yeah, pushed out of the way, or bypassed in some way. That allows a person to go ahead and [progress] and it’s unrealistic to think that everything has been resolved. [...] a lot of the things that change [...] actually help to push these things aside, to bypass them in one way or another, whereas before somebody has [made as much progress] these would have been sufficiently problematic in their life that, in one way or another, they would be aware of them, whether or not they did anything about them or were at a place of just taking for granted that I have these, quote, “personality characteristics” that are a bit difficult.

    I used to be very enthusiastic about TMI’s meditation system. I still consider it important and useful to make progress on, but am slightly more guarded after some of my own experiences, hearing about the experience of a friend who reached a high level in it, reading some critiques of its tendency to emphasize awareness of positive experiences [1 2], and considering both the interview quoted above and Culadasa’s subsequent actions. (That said, the focus on positive experiences can be a useful counterbalance for people who start off with an overall negative stance towards life.)

    I continue to practice it, and would generally find it safe until you get to around the sixth or so of its ten stages, at which point I would suggest starting to exercise some caution. Off the couch, I mostly don’t do much concentration practice (except in a context where I would need to concentrate anyway). Rather I try to focus my introspective awareness towards just observing my mind without actively interfering with it, Internal Family Systems -style practice, and other activities that do not seem to risk excluding too much unpleasant material.

    Finally, developing too much awareness into your mind may cause you to start noticing contradictions between how you thought it worked, and how it actually works. I suspect that a part of how our brains have evolved to operate, relies on those differences going unnoticed. This gets us to the topic of enlightenment, which I have not yet discussed, but will do in my next post.

    Thanks to Maija Haavisto, Lumi Pakkanen and Romeo Stevens for comments on an earlier draft.



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    Comment on Section II Football Playoff Brackets released by Jacob Gilbert    

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    Hmm, if I'm reading the B bracket right, Schalmont & Holy Trinity could wind up meeting again after last week's game, which was surprisingly one-sided. I watched that game on TV, and couldn't believe HT came out as flat as they did. Seems they didn't learn anything from Troy making the same mistake last year vs. Schalmont. Speaking of Troy, they escaped vs. Scotia last year, but I don't think the Tartans will sneak up on Troy this time. The beatdown issued to Albany was a message to Scotia, IMPO. Thinking of a possible rematch with Amsterdam in the semi-finals, since Troy won't see Burnt Hills unless both teams make it to the Super Bowl.

              

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    Homem que matou pastor e enterrou corpo em quintal no Maiobão já está em liberdade   

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    O assassino do pastor Mackson da Silva Costa, de 37 anos, foi solto nesta quarta-feira (06). Saulo Pereira Nunes, de 38 anos, foi beneficiado por um habeas corpus concedido pelo desembargador Josemar Lopes Santos. (leia a íntegra abaixo)

    Saulo Nunes matou o pastor a facadas na sexta-feira, 11 de outubro. O corpo foi encontrado na segunda-feira (14/10), enterrado no quintal da casa do assassino, na rua 07, no Conjunto Maiobão, em Paço do Lumiar. O crime teve motivação passional.
    ALVORADA GÁS

    A residência do assassino é próxima ao local onde o veículo do pastor, um Fiat Mobi, de cor vermelha, de placa PSX-9805, foi encontrado no domingo (13/10). 

    Mackson da Silva estava desaparecido desde a sexta-feira (11/10), dia do crime. De acordo com informações de familiares, no dia do desaparecimento, o pastor trabalhou pela manhã e antes de ir almoçar em sua residência, na Vila Palmeira, disse que passaria em uma agência bancária para fazer um saque. Desde então, não manteve mais contato com os parentes.

    Saulo Nunes confessou o crime. Ele foi preso e conduzido para a Superintendência de Homicídios e Proteção à Pessoa (SHPP) para autuação em flagrante.

    O assassino responde pelos crimes previstos nos artigos 121, § 2º, incisos I e IV (Matar alguém: Pena - reclusão, de seis a vinte anos. § 2º Se o homicídio é cometido: I - mediante paga ou promessa de recompensa, ou por outro motivo torpe; IV - à traição, de emboscada, ou mediante dissimulação ou outro recurso que dificulte ou torne impossível a defesa do ofendido; Pena - reclusão, de doze a trinta anos), c/c 211 (Destruir, subtrair ou ocultar cadáver ou parte dele: Pena - reclusão, de um a três anos, e multa).

    Ao conceder habeas corpus a Saulo Nunes, o desembargador determinou as seguintes medidas cautelares diversas da prisão, previstas no art. 319 do Código de Processo Penal:  quais sejam: 1. Comparecimento em Juízo, a cada 30 (trinta) dias, para informar e justificar suas atividades, comprovando o seu vínculo empregatício; 2. Proibição de mudar de endereço e de se ausentar da Comarca sem autorização judicial; 3. Recolhimento domiciliar no período noturno, a partir das 22 (vinte e duas) horas às 06 (seis) de segunda à sexta e nos dias de sábado, domingo e feriados durante todo o dia na sua residência; e, 4. Monitoramento eletrônico.

    Leia a íntegra do habeas corpus


    do blog do Gilberto Lima.


              

    Inauguração da EMEIEF “Professor Osmar Genovez” é marcada por emoção em Tupã   

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    Escola já está atendendo cerca de 190 alunos. O Núcleo “Raul de Mello Senra” e a EMEIEF “Professor Osmar Genovez” foram inaugurados pela Prefeitura de Tupã, por meio da Secretaria Municipal de Educação, na noite desta quarta-feira (30). A escola localizada na Rua 15 de Novembro, nº 52, já atende cerca de 190 alunos. A solenidade de inauguração contou com a presença da população, familiares dos homenageados, vereadores Gilberto Neves Cruz, Osmídio Fonseca Castilho, Renan Pontelli, Charles dos Passos, Telma Tulim, Israel Veloso e Alexandre Scombatti, além do prefeito Caio Aoqui. Escola já está atendendo cerca de 190 alunos Prefeitura de Tupã/Divulgação Raul de Mello Senra Bisneto, representando a família de um dos homenageados, destacou a emoção e a honra que tem de fazer parte da quarta geração de Raul de Melo Senra, que em 2020 completa 150 anos. “Emocionei-me ao fazer o discurso alusivo ao meu bisavô Raul de Melo Senra, um benemérito que contribuiu muito para o desenvolvimento de Tupã. Quando ele chegou a Tupã, a cidade ainda não estava totalmente formada, desencadeou a abertura da nossa fazenda e depois surgiu o município de Tupã. Desde então, até sua morte, meu avô procurou ajudar ativamente no desenvolvimento da cidade”, comentou. Já Osmar Genovez Junior, filho de Osmar Genovez, salientou que o sonho de seu pai sempre foi fomentar ainda mais a educação, pois a vida inteira trabalhou nesta área. “Meu pai sempre frisou que não queria de forma alguma que um dia todo o trabalho que ele fez em Tupã fosse em vão, e na reinauguração, ver a homenagem a ele, sem dúvidas, é tudo que sempre sonhou. Foi indiscutível a emoção e alegria de todos os presentes”, destacou. Já o secretário municipal de Educação, professor Valdir Berti, disse que a escola, no período em 1 ano e 2 meses, teve um investimento de mais de R$ 1 milhão com toda a infraestrutura, adequações, material mobiliário e pedagógico. Representando o Legislativo, o vereador Alexandre Scombatti disse que o município investe muito em educação e que este é o caminho. “Vale destacar que assim que assumimos o legislativo, fizemos a indicação para que esta escola fosse totalmente reformada, além de possuir o ensino SESI. Será uma escola com material diferenciado, quem ganha é a população, os alunos e a comunidade”, destacou o parlamentar. Para o vereador Charles dos Passos, a reinauguração de uma escola que ficou quase 18 anos sem uso foi um momento de muita alegria e satisfação. “O local possui um grande espaço. Esta é mais uma oportunidade de os alunos terem equipamentos de qualidade para a educação, tendo em vista que a educação modifica as pessoas, e as pessoas modificam o mundo. Nossas crianças são o futuro da nossa nação”, falou. O prefeito Caio Aoqui destacou a alegria de entregar esta importante obra para o município no mês de aniversário da cidade. “Para nós do poder público é muito gratificante entregar um núcleo educacional como este, reivindicado há muitos anos”, frisou. Caio agradeceu ainda a todos os envolvidos na inauguração da escola. “Quero agradecer todos os secretários que estiveram envolvidos para a entrega desta obra, além da presença e apoio da população, alunos, vereadores e secretários”, agradeceu.

              

    Mãe e filha são presas acusadas de assassinato em Anajatuba; vítima é o ex-companheiro   

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    A polícia civil do Maranhão, por meio da Delegacia Regional de Itapecuru, prendeu Adriana Marinho Martins, em cumprimento a mandado prisão preventiva, e apreendeu adolescente J.M.C., de 17 anos, em cumprimento de internação.

    A operação policial foi realizada na terça-feira (05) no bairro São Benedito, em Anajatuba, a 137 km de São Luís, e contou com o apoio da equipe de investigação local.

    As duas mulheres, que são mãe e filha, são acusadas dos crimes de homicídio e associação criminosa. A vítima foi identificada como Augusto Cassius Gonçalves Costa, ex-companheiro e pai, respectivamente, de ambas.

    Augusto foi executado com seis disparos de arma de fogo no mês de janeiro, em sua residência, no povoado São José, zona rural de Anajatuba.

