Sunday, November 24, 2019

Child Welfare essays

Child Welfare essays Child welfare is a set of government and private services that protects children and encourages family stability. These services include investigations of alleged child abuse, foster care, adoption services, and services that can provide support at-risk families so that they can remain intact especially in poorer countries where the government infrastructure is much weaker (Child Welfare 2003). However, there are many challenges that child welfare is facing due to lack of funding and resources. Some of these challenges come from child abuse, where parents' rights come first rather than the childs best interest. Another challenge is adoption because so many potential parents are rejected due to their race and more children are left limbo (Bartholet 1999).. There are solutions for these issues; however they remain unused, which puts child welfare into an unfair position. Despite the issues, there are still debates if gay adoption should be allowed because some people believe that lesbians and gay men encourage homosexuality even though there are others that believe that they can provide a stable home. Along with that, it has been proven children from divorced parents or have other issues have problems with low self-esteem and social competence because they left out from one or both parents. This is due to the fact that the parent is usually self-absorbed from their own emotional pain, which causes them to unintentional neglect their son or daughters needs. By this occurring, children become very withdrawn in the classroom even though they do attempt express their emotional pain to their teacher. From there, it has been concluded from research divorced children have more emotional and social issues than those who come from a two-parent home. The present findings support in part Holland's position that persons tend to become like the dominant persons in the environment. Daughters whose mothers and...

Thursday, November 21, 2019

Drugs Essay Example | Topics and Well Written Essays - 500 words

Drugs - Essay Example An example would be, if a person gets addicted to heroine, it is almost impossible to quit. Even though there are other soft drugs like marijuana, and others still they are addictive. And, in this light drugs should be made illegal as they are harmful to people. I strongly, propose that drugs should be made illegal. Another side of the problem is Why should drugs be legal Drugs are used for lot of other useful remedies, and keeping it illegal causes some problems. Government should do something to control the drug problem. It should make people aware that abuse of drugs is illegal. Illegal use of drugs causes several problems of social and criminal nature. This leads to many drug violators and serious offenders behind the bars. The money and expense used in managing the drug related problem is very big. It makes government spend too much money to buildings which are needed to accommodate these criminals. This is also a burden on the taxpayers, and nobody likes this situation. "it is possible to stop most drug addiction in the United States within a very short time. Simply make all drugs available and sell them at cost" (Vidal 384). I think this part is important to support the legalizations. The drugs are now spread out to the black market such as mafia. It relates with money, they make lots of money from drug businesses. However if government make that legal and sell it at cost, then black market could not sell the drugs illegally. The active part to control and legalize the drugs will help solve the problem. The second part of the problem is when it is illegal? Drugs have deep impact on the minds of the people, which make them get involved in crime.

Wednesday, November 20, 2019

Practical report Essay Example | Topics and Well Written Essays - 2000 words

Practical report - Essay Example The contents include fats, carbohydrates and proteins. The enzymes that break apart DNA are thereafter destroyed (Bruns 2007, 50). DNA content is then separated from other cell components. The researcher then precipitates the DNA and re-suspends it in a solution suitable for its studies. When extracting DNA from the cheek cells, saline solution used to rinse the mouth helps to prevent the cells extracted from splitting open or lysing too soon. Centrifugation separates the cheek cells from mouth wash used (Johannson 1972, 39). Spinning the mixture in a centrifuge settles the heavier cells to the bottom of the tube to form pellets. Saline solution pours away, leaving the clumped cheek cells at the bottom of the tube. Lysis buffer added to the cell clump splits open the cells to release DNA from inside the nucleus. The buffer contains soap that dissolves and breaks fatty membranes of the cells, buffer that maintains the pH of the solution and ions that increase osmotic pressure outside the cheek cell and aids in ripping open the cell membrane. Incubation in hot water helps denature cytoplasmic enzymes that break up DNA. Concentrated salt solution changes polarity of the solution under study. DNA elements dissolve in ionic solutions. This is as opposed to other components of the solution; proteins, carbohydrates and fats. ... The process is additionally useful in assessing and distinguishing the variable sizes of alleles. This discerning of allele sizes best takes place with the DNA strands placed at a single locus. Gel Electrophoresis also assesses the quantity and quality of DNA that is present in a sample (Komrakova 2006, 51). This method separates chemical molecules and compounds by charge and size. Substances that are separated are stationed in wells in the agarose gel and an electric field applied. Positively charged molecules and compounds move towards the negative terminal while the negatively charged particles and compounds move towards the positive anode. Larger and longer particles experience difficulty in moving across the mixture to the positive or negative terminal, and are suspended in the gel matrix. Smaller and shorter molecules move easily through the agarose gel matrix and take positions according to their polarity. When strained, the small sized segments form a tight band as they move at relatively the same speed. Type of medium and concentration of the gel determines the gel’s pore size and its ability to segregate same sized fragments. While polyacrylamide gels separate DNA segments differing by a base pair, agarose gels separate fragments of DNA differing by hundreds or more base pairs. Combs forming wells are placed into the gel as it solidifies and cools. The combs are then removed after the gel solidifies. Students can use gel electrophoresis in determining quality and quantity of the DNA matter they extract from their cheek cells. In day-to-day applications, the method is useful in fingerprinting or profiling, DNA sequencing and genetic

