Sustainable Hospitality Management Essay Example | Topics and Well Written Essays - 2750 words

Sustainable Hospitality Management - Essay Example Under such circumstances, the 2010 Commonwealth Games to be conducted at New Delhi, just few less than 1000 days away from inaugural, considered to be pride of India, the development has started at the banks of Yamuna River, will be the biggest and most expensive sports event to ever be held in India. But is it necessary that for merely conducting 15 days of play, the livelihood of thousands of villagers living around should be disturbed and turn them into immigrants and incur them huge losses, financially, socially and psychologically. New Delhi promises to present a next biggest stadium in the world, which will host the games and accommodation for participating players in the mega event for 15 days, but at the cost of poor indigenous peoples. As per the Brundtland Commission, "sustainability is development that meets the needs of the present without compromising the ability of future generations to meet their own needs".1 Sustainable development is an assorted concept, as a wide array of views fall under its umbrella. The concept has included notions of weak sustainability, strong sustainability and deep ecology. Different conceptions also reveal a strong tension between ecocentrism and anthropocentrism. One of the first and most oft-cited definitions of sustainability, and almost certainly the one that will survive for posterity, is the one created by the Brundtland Commission, led by the former Norwegian Prime Minister Gro Harlem Brundtland. The Commission defined sustainable development as development that "meets the needs of the present without compromising the ability of future generations to meet their own needs."2The Brundtland definition thus implicitly argues for the rights of future generations to raw materials and vital ecosystem services to be taken into account in decision making. People talked about living conditions, resources, population pressures, international trade, education, and health. Environmental issues were related to all of these, but there was no hard and fast division separating environmental issues, social and economic issues. All the problems were intertwined. There were links among the environment, the economy and society that caused problems in one of these areas to affect the other areas. Sustainable development does not focus solely on environmental issues. More broadly, sustainable development policies encompass three general policy areas: economic sustainability, environmental sustainability and social sustainability as mentioned in the diagram below at figure 1. In support of this, several United Nations texts, most recently the 2005 World Summit Outcome Document, refer to the "interdependent and mutually reinforcing pillars" of sustainable development as economic development, social development, and environmental protection. Figure 1: Scheme of sustainable development: at the confluence of three constituent parts The Indian capital New Delhi gets ready to host the mega single event of Commonwealth Games in 2010 for the first time. The Government of New Delhi has implemented a strategy to construct a 'New Delhi Games Village" just for hosting 2010 Commonwealth Games. It is definitely a pride issue for all the Indians,

Arthur Conan Doyle Essay Example for Free

Arthur Conan Doyle Essay A critical account of The Speckled Band and The Engineers Thumb by Arthur Conan Doyle  In the story of The Speckled Band a woman called Helen Stoner arrives at Holmes rooms in a state of terror. She is the stepdaughter of Dr Grimesby Roylott, a violent man who spent five years in India and associates only with gipsies, and has such exotic pets as a baboon and a cheetah. Helens mother is now dead, and two years previously her sister died in mysterious circumstances: a strange whistling disturbed her in her sleep for some nights, and on the night of her death she appeared transfixed, able only to shriek, the speckled band! she had been about to marry and now Helen is planning to do the same; her stepfather has moved her to her sisters bedroom next to his and the whistling has recurred. Despite a warning from the maniacal Dr Roylott, Holmes and Watson head for Stoke Moran, examine the house and wait the night in Helens bedroom. Holmes deduction proves correct: Dr Roylott sends a swamp adder (the speckled band) through a ventilator to kill Helen, Holmes cane drives it back and the murderer is poisoned. The main characters in the story consist of: Helen stoner who is the main client. She arrives at Sherlock Holmes rooms in Baker Street to ask him for help. The character of Helen Stoner sets the tone of the story: shivering with fear, her face all drawn and grey, with restless frightened eyes, like those of some hunted animal. She is obviously a sensible and levelheaded woman: therefore there must be a reason for her terror. The character of Sherlock Holmes in the story appears to be that of an appealing eccentric. In this story he uses his powers of deduction to identify minute details with which to solve the final mystery, for instance he knew you must have started early, and yet you had a good drive in a dog cart, along heavy roads before you reached the station. Through the story he displays elements of humour, after doctor Roylott threatened with a poker he replies, he seems a very amiable person. Subtly alluring to his own physical power by, he picked up the steel poker and with a sudden effort straightened it out again. Whilst examining the premises of Stoke Moran, he threw himself down upon his face with his lens in his hand, and crawled swiftly backwards and forwards, examining minutely the crack between the boards. This illustrates Holmes minute attention to detail. Dr Watson is the ideal narrator of this story. His ability to perceive and describe details is as important as his inability to deduce from them what Holmes can. He says, Holmes, I seem to see dimly what you are hitting at, after Holmes had described the position of the ventilator and the rope. The relationship between Sherlock Holmes and Dr Watson is one of an intimate friend and associate. In contrast to Holmes, Dr Watson makes the sensible deductions and assumption of the of the ordinary intelligent man. He is portrayed as an amiable man as well as the devoted recorder of Holmes achievements. A vivid description is built up of Dr Roylott by the description of Helen stoner. We know that he came from an aristocratic background. However successive heirs had squandered the money. After taking a medical degree he went to India, where he spent some time in prison from murdering a native servant. She describes his violence of temper approaching to mania.  We are also told that he likes to associate with gypsies and also keeps exotic animals, for example, a cheetah and a baboon. In another passage Dr Roylott enters Holmes room and is described as a huge man with a face marked with every evil passion. He is said to resemble a fierce old bird of pray. We are led also to believe that Dr Roylott is violent towards his Stepdaughter when Homes sees burses on her wrists. The story is set during the Victorian era with the backdrop of the decaying grandeur of Stoke Moran this help this links closely to the character of Dr Roylott as a fallen aristocrat and also helps to create a mysterious atmosphere. The building was of grey, lichen-blotched stone with a high central portion, and two curving wings, like the claws of a crab, thrown out on each side. In one of these wings the windows were broken, and blocked with wooden boards, while the roof was partly caved in, a picture of ruin.

I’m Not Chinese Anymore and I’m Never Going to be an American Essay

I’m Not Chinese Anymore and I’m Never Going to be an American I could open this piece with a clear statement, a thesis or controlling idea of some sort—a brief preview for you, my reader, of what is to come and what is to be told. However, I won't. Instead, please close your eyes for a minute—just for a minute—and imagine yourself sitting before a young East Asian girl. You know she's East Asian because of her black hair, off-white skin, a pair of ebony eyes and a nose that is just a bit too flat to be mistaken for an Indian. Sitting in an armchair with her left arm supporting her cheek, she stares at you for a little while then starts to speak—slowly, thoughtfully, almost tonelessly: "I was born in China and came to United States about four years ago, when I was thirteen. I had no idea what the world was then, even though I thought I did. And this very moment, four years later, I still have no idea what the world is. I've seen more parts of it, true. But the puzzle pieces refuse to come together somehow. People often ask me if I'm a Chinese living in America or an American born in China. An unanswerable question, yet how can you hope to understand life without knowing who you are? I am not Chinese anymore; there is no purpose in denying it. But I am not—and I don't want to be—an American. Not completely†¦not like this." Now open your eyes, silently think for a few moments about what she said, and return to my words—or rather, echoes of someone else'. "†¦Being Mexican-American is tough. The Anglos jump all over you if you don't speak English perfectly. Mexicans jump all over you if you don't speak Spanish perfectly. We gotta be twice as perfect as everyone else," so said a character from the 1997 hit movie "Selena."... ...n prom queen: A bookish girl, I've always been awkward in crowds, and people's first impression of me usually is that of a nervous, withdrawn little creature. An unfortunate gift from the past, you may call it, shaped by years of stern guidance and harsh social opinions. But all those years are gone, no matter how happy or gloomy they may be. I don't seek to relive the past, I simply need to make peace with it and somehow move on, as myself, under the sunlight of Manhattan and the shadows created by its glorious skyscrapers. Works Cited Cofer, Judith Ortiz. "Silent Dancing." Encounters: Essays for Exploration and Inquiry. Pat C. Hoy II and Robert DiYanni. New York: McGraw-Hill. Golden, Arthur. Memoirs of a Geisha. New York: Random House. 1999. Selena. Dir. Gregory Nava. Pref. Jennifer Lopez. Becky Lee Meza. Edward James Olmos. Warren Brothers. 1997.