    Essa ação policial é complemento da operação Cifra Negra que resultou nas prisões de Helton Melônio Pereira e Franciomar Costa Travassos, diretamente ligados ao assassinato de Augusto Costa. Eles foram contratados para executar o crime.


    do blog do Gilberto Lima.

              

    Criminosos são presos com fardamento exclusivo da PM e cocaína em São Luís   

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    A Policia Civil do Maranhão, por meio da Superintendência Estadual de Investigações Criminais (Seic), prendeu em flagrante, na tarde de terça-feira (05), no bairro Anil, em São Luís,  Matheus Pinho Costa, de 21 anos, e Hilton José da Piedade Cardoso, de 29 anos, pelos crimes de tráfico de drogas e associação para o tráfico.

    Segundo informações da polícia, Departamento de Combate ao Crime Organizado (DCCO) da SEIC já vinha investigando os criminosos, apontados como pertencentes a uma quadrilha responsável pela distribuição de drogas na região do bairro Anil e adjacências.

    Com os presos, foram encontradas mais de 80 gramas de cocaína, avaliada em cerca de R$ 4 mil, além de uma balança de precisão, utilizada no preparo da substância entorpecente.

    Em um dos imóveis, os policiais encontraram três gandolas com símbolos da PMMA, referente às patentes de coronel e soldados, uma boina e duas capas de coletes balísticos com identificação plástica da corporação.

    As investigações apontam que estas vestimentas, de uso exclusivo da Polícia Militar do Maranhão, vinham sendo utilizadas por membros de facções criminosas para o cometimento de roubos, extorsões a comerciantes da área e ataques a membros de grupos rivais.

    Depois dos procedimentos legais, os dois foram encaminhadas ao Complexo Penitenciário de Pedrinhas, onde permanecerão à disposição da Justiça.

    do blog do Gilberto Lima.


              

    Envolvido em atropelamento e morte de vigilante é baleado em borracharia no Jardim São Cristóvão 2   

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    O homem identificado como Paulo Antônio Viegas Silva foi atingido por dois disparos de arma de fogo, na tarde dessa terça-feira (05), em uma borracharia na Avenida 1-C, no Jardim São Cristóvão 2.

    Os tiros o atingiram nas costas e foram disparados por dois homens que estavam em uma motocicleta. Eles ainda foram perseguidos por um amigo de Paulo Silva, mas conseguiram fugir.

    Ele foi socorrido e levado para o hospital Clementino Moura, o Socorrão 2, onde está internado. A suspeita é de que o crime tenha sido motivado por vingança em função do envolvimento de Paulo Antônio na morte do vigilante Ricardo Pereira.

    Paulo Silva é sobrinho de Carlos André Farias Viegas, de 38 anos, conhecido como “Dedeu”, o principal suspeito de atropelar e matar o vigilante Ricardo Bruno Costa Pereira, na noite do último sábado (02), na Cidade Operária. Paulo estaria no veículo Astra de placas DFN-3825, que atropelou e matou o vigilante.

    Na tarde de segunda-feira (04) teria se apresentou na Delegacia Especial da Cidade Operaria onde foi ouvido acerca da morte do vigilante e depois liberado por não ter mandado de prisão. A polícia vai esclarecer quem realmente estava dirigindo o veículo.


    do blog do Gilberto Lima.


              

    Motorista e bandido morrem em tentativa de assalto a ônibus em Zé Doca   

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    Um motorista e um bandido morreram em uma tentativa de assalto a um ônibus, por volta das 2h40 da madrugada desta quarta-feira (06), em Zé Doca, a 311 km de São Luís. 

    O ônibus, que pertence à empresa Jamjoy e fazia a linha Belém/PA-São Luís, foi interceptado por cinco criminosos nas proximidades do Km 190 da BR-316, entre os povoados Josias e Fortaleza.

    O ônibus transportava 11 passageiros adultos e dois motoristas.  No momento do roubo, os assaltantes dispararam tiros contra o motorista Haroldo Setúbal Ferreira, de 35 anos e natural de Martinópole/CE. Ele morreu no local do assalto.

    Um policial militar que estava no ônibus disparou tiros contra um dos assaltantes, identificado apenas como “Xeique”, natural da cidade de Codó, que seria residente em Zé Doca. Ele também morreu no local. Os outros assaltantes conseguiram se evadir.

    As guarnições da PM resgataram os passageiros e levaram os corpos, com auxílio de uma funerária, ao hospital. A delegada de plantão foi acionada para adotar as providências cabíveis.

    Os policiais militares fizeram incursões e cerco em toda a região do acidente, mas não conseguira localizar os outros assaltantes.


    do blog do Gilberto Lima.

              

    Presa quadrilha especializada em roubo a bancos na modalidade “sapatinho”   

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    A Polícia Civil do Maranhão, por meio da Superintendência de Investigações Criminais (Seic), prendeu, na tarde da última sexta-feira (1º), oito integrantes de uma quadrilha especializada em roubo a bancos, na modalidade “sapatinho”.

    Os presos foram identificados como Anderson da Silva Viana, conhecido como "Dudu", Ronildo Freitas Mendes, o "Indio Bravo", Moisés Lopes De Moraes, Pedro Alves Sousa Oliveira, o "Pedrinho", Lucas Cardoso Assunção, Wanderson Aguiar Da Luz, o "Juninho", Cleidiane Cordeiro Da Silva, a "Loura" e o menor J.P.A.S.

    Eles foram surpreendidos pelos policiais no momento em que se preparavam para praticar o crime de extorsão mediante sequestro contra funcionários de uma instituição financeira na cidade de Poção de Pedras, a 316 km de São Luís.

    Foram apreendidos dois revólveres, uma pistola, uma escopeta e aparelhos celulares.

    De acordo com informações da polícia, Anderson Viana, o "Dudu" já possuía mandados de prisão pelas comarcas de Timon e Buriticupu. Já Ronildo Mendes, o "Índio Bravo", é foragido da Justiça do Estado do Pará, onde responde a vários processos criminais.

    Após autuação, os presos foram encaminhados ao Complexo Penitenciário de Pedrinhas, onde ficarão à disposição da Justiça.

    A operação para desarticular essa quadrilha contou com o apoio das Delegacias Regionais de Bacabal e Pedreiras, além do apoio operacional do Centro Tático Aéreo (CTA) e do COSAR.

    O roubo na modalidade “sapatinho”

    No assalto na modalidade “sapatinho”, funcionários do banco e seus familiares são sequestrados para facilitar a invasão de agências sem chamar atenção.

    Geralmente uma parte da quadrilha faz a família refém, enquanto um dos bandidos segue com o funcionário à agência, com o objetivo de se apropriar de dinheiro.


    Após o roubo, os reféns e o funcionários são libertados em algum lugar distante da cidade.


    do blog do Gilberto Lima.

              

    Holiday Eats: What's (and Who's) Cookin'   

    Cache   

    Here are ideas on how to help get the holiday gathering started.

    There's much to look forward to during the holidays. Warm camaraderie to keep the cold outside at bay. Toasts with family, friends, and coworkers to raise the spirits. A seasonal smorgasbord. Of course, no one looks forward to the extra cooking, shopping, and dishes, though. That's where we come in. For some ideas on how to help get the holiday gathering started (and avoid the extra cooking), read this special message from our advertisers. 

    62 South Front Street

    62 S. Front, (941-0784) • 62southfrontstreet.com

    Come celebrate with us! Located on Historic Cotton Row, at 62 South Front, you can host your corporate meetings, receptions, and special events in style — with 3,000 square feet and a full kitchen for the caterer of your choice. Free wifi and free use of 20 tables and 40 chairs. Please call us with any questions regarding pricing or history of the venue.

    Boscos Squared

    2120 Madison, (432-2222) • boscosbeer.com

    Looking for a private party room, banquet room, or event space where guests can enjoy local, handcrafted beer while dining on chef-created specialties like Boscos wood-oven shrimp, smoked pork chop, or wood-fired oven pizzas? Boscos Restaurant & Brewing Co. has everything you need to host your holiday party, birthday celebration, banquet, or office party for up to 30 guests. Boscos Restaurant & Brewing Co. can meet all of your private dining needs.

    Call us at (901) 432-2222 to create your private dining experience at Boscos.

    Char Restaurant

    431 S. Highland, #120, (249-3533) • memphis.charrestaurant.com

    Bring Char to your holiday table this year! Family-style sides and whole pecan pies are available to order for pick-up for all of your holiday celebrations. Order by November 25th for Thanksgiving and December 20th for Christmas. Call us today to place your order.

    The Curb Market

    1350 Concourse Ave, Suite 163, (453-6880) • curbmarket901.com

    Curb Market makes all hot dishes from scratch, with fresh ingredients, and we cater! Make sure your holiday parties are something to remember, whether at home or at the office. Contact catering@curbmarket901.com today!

    El Toro Loco - Mexican Bar & Grill

    2809 Kirby, #109 (at Quince), (759-0593)

    Now booking holiday parties and special events. With karaoke and DJs every Thursday, Friday, and Saturday. For catering and event booking, please call us.

    Jack Pirtle's Chicken

    jackpirtleschicken.com

    Memphians have enjoyed our delicious fried chicken, steak sandwiches, and all the trimmings since 1957. Come see what keeps the Mid-South coming back for more! It's down-home delicious. For catering information and pricing call (901) 372-9897 or visit one of our eight Memphis locations.

    Molly's La Casita

    2006 Madison, (726-1873) • mollyslacasita.com

    Bring your family to our Molly's family for some good fun, food, and drinks. Margarita Monday and Taco Tuesday are a good start to your Thanksgiving week. Ask about our party-size dips for your holiday parties.