Sunday, November 17, 2019

MHE503 Survey of Emergency and Disaster Mgt Module 1 Case Essay

MHE503 Survey of Emergency and Disaster Mgt Module 1 Case - Essay Example Tsunamis are undersea-bed earthquakes that create a great effect on the water above the surface. However, in the case of the Indian Ocean tsunami of 2004, there were no specific indications that something was already happening in the seabed. This is the reason why it was not that easy for the resort goers to immediately flee from the area towards a safer place. They were all caught in surprise when the water waves began splashing huge amounts of water to the sea shore killing hundreds of people who were just sitting and resting around the area. The waves were big and disastrous along with the mixed heavy winds that it comes along with. The complete disaster was even forcefully controlled by the unwillingness of some to flee away from their houses near the sea area believing that this was just a simple sea wave change. Little did these people know that this was a huge tragedy that waits to devastate their lives. Besides the natural reaction of the earth from heating up, the human works of denuding the forests made it harder for nature to control the situation itself. Apparently, the reduction of such trees limited the possibility and the capability of the warmed up earth to cool itself down. Besides this, the lack of signs from the actual behaviour of the sea from where the tsunamis are already happening below its sea bed made it hard for the people to tell that something wrong was going to happen. The bubbling or frothing of the sea at the top portion which is seen by the people has not happened and was not able to signal the people around. Basically, caused by the imbalance in nature, even this warning was not undergone properly by the process that was supposed to give a cue as to what was going to happen next. The incapability of the people to tell made the disaster even more tragic for the human population living within the areas affected. As seen from the television news, some of the tourists were even enjoying the cool breeze of the air when the waves suddenly turned gigantic eating them out from the seashore towards the sea's center turbulent area. Without the capability of the earth to support the need of limiting such disasters from happening, the earthquake lasted for at least several minutes that were enough to kill thousands within Thailand, Indonesia and Sri Lanka. This disaster reminds people at present that apparently, too much development may cause devastation on the capability of the earth to heal itself. No matter how prepared people could be, no matter how knowledgeable they may seem about the occurrence of such devastating events in the natural environment, it could not be denied that the imbalance of the earth's temperature and composition makes all these efforts of being prepared worthless. This is the reason why the Hokkaido incident was less damaging compared to the properties lost and the lives that were taken from that of the occurrence of the Indian Ocean earthquake of 2004. What mitigation and/or