Character Analysis for Maus by Art Speigleman

Character List- round or flat Art Spiegelman- r * Art Spiegelman is the author and narrator of Maus, and also one of the story's main characters. * Born in Stockholm after the Holocaust, he is the only surviving child of Vladek and Anja Spiegelman. * He is married to Francoise, a French woman who converted to Judaism upon their engagement. * Maus centers around two primary narratives: Vladek's experiences as a Jew in World War II Poland, and Art's relationship with his aging father. * When the story opens, Art lives in New York and does not see his father very often, though he lives only a short distance away in Queens. But as Art begins to draw this story about Vladek's Holocaust experiences, he begins to visit his father more and more frequently. * Their relationship is strained, as Vladek's gruff demeanor and unwillingness to spend money routinely infuriate his son. * Art is filled with complex feelings towards his father ranging from admiration for his survival in Auschwitz, to f rustration towards his aggravating tendencies, and guilt for his own neglect of a father who has lived through so many difficult times. * Art also has complex emotions towards the Holocaust.Though he did not live through it personally, he feels that he is constantly affected by it. * His father's personality was largely formed from his experiences in Auschwitz, and this personality in turn directly affected the way in which Art was raised. Vladek Spiegelman- r * Vladek is Art Spiegelman's father. * He grew up in pre-war Poland, and much of Maus traces his experiences in the Holocaust, as told in his own words to his son. * As the story opens in 1978, he is married to his second wife, Mala. The couple does not get along * Vladek's personality is largely dominated by his Holocaust experiences. During the Holocaust, he exhibited a spectacular resourcefulness, work ethic, and presence of mind that often enabled him to secure food, shelter, and safety for himself and his family. * He was a shrewd businessman, and in the most troubling times he saved everything of use. In 1978, he still saves everything and tries to exchange those things that he no longer needs. * Once so resourceful and competent, he is still constantly working on small projects, some of which he is incapable of completing. Anja Spiegelman- r * Anja is Art's mother and Vladek's first wife.The couple meets in Poland while Vladek is in a long-term relationship with another woman, Lucia Greenberg. * Always an anxious woman, she suffers an acute depression shortly after the birth of her son and spends three months recovering in a sanitarium. * She survives the Holocaust with her husband, and they immigrate to the United States a few years after the war. * Anja commits suicide in 1968, leaving both Art and Vladek in emotional turmoil. * Art's last memory of his mother is recorded in a comic called â€Å"Prisoner on the Hell Planet,† in which she enters Art's room and asks him if he still loves he r.His response, a terse and dismissive â€Å"sure,† haunts him for years. Lolek- f * Vladek's nephew and Uncle Herman's son. * Lolek lives with Anja's family for much of the initial German occupation, first at Anja's father's house and then in the Srodula ghetto. * When the situation deteriorates and Vladek makes preparations to hide in a shelter until the Nazis have evacuated the town, * Lolek tells his uncle that he is tired of hiding, and he is soon transported to Auschwitz. He survives the camps and eventually becomes a college professor. Richieu Spiegelman- f Richieu is Vladek and Anja's first child, born in Poland in 1937. * In 1943, Vladek and Anja send him to live under the protection of Uncle Persis, where they think he will be safer. * Richieu travels with Anja's sister, Tosha; * But soon after, Zawiercie is liquidated by the Nazis. Rather than be taken to the gas chamber, Tosha poisons herself and the children under her care, including Richieu. * After his death, V ladek and Anja keep a photograph of their first child hanging on the wall of their bedroom. Mala Spiegelman- f * Mala is Vladek's second wife, and a friend of his family from before the war. The couple does not get along. * Mala is consumed with frustration towards Vladek's inability to part with money, while Vladek views his wife with considerable distrust and accuses her of trying to steal his money. Francoise- f * Art's wife. * She is French and converted to Judaism in preparation for their marriage to please Vladek. * She is intelligent, kind, and opinionated, and their relationship is strong. * She plays a relatively minor role in the story, serving mostly as a means for Art to discuss his relationship with his father and the Holocaust. Mr. Zylberberg- f Anja's father. * Before the war, he is a wealthy manufacturer who owns a factory. * When Vladek and Anja are married, he provides Vladek with a factory of his own. * He survives with his family in German-occupied Poland, until the family is captured and sent to await transport to Auschwitz. * By bribing his cousin, Haskel, Vladek is able to arrange for the release of himself and Anja. Orbach- f * A friend of Vladek's family in Poland. * When Vladek is a prisoner of war, Orbach claims him as a cousin, so that Vladek is released into his custody and eventually returns home to Sosnowiec.Vladek's father- f * Vladek's father is a tough and deeply religious man. * His wife dies of cancer before the worst of the Holocaust. * Before the war, Vladek's father intentionally starves his son so that he will be declared unfit for the army. * Later, the Nazi grip tightens, and all Jews are made to register in a nearby stadium. Those who are fit to work are sent to one side, while the elderly and women with many children are sent to their deaths at the concentration camps. By registering at a table manned by his cousin, Mordecai, Vladek's father is spared. Before he leaves the tadium, however, he sees his daughter, Fela (Vladek's sister) and her four small children standing with those destined for Auschwitz. He crosses over to be with her, and all die in the camps. Uncle Herman- f * Anja's brother. * Along with his wife, Hela, he is visiting the New York World's Fair when the war begins, and they remain in the United States to escape the horrors abroad. Tosha- f * Tosha is Anja's older sister. * At the beginning of the German occupation of Poland, she lives with Anja's family in her father's house, along with her husband, Wolfe, and their small daughter, Bibbi. As the situation deteriorates Uncle Persis offers to keep her safely in nearby Zawiercie ghetto, where he is a prominent member of the Jewish Council. * She agrees, and leaves with Wolfe, Bibbi, and Vladek's son Richieu. Soon, though, the Germans slaughter the Jewish Council and begin to evacuate the Jews of Zawiercie to the camps. Rather than be sent to the gas chambers, Tosha poisons herself, her daughter, Herman's daughter Lonia, and Vlad ek's son Richieu. Mr. Ilzecki- f * A former customer of Vladek's from before the war. The two meet again after the German occupation and begin conducting business on the Sosnowiec black market * Mr. Ilzecki has a son about the same age as Vladek's, and he offers to send Richieu along with his own son to a Polish friend to hide until things get better. Nahum Cohn- f * A friend and business partner of Vladek's during his black market days in Sosnowiec. * Nahum is arrested along with his son for selling goods without coupons. * The Nazis decide to make an example of them and they are hanged in a well-know black market center and left there for a full week. Anja's Grandparents- f During the initial period of the German occupation, they live in Anja's father's house with the rest of the family. * Later, they are told to relocate to a â€Å"community better prepared to take care of the elderly. † * The family hides them for over a month, until the authorities arrest Anja's father a nd threaten to arrest more of his family if the grandparents are not given over to the Germans. * Anja's grandparents are taken away to Auschwitz, where they are killed. Haskel Spiegelman- f * Haskel is Vladek's cousin, and chief of the Jewish Police in the Srodula ghetto. He is the brother of Miloch and Pesach. He is what Vladek calls a kombinacya, or â€Å"schemer. † * While he is a rather unsavory character, he is a good person to know in the ghetto. * When Vladek's family is discovered in the â€Å"chandelier† bunker and sent to a compound to wait for transport to Auschwitz, Haskel arranges for Vladek, Anja, and Lolek to be released in exchange for valuables. Miloch Spiegelman- f * Miloch is Vladek's cousin, and brother to Haskel and Pesach. * He is Vladek's supervisor at the shoe repair shop in the Srodula ghetto, and an honorable man compared to the scheming Haskel. When the Germans make plans to eliminate all Jews in the ghetto, he prepares a hidden shelter behi nd a pile of shoes at the shop, where Vladek, Anja, and 15 other people hide for days. Pesach Spiegelman- f * Pesach is Vladek's cousin, and brother to Miloch and Haskel. * Like Haskel, he is a schemer and a rather unsavory character. * His most significant involvement centers on a scheme to sell cake to the inhabitants of the ghetto. * He makes a fortune, but everyone who eats it becomes sick – the cake was accidentally made with laundry soap in addition to flour. Mr. Lukowski- f The janitor at Anja's father's house. * When Vladek and Anja escape from the Srodula ghetto, they knock on his door and he allows them to stay in a shed behind his house. Mrs. Kawka- f * Mrs. Kawka is the owner of a small farm on the outskirts of Sosnowiec, and for a price she allows Vladek and Anja to hide in her barn. * Mrs. Kawka is the person who tells Vladek about the smugglers who can take him to Hungary. Mrs. Motonowa- f * Vladek befriends Mrs. Motonowa at the Sosnowiec black market after the liquidation of Srodula, and she offers to hide him and Anja at her farm, with her seven-year-old son. She is a kind woman, and the house is comfortable, except for a ten-day period in which Mrs. Motonowa's husband returns home from Germany on vacation, and they are forced to stay in the basement. * After Vladek and Anja attempt to escape to Hungary, she shelters Miloch and his family for the remainder of the war. Mandelbaum- f * Before the war, Mandelbaum owned a pastry store in Sosnowiec where Vladek and Anja often shopped. Abraham- f * Abraham is Mandelbaum's cousin. * He agrees to accompany the smugglers, and promises to write Mandelbaum and Vladek if he arrives safely in Hungary. He is betrayed, however, and forced at gunpoint to write the letter anyway. The Karps- f * The Karps are Vladek's neighbors at his Catskills bungalow. * When Art visits his father there, they take him aside and tell him that Vladek cannot possibly take care of himself. Vladek's Kapo- f * A â€Å"kapoà ¢â‚¬  is a Polish supervisor at a concentration camp. * Soon after Vladek arrives at Auschwitz, Vladek's kapo asks the Jews in the barracks if anyone there can speak English. Pavel- f * Pavel is Art's psychiatrist. * Like Art's father, Pavel is a survivor of the Holocaust. Art sees him once a week, and the sessions always seem to make him feel better. Mancie- f * Mancie is a female Hungarian Jew at Birkenau with Anja, * has higher status as a result of an affair with S. S. guard. * She acts as a go-between for Vladek and his wife, carrying notes and food. The Frenchman- f * After Vladek is transferred from Auschwitz to Dachau, he befriends a Frenchman with whom he converses in English. * Because he is not Jewish, the Frenchman is able to receive packages of food through the Red Cross, which he shares with Vladek, probably saving his life. http://www. gradesaver. com/maus/study-guide/character-list/

