Different essays Essay Example | Topics and Well Written Essays - 3000 words

Different essays - Essay Example stently met; and providing subtle but regular enhancement in the quality of an item or service, so that there are lesser and lesser flaws on delivery. The particulars of how each of these terms is interpreted are specific to the industry or business in question. Risk management, on the other hand, is the process of identifying, assessing and peritonising the risks to efficient functioning within a system. The essence of risk management is improvement in the value of the end result by being flexible yet systematic; transparent and inclusive of all factors and circumstances; integral to the analytical process, but able to provide solutions specific enough to the given problem. Possible the most important factor is that it should be able to evolve continuously to meet changing needs. While both processes – Quality management and Risk management are essential for ensuring smooth operations, and thus have a number of overlaps in their core principles; they ad differ on one significant account. Quality Management focuses on the end result and the extent to which error may be avoided in the deliverables; while risk management focuses on the extent to which already occurred errors may be rectified and repeat ion be avoided. Cianfrani, C.A., West, J. E. (2009).  Cracking the Case of ISO 9001:2008 for Service: A Simple Guide to Implementing Quality Management to Service Organizations (2nd Ed.). Milwaukee: American Society for Quality. pp.  5-7 Continuous quality improvement (CQI) is embedded in patient safety-the ability to learn from mistakes and take actions to prevent the mistakes from re-occurring. Identify and explain how principles of CQI reduce the risk of harmful medical injuries. Tindill and Stewart (1993) have defined CQI as â€Å"A comprehensive management philosophy that focuses on continuous improvement by applying scientific methods to gain knowledge and control over variation in work processes†. Baker (1997) gives the steps to using CQI. The first step

A report reflecting on the skills and career Essay

A report reflecting on the skills and career - Essay Example In fact, it seems that my academic skills, as developed during my studies in the past, have been adequate for helping me to respond to the needs of daily life but could not help me to face the demands of professional environment. The educational institute I’ve chosen uses learning practices that help learners to become efficient not only in regard to academic tasks but also to tasks related to the workplace. Also, the assignments delegated to learners, as individuals or as groups, are structured in such way so that decision making and initiatives, by the learners’ side, are encouraged. In the Personal Development Programme, which is part of the Course I’ve chosen, students have the chance to monitor their progress in regard to their academic and career-related skills. This report has been prepared for showing my progress as of the skills mentioned above. Literature has been employed, along with my experiences in the class, in order to show the level at which the Course has helped me to improve my performance both as a learner and as a future employee in a managerial role. When referring to academic skills reference is made to specific aspects of a person’s capabilities. Three seem to be the most important academic skills in educational institutes of all levels: ‘reading, writing and mathematics’ (Oakland and Harrison 2011, p.94). My personal status, in regard to these skills, is analyzed below using appropriate literature. In general, reading is considered as one of the most critical academic skills. Indeed, it is not possible for a learner to respond to the needs of his learning programme without achieving a continuous improvement of his reading skills. As noted in the study of Downing (2013) each learner has to monitor his progress in regard to his reading skills; such task can be developed through a schedule customized accordingly. Personally, I have not employed such schedule during my studies. However, I have tried to identify