Friday, November 15, 2019

Patient with Congestive Heart Failure

Patient with Congestive Heart Failure Patient S.V. is a 54 years old female. She is a postmenopausal housewife and her family history is not being recorded. She is a non-smoker and does not drink alcohol at all. She has no-known drug allergic. The past medical history showed us that Madam S.V. is having, rheumatoid arthritis (RA), hypertension (HPT) for 10 years and diabetes mellitus (DM) for 7 years. She was admitted to the hospital on few weeks ago due to congestive heart failure. Madam S.V.s drugs history include: T. furosemide 40mg od Oedema HF T. perindopril 4mg od HF HPT T. spironolactone 25mg od HF T. Losec (Omeprazole) 20mg bd Duodenal ulceration P. Calcium lactate 1 puff od Calcium supplement T. Rocatriol 0.25mg bd Vitamin D supplement T. Metformin 500mg bd DM T. folate 5mg od Folate deficiency T. Methotrexate 20mg/week RA Clinical data The abnormal result of FBC may due to folate deficiency that caused by side effect of methotrexate. Besides that, patient was having high neutrophil number for his differential count which is 8.7 k/ µL (normal range 1.9-8.7 k/ µL). This may due to the long-term use of corticorsteroid. Patients total carbon dioxide in the blood was two times higher than normal range (23-27 Vol%). Prothrombin time and INR of the patient was low: PT =11.1 sec (normal range = 11.9-14.5 sec), INR = 0.82 (normal range 2-4). However, the reason is unknown. Diagnosis ECG and chest X-ray were carried out and the results showed that patient was having sinus tachycardia and cardiomegaly. Cardiovascular system of patient also had been checked. It found that the patient was having a 3rd heart sound. Hence, the patient was diagnosed with congestive heart failure (CHF). Clinical progress DAY 1 Patient is admitted to the hospital at 10.30am by ambulance. She is weak but conscious and alert. The patient complains that she is shortness of breath (SOB) and her sleep has been interrupted due to SOB. It can also be considered as paroxysmal nocturnal dyspnoea (PND) which is sudden, severe SOB at night that awakes a person from sleep, often coughing and wheezing. At the same time, she also experiences from chest discomfort and swelling leg. Besides that, the patient also shows the symptoms of cushings syndrome such as moonface and hirstuism. The blood pressure (BP) and pulse rate (PR) of Madam S.V. are found to be quite high as well, which is 118/87mm/Hg and 146b/min respectively. Test ordered include FBC, RP, LFT, ABG, Coagulation test, UE, CXR, ECG and random glucose test. Nebulizer is given to patient once she is admitted. She is also on high flow mask oxygen 15L/min at the same time to ease the problem of SOB. Salfasalazine 1g bd is added to patient. The management plan is to carry out lung function test, continue to on the face mask for oxygen supply, revise all test results, restrict fluid and continue with old medications. DAY 2 Patient still complain of minimal SOB and minimal chest pain. Another new complain, headache, has been recorded. Her BP and PR have been slowly decreased but they are still not within the normal range. T. bisoprolol 2.5mg od is added for a better control of HPT and HF. Management plan include restrict fluid DAY 3 Patient is no longer complaining for anything. She has no chest pain and SOB anymore. Her PR has back to normal range. However her BP is still slightly higher than normal range. Management plan is same as day 2. Sulphasalazine since the condition of RA is improved. DAY 4 Patient is feeling well, comfortable and tolerating orally. Her BP and PR are within the normal range. The management plan is to perform a CRX report, patient can be discharged if normal result is obtained and continue old medications. Pharmaceutical care issues There are few things need to be taken care of in this case. Firstly, the patient is having the problem of nausea and vomiting and no action is taken to solve this problem. Antiemetic drug (H1 receptor antagonist, cyclizine; D2 receptor antagonist, halopiridol) should be given. At the same time, underlying cause of nausea and vomiting has to be identified if possible. This may caused by side effect of perindopril. Secondly, patient is having cushings syndrome due to long-term usage of steroids for her rheumatoid arthritis. However, there is no any record about the steroids intake for patient in clinical notes. Hence, we have to ask GP or patient to make sure that whether she has stopped taking steroids or still continue with it. According to CSM, long-term corticosteroids therapy should be withdrew gradually. Abrupt discontinuation of corticosteroids therapy may cause severe symptoms because normal production of steroids by the body has been affected. The dose may be reduced rapidly down to physiological doses (prednisolone 7.5mg daily). Then, the progress of dose reducing can be slowed down. The patient is hirudism which is one of the symptoms of cushings syndrome. This problem can be overcome by local measures such as shaving, or depilation such as using wax or cream (eg: eflornithine). The dose of T.folate for patient which is 5mg once daily is indicated for treatment of megaloblastic anemia. However, the FBC test result does not show any symptoms of megaloblastic anemia. The dose of T.folate should be 5mg once daily if it is indicated for folate deficiency induced by mehtotrexate. Blood film should be carried out to make sure that whether the patient is having megaloblastic anemia or not. FBC, serum folate and serum B12 are reliable indicator of folate status. Real indication of T.folate has to be clarified with doctor before dispense the drug. Oedema problem never been improved since the day patient been admitted into the hospital. Restrict fluid intake and strict I/O charting is carried out. However, patient is not compliance to it. Some simple self-care techniques can be taught to patient to reduce the build up of fluid. Counsel the patient about the importance of following Strict I/O chart. Dose of furosemide can be increased if oedema doesnt improve. The blood pressure of patient is still not stable yet. Patient has to be counseled to improve her diet and lifestyle. It is also necessary to monitor BP of patient regularly. Increasing dose of ÃŽÂ ²-blocker can be considered if BP is not reducing. However, due to its negative inotropic effect, ÃŽÂ ²-blocker should be