    Mulan Asian Bistro

    Mulan offers traditional Chinese and authentic Szechuan cuisine, as well as sushi and hibachi. Mulan provides catering, delivery services, and has a private party room available for special events. Contact us today to start planning your holiday celebrations.

    • Mulan Asian Bistro East

    4698 Spottswood, (609-8680)

    • Mulan Asian Bistro Midtown

    2149 Young, (347-3965)

    • Mulan Asian Bistro Collierville

    2059 Houston Levee, (850-5288)

    Pueblo Viejo - Mexican Restaurant & Buffet

    3750 Hacks Cross, (751-8896) • puebloviejorestaurantandbuffet.com

    Let us host your holiday parties and special events. We have karaoke and DJs every Thursday, Friday, and Saturday. We offer catering and event space.

    Restaurant Iris / Second Line

    Place your Iris order for the holidays — herb-brined chicken, $25 (serves 4); roasted honey duck, $35 (serves 4); and sides, which include fettuccine casserole (no veggies), stuffing with sage, sausage, and apples, sweet potato casserole, green bean casserole, apple cobbler, $20 each (serves 8-10). Book your holiday event for the main room or entire restaurant. Email pgilbert@chefkellyenglish.com for orders or reservations.

    • Iris, Etc.

    irisetc.com

    • Second Line

    2144 Monroe, (590-2829) • secondlinememphis.com

    • Restaurant Iris

    2146 Monroe, (590-2828) • restaurantiris.com

    Soccer City 901

    5560 Shelby Oaks Drive, (240-1415) • soccercity901.com

    Soccer City 901 has you covered for all your holiday festivities. Play soccer in our indoor and outdoor soccer fields. Enjoy food and drinks throughout our spacious restaurant. Watch your favorite games on our many TVs. Our mission is to provide the No. 1 spot in the city where all communities come together to embrace sports, Latin culture, and quality time with their families and friends.

    The Guest House at Graceland

    3600 Elvis Presley • guesthousegraceland.com

    2019 Thanksgiving Day Buffet at Delta's Kitchen

    Celebrate with friends and family and enjoy a traditional Thanksgiving Day feast with all the favorite trimmings at The Guest House at Graceland.We look forward to celebrating Thanksgiving with you and your loved ones!

    To make reservations, please call (901) 443-3000.

    The Vault

    124 GE Patterson, (591-8000) • vaultmemphis.com

    Give us a call to plan your holiday party needs. We have an upstairs space available that will hold up to 70 people. We can create a menu for you, or you can choose items off our menu. Happy holidays!

    Young Avenue Deli

    2119 Young, (278-0034) • youngavenuedeli.com

    Pick Young Avenue Deli for your holiday parties this season! We have pool tables, games, and great food, and we can accommodate large groups — we will rent out the entire restaurant. Please email tessa@youngavenuedeli.com for details.


              

    Acidi grassi polinsaturi omega-3: quale utilità?   

    Cache   

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    Acidi grassi polinsaturi omega-3: quale utilità?

    Enrico Bologna

     

    Specialista in Medicina Interna, Gastroenterologia e Patologia generale.
    Già Primario Ospedale Fatebenefratelli, Isola Tiberina, Roma.
    Libero docente in Patologia Medica, Università di Roma “Sapienza”.


    Riassunto

    Gli acidi grassi polinsaturi a catena lunga rappresentano una componente alimentare necessaria per il normale metabolismo cellulare. Quelli della classe ω-3, utilizzati da oltre 35 anni per il trattamento di alcune dislipidemie e par la prevenzione del reinfarto, sono stati recentemente oggetto di discussioni relativamente alla reale utilità in quest’ultima indicazione ma anche alla possibile efficacia in indicazioni completamente diverse.

    Summary

    Polyunsatured long-chain fatty acids are a component of diet essential for cellular metabolism. Omega-3 PUFA in the last 35 years were widely prescribed for treating hypertriglyceridemia and for secondary prevention of myocardial infarction. Recently, questions were posed on the thrue efficacy in the latter indication,  but also on possible utility in other indications. 

     

    Nel 1976 uno studio condotto su Eschimesi Inuit dimostrò che nei soggetti residenti in Groenlandia la frequenza delle malattie cardiovascolari era inferiore rispetto a quella osservata in soggetti della stessa etnia residenti in paesi industrializzati (5). Il fenomeno fu attribuito alle differenti abitudini alimentari, in particolare al maggior quantitativo di pesce consumato e quindi degli acidi carbossilici, noti come acidi grassi polinsaturi (PolyUnsatured Fatty Acids, PUFA) assunti dai soggetti residenti in Groenlandia. Da questa osservazione originò un rinnovato interesse per gli acidi grassi essenziali, che erano stati identificati negli anni trenta ma che erano stati oggetto di studio solo come fattori necessari all’accrescimento umano e animale.

    L’esistenza di un rapporto tra l’alimentazione e il rischio di reinfarto trovò conferma alla fine degli anni ’80 dai risultati dello studio  Diet and Reinfarction, che prese in esame il consumo di pesce, grassi e fibre (9). L’interesse per i PUFA crebbe con i risultati dello studio condotto 10 anni dopo dal Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (GISSI) (27). Questo studio, condotto su 11.324 pazienti con recente infarto del miocardio, dimostrò una riduzione del 15% del rischio combinato di letalità, infarto non fatale e ictus nei soggetti trattati per tre anni con 1 g/die di PUFA ω-3 a catena lunga (EPA e DHA). In particolare, il rischio di letalità cardiovascolare risultò ridotto del 30% e quello di morte improvvisa del 45%. Un secondo studio (28), effettuato somministrando per un periodo medio di 3,9 anni 1 g/die di PUFA ω-3 a 6.975 pazienti con insufficienza cardiaca cronica, dimostrò che il trattamento si associava con una moderata riduzione  dei ricoveri  per malattie cardiovascolari e della letalità per tutte le cause. Nel Japan Eicosapentaenoic acid Lipid Intervention Study (JELIS) , condotto per 4,6 anni su 18.645 soggetti ipercolesterolemici di entrambi i sessi trattati con statine, la somministrazione di 1,8 g/die di acido eicosapentaenoico (EPA) si associò ad una riduzione del 19% di eventi coronarici maggiori non fatali, ma non degli eventi fatali (66). Questa apparente limitata efficacia di EPA potrebbe però essere attribuita al fatto che la popolazione in esame faceva ampio uso di alimenti ittici ed aveva quindi elevati valori basali di PUFA . Molti altri studi, condotti in popolazioni e con modalità differenti, hanno successivamente confermato il beneficio dell’alimentazione ittica e dei supplementi a base di PUFA (ω-3 a catena lunga 47).

    Ma, più recentemente,  alcune ricerche hanno portato a risultati molto differenti. Secondo una metanalisi condotta su 10 studi clinici relativi a 69.480 pazienti ha mostrato che i soggetti trattati con PUFA ω-3 non hanno presentato  significativa riduzione della letalità per tutte le cause, della morte cardiaca, della morte improvvisa, dell’infarto miocardico e dell’ictus cerebrale (53). Anche lo studio randomizzato in doppio cieco ORIGIN, condotto su 12.536 soggetti ad alto rischio cardiovascolare e intolleranza glicidica o diabete mellito, ha dimostrato che la somministrazione per 6,2 anni di 1 g/die di PUFA ω-3 non si è associata ad alcuna significativa riduzione di rischio (50).

    Ugualmente deludenti i risultati di uno studio, effettuato in Italia, su 12.512 pazienti con malattia aterosclerotica o con molteplici fattori di rischio cardiovascolare seguiti da 860 medici di Medicina generale. I pazienti sono stati trattati con 1 capsula/die contenente 1 g di PUFA ω-3 o 1 g di olio di oliva quale placebo per 5 anni. La letalità e morbosità cardiovascolari non hanno mostrato significative differenze nei due gruppi di pazienti (52). Questo studio è stato criticato per l’uso come placebo di olio di oliva in quanto contenente PUFA, ma la critica appare inconsistente considerando l’elevato uso di olio di oliva nel nostro paese (stimato in oltre 30 g/die).

    I contrastanti risultati di questi studi hanno determinato incertezze e dubbi, che in Italia hanno portato dapprima alla modificazione della prescrivibilità dei PUFA ω-3 che, con determinazione AIFA del 26/4/2013 venne limitata al trattamento di secondo livello dei soggetti con iperlipidemia familiare combinata e dei pazienti con insufficienza renale media-grave e ipertrigliceridemia > 500 mg/dl; con la stessa determinazione fu infatti annullata la prescrivibilità a scopo di prevenzione secondaria nei soggetti con pregresso infarto del miocardio. Ma in data 22/11/2013 la prescrivibilità è stata ripristinata per i pazienti con sindrome coronarica acuta con innalzamento di ST o con aumento dei biomarcatori verificatasi nei 90 giorni precedenti.

    Per comprendere i motivi di queste  incertezze è utile ricordare brevemente il significato biologico dei PUFA. Questi vengono distinti, in base alla assenza o presenza nella molecola di doppi legami, in saturi e rispettivamente insaturi (mono- o polinsaturi secondo il numero dei doppi legami localizzati in corrispondenza degli atomi di carbonio). Il numero dei doppi legami è un fattore determinante, poiché da esso dipendono le caratteristiche funzionali dei PUFA, quali la  fluidità delle membrane cellulari in cui essi sono contenuti, l ’attività dei sistemi cellulari di trasporto e degli enzimi legati alla membrana come anche la suscettibilità alla perossidazione dei lipidi. I PUFA a catena lunga, in particolare, sono i precursori di molecole-segnale che a seconda della struttura (ω-3 ovvero ω-6) intervengono in molteplici processi fisiologici, in particolare quelli infiammatori e immunitari, e condizionando la formazione delle VLDL e dei trigliceridi.