New paradigms for health care delivery

Changes occurring in Health care delivery and Medicine are the result of social, economical, technological, scientific forces that have evolved in the 21st century. Among the most significant changes are shift in disease patterns, advanced technology, increased consumer expectations and high costs of health care. These factors have redefined medical practices to fit into the changing health delivery system. Many health care professionals have come to the conclusion and belief that they will be compelled to explore new paradigms for health care delivery in the future like electronic medical record keeping, telemedicine, computer-based diagnostics and health monitoring to keep pace with the changing scenario. This is due to the accountability of the medical profession today and changing disease patterns. Doctors are under increasing pressure to keep up to date and to base their decisions more firmly on evidences as opposed to anecdotal information of the past. Patients are much more informed than they were 10 years ago. No doctor can tell a patient what to do without being questioned today. Further, with the advent of concepts like informed consent and advance directives, such scientific changes gain relevance. ELEMENTS OF THE NEW PARADIGM The use of electronic documentation is becoming increasingly prevalent in terms of convenience. The National Academy of Sciences report states that the US health care industry spent between $10 and $15 billion on information technology in 1996. Much of this expenditure is attributed to creating electronic records systems and converting conventionally stored data to electronic formats.   There are many software programs specially developed for electronic record keeping. This includes ‘Doctors partner’, an advanced Electronic Medical Records (EMR) System with Integrated Appointment Scheduling Billing, Prescription Writer, Transcription Module, Document Management and Workflow Management built to meet HIPAA standards. ‘Practice Partner Patient Records’ is an award winning electronic medical records (EMR) system, allowing practices to store and retrieve patient charts electronically. There are innumerable such branded medical record softwares available today. The standards in practice for EMR include ASTM International Continuity of Care Record , ANSI X12 (EDI) CEN , EN13606, HISA, DICOM , HL7 ,ISO   and openEHR . (Ringold et.al.,2000). The American Medical Association and 13 other medical groups representing 500,000 physicians have signaled their intention to go electronic with the AMA formed   Physicians' â€Å"Electronic Health Record Coalition† to recommend affordable, standards-based technology to their constituents. President Bush has also promoted a nationwide computerized medical records system in a recent visit to a children's hospital at Vanderbilt University. Scientific innovations have found a niche in complicated medical procedures as well. A recent study successfully has evaluated a bar code patient identification system, which involves a hand-held computer for sample collection and for compatibility testing administration of blood. (Turner et.al, 2003). A recent research article (Sandler et.al, 2000) reports of a solid phase and micro titer plate hemagglutination method for pretransfusion compatibility tests. This I-TRAC is an automated process of blood matching with improved serological sensitivity and standardized compatibility testing supporting electronic record keeping and linking to a bar code identification system. San Raffale Hospital in Milan, Italy, has recently collaborated with Intel and CISCO systems to use wireless-enabled infrastructures and Radio frequency identification (RFID) technologies. The system uses RFID-radio frequency identification technology to address the sources of   human and systems error in blood transfusion supply chain. This pilot programme has been   implemented at the 1,100 bed San Raffale hospital where more than 15000 blood transfusions are done every year. The CAT (Computer Aided Tomography) is yet another revolution in medicine which combines the X-ray technology with computer signal processing to generate images of tissues of the body obscured by other organs. Magnetic Resonance Imaging (MRI) is a common technique used to scan pathological or physiological status of living tissues. Much is known about the computer aided continuous ECG monitoring with a play back facility for assessing the cardiac status of the patient. Today we are in a wonderful situation where we will be able to develop a drug based on computer analysis skipping a few phases of clinical testing. PERSPECTIVES ON THE PARADIGM SHIFT Thus, scientific innovations are part of the evolutionary process of the medical science. The basic instrument of a physician, the Stethoscope, the Sphygmomanometer used for monitoring the patient blood pressure, the Catheter, Radiotherapy, Chemotherapy, the EEG, ECG, EMG, Echocardiogram, Ultrasonic scan, to name a few were nothing but such scientific innovations integrated into the field of medicine in the nineteenth and twentieth century. Thus, Computer based telemedicine, medical record system, and diagnostic procedures are scientific innovations of the twenty-first century. Hence, it is nothing but a natural and moral obligation of the health care sector to integrate them into the field of medicine. Changes in financial incentives and health care delivery structures are producing new threats to health care quality (A.Brennan, 1991). The retributive measures are cumbersome and expensive. Hence, there is a need for more accountable health delivery system, which will enable application of modern scientific approaches to quality health care system. In this context, quality of the medical care depends on promotion of quality medical care by managed care organizations. REFERENCE Brennan, T, et.al, â€Å"Incidence of adverse events and negligence in hospitalized patients: the results of the Harvard Medical Practice Study†, New England Journal of Medicine 324: 370-76, 1991. Là ¦rum Hallvard, MD, Tom H. Karlsen, MD, and Arild Faxvaag, MD, PhD . â€Å"Effects of Scanning and Eliminating Paper-based Medical Records on Hospital Physicians' Clinical Work Practice†. Journal of the American Medical Informatics Association 10: 588-595.2003. Ringold DJ , JP Santell, and PJ Schneider , â€Å"ASHP national survey of pharmacy practice in acute care settings: dispensing and administration–1999†. American Journal of Health-System Pharmacy 57 (19): 1759-75. 2000. Sauer et.al, â€Å"Errors in transfusion medicine† Lab Med. 32(4): 205-207, 2001. Turner et.al, â€Å"Bar code technology: its role in increasing the safety of blood transfusion†, Transfusion, 43(9): 1200:2003.