started in very low dose and increase gradually. Lastly, upon discharge, ensure all appropriate medications are prescribed and patient is counseled appropriately. We have to tell patient that Perindopril is added in and ensure patients compliance with medication. Patient should be told to avoid alcohol and cranberry juice and consult GP if anything goes wrong. Disease overview Incidence Heart failure (HF) affects 0.3-2% of general population. In 2001, officially there are 11500 deaths are recorded in the UK due to HF. The incidence rate increase by double each decade from age 45. It affects 3-5% of those over 65 years and 8-16% of those over 75 years. The Rotterdam study shows that prevalence is higher in men compared to women. Pathophysiology Heart failure can be defined as inability of the heart to supply sufficient blood flow to meet the bodys needs. HF can result from any disorder that reduces ventricular filling (diastolic dysfunction) and myocardial contractility (systolic dysfunction). The leading causes of HF are coronary artery disease and HPT. As cardiac function decreases after myocardiac injury, the heart relies on few compensatory mechanisms. Although those compensatory mechanisms can initially maintain the cardiac function, they are responsible for HF symptoms and contribute to disease progression. An initiating event such as acute MI can cause the HF state becomes a systemic disease whose progression is largely mediated by neurohormones and autocrine/paracrine factors such as agiotensin II, norepinephrine, aldosterone, natriuretic peptides, and so on. Some drugs may exacerbate HF due to their inotropic, cardiotoxic and sodium-/water- retention properties. Diagnosis A complete history, physical examination and appropriate lab testing are essential in initial evaluation of patients suspected from having HF. The signs and symptoms are the key for early detection. Breathlessness, angina, fatigue and wheeze are common signs and symptoms. Patient complains that she is having SOB and PND. Electrocardiogram (ECG) and B-type natriuretic peptides (BNP) are essential tests for every patient with suspected HF. ECG is carried out once the patient is admitted into the hospital. Madam S.V. was detected to have sinus tachycardia by ECG which is one for the common ECG abnormalities in HF. Others common ECG abnormalities include sinus bradycardia, atrial fibrillation, ventricular arrhythmias and so on. Plasma BNP is not measured in this case. Chest X-ray (CXR) is also an essential component of diagnostic work-out in HF. It is very useful for detection of cardiomegaly, pulmonary congestion and pleural fluid accumulation. It also demonstrates the presence of any pulmonary disease or infection that will lead to dyspnoea. Via CXR, patient is detected from having cardiomegaly which is also one of the abnormalities for HF. Echocardiography (ECHO) should be performed shortly if one or both ECG and BNP get an abnormal result. ECHO is widely available and safe and provides essential information on aetiology of HF. However, ECHO is not carried out in this case. Some other tests such as FBC, RP, LFT, ABG, UE and random glucose test have been carried out to exclude others possible conditions. Pharmacology basis of drug therapy Diuretics The most important function of diuretic drug is to act by decreasing Na+ reabsorption. Diuretic drugs can inhibit Na+ reabsorption by actions on different transport mechanism, which are located at different sites in nephron. All diuretics are acting on the luminal surface of the nephron. They are protein bound in blood and reach the tubular fluid by secretion into proximal convoluted tubule utilizing the organic acid transport mechanism. They are mostly used to control symptoms of breathlessness and fluid retention. However, they do not alter disease progression or prolong survival. Thus they are not considered mandatory therapy for patients without fluid retention. Loop diuretics for example furosemide is most widely used if compared to other thiazide. It produces diuresis with NaCl loss. It also has vasodilator action which is partly mediated via prostaglandin. This will increase blood flow in the medulla and hence contributes to their natriuretic effect. Unlike thiazides, loop diuretics maintain their effectiveness in the presence of impaired renal function, although higher doses may be necessary. Thizide diuretics are relatively weak diuretics and used alone infrequently in HF. However, thiazide like metolazone can be used in the combination with loop diuretic to promote effective diuresis. Angiotensin-Converting Enzyme Inhibitors (ACEIs) ACE is binding to the plasma membrane and can also exist as a soluble enzyme. The ACEIs act by substrate competition by binding in the Leu-His binding pocket on ACE. Thus, action of angiotensin-I is inhibited. They also decrease the concentration of angiotensin II and aldosterone and attenuating many of their deleterious effects, including reducing ventricular remodelling, myocardial fibrosis, vasoconstriction and sodium and water retention. In addition, they also very helpful in reducing blood pressure due to arterial vasodilation. However, they will inhibit the breakdown of bradykinin which contributes to strong hypotensive action and cough. There are currently 11 ACEIs available for clinical use with similar structure and properties, including captopril, enalapril, lisinopril and others. ACEIs are indicated in all grades I to IV of heart failure which stated in NYHA. Potassium sparing diuretics should be stopped before starting ACEI. ACEIs may increase the risk of renal failure in patient with high dose diuretics, elderly, those with existing renal dysfunction and patients with grade IV HF. Hence regular renal function monitoring is required once patient has stabilized on drug. ÃŽÂ ²-blockers ÃŽÂ ²-blockers can be either selective for ÃŽÂ ²1-adrenoceptor which is cardioselective such as atenolol, bisoprolol and metoprolol or non-selective which can act on both ÃŽÂ ²1-and ÃŽÂ ²2-adrenocepors such as propranolol and timolol. Blockade of ÃŽÂ ²1-receptors will decrease rate and force of contraction of heart. Meanwhile, ÃŽÂ ²2-adrnoceptor blockade inhibits adrenaline-induced vasodilatation mediated by these receptors. Via these mechanisms, heart rate and cardiac output can be reduced. Beneficial effects of ÃŽÂ ²-blockers may result from antiarrhythmic