    I PUFA sono acidi grassi essenziali, cioè non prodotti dai mammiferi che mancano degli enzimi necessari a inserire il doppio legame, il cui apporto è indispensabile per il normale svolgimento delle  funzioni biologiche fondamentali sopra ricordate. Al contrario dei mammiferi, alcuni vegetali, e in particolare  le alghe unicellulari presenti nel fitoplancton, sono in grado di sintetizzare vari PUFA che quindi passano nei pesci che si cibano di queste alghe. Per inciso, è questo il motivo per cui apporto di PUFA non si ha dai pesci allevati ma solo da quelli pescati in mare.

    Le famiglie di PUFA più importanti per il metabolismo umano sono quelle denominate omega-6 (ω-6 o n-6) e omega-3 (ω-3 o n-3). Questa denominazione è basata sulla disposizione del primo doppio legame a partire dal terminale Carbonio (Carbonio ω o Carbonio n). Nelle due famiglie il primo doppio legame si trova quindi nel sesto (ω-6) e rispettivamente nel terzo (ω-3) rango. Tutti i doppi legami sono in configurazione cis,  vale a dire i due atomi di idrogeno che vi sono contenuti si trovano dalla stessa parte del piano formato dal doppio legame. Nell’uomo la presenza di particolari enzimi (reduttasi ed elongasi)  permette la produzione di vari PUFA a catena lunga a partire dall’acido linoleico per la serie ω-6 e dall’acido linolenico per la serie ω-3.

    La denominazione completa di un PUFA, prendendo ad esempio l’ac. α-linolenico (Fig.1), è rappresentata come segue:

    Fig. 1 Ac. α-linolenico (ALA) [acido octadecatrienoico]: (18:3; ω-3; all-cis 9,12,15

     La prima cifra indica il numero di atomi di carbonio da cui la molecola è costituita e la seconda il numero di doppi legami; seguono la posizione del primo doppio legame a partire dal terminale ω e successivamente la configurazione (in questo caso cis) e infine la posizione dei doppi legami a partire dal terminale α.  (15). Un elenco dei PUFA ω-3 è riportato nelle tabelle 1 e 2.

    DENOMINAZIONE

    DESCRIZIONE

    Ac. esadecatrienoico (HTA)

    16:3; all-cis-7,10,13

    Ac. octadecatrienoico (ALA) [Ac. α-linolenico]

    18:3; all-cis-9,12,15

    Ac. octadecatetraenoico (SDA) [Ac. stearidonico]

    18:4; all-cis-6,9,12,15

    Ac. eicosatrienoico (ETE)

    20:3; all-cis-11,14,17

    Ac. eicosatetraenoico (ETA)

    20:4; all-cis-8,11,14,17

    Ac. eicosapentaenoico (EPA) [Ac. Timnodonico]

    20:5; all-cis-5,8,11,14,17

    Ac. eneicosapentaenoico (HPA)

    21:5: all-cis-6,9,12,15,18

    Ac. docosapentaenoico (DPA) [Ac. clupanodonico]

    22:5: all-cis-7,10,13,16,19

    Ac. docosaesanoico (DHA) [Ac. cervonico]

    22:6: all-cis-4,7,10,13,16,19

    Ac. tetracosapentaenoico

    24:5: all-cis-9,12,15,18,21

    Ac. tetracosaesanoico [Ac. nisinico]

    24:6; all-cis-6,9,12,15,18,21

    Tab. 1. Omega-3

     

    DENOMINAZIONE

    DESCRIZIONE

     Ac. octadecaenoico (Ac. linoleico) (LA)

    LA

     Ac. octadecatrienoico (Ac. gamma-linolenico) (GLA)

     18:3: all-cis-6,9,12

     Ac. eicosadienoico (EDA)

     20:2; all-cis-11,14

     Ac. Ac. diomo-gamma-linolenico (DGLA)

     20:3: all-cis-8,11,14

     Ac.arachidonico (AA)

     20:4: all-cis-5,8,11,14

     Ac. docosadienoico

     22:2; all-cis-13,16

     Ac. adrenico

     22:4; all-cis-7,10,13,16

     Ac. docosapentaenoico

     22:5; all-cis-4,7,10,13,16

     Ac. tetracosatetraenoico

     24:4; all-cis-9,12,15,18

     Ac. tetracosapentaenoico

     24:5; all-cis-6,9,12,15,18

    Tab. 2. Omega-6

    I principali PUFA ω-3,  presenti  quasi esclusivamente nei pesci, sono EPA e DHA; i principali PUFA ω-6, per contro, sono contenuti negli oli vegetali e nelle carni e sono rappresentati da GLA e AA.

    Una volta ingeriti con gli alimenti, i PUFA ω-6 e ω-3 competono per uno stesso sistema di enzimi, rappresentati da desaturasi e da elongasi, che determinano allungamento e desaturazione delle molecole con la formazione di derivati bioattivi (Fig. 2). Questa competizione per  uno stesso sistema enzimatico fa sì che il rapporto quantitativo tra i  derivati delle due famiglie  di PUFA corrisponda a quello dei PUFA assunti con gli alimenti.

    La prima tappa della biotrasformazione dei PUFA dipende dall’intervento di una Δ6 desaturasi che, pur avendo  maggiore affinità per ALA che per LA, è utilizzata soprattutto per la catena dei composti ω-6 in quanto prevalenti rispetto agli ω-3 nella alimentazione. Per questo motivo nell’uomo la produzione di EPA e DHA è molto modesta; i livelli di questi PUFA dipendeono soprattutto dall’apporto alimentare, in particolare dal consumo di pesci (31), il cui contenuto in  EPA e DHA, derivante come già detto dal consumo di alghe e di plancton,  è particolarmente elevato per maccarelli, salmoni, aringhe, alici e sardine (1).

    I PUFA ω-3 e ω-6 svolgono numerose funzioni vitali nell’organismo umano. Quali componenti dei fosfolipidi strutturali di membrana modulano il signaling cellulare, le interazioni tra cellule e, come già ricordato, la fluidità delle membrane stesse. Influenzano inoltre il sistema immunitario agendo come precursori di metaboliti eicosanoidi sintetizzati a partire dai PUFA ω-6 (Ac. arachidonico) e ω-3 (EPA) che per l’intervento di Cicloossigenasi (COX) e Lipoossigenasi (LOX) e vengono trasformati nelle prostaglandine immunomodulatrici Trombossano(TX) e leucotrieni (LX).

    Questi processi di biotrasformazione coinvolgono preferenzialmente i PUFA ω-3, al cui apporto - per la già ricordata competizione enzimatica - fa riscontro una minor generazione degli eicosanoidi derivati da Ac. arachidonico ed un aumento degli eicosanoidi derivati da EPA e di DHA, caratterizzati da capacità antiinfiammatoria, che si oppone a quella proinfiammatoria dei derivati di Ac. arachidonico (7, 60). La capacità antiflogistica dei PUFA ω-3, che determinano riduzione degli eicosanoidi infiammatori, di citochine (Interleukina 1 e, interleukina 6, TNF-alfa),di molecole di adesione e delle specie reattive dell’ossigeno, dipende da meccanismi diretti, (inibizione del metabolismo dell’acido arachidonico) e indiretti (alterata espressione di geni infiammatori per inibizione dei fattori di trascrizione e produzione di mediatori antiinfiammatori come  le resolvine) (10).

     

     

    I meccanismi mediante i quali i PUFA ω-3  possono influenzare le funzioni dell’apparato cardiovascolare esercitando una protezione antiaterosclerotica  sono stati oggetto di una esauriente e recente rassegna si Dessi et al (16). In sintesi, l’incorporazione di EPA e DHA nelle membrane cellulari ne condiziona l’organizzazione, la permeabilità e la fluidità; modifica inoltre l’attività di proteine e strutture transmembrana tra cui recettori, enzimi e canali ionici- In particolare l’azione sui canali di potassio, sodio e calcio modula l’eccitabilità e la contrattilità dei miociti. Questi effetti appaiono svolti soprattutto da DHA. Questo PUFA influenza inoltre il sistema adrenergico e la liberazione di ATP dall’endotelio con aumento della produzione di NO; queste azioni, insieme alla riduzione dei livelli di noradrenalina, spiegano gli effetti antiaritmico, antiipertensivo e bradicardizzante di DHA. Anche la variabilità della frequenza cardiaca, che costituisce un fattore predittivo di morte improvvisa e di aritmie, appare correlato positivamente con i livelli plasmatici di PUFA ω-3. Il benefico effetto di questi derivati nei confronti delle malattie cardiovascolari, e in particolare della malattia coronarica,   viene attribuito anche alla capacità di proteggere la funzione endoteliale (18), di ridurre la produzione di trombina  e di rendere meno stabile il coagulo fibrinico (23). I PUFA ω-3, inoltre, potenziano l’effetto dei farmaci antiaggreganti (22, 39).