Stephen Kings All That You Love Will Be Carried Away

Stephen Kings All That You Love Will Be Carried Away Free Online Research Papers Stephen King’s â€Å"All That You Love Will Be Carried Away† is about a frozen food salesman Alfie Zimmer, who has to decide to either change his life and write a book or end his life by his own hand. He wants to write about his collection of sayings he has written down during his traveling. King’s ending of the story is obscure, and I want to prove that Alfie has too much to live for and that he is too committed to his notebook to end his own life. Alfie Zimmer makes money for his family by selling gourmet foods from the trunk of his car. However he is intrigued by the graffiti that litters the walls of rest stops and truck stops that he has encountered on his monotonous sales route. Alfie feels that writing a book about the sayings would be too hard of a change in his life and decides to commit suicide instead. Alfie chooses Room 190 at the Motel 6 in Lincoln, Nebraska to end his life. When he enters the room and sits on the bed â€Å"he reached for the telephone then remembered his notebook† (83). Alfie is intrigued by the old spiral notebook; it was more than a hobby now â€Å"(he) had been carrying this notebook, for almost seven years†¦Ã¢â‚¬  (83), it now was his work, his life. Alfie eats, drinks, and lives for the graffiti on the walls. He even analyzes it to make sure it is fit for his book, â€Å"â€Å"Poopie Doopie you so loopy (Papillion Neb)† Something about the â€Å"-ie –ie† and then, boom you got â€Å"y†Ã¢â‚¬  (84). Alfie thinks about the English Classes he wants to take to learn about the rules of writing. Although Alfie has decided to end his life that day, he says â€Å"Time to record today’s finds† (84) because it is his routine and his fun in life. As Alfie flips to an open page he thinks â€Å"Now two in one day. Two on the last day. Like some sort of omen† (84) it’s like he is searching for an excuse or answer not to take his life. Alfie also thinks of his family and calls them twice to remind them about errands and appointments tells them, he loves them for the first time in five years, hangs up the phone and inserts the fully loaded gun into his mouth. He pauses to think of his own graffiti about his death, â€Å"Here I sit, about to cool it, my plan to eat a fuckin’ bool it’. He grinned around the barrel. That was terrible. He never would have written that down in his book† (86). I also believe he knows that suicide is not written in his book of life. Alfie knows that by writing the book, it would change his life, he may be reje cted or accepted and he is not sure it is worth it. Alfie â€Å"had thought of writing a book, just a little one† (85) he just felt that society would not get the humor that he did out of the poetry. While sitting on the bed writing his daily finds â€Å"he put the pen back in his pocket wondering why he or anyone would continue anything this close to ending everything† (84). He cannot control his intrigue with the notebook, he compares it to â€Å"just†¦well†¦breathing he said, and smiled.† (84). When Alfie had called his family and recorded his notebook entries, he thought he was ready to do the â€Å"end† deed but then â€Å"he frowned and put the gun down. The book was open to the last four entries† (86) the notebook once again stopped him from shooting his brains out. He thought of what the police would think. Finding a dead man with a notebook of crazy sayings â€Å"he was not crazy, and the things he had written here over the years weren’t crazy, either† (86). So Alfie thinks of ways to destroy or hide the notebook He decides to flush it down the toilet, but makes the excuse that it would clog the toilet but he also thinks â€Å"besides, the notebook had been with him so long†¦He hated the idea of flushing it away† (87). He keeps thinking of the notebook, he is very compulsive about his findings â€Å"he loved the stuff in the notebook† (87). Alfie realizes that without him â€Å"the notebook might be a real embarrassment once he was dead† (87) and he just can’t come to destroy the notebook. Alfie still feels the need to commit suicide but â€Å"there was no need to destroy it (notebook) after all† (89). So he goes out into the blustery January day and throw the notebook into the farmer’s field â€Å"Alfie drew the book back to throw it, then lowered his arm. He hated to let it go, that was the truth of it† (89). He was not ready for the future, but with his book in hand, he felt alive. With notebook in hand he made himself a deal, â€Å"if the spark lights of the farmhouse reappeared at anytime during the count, he would try to write the book† (89). Alfie once more intrigued by his collections, he thinks about the book, what it should contain, the des criptions, noises, and smells of the rest stop restrooms and truck stops. Alfie had already thought of a title for the book, he was just scared that the book would be rejected by society and he would be laughed at. As â€Å"Alfie stood there counting inside his head waiting to see if the wind would drop† (89) however I believe that Alfies own spark lights came on because he realized the book is his life, his life that would be filled with fun and enjoyment. I also think he knows he can’t kill â€Å"Alfie the Salesman† because it would kill â€Å"Alfie the Writer† and â€Å"Alfie the Dad†. The notebook is Alfie’s life if he cannot destroy the notebook, he cannot destroy himself. Research Papers on Stephen King’s â€Å"All That You Love Will Be Carried Away"Book Review on The Autobiography of Malcolm XHarry Potter and the Deathly Hallows EssayThe Masque of the Red Death Room meaningsComparison: Letter from Birmingham and CritoArguments for Physician-Assisted Suicide (PAS)Trailblazing by Eric AndersonEffects of Television Violence on Children19 Century Society: A Deeply Divided EraCapital PunishmentMind Travel