effects, slowing ventricular remodelling, decrease myocyte death, improving LV systolic function, decreasing heart rate, and ventricular wall stress. The use of ÃŽÂ ²-blockers is not suitable for patients who have unstable HF. Patients should receive a ÃŽÂ ²-blocker even if symptoms are mild or well controlled with ACEI and diuretic therapy. Because of negative inotropic effects of ÃŽÂ ²-blockers, they should be started in very low doses with slow upward dose titration to avoid any symptomatic worsening. ÃŽÂ ²-blockers may worsen HF in the short term, but if use with caution they may be very useful in preventing long-term deterioration. Aldosterone antagonists Aldosterone antagonists such as spironolactone and eplerenone also can be called as potassium sparing diuretics. They act on aldosterone-sensitive portion of nephron (last part of distal convoluted tubule and first part of collecting tubule. They block the mineralcorticoid receptor and inhibit Na+ reabsoption and K+ excretion. Spironolactone can be added to ACEI, diuretic and digoxin to improve morbidity and mortality in patient with severe HF. Eplerenone is more specific compared to spirinolactone as inhibitor of aldosterone receptors and has been shown to reduce morbidity and mortality in patient with left ventricular dysfunction post-MI. However, the diuretic effects of aldosterone antagonists are minimal. Combination of aldosterone antagonist with thiazide or loop diuretics will potentiate the effect of thiazide or loop diuretics. This is a more effective alternative compared to potassium supplement. Angiotensin receptor blockers (ARBs) and Digoxin ARBs may be used as an alternative to ACEIs (eg: losartan) when patient is intolerant to ACEIs or may be used as adjunct therapy (eg: valsartan and cadesartan) in patient who remains symptomatic despite the dose of ACE and ÃŽÂ ²-blockers have been optimised. However, ARB is not given to the patient since she is well tolerated to ACEIs. Digoxin is one of the main drugs for HF treatment. However, digoxin is not recommended in this case. Digoxin can only been given if patients HF is worsening or patient is having atrial fibrillation at the same time. Hence, it is reasonable to exclude digoxin from treatment in this case. Evidence for treatment of the conditions Diuretics Diuretic is a very important drug for heart failure treatment especially for symptoms of fluid retention. A meta-analysis which includes 18 randomised controlled trials (RCT), n=982, had been carried out to study the role of diuretics (loop diuretics and thiazides) in patient with congestive heart failure (CHF). 8 trials were placebo-controlled and another 10 were comparison between diuretics and other drugs such as ACEIs, digoxin and ibopamine. The results had shown that diuretics reduce the risk of deterioration of disease and mortality compared to placebo group. When compared to active controls, diuretics also showed significant improvement in patients exercise capacity. The beneficial effects of diuretics are further supported by Cochrane database which also indicated that diuretics cause significant reduction rate and improvement in patients morbidity. Another study also proved that the withdrawal of furosemide will cause increase in volume load and right ventricular pressure. There will lead to deterioration of CHF which include impaired quality of life, weight gain and walking distance reduced. Higher dose of furosemide will have more desirable effects such as increasing general well-being and reducing symptoms of disease. However, the inappropriate high dose of furosemide will lead to hypotension. The risk of hypotension will be increased if patient on ACEIs or vasodilators at the same time with diuretics. According to NICE guidelines, low dose should be prescribed for the initiation of therapy and titrated up according to patients condition. Furosemide is the most commonly used loop diuretic. However, some patients are more responsive to other loop diuretic such as torasemide. This may due to its longer duration of action and high absorption. Some pharmacoeconomic analyses also proved that torsemide reduces hospitalisation for patient with CHF. Hence, overall treatment costs are reduced although torasemide is more expensive than furosemide. Patients that treated with torasemide have improved their quality of life. The data also suggest torasemide to be used as first-line treatment for patients with CHF and for those who are not response to furosemide. Besides that, according to a double-blind study, n= 1663, additional of aldosterone antagonist, spironolactone with furosemide had significantly reduced mortality and morbidity rate of patients with severe HF Hence from the evidences above, we can conclude that furosemide 40mg od is rationale to be given to patient to treat the symptoms of her CHF. Angiotensin-Converting Enzyme Inhibitors (ACEIs) The patient is taking perindopril 4mg od for her HF. A clinical trial has been carried out to compare the effectiveness between ACEIs and placebo in patients with symptomatic CHF. The overall results showed the significant reduction in total rate of mortality and risk hospitalisation. The benefits of ACEIs are further supported by five long-term randomised trials which had recruited 12763 patients with heart failure or left-ventricular systolic dysfunction (LVSD) to compare the effectiveness between ACEIs and placebo. Results showed that mortality rate has been reduced by 23%, readmission rate of heart failure reduced by 35% and re-infarction rate had been reduced by 26% for the patients who assessed ACEIs compared to placebo group. The benefits of ACEIs were observed at the beginning of therapy and it persisted long term. In SOLVD investigation, n=4228, ACEIs (enalapril) reduced the rate of hospitalisations and also incidence of heart failure in patients with reduced left ventricular ejection fractions compared to placebo group. Some randomised controlled trials proved that ACEIs also improve the exercise capacity and quality of life in majority of the patients. Not all the patients with heart failure due to left-ventricular systolic dysfunction experienced the improvement of exercise capacity. However, ACEIs alone is not enough for the treatment of heart failure with pulmonary oedema. Diuretic is needed to maintain sodium balance and prevent any fluid retention. ACEIs are more often