    Fig. 2 (Modif. da 35)

    I risultati del già citato studio sugli Eschimesi hanno dato luogo a numerose ricerche sul ruolo fisiologico dei PUFA e sulle conseguenze di variazioni dell’apporto alimentare o aggiuntivo di queste sostanze, con particolare attenzione al rapporto fra derivati ω-3 e ω-6. Queste indagini  hanno dimostrato che i PUFA ma possiedono numerose proprietà pleiotropiche e sono state oggetto di ampie rassegne fui si rimanda (12, 16). In questa sede verranno sinteticamente riassunte le conoscenze relative al ruolo dei PUFA non solo nelle malattie cardiovascolari,  ma anche metaboliche, respiratorie, articolari, neoplastiche e psichiche (13, 33,35, 36, 37). La responsabilità dei PUFA in tutte queste condizioni sarebbe rappresentata da un deficit relativo di ω-3 con eccesso di ω-6, con conseguente accumulo nelle cellule di mediatori appartenenti alle due  famiglie di acidi grassi nelle stesse proporzioni in cui sono assunte con l’alimentazione  (37:). A questo proposito è da rilevare che dal XX secolo i profondi cambiamenti nella produzione e nella promozione degli alimenti ha indotto un aumento del consumo di derivati ω-6 più che di ω-3 rispetto al passato; questo fenomeno, rilevato dapprima negli USA, si è esteso a tutti i paesi occidentali e, più recentemente, anche a quelli emergenti e in via di sviluppo.

     

    DISLIPIDEMIE

    La prima applicazione clinica dei PUFA ω-3 fu quella ipolipemizzante. L’effetto riguarda prevalentemente i trigliceridi la cui riduzione, che può giungere in misura dose-dipendente fino al 30%, deriva da ridotta sintesi epatica e da aumentato catabolismo delle VLDL.  I PUFA ω-3 determinano inoltre riduzione della lipemia post-prandiale, lieve aumento delle HDL ed anche delle LDL; quest’ultimo effetto sarebbe perς favorevole in quanto riferibile ad un aumento del volume anzichι del numero di queste particelle, la cui lesivitΰ θ  inversamente proporzionale alle dimensioni (59, 42). Per queste caratteristiche, che si associano a buona tollerabilitΰ e assenza di rilevanti interazioni farmacologiche,  I PUFA  ω-3 trovano indicazione nelle ipertrigliceridemia primarie e secondarie (55 ). Ne è stata inoltre dimostrata l’efficacia in soggetti con steatoepatite non alcoolica, condizione spesso associata a malattie cardiovascolari, sindrome metabolica  e diabete mellito (43)-

     

    ARITMIE

    Alcuni grandi studi clinici controllati (DART, GISSI, GISSI HF)  (9 , 40, 62) hanno dimostrato che il trattamento con PUFA ω-3 riduce il rischio di aritmie ed aumenta la sopravvivenza di soggetti infartuati e di pazienti con insufficienza cardiaca su base ischemica. Questi favorevoli risultati non hanno trovato conferma nello studio Alpha Omega (34 ), condotto  su soggetti anziani infartuati fino a 4 anni prima dell’inizio del trattamento con  PUFA ω-3 . Questa discordanza di risultati potrebbe essere spiegata con la minore entità della dose di ω-3 somministrata in questo studio, dal più tardivo inizio del trattamento e dall’uso di altri PUFA nel gruppo di controllo. I PUFA ω-3 svolgerebbero forse  una azione protettiva contro le aritmie in soggetti portatori di defibrillatori impiantabili, mentre non sembrano ridurre la ricorrenza di fibrillazione dopo cardioversione elettrica (8,19).

     

    IPERTENSIONE ARTERIOSA

    Secondo una metanalisi condotta su 36 studi clinici randomizzati la somministrazione di PUFA ω-3 si associa ad una lieve riduzione della pressione arteriosa (- 2,1 mm Hg per la sistolica, -1,6 mm Hg per la diastolica). Gli autori, considerando che la riduzione dei valori pressori osservata in questa metanalisi è minore rispetto a quella rilevata in singoli studi, attribuiscono la differenza al fatto che in alcune delle indagini da essi prese in esame i PUFA sono stati somministrati in forma non purificata e/o a bassa dose, mentre in altri la pressione arteriosa non era compresa tra gli end-point maggiori (11, 25).

     

    INSUFF CARDIACA CRONICA

    Miglioramenti della frazione di eiezione ventricolare sinistra associati al trattamento con PUFA ω-3, 1 g/die, sino stati osservati  nello Studio GISSI HF (28) come anche, a dosi di 4 g/die, dopo trattamento con 4 g/die per 3 mesi (45).

    Anche in soggetti con cardiomiopatia dilatativa la somministrazione di PUFA ω-3 per un anno si è associata ad aumento significativo della frazione di eiezione ventricolare sinistra (49). A questi rilievi fa riscontro quello di una significativa riduzione della concentrazione plasmatica di peptide natriuretico atriale in uno studio condotto su soggetti trattati con 2 g/die di PUFA ω-3 (70). Questi favorevoli risultati sono stati messi in relazione con  i già ricordati effetti dei PUFA sulla funzione endoteliale e con l’’effetto antiaritmico.

     

    INSUFFICIENZA  RENALE

    In soggetti con nefropatia diabetica e da IgA la somministrazione di PUFA ω-3 si è accompagnata a diminuzione della proteinuria ed a miglioramento del quadro lipidico, mentre in pazienti dializzati il trattamento si è associata a maggior durata degli accessi vascolari. Nei soggetti nefropatici,inoltre, i PUFA esercitano un sensibile effetto antiipertensivo (46) ed una elevata efficacia ipotrigliceridemizzante (21, 65,67)

     

    MALATTIE NEUROLOGICHE E PSICHICHE

    I PUFA ω-3 sono presenti in elevata concentrazione nel sistema nervoso centrale dei mammiferi, dove favoriscono le attività sinaptiche, proteggono l’integrità dei neuroni in condizioni di ischemia e svolgono attività antiapoptosica (44). Per questi motivi l’effetto dei PUFA è stato valutato nei confronti del danno ischemico, del declino cognitivo senile e della demenza di Alzheimer. I discordanti risultati di queste osservazioni, dipendenti anche da disomogeneità qualitativa e quantitativa dei trattamenti,  non permettono di trarre conclusioni (2, 26,30, 51,61,63)

    Risultati in gran parte positivi sono stati invece osservati nelle sindromi depressive, in particolare in quelle di maggior gtravità, in quelle perimenopausali,in  quelle senili e in quelle che accompagnano la malattia di Parkinson. Questa azione antidepressiva sembra dipendere soprattutto da EPA, mentre DHA avrebbe effetto molto minore  (3, 14, 20, 41, 54)

     

    NEOPLASIE

    Le alterazioni della fisiologia cellulare responsabili della comparsa e dello sviluppo delle neoplasie sono rappresentate da autosufficienza dei segnali di crescita, insensibilità ai segnali inibenti la crescita, attività antiapoptosica, illimitata capacità re plicativa, angiogenesi protratta,invasività e metastatizzazione, riprogrammazione del metabolismo energetico ed inibizione della distruzione immunitaria (32). La possibile capacità dei PUFA ω-3, in particolare di EPA e DHA, di proteggere  dalle neoplasie dipenderebbe da inibizione del metabolismo di AA, interferenza con le citochine coinvolte nella genesi delle neoplasie, inibizione dell’angiogenesi e della diffusione. In particolare i PUFA svolgerebbero, insieme ad un effetto antiinfiammatorio,  una azione antitumorale mediante processi immunomodulatori capaci di modificare la produzione di LT, PG, TX e di indurre la produzione di altre molecole come le resolvine e le protectine (4, 60). Queste potenzialità dei PUFA ω-3, rilevate in studi sperimentali, non hanno trovato adeguata conferma negli studi clinici nei quali, peraltro, la valutazione dell’apporto dietetico è soggetta ad un largo margine di errore; ma l’unico studio condotto con la somministrazione di EPA e DHA ha dimostrato che questa era significativamente associata ad un risotto rischio di neoplasia mammaria, mentre il consumo dii acidi grassi monoinsaturi era significativamente associato con un rischio aumentato (57).Appare verosimile che la discordanza di risultati sia da mettere in rapporto sia con la diversità delle dosi di PUFA, sia con la frequenza di mutazioni dei geni preposti al metabolismo dei PUFA (56).

    L’efficacia dei PUFA nei confronti dell’infiammazione ha stimolato numerose ricerche miranti a stabilirne l’efficacia in condizioni morbose caratterizzate da infiammazione. Risultati positivi sono stati riportati in alcune malattie respiratorie, in particolare asma, e in molte malattie reumatologiche in cui, come nel caso dell’artrite reumatoide e del lupus sistemico, i PUFA riducono significativamente la necessità di utilizzare i FANS (12). Efficacia è stata inoltre riferita in pazienti con malattie infiammatorie intestinali (24,29, 68, 64, 58).

     

    EFFETTI AVVERSI

    L’osservazione che i PUFA ω-3 possono far aumentare il tempo di sanguinamento e quindi favorire emorragie in soggetti a rischio in quanto trattati con aspirina o anticoagulanti ovvero sottoposti a interventi su cuore o arterie ha dato luogo a vari studi clinici controllati il cui esito ha escluso questo rischio. La capacità dei PUFA ω-3 di favorire la comparsa di diabete mellito tipo 2 è stata oggetto di vari studi, che hanno fornito risultati contrastanti. Mentre lo Studio Womens’ Health Initiative ha mostrato che l’apporto di PUFA ω-3 superiore a 2 g/die  si associa ad una incidenza significativamente maggiore di diabete (17), è stato rilevato che  il DM2 è meno frequente nelle popolazioni con elevato consumo di prodotti ittici (48). Una recentissima metanalisi, condotta su studi relativi agli effetti del consumo di pesce e di prodotti a base di PUFA ω-3 non ha mostrato alcuna significativa associazione con l’incidenza di diabete, mentre ha rivelato l’esistenza di una notevole eterogeneità di risultati che comunque appaiono prevalentemente favorevoli (53, 69).