Bunker Hill Essays - Charlestown, Boston, Battle Of Bunker Hill

Bunker Hill Essays - Charlestown, Boston, Battle Of Bunker Hill Bunker Hill The battle on Breeds Hill, wrongly named the Battle of Bunker Hill, changed the course of the American Revolution. This battle was the first large-scale engagement and also one of the bloodiest battles of the American Revolution. It was held on June 17, 1775 in Charlestown (now part of Boston), Massachusetts. The prior battle to this one would be the at Lexington and Concorde which sort of started it all. This battle took place April 19, 1775. After the battle at Concorde British troops decided to give up and stop fighting and marched back. Meanwhile the Americans continuously made hit and run attacks on the retreating forces. This heightened the heat between the rebels and the British. Later, 5 days before the battle at Breeds Hill, General Thomas Gage would declare martial law. Stating to give pardon to anyone who would lay down their arms and pledge himself to King George. He did this to avoid further uprisings and armed conflict. Unfortunately, this had the opposite effect and upset many of the colonists. Thus, adding to the flame and making the battle almost imminent. On June 16, 1775 the Americans became aware of the British plan to take control of Bunker and Breeds Hills. So the rebels decided to invade the area before the British in a hope to fortify it and be prepared for the Redcoats. Colonel William Prescott and 1,200 men, mostly from Massachusetts, moved in to the peninsula with the mission to fortify Bunker Hill. Two ours upon arriving they realized that they needed to fortify Breeds Hill and fall back on Bunker Hill if necessary. During the night of the sixteenth Colonel Prescott gave them the orders to Dig, and dig hard. Trying to get the soldiers to fortify Breeds Hill as best as possible. If they learned anything from that night they learned that a Yankee soldier, at this stage of war, was a great digger. The nights work turned out to be tactically genius. Between those ours of midnight and first light the troops dug up a square frame on the hill. Each side being about 45 yards. They also fortified an area running northeast from the hill about halfway to the water. A quarter of a mile behind that, they continued the barricade along a stone wall and rail fence that went the rest of the way down the shore. Breeds Hill was now tactically secure and was ready for battle. The next day when the British discovered this fortification they became infuriated. The boat Lively opened fire upon the hill. Joined in by the Glasgow and Somerset these three ships made much noise and did minimal to no damage. The British finally realized that the American position was not as completely stupid as it looked some eight hours later. Sir William Howe received tactical information from Gage on commands of operation. With this and 1,200 men Howe landed on the peninsula. Throughout that day the American forces had been reinforced to about 1,500 troops. The British grew to about 2,500 that would actually partake in the battle. The stage was now set for one of the bloodiest battles of the Revolutionary War. The British could have easily taken over the hills by surrounding them but they wanted to show them who was boss so they decided on a head on battle. They realized faults in their plan where the rebels fortified the areas well, however the British paid no attention to it. They had no reason to stop and think twice from their past experiences with the rebel forces. So far they had shown no great ability to shoot and these men behind low stone walls or rails surely would be nothing to think twice about. British brought some light cannons for some direct artillery support but foolishly brought the wrong size ammunition, but no one expected to use them anyway so they remained there useless. This type of thinking was part of why the British had such seve re casualties. When it was obvious the battle was going to begin the officers were extremely nervous on the American side. Many of the officers paced back and forth in the trenches behind their men. They had

ONE FOOT IN FRONT OF THE OTHER

ONE FOOT IN FRONT OF THE OTHER Finding time to write is hard, but you do it. Improving your writing is time consuming, but you manage. Its hard to find critiquers for your work, but you keep searching until you do. You never think youll find a publisher, but its doable. Then you hold a book in your hand, and you beam with happiness. Youve done it, and you want to whoop your achievement to the world. Friends pat you on the back and others email you with congrats. And the hard part hasnt started. Promotion is harder than all that combined. Surely she jests, I hear you say. Nope. Im serious as a heart attack. In all my years of writing, editing, researching, and building a platform, Ive never run into anything as frustrating as promoting a book. Ive been tossed Ive had my magical moments of selling 20 books in one night. Ive had my down evenings where I doubted what I was doing trying to establish myself as an author. Then I always tell myself that each and every author was a nobody before he became somebody. He sold one book at a time, hoping whoever bought it would spread the word until books sold he wasnt even aware of, the number adding up until he realized the hellacious journey he traveled over the years was finally beginning to show results. You dont see success coming. It just shows up one day, asking you to let it in . . . unless you quit along the way. Then it goes and knocks on somebody elses door.

COMS 445 Portfolio Paper Essay Example | Topics and Well Written Essays - 1750 words

COMS 445 Portfolio Paper - Essay Example The theme song and opening sequence set the sequel of the show. Why was the show viewed negatively? In this paper I will recommend that The Fresh Prince of Bel-Air, the African American sitcom broadcast in the 1990s, might be recognized a vehicle through which the accepted representation of dark characters in the last part of the twentieth century has been undermined, addressing the old stereotypes about African Americans, consistent with which a character must be poor, ghettoized or a criminal. One of the points of this paper is to highlight and to analyze why the show was seen contrarily in connection to the everlasting social crash between blacks and whites and, most importantly, as Brooks and Marsh uphold, "the troubles confronted by blacks in a white social order" (Brooks & Mash, p368). Moreover, having investigated the first season of the arrangement, I will offer a few perceptions identified with the part of the primary character, featured by the performer Will Smith, and his connection with alternate parts of the family, highlighting that the hero's assignment to think about his relatives' societal position and conduct as absence of Blackness is a methodology that permits the other dark characters to subvert the universal picture of African Americans offered by American broad communications everywhere throughout the planet. The point of this approach could be recognized an approach to decipher the new dark socio-social environment of the most recent decades of the previous century in the USA, permitting viewers of the nations where the sitcom was publicized to meet and comprehend key parts of the American dark group of that period (Brooks & Mash, p367). Judging by a confounding African American circumstance parody by Means Coleman for its unique approach to delineate additionally undermine conventional pictures of dark stereotypes, The Fresh sovereign of Bel-Air is frequently looked into (Coleman, p144). It is conceivable to look after that all around t he entire first season, that incorporates 24 scenes, two propensities are unmistakable: the first is undoubtedly the representation of the everlasting crash between the primary character of the story and his relatives, addressing the accepted part of dark characters in the handling on TV in the twentieth century, and the second one is identified with the challenges of living in a white rich neighborhood being part of the Black group. These two focal issues are addressed and confronted through two coordinating techniques. The clearer of the two is portrayed by the incessant verbal battles between the principle characters, and the other one uses amusing and evidently say-nothing circumstances to highlight the issues this rich dark family needs to face as a result of a white-focused social order (Coleman, p168). How does Zook re-interpret the show? How does Zook re-translate the Fresh Prince of Bel-Air? According to zook, when Fox's urban system was started in 1986, the system tight th rew or focused on a particular back viewership and counter-customizing against different shows to suite that group of onlookers' taste (Zook, p90). As per Zook, a normal for dark Tv is socially particular feel. While rap music and graffiti-like representation were regular on white shows of this period also, Afrocentric Clothing, haircuts, and antiquities performed particular capacities in dark shows, for example the new ruler of bel-air with continuous references to Malcom X,

The Performance Appraisal Meeting and Performance Diagnosis PowerPoint Presentation

The Performance Appraisal Meeting and Performance Diagnosis - PowerPoint Presentation Example tly by checking whether they have accomplished their goals but only after a year.  Effective performance management in ACME is illustrated under the leadership of managers who apply various techniques in dealing with performance management. If performance management is treated as a complete system not leave any parts, and if there is success with performance planning and ongoing performance communication, there can almost be guaranteed success during the performance meetings. There are two reasons for this: First, the employee will understand appraisal process is a partnership. Second, there will be no surprises in the appraisal meeting (Bacal, pg.102). During the appraisal meeting the most crucial tasks for the managers is to evaluate and relate the output of the employee with their targets. The managers carry out a regular overview of the progress of each employee in relation to the tasks assigned to the employee. In return, the management expects each employee to meet the set goals in their working area, and this ends up being a collective objective that can enhance an organizations success. During the appraisal meeting, the manager should take on role of helper, problem solver, rather than evaluator, employee is in partnership and is a self-evaluator, employee should understand what to expect, in terms of content and process, manager should treat meeting as important, and most importantly, both manager and employee should understand why of the apprai sal. At ACME Healthcare Inc. there seems to be a need to integrate the need to prepare the employee for the appraisal meeting without a conversation of what is expected. Managers should let the employee understand purpose of meeting. Performance Diagnosis is the process that should be used with an employee to determine the causes of his or her success and/or difficulties. Performance is affected by the interaction of the work environment and the individual, and not by one or the other alone. ACME Healthcare Inc.