to be prescribed compared to vasodilators and angiotensin receptor blockers due to more evidence supports. ACEIs will cause hyperkalaemia, cough and deterioration of renal function. Hence, renal function and serum potassium level need to be checked before the treatment is initiated. The SOLVD data, a randomised, double-blind and placebo controlled trial with 3379 patients, proved that enalapril caused 33% increased in deterioration of renal function compared to control group (P = 0.03). There is another study (n=191) showed that 44% of patients taking ACEIs suffered from persistent cough compared to controls which is only 11.1% (P The studies above showed that ACEIs are rationale to be used as first-line treatment HF. ÃŽÂ ²-blockers ÃŽÂ ²-blockers should be included in the treatment of HF even though the patient is already well controlled by diuretics and ACEIs. The European Journal of Heart Failure suggested that ÃŽÂ ²-blockers should be prescribed to all patients with stable HF and when left-ventricular ejection fraction à ¢Ã¢â‚¬ °Ã‚ ¤ 40%. A lot of meta-analyses showed that ÃŽÂ ²-blockers play a role in increasing life expectancy in patients with HF due to LVSD. In a meta-analysis which includes 21 trials (n= 5894), ÃŽÂ ²-blockers showed a significantly reduction of overall and cardiovascular mortality by 34-39%in patients with severe HF. Another meta-analysis of 16 clinical studies also showed the reduction of 24% for patients who were taking ÃŽÂ ²-blockers for their HF treatment rather than placebo. An interesting meta-analysis had been carried out to test the efficacy of ÃŽÂ ²-blockers in the patients with diabetes mellitus (DM) and CHF. The result of this meta-analysis showed that ÃŽÂ ²-blockers had reduced the mortality rate of patient with DM and CHF. However, the reduction was not significant (P=0.11) compared to CHF patients without DM. Most of the survival benefits for patient with NYHA class II and III are well documented. There is a meta-analysis had proven that ÃŽÂ ²-blockers are having the same improvement of survival rate among the patients with severe HF compared to patients with NYHA class II and III. However, further studies need to be carried out to evaluate overall benefits versus risks of treatment in NYHA class IV. There are three main studies, nà ¢Ã¢â‚¬ °Ã‹â€ 9000, had been carried out to compare the efficacy between ÃŽÂ ²-blockers (bisoprolol, metoprolol succinate CR, carvedilol) and placebo. Almost 90% of patients involve in there three randomised trials were on ACEIs or ARB. Most of them also took diuretics and digoxin. All trials showed the improvement of mortality rate (RRR= 34%), risk of hospitalisation (RRR= 28-36%) and self-reported well being. So far, there are no significant differences between selective and non-selective ÃŽÂ ²-blockers and those with or without vasodilating propert ies. In one randomised controlled trial (COMET), n=3029, carvedilol was used to compared with the efficacy and clinical outcome of metoprolol tartate. The result has shown that carvedilol reduced the mortality rate significantly among the patients compared to short-acting metoprolol tartate (P=0.0017). However, there is no any clinical trial about comparison between carvedilol and long-acting metoprolol succinate. There is little economic evidence can be found for ÃŽÂ ²-blockers. NICE guidelines suggested that ÃŽÂ ²-blockers are cost effective due to reduction of hospitalisation rate. Bisoprolol 2.5mg od had been added to the patient on second day since patient was admitted. The evidences above do support that the usage of ÃŽÂ ²-blocker should be included in patient with HF. Aldosterone antagonists Spironolactone is the most common aldosterone antagonist used in treatment of HF. In a double-blind study (RALES), 1663 patients with severe HF (NYHA class III and IV), left ventricular ejection fraction à ¢Ã¢â‚¬ °Ã‚ ¤ 35% and being treated with diuretics, ACEIs or digoxin were recruited to test the effectiveness of spironolactone on their morbidity and mortality. The result showed 30% reduction in mortality rate and 35% reduction of frequency of hospitalisation compared to placebo group. Addition of spironolactone to ACEIs, diuretics or digoxin had reduced the mortality rate in patients with severe HF. Additional of spironolactone may lead to hyperkalaemia. However the problem of hyperkalaemia can be solved by closing monitoring the potassium level of patients. Another study also showed that spironolactone reduced 30% mortality rate in patients with HF when it has been added to ÃŽÂ ²-blockers and digoxin. A selective aldosterone antagonist, eplerenone, has fewer side effects compared to spironolactone. A randomised controlled trial (EPHESUS), n=6633, proved that morbidity and mortality rate among patients with left ventricular dysfunction after acute myocardial infarction had been reduced with the addition of eplerenone compared to placebo group. There is no relevant economic evidence of aldosterone antagonist. Eplerenone is mostly used when patients cannot tolerate with spironolactone. Hence, spironolactone 25mg od is appropriate to used as adjunct to diuretics, ACEIs or maybe ÃŽÂ ²-blockers for patient in this case. Since the patient does not suffer any side-effects from spironolactone, it is not necessary to change to eplerenone. Conclusion As a conclusion, patients CHF has been appropriately treated by following the guidelines and also supported by numerous of clinical studies. From the clinical process, we can see that the condition of patient was gradually improved day by day. A ÃŽÂ ²-blocker, bisoprolol was added in the second day in order to achieve a better control of patients HF and also HPT. According to guidelines, the dose of bisoprolol should be initiated with 1.25mg, not 2.5mg. The potassium levels need to be monitored regularly due to the concomitant use of perindopril and spironolactone which may cause hyperkalaemia. ARB and digoxin are not prescribed to the patient because she is well tolerated with ACEIs and she does not have AF. Other treatment for HF such as vasodilators (hydrazine and ISDN) will only be considered when all of the treatment options above have failed to this patient. Non pharmacological treatment such as life-style modification, healthy diet, restrict fluid intake and salt intake als o play a very important in controlling patients HF and HPT for long-term.