    In conclusione, a fronte di valide documentazioni di efficacia in varie condizioni morbose, il valore terapeutico o preventivo dei PUFA non è ancora ben definibile la maggior parte delle ricerche cliniche finora condotte presentano aspetti criticabili relativamente a differenze  qualitative e/o quantitative nell’alimentazione ittica, diversità genetiche, diversità in composizione e purezza dei preparati di PUFA.

    In particolare varie metanalisi, come quella di Rizos +(  ), dalle quali non risulta alcun effetto benefico dei PUFA, presentano vari aspetti discutibili: l’inserimento nelle casistiche esaminate di soggetti trattati sia con modificazioni alimentari sia con preparati di PUFA e, in questi ultimi, con dosi variabili da 1 a 6,2 g/d e con contenuto in PUFA variabile e con rapporto EPA/DHA compreso fra 0,5 e 2 (ricordiamo che nei preparati disponibili in Italia il contenuto in PUFA è non inferiore all’85% e che il rapporto EPA/DHA è compreso tra 0,5 e 1,5); in alcune casistiche, peraltro,  era somministrato solo EPA.. La durata mediana del trattamento, inoltre, era compresa tra  1 e 6,2 anni con mediana di 2 anni, quindi con alcuni studi durati troppo poco per valutare la capacità preventiva nei confronti di molte affezioni, soprattutto  cardiovascolari eneoplastiche. Altri problemi sono rappresentati dalla possibile influenza degli altri trattamenti attuati nei soggetti studiati, in particolare quelli con statine, anticoagulanti r antiaggreganti e con altri farmaci attivi sull’apparato cardiovascolare. Appare evidente la necessità di ulteriori indagini controllate condotte in popolazioni  omogenee con una stessa fonte di PUFA avente contenuto adeguato sia di EPA che di DHA nelle proporzioni standard .

    .

    FONTI ALTERNATIVE DI PUFA OMRGA-3

    L’apporto di PUFA ω-3 mediante consumo di pesce trova alcune limitazioni, rappresentate dal progressivo  depauperamento del patrimonio ittico provocato dal continuo aumento della pesca e in particolare dall’impiego di metodi che non ne rispettano l’ecosistema; un’altra importante limitazione è costituita dalla contaminazione da metilmercurio, che secondo i dati del Natural Resource Defense Council statunitense è elevatissima nei pesci predatori (fra cui Pesce spada, Cernia, Pesce specchio atlantico, Maccarello reale, Squalo, Sgombro reale) ed elevata in molti altri (fra cui Branzino, Ombrina, Halibut,  Trota di mare, Pesce serra, Tonno). In tutti i casi la concentrazione di mercurio nelle carni di questi pesci è proporzionale alle loro dimensioni: infatti gli esemplari di maggiori dimensioni divorano quelli più piccoli e il mercurio così assunto non viene eliminato. Per quanto riguarda il tonno va considerato che il contenuto in mercurio, è minore nelle confezioni in scatola poiché queste sono preparate con gli esemplari più piccoli. Basso contenuto in mercurio caratterizza invece aringhe, alici, naselli, sardine e sogliole. A questo proposito è opportuno ricordare che nelle capsule contenenti olio di pesce, disponibili in molti paesi anche europei la presenza di mercurio è trascurabile in quanto questo metallo nelle carni dei pesci è legato in grandissima parte alle proteine e ben poco alla frazione lipidica.

    I problemi legati al consumo di pesce e le incertezze sul valore dei preparati disponibili in commercio  hanno indotto a cercare fonti alternative di PUFA. Tali ricerche riguardano gli oli provenienti da vegetali (soprattutto di Boraginaceae e Primulaceae) contenenti ac. stearidonico quale precursore di EPA e soprattutto l’olio di alghe, in particolare della varietà Schizohytrium, molto ricca di DHA (38).

    Ma oltre ai vegetali e alle alghe, una risorsa è rappresentata dalle noci, particolarmente ricche in acido α-linoleico (ALA), e cioè del precursore di acido eicosapentaenoico (EPA) e di acido docosapentaenoico (DPA). Gli effetti del consumo di noci sono stati oggetto di uno studio, pubblicato nel novembre 2013,  condotto su due ampie coorti di professionisti sanitari (76.464 donne seguite per 30 anni (1980 – 2010) nel Nurses’ Health Study e 42.464 uomini seguiti per 25 anni (1986 – 2010) nel Health Professionals Follow-up Study) per un totale di oltre 3 milioni di persone-anno.

    Lo studio, nel corso del quale si sono registrati 16.200 decessi tra le donne e 11.229 tra gli uomini,  ha preso in esame il rapporto tra consumo di noci e letalità totale e causa-specifica.

    Il consumo di noci è risultato significativamente associato in misura inversa con la letalità in entrambe le coorti; questa associazione è risultata tanto più stretta quanto maggiore era il consumo settimanale di noci. L’associazione inversa è risultata ugualmente significativa per le morti provocate da neoplasia, cardiopatia e malattia respiratoria (6).

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    Dai fattori di rischio allo scompenso cardiaco cronico   

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    DAI FATTORI DI RISCHIO ALLO SCOMPENSO CARDIACO CRONICO

     

    Claudio Di Veroli

    Specialista in Nefrologia, Malattie del Fegato e del Ricambio, Malattie dell’Apparato Digerente.
    Docente di Nefrologia - Università di Roma “Sapienza”.
    Centro dell’Ipertensione Arteriosa e delle Malattie Metaboliche e Renali.

    Casa di Cura “San Domenico” - Roma



    ABSTRACT

    Lo scompenso cardiaco cronico o insufficienza cardiaca cronica è un’importante modificazione strutturale (rimodellamento) e funzionale del cuore, che nel tempo si manifesta con segni e sintomi, tra cui quelli più rilevanti sono i disturbi respiratori. Le cause sono molteplici, ma possiedono un ruolo considerevole, in un “continuum cardiovascolare”, i fattori di rischio cardiovascolare e tra questi l’ipertensione arteriosa è prevalente con un’alta percentuale.

     

    DEFINIZIONI E DIMENSIONE EPIDEMIOLOGICA DEL PROBLEMA

    Le numerose definizioni dello scompenso cardiaco cronico (o insufficienza cardiaca cronica) tendono ad evidenziare soltanto alcuni aspetti specifici di questa sindrome complessa. Nessuna definizione, anche di organizzazioni autorevoli, però può essere considerata pienamente soddisfacente, perché non esistono valori di riferimento certi della disfunzione cardiaca che possano essere impiegati in modo attendibile per identificare i soggetti con uno scompenso cardiaco.

    La diagnosi di tale patologia è attualmente basata sulla valutazione clinica, ovvero sulla storia clinica, sull’esame fisico e su appropriate indagini strumentali. Nonostante queste premesse “La Società Europea di Cardiologia” ritiene che le componenti essenziali per definire lo scompenso cardiaco debbano comprendere:

    • I sintomi dello scompenso (a riposo o durante sforzo),
    • I segni obiettivi della disfunzione cardiaca (a riposo),
    • Un’adeguata risposta alla terapia (in caso di diagnosi dubbia).

     

    Nel 1935 (Poole-Wilson) fu proposta un’interessante definizione dello scompenso cardiaco, ma sempre su base strettamente clinica E’ una sindrome clinica, causata da una cardiopatia che ha determinato anomalie strutturali o funzionali ed è caratterizzata da un tipico quadro emodinamico, renale e neuro-ormonale”.

    In precedenza nel 1933 un cardiologo (Sir Thomas Lewis)ci ricorda che “Il fulcro principale della cardiologia deve consistere nel precoce riconoscimento dello scompenso cardiaco”.

     

    La tabella 1 riporta la nota classificazione dello scompenso, secondo la New York Heart Association (NYHA), che si basa esclusivamente sui segni e sui sintomi respiratori. Questa classificazione ci fa vedere con chiarezza, attraverso quattro classi, la storia naturale dello scompenso cardiaco: dalla fase senza disturbi respiratori, ma con la terapia, ad una fase con gravi disturbi (dispnea) nonostante un appropriato trattamento farmacologico.

    Lo scompenso cardiaco, ovvero la difficoltà che ha il cuore di adempiere alle sue normali funzioni per la grave dilatazione o rimodellamento, costituisce il momento finale e comune di tutti i processi patologici a carico del miocardio e del sistema coronarico, con possibilità nel tempo di incidere sempre più in modo negativo sulla qualità della vita e sulla sopravvivenza. Proprio questa, più o meno lenta progressione verso lo scompenso per le alterazioni strutturali e funzionali con i relativi sintomi (dispnea, astenia, ecc.) e segni (edemi, rantoli, ecc.), viene generalmente definita come un continuum cardiovascolare nella storia naturale della malattia.