BMW Automobiles. BMW Demand and Supply Coursework

BMW Automobiles. BMW Demand and Supply - Coursework Example Microeconomic Analysis Demand is the willingness and the ability of consumers to buy a certain product for a certain price at a particular period. While other factors are held constant, the prices of goods and services increase as its demand increases and vice versa. Supply is the willingness of the manufacturer or the company producing then goods or services to sell the products at a given price at a given period. While other factors are held constant, the supply of goods and services will increase at an increase in price. Various demand and supply factors affect the production and sale of BMW 3 series vehicles (Flaschel, 2010, p.1). The first factor is affecting BMW’s demand and supply is consumer taste and preference. Different consumers have a varied taste and preference for the product. BMW 3 series is a mid-level luxury performance sedan. The car is also a bench marker in the market. It has played a great role in influencing the competitor’s in trying to achieve i ts class. The consumers also have their taste, which varies with the individual. The taste and preference of this car by some individual consumers is predominantly affected by its price in the market, the performance both on road and on off roads modes, the cars ability to perform, and the fuel consumption. The BMW 3 series has a relatively high fuel consumption capacity as compared to its competitors and it is better in performance than its competitors are. Secondly, consumer income affects the demand of the BMW 3 series. Consumer income is the amount that the consumer has which they are willing to invest on that commodity. The BMW 3 series retail price varies depending with the model. The lowest price for the BMW 3 series is $32,400. This price may not be affordable to many consumers. The consumer income is the greatest determiner of the demand for this product both in America and outside the American market (Flaschel, 2010, p.1). Additionally, price of substitutes and other compl ementary vehicles affects the demand of the BMW 3series cars. BMW, being a luxury mid-level vehicle, has many substitutes and complementary vehicles. An example of these substitutes is the Audi A3, Infiniti G35, Cadillac CTS, and the Acura TL. These substitutes have a relatively low price and perform equally with the BMW 3 series. The availability of these substitutes has greatly affected the consumers’ decision in determining the best car available for them. The availability of these substitutes also influences the ability of the consumer to save in comparison to what they would have used if they purchased the BMW 3series. Additionally, the BMW 3 series has been affected by the complementary goods. Complementary goods are the goods that are used alongside the product. The BMW 3 series is a relatively high consumer if gasoline in comparison to its competitors. This has hugely influenced the demand of this car (Hortacs, et al, 2010, p.1). The forth factor that has influenced t he demand of this car is the consumer expectations. The BMW 3 series car has largely met the consumers’ expectations. BMW is actually an envy of many people, which has also increased the demand of this vehicle. The BMW 3 series is a great performer both on road and on off road modes. This has enabled it to have an innovative over the others in the market. The BMW also produces high quality vehicles that are not prone to damages as compared to it

Survey online travel agencies Essay Example | Topics and Well Written Essays - 750 words

Survey online travel agencies - Essay Example The second type is the 'blind' sites which are similar to open sites but they allow a customer to bid a price, a location or a time to get his/her ticket reservation but a user may not know the airline, departure time or specific hotel until the actual ticket is bought. These websites also have the normal search functionality where a customer can view the travel fares without bidding. The third type of online travel sites are merely search engines popularly known as 'meta search engines' (Rand, 2006). The term means that they search other sites which provide air travel. The search engine goes through all available online travel agencies websites (open sites) and finds the best results for the user. (CR, 2008) As mentioned above, there are three types of online travel agencies. These agencies fight within themselves to get the highest market share (Rand, 2006). For the analysis sake, the business strategy is compared according to these types. Popular open sites include agencies like Orbitz, Expedia, and Travelocity amongst others. Orbitz (www.orbitz.com) strategy is to market itself in the eco-tourism and beats the other two companies in terms of thoroughness and provides car rentals and hotel reservations at guaranteed prices. Expedia (www.expedia.com) is a highly rated site which offers extra benefits to the customers like rewards for frequent flyers, going to less-common foreign routes and awards programs. Travelocity's (www.Travelocity.com) website is easily customizable to find what the user wants. Best fares, time frame and different combinations of airline, hotels, car rentals etc. can be entered as search parameters and found easily. (CR, 2008) Blind Sites Two popular blind sites are there in the category, Priceline and Hotwire. Priceline's (www.priceline.com) strategy is to let travelers bid a price on where and when they want to fly. The website then searches for all available seats on any airline matching the cost, time and the destination. The bid can be rejected if the bid is too low, where a traveler can increase the bid and try again in 24 hours. Due to the inconvenience of not knowing the exact time of departure and airline, Priceline is best option only for people who are flexible and need a low cost travelling solution. On the other hand, Hotwire (www.hotwire.com) is successful on its own strategy. Travelers can select a tourism package complete with hotel and car reservation without knowing the airline or the hotel. However by specifying the location radius, the website can choose the best priced hotel within that radius. The site also offers consultancy with the help of historical trends which makes Hotwire more interesting and better in terms of customer perception. (CR, 2008) Search Engines Travel search engines like Kayak and Yahoo! FareChase are two of the most popular Meta search engines. Kayak (www.kayak.com) plays on its extra features like finding the lowest fares from a traveler's closest airport. Their deals with hotels and airlines return a very good price for the customers. Its most helpful feature includes the fare comparison tool that lets a customer check the lowest fares that other passengers paid for similar routes and to compare search results against those found on other open or blind sites. Yahoo!