Tuesday, November 12, 2019

Tyranny in Shakespeares Macbeth Essay -- Macbeth essays

Tyranny in Shakespeare's Macbeth   Ã‚  Ã‚   All humanity is tyrannical.  Every person wants the world to conform to their wishes.  A product of the ego, this desire culminates in tyranny among those that have the arrogance, opportunity, and instability to embrace and foster it.  We find Macbeth with the opportunity, and his arrogance and instability are bred by ego and contranatural forces, such that he becomes a tyrant.   Duncan's soft handed rule allows Macbeth the opportunity to plot against him while his proclamation of Malcom as the heir to his throne provides motive, a wounded ego.   Lady Macbeth and the witches, whether they be contranatural forces or perverted minds, prod him into action, exacerbating his tyrannical leanings, and sway the inner conflict which eventually develops.   Macbeth's rise to tyranny and his hold on it are products of his ego, provoked by inner conflict and those around him, and as such are opposed to the natural order which strives for balance.   Ã‚  Ã‚  Ã‚  Ã‚   Tyranny is not something easily obtainable.   By it's nature, it cannot be.   The rule of one must be a complicated task simply because it requires the subjugation of all others.   At first, Macbeth feigns indifference, claiming that "If Chance will have me King, why, Chance may crown me, without my stir,"1 and "I dare do all that may become a man; Who dares do more, is none."2   There is an inner conflict inside Macbeth, a sign of his weak character, which outwardly questions the morality of his actions, but more truthfully questions the probability of success.   He is not at all concerned with whether what he is doing is right, he only cares about whether he will succeed.   Finally, his strength comes to him, when "Nature seems dead, and w... ...eclaims the power that Macbeth has usurped.   Each force that played a part in his accession played an equal part in his downfall.   Self, wife, and witch together toppled Macbeth as they proved poor opponents for the force of Nature.   The offensive tyrant is banished, and Nature returns what is rightfully his to Malcom. Work Cited Shakespeare, William.   Tragedy of Macbeth . Ed. Barbara Mowat and Paul  Ã‚  arstine. New York: Washington Press, 1992.  Ã‚  Ã‚   1Act I. Sc. III. Ln. 142-4 2Act I.Sc. VII. Ln. 46-7 3Act II. Sc. I. Ln. 50-1 4Act I. Sc. VII. Ln. 27 5Act I. Sc. VII. Ln. 12 6Act I. Sc. V. Ln. 40-6 7Act V. Sc. I. Ln. 68-9 8Act V. Sc. I. Ln. 9 9Act III. Sc. I. Ln. 60, 65 10Act IV. Sc. I. Ln. 50, 104-5 11Act I. Sc. V. Ln. 1-3 12Act II. Sc. III. Ln. 58-9 13Act II. Sc. IV. Ln. 9-10 14Act II. Sc. II. Ln 60-2

Sunday, November 10, 2019

Financial Performance Analysis Essay

This project work has not formed the basis for the award of any degree/ diploma by Bangalore University or any other university. Name of the Guide: Mr. Jagdish Designation: Place: Bangalore Date: Guide’s Signature. This is to certify that this project work title â€Å"A study on the financial performance of the A&S Inc. † is based on an original project study conducted by Monisha Tirkey (07JJC08051) of BBM under the guidance of Mr. Jagadish K. K. This project work is based on original and has not formed the basis for the award of any degree / diploma by Bangalore University or any other university. Monisha Tirkey hereby declare that this project work titled â€Å"A study on the financial performance of the A&S Inc. † is based on the original project conducted by me under the guidance of Mr. Jagadish K. K. This has not been submitted earlier for the award of the award of any other degree / diploma from Bangalore University or any other university. Student Name: Monisha Tirkey Registration Number: 07JJC08051 Place: Bangalore Date: The successful completion of this project would not have been possible without the guidance, help and timely assistance from a number of people. I should at the very outset express my gratitude to the almighty God for his wonderful plan that brought me into this institution for my studies and for helping me throughout the project. I also thank HOD, Mr. Surendranath Reddy, who encouraged me to undertake this project. I express my sincere thanks to Mr. Jagdish, my guide, for the valuable help he extended in carrying out this project.

Friday, November 8, 2019

Developing a procedurally Just performance appraisal process essays

Developing a procedurally Just performance appraisal process essays Developing a procedurally Just performance appraisal process When organizations make decisions about people, such as whom to hire or promote, appraisal ratings or merit raise to give, or how important that the decisions are seen as fair and just. Research has shown that at least two aspects of justice influence employees job satisfaction and organizational commitment and both must be considered in organization decisions. The first type is distributive justice, or the perceived fairness of particular outcomes. It has to do with the distribution of rewards and punishments across people. Distributive justice would exist if employees agreed that the best person had been chosen for a promotion, that the punishment fit the crime in a discipline case, or that the size of merit raises accurately reflected true differences in performance across the people involved. Distributive justice is specific to particular decision. We might agree that one promotion decision was fair, but that is no guarantee that we will think the next one is fair. This is because distributive justice doesnt include evaluation of the fairness of the merit or process by which the decision was made. The latter is called procedural justice. Presumably, a just policy or procedure should help assure equitable outcomes every time, whereas single instance of distributive justice could occur by chance, favoritism or some other unfair process. What makes an allocation procedure just following are six rules for procedural justice? Following are six rules for procedural justice Consistency Rule: allocation procedures should be consistent across persons and over time Bias Suppression Rule: personal self interest in the allocation process should be prevented; Accuracy Rule: decisions must be based on accurate information Correctability Rule: Opportunities must exist to enable decisions to be modified: ...