    La prevalenza di morbilità e di mortalità attribuite allo scompenso cardiaco è elevata, la sopravvivenza è scarsa ed il trattamento non è sempre risolutivo. Il tasso di ospedalizzazione tra i 45 ed i 64 anni è andato aumentando dall’8,2 per 10.000 nel 1971, al 33,8 per 10.000 nel 1994. Si calcola che in Italia, come negli Stati Uniti d’America, l’insufficienza cardiaca sia presente nell’1% della popolazione generale e nel 10% della popolazione anziana (>65 anni). Studi prospettici ci informano che l’incidenza dello scompenso aumenterà negli anni nelle persone con oltre 65 anni. In particolare, nel 2026 i soggetti con oltre 75 anni affetti da tale forma morbosa saranno triplicati rispetto al 1996. Nei paesi industrializzati, pertanto, rappresenta un considerevole problema di sanità pubblica.

     

     

    L’IMPORTANZA DEI FATTORI DI RISCHIO CARDIOVASCOLARE PER LO SCOMPENSO CARDIACO

    L’importate studio di “Framingham” ha posto per primo l’attenzione sui fattori di rischio cardiovascolare nel favorire lo scompenso cardiaco prima e durante il continuum cardiovascolare. Tra questi fattori (noxae patogene) sicuramente l’ipertensione arteriosa gioca un ruolo rilevante (30-40% dei pazienti è iperteso!); infatti, proprio questo studio ha dimostrato, tra l’altro, che anche a parità di livelli di pressione arteriosa il paziente iperteso con la coesistenza di una ipertrofia ventricolare sinistra (ovvero con la presenza di un altro fattore di rischio cardiovascolare) ha una prognosi peggiore rispetto al soggetto iperteso senza ipertrofia ventricolare sinistra. In particolare, desideriamo ancora sottolineare, che una coorte del Framingham Study (n=9.404) è stata seguita per 40 anni, per evidenziare quale tipologia di paziente andasse incontro allo scompenso cardiaco congestizio. Tra i soggetti di sesso maschile (n=331) e quelli di sesso femminile (n=321) che hanno sviluppato lo scompenso cardiaco, rispettivamente il 35% ed il 37% dei soggetti, erano portatori soltanto di ipertensione arteriosa, mentre il 40% di entrambi i sessi erano nel contempo ipertesi e coronaropatici. A questo proposito non possiamo tralasciare di ricordare come anche le sole malattie coronariche (macro- micro-angiopatiche), specie nei paesi industrializzati, generino insufficienza cardiaca con una percentuale intorno al 20%.

         È difficile però che un soggetto abbia un solo fattore di rischio cardiovascolare. Essi tendono prima o poi a presentarsi in maniera associata (cluster) ed integrata nelle stesse persone. In particolare, le alterazioni metaboliche sono più frequenti negli ipertesi e l’ipertensione è più frequente nei soggetti con dismetabolismi, specialmente con il diabete del 2° tipo. La Tabella 2 ci fa vedere, secondo le  Linee Guida del 2007 dell’ipertensione arteriosa, i fattori di rischio che possono favorire lo scompenso cardiaco, alcuni di essi, specie i metabolici, attraverso la via del danno aterosclerotico coronarico a livello macro- e micro-angiopatico.

                In tutti i casi è molto importante identificare precocemente e con certezza il fattore o i fattori di rischio, in modo da rallentare con appropriati trattamenti l’evoluzione verso lo stato di scompenso più o meno manifesto.

     

     

    DAI FATTORI DI RISCHIO ALLO SCOMPENSO CARDIACO

    I processi che colpiscono il cuore possono avere un esordio acuto, essere insidiosi e subdoli e/o avere una maggiore o minore base genetica. Inizialmente, se non opportunamente corretti da un’appropriata terapia, determinano un’alterazione funzionale del ventricolo sinistro (disfunzione ventricolare), che può essere sistolica, per una ridotta contrattilità del miocardio con conseguente alterato stroke volume (il cuore non si contrae sufficientemente) oppurediastolica, per un alterato rilasciamento con conseguente modificato riempimento ventricolare (il cuore non si riempie sufficientemente). In particolare, nell’iperteso queste due disfunzioni possono coesistere: ad un’iniziale alterata funzione diastolica, che si associa all’ipertrofia ventricolare sinistra (iniziale rimodellamento o modificazione della forma), si può aggiungere la disfunzione sistolica, quando il ventricolo riduce le sue proprietà contrattili (cioè diminuisce l’effetto pompa, a causa di un grave rimodellamento)(Tabella 3).

     

     

    DAL MODELLO CARDIO-RENALE A QUELLO COMPOSITO: EMODINAMICO E NEURO-ORMONALE

    Il primo modello dell’insufficienza cardiaca è stato quello della teoria cardio-renale (1950-1960 circa) ove si riteneva sostanzialmente che la ridotta compliance cardiaca non fosse in grado di garantire un accettabile ed adeguato volume ematico alle richieste dell’organismo (scompenso anterogrado). Conseguenze di tale situazione erano considerate l’edema, a causa di una ridotta escrezione idro-elettrolitica, ed il decremento dell’accoglimento del sangue verso l’atrio destro con successivo incremento della pressione intravascolare (scompenso retrogrado).

                Successivamente prende corpo il modello della teoria emodinamica o cardio-circolatoria (1960-1980 circa) che considerava l’alterazione cardiaca (noxa) causa della riduzione della forza contrattile cui faceva seguito una cronica costrizione periferica riflessa di tipo artero-venosa. Si veniva a determinare un disordine emodinamico, ovvero una costrizione venosa (aumento del pre-carico) ed una costrizione arteriosa (aumento del post-carico) con difficoltà di perfusione ad organi ed apparati ed incremento ulteriore di lavoro per il muscolo cardiaco sino allo scompenso. La riduzione della perfusione interessava pertanto i muscoli, con conseguente deficit motorio, e i reni che, attraverso la ritenzione idro-salina, favorivano gli edemi. Si effettuavano terapie centrate su farmaci inotropi positivi e vasodilatatori periferici. Questi inducevano un miglioramento clinico, ma non risolvevano il problema di fondo.

                Il modello emodinamico, tecnicamente perfetto, venne però migliorato da osservazioni scaturite dai grandi trial clinici agli inizi degli anni ’80, ove vennero affrontate, con metodiche più avanzate, le problematiche legate allo scompenso cardiaco e alle sue anormalità. La domanda che gli Autori/Ricercatori si posero era: “La terapia utilizzata era in grado di modificare la storia naturale di questa sindrome, gravata ancora da un alto tasso di mortalità”? La risposta data fu “no”: “La terapia in uso non modificava la mortalità di queste persone”. Verso la fine degli anni ’80, infatti, alcuni studi scandinavi identificarono l’uso, apparentemente illogico, dei beta-bloccanti nello scompenso cardiaco: emergeva così il concetto neuro-ormonale che arricchiva quello dello squilibrio emodinamico.Iniziarono a questo punto studi clinici con farmaci capaci di antagonizzare l’iperattività del sistema adrenergico e successivamente anche del sistema renina-angiotensina-aldosterone sull’end-point primario che era la riduzione della mortalità.I risultati chiarirono in tempi relativamente brevi che l’antagonismo verso i sistemi neuro-ormonali alterati migliorava la morbilità e la mortalità cardio-vascolare.

                In seguito furono identificati altri sistemi, variamente interagenti, che contribuivano anch’essi al decremento della funzione cardiaca (sistema nervoso parasimpatico, arginina-vasopressina, peptide natriuretico atriale, peptide natriuretico cerebrale, prostaglandine, tumor necrosis factor, endotelina, ecc.).

     

     

    I PRINCIPALI SISTEMI NEURO-ORMONALI ALTERATI

    Il sistema adrenergico (sistema simpatico) è profondamente alterato nelle sue funzioni durante il lento e progressivo divenire che porta allo scompenso cardiaco (continuum cardiovascolare), favorendo un vero e proprio rimodellamento del muscolo cardiaco (miocardio). Nel muscolo cardiaco i nervi del simpatico diventerebbero mal funzionati e potrebbero perdere la loro ordinata capacità di sintetizzare, immagazzinare e rilasciare noradrenalina.Queste condizioni favorirebbero una continua stimolazione adrenergica, con aumento del consumo di ossigeno, modificazione dell’espressione delle proteine contrattili, ipertrofia ventricolare e perdita di miociti funzionanti (anarchia adrenergica).

    L’altro sistema che viene fortemente interessato nello scompenso cardiaco è il sistema renina-angiotensina-aldosterone che è presente in molti tessuti ed organi dell’organismo. Quando il sistema viene attivato, come nello stress meccanico (da ipertensione), può sovra-esprimersi, svolgendo in tal modo alcune importanti funzioni che possono risultare “esagerate”, come la regolazione del tono dei vasi coronarici, l’azione inotropa positiva, l’azione cronotropa positiva, lo stimolo alla crescita delle cellule miocardiche (ipertrofia dei cardiomiociti) e lo stimolo alla crescita dei fibroblasti (fibrosi del miocardio). Tale condizione è in vari modi anche favorita dall’aldosterone che è presente in eccesso e che aggrava ulteriormente lo scompenso cardiaco.

    Esistono, abbiamo accennato, altre sostanze e sistemi che giocano un importante ruolo nello scompenso cardiaco, come il peptide natriuretico cerebrale (BNP), che è un marker di scompenso cardiaco (indicatore di un’elevata pressione intra-cardiaca) con un buon valore diagnostico e prognostico perché consente di monitorizzare il trattamento. A proposito di diagnosi più recentemente lo studio BACH (Biomarkers in Acute Heart Failure) ha dimostrato la non inferiorità diagnostica del MR-proANP (Mid-Regional pro-Atrial Natriuretic Peptide)(>120pmol/l) rispetto al BNP (>100 pg/ml), consentendo pure di monitorare la terapia.