Criminal law newspaper article anyleses Assignment

Criminal law newspaper article anyleses - Assignment Example laws concerns the jurisdiction of disputes between different parties and with which the jurisdiction’s law is applied, we have also the constitutional and administrative law which deals with the governing of the interactions within a state. The aim of this paper is to analyze the three articles concerning the criminal law and thereby analyzing them with regard to legal issues involved and thereby giving views concerning the press reports’ overall accuracy. If there are any inaccuracies, the paper will identify the common reasons for inaccuracies depicted by those reports. According to the article in the Daily mail on-line, 15 January 2011 about the jail for Sainsbury’s IT boss who stole 17 million Nectar points’ the fraud crime is identified. Fraud is said to be a deception made for personal gain that the intentions is either to hurt another individual. Fraud is a civil law violation that is punishable. According to the article about Sainsbury’s he was able to fraud the Nectar points because he had access to the internal administration systems there for fraud occurs when one have the authority or connections to the individual or the intended media of fraud. His fraud was motivated by persona l greed of money, after carefully planning he found a way which he could implicate the fraud, Stevenson had worked in the Sainsbury’s company for 20 years before he was arrested of the Nectar points fraud. During his prosecution he gave an explanation for the fraud, he admitted that he had found a loophole in the system of the company that he used to put points to his own card. Therefore a fraud occurs when there are loopholes in a company that reads to people to gain access and manipulate the resources also being trusted can lead to manipulation of resource. Stevenson said that he was trusted employee so no one was looking over his shoulder. In relation to this Mr. Stevenson was given a penalty of 20 months in jail for the fraud. The related law according to

Survey online travel agencies Essay Example | Topics and Well Written Essays - 750 words

Survey online travel agencies - Essay Example The second type is the 'blind' sites which are similar to open sites but they allow a customer to bid a price, a location or a time to get his/her ticket reservation but a user may not know the airline, departure time or specific hotel until the actual ticket is bought. These websites also have the normal search functionality where a customer can view the travel fares without bidding. The third type of online travel sites are merely search engines popularly known as 'meta search engines' (Rand, 2006). The term means that they search other sites which provide air travel. The search engine goes through all available online travel agencies websites (open sites) and finds the best results for the user. (CR, 2008) As mentioned above, there are three types of online travel agencies. These agencies fight within themselves to get the highest market share (Rand, 2006). For the analysis sake, the business strategy is compared according to these types. Popular open sites include agencies like Orbitz, Expedia, and Travelocity amongst others. Orbitz (www.orbitz.com) strategy is to market itself in the eco-tourism and beats the other two companies in terms of thoroughness and provides car rentals and hotel reservations at guaranteed prices. Expedia (www.expedia.com) is a highly rated site which offers extra benefits to the customers like rewards for frequent flyers, going to less-common foreign routes and awards programs. Travelocity's (www.Travelocity.com) website is easily customizable to find what the user wants. Best fares, time frame and different combinations of airline, hotels, car rentals etc. can be entered as search parameters and found easily. (CR, 2008) Blind Sites Two popular blind sites are there in the category, Priceline and Hotwire. Priceline's (www.priceline.com) strategy is to let travelers bid a price on where and when they want to fly. The website then searches for all available seats on any airline matching the cost, time and the destination. The bid can be rejected if the bid is too low, where a traveler can increase the bid and try again in 24 hours. Due to the inconvenience of not knowing the exact time of departure and airline, Priceline is best option only for people who are flexible and need a low cost travelling solution. On the other hand, Hotwire (www.hotwire.com) is successful on its own strategy. Travelers can select a tourism package complete with hotel and car reservation without knowing the airline or the hotel. However by specifying the location radius, the website can choose the best priced hotel within that radius. The site also offers consultancy with the help of historical trends which makes Hotwire more interesting and better in terms of customer perception. (CR, 2008) Search Engines Travel search engines like Kayak and Yahoo! FareChase are two of the most popular Meta search engines. Kayak (www.kayak.com) plays on its extra features like finding the lowest fares from a traveler's closest airport. Their deals with hotels and airlines return a very good price for the customers. Its most helpful feature includes the fare comparison tool that lets a customer check the lowest fares that other passengers paid for similar routes and to compare search results against those found on other open or blind sites. Yahoo!

Support Assessment for Learning Coursework Example | Topics and Well Written Essays - 2500 words

Support Assessment for Learning - Coursework Example The assessment for learning should provide feedback to ensure the pupils identify personal improvement. The assessment must also encourage confidence for future improvement in comparison to the previous achievement1. Both the teacher and the student must be offered a platform for reflection on the pupil’s performance. Therefore, an assessment for learning must be a conclusive process with the ability to recognize, motivate and develop self-esteem of the pupil. The characters listed above are vital in the assessment of learning because they are the core values of the assessment for learning concept. Assessment must be employed by the staff to support the learning process. The staff must ensure that the assessment follow and fulfil the curriculum. The process ensures that learners experience is relevant, engaging and motivating with the assessment support learning. The teachers must ensure that the assessment has high-quality interactions and feedback encouraging transition on t o the next steps of learning. The pupils must understand clearly the kind ad quality work essential for success to be achieved together with the agreed outcomes2. Assessment for the young involves dialogue between the learners and the staff. The dialogue must be based on the thoughtful probing focusing on key points of learning. Assessment includes the use of dialogues, activities and tasks that encourage interaction with the learners. The interaction must challenge them and build on the learning achieved to date. In addition, the use of discussion will encourage the development of confidence in communicating and thinking about learning. Despite encouraging participation, the assessment for learning must support the individual learning process. Individual learners should seek and receive accurate and developmental feedback on what has been learnt and the extent of learning. Personal strengths and weakness must be discussed with the teachers in relation of the strengths of the work p resented. The evaluation of personal learning process will ensure the assessment or learning is comprehensive and effective. The learners should be engaged fully in their learning3. The learners must collaborate during planning, shaping and reviewing of the progress. The review of the process includes; shaping of their learning, agreeing, and establishing targets. The staff should provide regular oral and written feedback on the pupils work whilst discussing the strengths and areas of improvement in the process. They must work with their peers offering comments on the progress. The approach in assessment will promote learner engagement while encouraging learners to be independent in the learning process. The success of the assessment learning support depends on the ability to integrate, motivate, inspire and lead the learner to personal learning which ensures self-esteem and confidence. The development of effective learning support assessment depends on contributions from learners, teachers and the support staff4. In addressing the various issues, in assessment support learning, the paper will evaluate the participation and role of individuals in the process and establish effective approach strategy. Characteristics of assessment for learning Assessment for learning has several characteristics that are important for success. The assessment must reflect and share the learning goals with pupils. The sharing of the goals with the pupil ensures that the objective and outcomes