Wednesday, November 6, 2019

Inventions of the 1800s essays

Inventions of the 1800's essays Many inventions were created during the middle of the 1800s. These inventions helped to improve the areas of farming, lifestyle, communications, and travel. This essay will explain how the inventions and improvements helped to improve these four areas of American culture. One of the many areas of inventions was lifestyle area. Many inventions were consisted in this area, such as the assembly line, sewing machine, and telegraph. I.M. Singer invented the assembly line. The assembly line consisted of a conveyer belt where people would align along the side of it and perform specific tasks. Another invention was the sewing machine. Elias Howe invented the sewing machine in 1846, but I.M. Singer improved it in 1851. Another invention was the telegraph. It was invented by Joseph Henry and improved by Samuel F. B. Morse. The telegraph helped get long distance messages in a quick amount of time. Farming inventions were a major improvement during this time. One invention was the steel plow. It was invented by, John Deere in 1837. Another invention was the Reaper; Cyrus McCormick invented it. A good invention for farming was vulenized rubber. That was invented by, Charles Goodyear. Communications greatly improved during this era. One of those was the telegraph, which helped daily life and helped people get messages quicker. Another thing was the quick and mass producing printing press. This helped newspapers and novels to be produced in mass production. Another thing was Morse code, which is what the telegraph used to get messages sent. Travel greatly improved during this time. Robert Fulton and Oliver Evans invented and started the steam engine that would propel boats at great speed and distances. There was also a great increase in railroad tracks. Canals were used to speed up transportation of heavy items that would take a long time to travel on road. In the 1800s transportation greatly improv ...

Sunday, November 3, 2019

Covenants Research Paper Example | Topics and Well Written Essays - 2250 words

Covenants - Research Paper Example The goal of this paper is to take a closer look at 5 of the Old Testament’s greatest covenants between God and certain men. We will take a close look at each of these covenants and look at their details and conditions if any. We will then determine which of these covenants are conditional and dependent on the fidelity of the human, and which one is everlasting and unconditional. This will be done thru the paper's parts and discussions such as: The five covenants of the Old Testament Covenant of God with Noah ?Covenant of God with Abraham ?Covenant of God with Moses ?Covenant of God with David. ... Covenant of God with Noah Definition: This covenant was made between Noah and God, although it does affect all of creation. This came about during the time of the great flood and Noah’s ark. According to presenttruthmag.com, God made the covenant with Noah before the earth was destroyed by flood. This is what saved Noah and his family. Afterwards, when Noah stepped out of the ark and presented the Lord with a sacrifice, God renewed the covenant with Noah that the world would never again be destroyed by flood. Scriptural basis: The covenant of God and Noah started with the story of the world’s judgment, the building of the ark, and the great flood. This story can be found in the bible’s book of Genesis, Chapter 6-8. This chapter was mainly dedicated to the story of Noah’s acts and covenant with God. In Genesis 6:9, Noah is recognized to be a man who â€Å"walked with God†, setting him apart from the rest of the world. Genesis 6:11 then goes on to des cribe the world as being corrupt and the people within it, corrupt as well. The succeeding verses then tell the story of how God told Noah to build an ark, how to build it and what to do in preparation of the flood. This story goes on from the flood its self, to Noah’s burnt sacrifice until finally in Genesis 8:20, the lord renewed the covenant and swore never again to â€Å"curse the ground† for our sake. This makes the covenant a covenant of salvation because the lives of evil men are spared in conjunction with God’s oath to Noah not to curse the land again. According to presenttruthmag.com, this is similar to Acts 27 when a ship full of people was saved because of the presence of Paul in the ship. Features: This covenant mainly revolves around

Friday, November 1, 2019

Poetry Essay Example | Topics and Well Written Essays - 500 words - 16

Poetry - Essay Example The first of these poems, Wilfred Owens "Dulce et Decorum Est," is a big example of anti-war poetry. The main theme in this dark poem is definitely war, and it definitely does not show it in a good light. From the very first lines, which describe a group of soldiers as "bent double, like old beggars under sacks, / knock-kneed, coughing like hags" ("Dulce" 1-2), it is clear that this poem is determined to destroy idealized visions of soldiers as glorious defenders of their country. The poem is filled with disturbing images of war, some of which are very realistic. An attack of poison gas is described with unflinching detail, telling how the soldiers, after "an ecstacy of fumbling / [fit] the clumsy helmets just in time" ("Dulce" 9-10). Owen also describes how the unlucky man who did not make it in time was "guttering, choking, drowning" ("Dulce" 16) and how blood was "gargling from the froth-corrupted lungs" ("Dulce" 22). The point of all this is not to gross out the reader, but to ar gue that patriots who "tell with such high zest / to children ... / the old Lie" that was is noble ("Dulce" 25-28) should reconsider their viewpoint. On the other hand, Edward Thomass "This is No Petty Case of Right or Wrong" takes a much more patriotic view. Although the poet seems to argue against war at first, with the lines "I hate not Germans, nor grow hot / With love of Englishmen, to please newspapers" (3-4), as the poem continues it grows clear that what he is protesting is not necessarily hatred of the enemy or love of ones countrymen, but what he perceives as shallow patriotism. This is clear by the end of line four, quoted above, that it is not just for newspapers, or for show, that the poets narrator loves his country. Indeed, for Thomas, it appears impossible to believe that anyone might feel otherwise. It is "with the best and meanest Englishmen / I am one in crying, God save England," he says (19-20), implying