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.