Quality Enhancement Policy Essay Example for Free

Quality Enhancement Policy Essay 1.1 Introduction and Background The Government of Pakistan established Higher Education Commission (HEC) in 2002 to facilitate growth of indigenous universities of Pakistan to become centers of quality of education and research and development. Though this process, HEC aims to play its role in building of knowledge-based economy in Pakistan. In order to achieve this goal, HEC has undertaken a systematic plan of implementation that is 5year Medium Term Development Framework (MTDF). The main aim of HEC was to focus on quality and relevance (HEC, 2010). The core strategic areas of MTDF are: 1- Faculty development 2- Improving enrollment 3- Quality in learning and research 4- Importance to national plan These plans are supported by well-integrated crosscutting themes for developing leadership, governance and management, enhancing quality assessment and accreditation, and physical and technological infrastructure development, (Batool, 2010). HEC introduces quality enhancement cell in universities for maintaining and improving the academic quality in the country by establishing that criteria are being met and educational activities are also in an agreement with the plans of the commission. According to international practices and development, HEC improves plans in order to more improve the standards. HEC intends to achieve excellence in the higher education and by taking major initiatives to develop the performance of universities and started up with the primary step of outlining the performance evaluation standards for the universities. For this, numbers of documents are defined, every document of these articulates a detailed element of the institutional quality. Therefor these documents are equally important for achieving the desired certifications to quality enhancement in higher education (Batool, 2010). Self-Assessment is an essential element in completing the HEC recognition. The recommendations for Self-Assessment are published as â€Å"The Manual for Self-Assessment† for the purpose of implementation at department / programed level in the universities. The complete practices of Internal Quality Assurance (IQA) are controlled by the QECs established under the umbrella of the Quality Assurance Agency (QAA) of HEC at the universities and consequently develop an integral part of the universities concerned. Furthermore the QECs also work in management with authorization bodies to make the process of program level accreditation. However, the institutional act of evaluation has many more measurements with greater complexity, (HEC, 2006).This thesis defines the Institutional performance evaluation standards and to make sure that quality establishment is certified by the HEC for the universities. The institutional act assessment comes under the Purview of the HEC whereas this process is dated by the results of IQA Exercise done by the universities through implementation of the â€Å"Self-Assessment Model†. The effects of Self-Assessment will agree to the process of Performance Evaluation Standards for the HEIs to be directed by the HEC in line with best performs of External Quality Assurance (Raouf,2010). The Higher Education Commission is working for continuous improvement of these standards and their effectiveness. The HEC through QAA will assess individual institutions periodically established on the performance evaluation standards defined here. These periodic reviews will be shown from side to side an arrangement of On-Site Assessment by Performance Assessment Teams under the direction of QAA. The quality standards observed by a university will be documented only as a result of successful performance assessment reviews through evaluation of institutional successes against pre-defined principles (HEC, 2011). To sustain academic quality and standards in higher education the institutions need to be professional, creative and innovative. The vision, mission and objectives are the essential values when applied in its principle, examined and measured are likely to be fruitful. The motivation of assigning all these movements and applying them under the authority of QEC is not only to emphasize on maintaining the best faculty, administrative staff and students but to be best in research, emerging interdisciplinary courses, academic performance, strategic and integrated academic planning (GCU, 2011) Quality in academic development means agreement of all the stakeholders where the challenge is to deliver education which is continuously improving and is at the same level with the international standards. In recent years it has become a requirement that institutions of higher education demonstrate the success of their academic programs in providing high quality education that impacts the concerned stakeholders. The Higher Education Commission develops methods for evaluating the quality of academic programs (Kanwal, 2007). Moreover with the establishment of Quality Assurance Agencies at Higher Education Commission, it was decided in the National Quality Assurance Committee (NQAC) meeting that Quality Enhancement Cells will be established at all universities to make stronger the internal quality assurance procedure with a special emphasis on the quality of higher education to fill the gap between the fundamental and the desired status of quality education, (HEC,2011). The matter of quality is being known as the major issue confronting the higher education sector in the Medium Term Development Framework (MTDF). Therefore, to enhance the quality of output and efficiency of the higher education learning systems, a mechanism for the establishment of QECs has been developed by the Quality Assurance Committee to improve the standards of quality of higher education in a systematic way with uniformity across the country. The Higher Education Commission (HEC) established Quality Enhancement Cells (QECs) at ten public sector universities in 2006-07 whereas in 2007-08 more twenty QECs were established in the remaining public sector universities for enhancement of their academic, teaching and learning standards. The QEC family is being extended to additional fifteen public sectors and fifteen private sector universities in 2009-10 and twenty four in public sector universities in 2010-11 (Zafar, 2006). At the moment, the HEC has given incentives to encourage research, appoint foreign faculty, funds for workshops and conferences, and granting scholarship to go overseas to present research or do postgraduate research. It shows the deep concern of HEC regarding QA. The quality of research is a special focus and HEC has developed a zero-tolerance policy for plagiarism, (kanwal, 2007) It has established a QA Cell that states the necessity to improve a culture of assessment is always together with the concept of quality. Both internal self-evaluation and external reviews are dynamic components of any well-developed quality assurance system. It is entirely critical to monitor and control growth of sub-standard institutions of higher learning. A comprehensive multi-level mechanism of accreditation is to be developed to make sure establishment of quality education. Qualification needs to occur at the department or program level, as well as the Institutional level. (HEC, 2011) 1.2FUNCTIONS OF THE QUALITY ENHANCEMENT CELLS 1. The Quality Enhancement Cell (QEC) is to be supervised by a Dean reporting directly to Vice Chancellor/Rector. 2. QEC is responsible for maintaining public confidence that the quality and standards of the reward of degrees are improved and secured. 3. QEC is responsible for the review of quality standards and the quality of teaching and learning in each subject area. 4. QEC is responsible for the assessment of academic affiliations with other institutions in terms of effective management of standards and quality of programs. 5. QEC is responsible for essential clear and explicit standards as points of reference to the evaluations to be carried out. It should also help the employees to know as to what they could expect from candidates. 6. QEC is responsible to improve qualifications framework by setting out the qualities and skills that can be expected from the holder of a qualification, i.e. Bachelors, Bachelor with Honors, Master’s, M. Phil., and Doctoral. 7. QEC is respon sible to improve program qualifications. These are standard set of information clarifying what knowledge, understanding, skills and other qualities a student will have developed on successfully completing a Degree. 8. QEC is responsible to improve quality assurance processes and methods of assessment to affirm that the quality of provision and the standard of awards are being maintained and to foster a program of study, subject and staff development, together with research and other academic activities. 9. QEC is responsible to make sure that the universitys quality assurance techniques are designed to fit in with the arrangements in place nationally for maintaining and improving the quality of Higher Education. 10. QEC is responsible to develop procedures for the following: a). New programs approval b). Annual monitoring and evaluation including program, faculty, and students monitoring perception. c). Departmental assessment e). Student comment f). Comments of Employer g). Quality assurance of Masters, M.Phil and Ph.D. degree Programs h). Review of Subjects i). Institutional assessment j). Program specifications k). Qualification framework Universities play a significant role in the overall development of a country, their significance lies not only in providing degrees, but also in producing quality human resources for various zones of the economy (GIKI, 2011).To succeed this goal, Quality Assurance Agency (QAA) has designed some guiding principle to evaluate the quality of education in Pakistan to the ever changing conditions and global needs (HEC, 2011). It is state that Higher Education’s unique and symbolic phase is Quality Enhancement in Pakistan by IMscience that Importance of Quality can be understood from the fact that rapid development in higher education requires Quality Assurance in order to put up with current levels of academic standards and improve modern learning processes (IMScience, 2011).

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.

The Indignity of the Church :: Essays Papers

The Indignity of the Church In the article â€Å"The Priest Scandal†, by Carol Cannon expresses her views in the American Journalism Review regarding the scandals within the Catholic Church. She continues to explain how the Catholic Church has been trying to keep the whole issue hidden from society. Carol Cannon makes a point how the media has struggled with pursuing this issue for many years, while America wasn’t ready to hear the truth on such a controversial topic. Carol Cannon is writing to many different groups. Catholics are probably going to be the most interested, but since this issue is so huge it affects many different audiences and ages. Cannon’s article on sexual child abuse by priests, is written through the use of logic, credibility and emotions. She displays a clear topic and supports with using reason along with values and beliefs. The claims that Cannon makes are logical because many priests have come forwards or been charged with child molestation. Cannon makes logical claims by issuing persuasive arguments on the issue that child molestation by priests has been covered up for years. She has been reporting on the issue of pedophilia by Church officials for more than 13 years. Cannon uses evidence to support her claim. She has a combination of evidence, some which of were interviews of children who were sexual molested by priests. Cannon, along with others has also been granted permission to explore archives where the priest’s cases have been taken to court. Cannon’s examples are convincing through her arguments. She also has credible sources of other journalists that wrote on the same topic as she did. Cannons argument appeal to everyday common sense because the issue has become such a big deal to Americans. The media has also played a large part in the growth of this topic. When reporters were told to pick another topic the news media didn’t listen and were heard. Since the issue of child molestation has been around for awhile, the public knows of the issue and has a stance on it. The structure of the article has much to do on the argument of the topic. The author starts out with her credibility and then a short narrative which is an attention getter.