     

     

    LE PRINCIPALI MANIFESTAZIONI CLINICHE DELLO SCOMPENSO CARDIACO

    Le manifestazioni cliniche possono essere così brevemente distinte, oltre, ovviamente, all’aspetto e alle condizioni generali del soggetto:

    1.     Alterazioni respiratorie:

    o   Dispnea: nelle fasi precoci compare soltanto dopo sforzo, successivamente, con l’avanzare dello scompenso si arriva ad uno stato dispnoico anche a riposo o per sforzi moderati.

    o   Ortopnea: dispnea che impedisce di rimanere in posizione supina, è una manifestazione tardiva dello scompenso cardiaco.

    o   Dispnea parossistica notturna: con l’asma cardiaco e l’edema polmonare esprime e rappresenta una grave insufficienza del ventricolo sinistro, che non riesce a mantenere un’adeguata portata cardiaca.

    o   Respiro di Cheyne-Stokes: a seguito di una diminuita sensibilità verso il centro respiratorio, vi è una fase di apnea ed una fase di respirazione (respiro periodico o ciclico).

    o   Rumori o crepitazioni da stasi polmonare, con trasudazione di fluidi negli spazi interstiziali.

    2.     Altri sintomi:

    o   Aumentata probabilità aritmica.

    o   Anemia per il decremento del flusso di sangue a livello renale  (ridotta portata cardiaca) con  conseguente ipoproduzione di eritropietina.

    o   Affaticamento e debolezza.

    o   Sintomi addominali: anoressia, nausea e dolori (prevalentemente per congestione).

    o   Sintomi cerebrali: specie gli anziani possono avvertire uno stato di confusione in relazione alla ridotta perfusione cerebrale.

    o   Ma anche: nicturia, oliguria, edemi declivi, turgore delle giugulari, ecc.

     

     

    LA LOGICA E I PRINCIPI DELLA TERAPIA

    La logica del trattamento dello scompenso cardiaco è quella di limitare l’iperfunzione neuro-ormonale (la sovra-esposizione) e di migliorare l’emodinamica. Seguendo i filoni di ricerca attuali possiamo considerare:

    ·      La riduzione dell’aumentata attività adrenergica (utilizzo di beta-bloccanti ed alfa-beta-bloccanti);

    ·      L’antagonismo delle azioni negative del sistema renina angiotensina-aldosterone (impiego di ACE-inibitori, antagonisti recettoriali dell’angiotensina II ed anti-aldosteronici).

    Per quanto riguarda gli anti-aldosteronici lo studio EMPHASIS-HF (Eplerenonein Mild Patients Hospitalization and Survival Study in Heart Failure) ha dimostrato in tempi relativamente recenti che nello scompenso cardiaco, specie se sintomatico ed unitamente al classico trattamento, può essere indicato l’utilizzo dell’eplerenone (25-50 mg/die) anche per livelli di insufficienza cardiaca molto elevata (FE <35%), che controindica l’utilizzo dei classici anti-aldosteronici.

                Secondo un sotto-progetto dello studio SHIFT (Systolic Heart failure treatment with the If inhibitor ivabradine Trial) anche l’ivabradina (derivato del verapamil) potrebbe essere utilizzata in questi casi. E’ stato dimostrato infatti che nei soggetti con scompenso cardiaco cronico, ma con un ritmo sinusale sotto-trattati o non trattati con i beta-bloccanti, l’end-point primario (morbilità o mortalità cardiovascolare per insufficienza cardiaca) risultava ridotto in modo significativo nei soggetti che erano stati trattati con ivabradina.

    Non va tuttavia dimenticata la storica terapia diuretica dell’ansa e digitalica, che peraltro, al momento attuale delle nostre conoscenze, non modifica in modo significativo la progressione verso lo scompenso cardiaco e la morte, progressione che invece è ridotta dall’antagonismo neuro-ormonale. La loro efficacia è legata essenzialmente ad un miglioramento dei segni e dei sintomi legati alla ritenzione di fluidi (edema, congestione). I diuretici dell’ansa si preferiscono se coesiste una ridotta funzione renale, altrimenti si dovrebbero impiegare i sodiuretici, e la digitale (digossina), con incremento per quest’ultimo prodotto dell’inotropismo a causa di un’aumentata concentrazione di calcio a livello delle cellule cardiache.

                Il trattamento deve anche prevedere un’energica correzione dei fattori di rischio cardiovascolare (Tabella 3), che possono alterare ulteriormente la muscolatura del cuore e il sistema delle coronarie e l’utilizzo di sostanze (nitrati) per migliorare il pre- e post-carico. Accanto alla terapia specifica dello scompenso non dobbiamo dimenticare altre terapie, come quella anticoagulante o anti-piastrinica (rischio trombo-embolico) ed anti-aritmica (20-25% dei casi).

    La terapia farmacologica, infine, deve sempre seguire ed essere accompagnata da un trattamento non farmacologico o meglio da un miglioramento dello stile di vita. Questo consiste essenzialmente in un vitto quantitativamente con poche calorie e, per qualità, orientato all’utilizzo in prevalenza di carni bianche (pesce, coniglio, tacchino, pollo e faraona), di frutta e di verdure associate ad olio extra-vergine di oliva (no vergine di oliva) e ad una ridotta assunzione del sale da cucina (4-5 g/die). Una discreta attività fisica di tipo aerobica, effettuata per almeno tre volte la settimana accompagnata da alcune passeggiate specialmente nei giorni senza attività fisica, devono completare la terapia, che in una parola può risultare e venir definita come “un eccellente stile di vita”, se eseguita nel suo insieme con scrupolo.

     


    Tabella 1 - CLASSIFICAZIONE DELLO SCOMPENSO SECONDO LA NEW YORK HEART ASSOCIATION (NYHA)
    I segni e i sintomi dello scompenso (valutazione obiettiva) possono essere utilizzati per stabilire in classi la severità della sindrome (capacità funzionale) e per monitorare gli effetti della terapia.

     

    Classe I - SCOMPENSO ASINTOMATICO
    Nessuna limitazione:l’attività fisica abituale non provoca astenia, dispnea, né palpitazioni (i pazienti devono avere segni obiettivi di disfunzione cardiaca e nell’anamnesi sintomi di scompenso ed essere in terapia con farmaci utili per porre in equilibrio funzionale lo scompenso).

    Classe II - DISPNEA PER SFORZI INTENSI
    Lieve limitazione dell’attività fisica:benessere a riposo, ma l’attività fisica abituale provoca affaticamento, dispnea, palpitazioni o angina pectoris.

    Classe III - DISPNEA PER SFORZI LIEVI
    Grave limitazione dell’attività fisica:benessere a riposo ma attività fisiche di entità inferiore a quelle abituali provocano sintomi sino a quelli di tipo coronaropatici.

    Classe IV - DISPNEA A RIPOSO
    Incapacità a svolgere qualsiasi attività senza disturbi: sintomi e segni di scompenso sono presenti anche a riposo, con aumento dei disturbi ad ogni minima attività.

     

     

    Tabella 2 - FATTORI  DI  RISCHIO CARDIOVASCOLARE SECONDO LE ULTIME LINEE GUIDA DELL’IPERTENSIONE ARTERIOSA (2007)

    • Livelli elevati di pressione sistolica e diastolica,
    • Pressione differenziale elevata (anziani),
    • Sesso maschile >55 anni, Sesso femminile >65 anni,
    • Abitudine al fumo,
    • Glicemia a digiuno 5,6-6,9 mmol/l (102-125 mg/dl) (intolleranza glicidica),
    • Glicemia post-prandiale alterata >11,0 mmol/l (198 mg/dl),
    • Diabete 2° tipo (glicemia a digiuno ≥126 mg/dl),
    • Colesterolo totale >5,0 mmol/l (190 mg/dl) o colesterolo LDL >3,0 mmol/l (115 mg/dl) o colesterolo HDL  M <1,0, F <1,2 mmol/l (M 40, F 46 mg/dl),
    • Trigliceridemia >1,7 mmol/l (150 mg/dl),
    • Familiarità per malattie cardiovascolari precoci (M <55 anni e F <65 anni),
    • Obesità addominale (circonferenza addominale nel sesso maschile ³102 cm, nel sesso femminile ³88 cm).

     


    Tabella 3 – SCHEMA DELLA STORIA NATURALE DELLO SCOMPENSO CARDIACO CRONICO

    Ipertensione e/o altri fattori di rischio cardio-vascolare

    non modificabili e modificabili (noxae patogene)

    si inizia a determinare lo stato disfunzionale del miocardio

    Danno cardiaco favorito anche

    da pregresse o concomitanti malattie

    lesioni del miocardio, delle coronarie e/o del microcircolo

    Alterazioni neuro-ormonali, microangiopatie,

    modificazioni emodinamiche con riduzione della portata renale,

    alterazioni flogistiche (sovra-espressione di citochine e chemochine), modificazioni metaboliche, ecc.

    progressiva riduzione di efficacia dei meccanismi di compenso, rimodellamento ventricolare

     ed aumento di angiotensina II ed aldosterone

    Ulteriore riduzione dell’inotropismo cardiaco

    graduale incremento delle resistenze periferiche (pre- e post-carico) e del riassorbimento idro-salino

    Ulteriore perdita della funzione cardiaca sino allo scompenso

    che da asintomatico diventa francamente sintomatico

     


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