Mission, Vision, and Goals Essay Example for Free

Mission, Vision, and Goals Essay My mission in life is to be happy with the way my life turned out. Yes, I would love to have a lot of money and to be known, but whats the point of having all of that when Im not happy that I have it? Most people mistake being grateful for happiness. Wrong! Many of the rich and famous are grateful for what they have, but not all are happy with it. No matter how my life turns out, I just want to be happy. Whether I am a homeless woman living in a shelter, or a successful entrepreneur living in a million dollar home, I just want to be happy!! Five-ten years from now, I see myself working on my clothing line and generating a good amount of sales. I see myself getting talked about in some of the hottest fashion magazines saying that I am one of the hottest successful plus size fashion designers around. During this time I hope to have a high rolling website for my line, and that I have a huge amount of customers that buy my items. I would also love to have at least one- two fashion boutiques fully designed and fully staffed. Being a fashion designer is my main career goal. I do not see myself being anything but a designer. Fifteen-twenty years from now, I see myself being in runway shows showing off all of my fabulous designs. I see luxurious clothing stores all across the map with my brand name a logo on the front. My stores will be fabulous and glamorous like Gucci, Guess, Coach, and Juicy Couture. My clothing will be very elegant and formal. Celebrities, both small and plus size will be flaunting my designs to the Grammys, Oscars, VMAs, and more. My name will be everywhere. I have a dream to be compared to other famous designer brands like Prada, Dior, Christian Louboutin, Vera Wang, Fendi and more! I want celebreties to specifically request me and my company to design an exclusive garment for a special occasion such as a wedding. Today, I am studying business management at Johnson and Wales University. My financial aid has recently put me in a position where unfortunately, I will most likely not be attending school next year. Instead, I will be working and saving money, so that I can go to a fashion school and get a fashion degree. While I am working during the summer, I play to buy a sewing machine, and teach myself how to sew clothes. I have been looking to buy a mannequin dress form, but unfortunately they range from $95 to nearly $500, so I have decided to make my own. I will be doing a small project where I will make my own mannequin dress form of my best friends body. My plan to help me get a better understanding of the fashion world, is to be an intern at a fashion company. I hope to land my first job as a fashion assistant, either before I go to fashion school (if Im lucky) or after I receive my degree. Fashion is a huge part of my life, and no matter what obstacles come in my way like not being able to attend school next year, I will make my dreams of becoming a fashion designer come true!

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.

Cloning :: Biology Cloning

For the last few decades, cloning was a fictitious idea that lay deep within the pages of some sci-fi novels. The very idea that cloning could one day become reality was thought to be a scientific impossibility by many experts but on one exhilarating day, what was thought to be "purely fiction" became reality. That fine day was February 22, 1997. A team from the Roslin Institute which was lead by Dr. Ian Wilmut changed the face of history forever by revealing what looked like an average sheep. That sheep was what was going to be one of the most famous if not the most famous sheep in modern day. Dolly was this seven month old Trojan lamb's name and Dolly was the first ever clone of a mammal. She was an exact biological carbon copy, a laboratory counterfeit of her mother. In essence, Dolly was her mother's biological twin. What surprised most thought, was not just the fact that Dolly was a clone but was that the trick to Wilmut and his team's success was a trick that was so ingenious yet so simple that any skilled laboratory technician could master it. Therein, lied a pathway towards a new future. This news shocked the world for Dolly was the key to many new and prosperous possibilities. But Dolly was not the first clone ever. Cloning of a more limited sort had been done before her. Creatures such as mice, frogs and salamanders had been cloned from as early as the 1950's. Then, a different procedure was used. This procedure included the destruction of the nucleus inside the egg cell. Then a new "donor" cell would be brought and injected into the egg cell as a replacement. The egg would then grow into an progeny of the same genetic make-up as the donor. Later on in the 1970's a new technique was developed. This technique included transferring the genes from one organism to another by combining the DNA from a plant or animal cell with the DNA in bacteria. When the bacteria divided the cells were now the clones of both plant/animal DNA as well as the DNA it had originally. This cloning technique allowed for the growth of many endocrine system treatments such as hormone, insulin and interferon. In 1993, researchers in the US began and successfully cloned a human embryo in order to develop new ways to treat human infertility.

Fear of the Water Essay -- Personal Narrative Writing

It was three weeks before my third birthday. The razor sharp air seemed to laugh at my winter coat, gloves, and hat. My Mother was pushing me along in a stroller at Carson Park. Walking briskly along the pond trail to keep warm, hiding that she did not want to be there. She knew that I loved to come look at the pond in the winter, and she braved the weather because of my birthday. I looked up with my curious eyes, trying to figure out why it was that the ducks left in the winter, why the water looked hard, and how people walked on the water like in the Bible. My Mother and I braved the weather for a whole day on the pond, and as the evening came, we decided to make our way home. She thought it would be nice if we took the long way out of the park and cross the bridge, and I couldn’t be more grateful, water mesmerized me. As we crossed the bridge, my world came to a halt. A group of crows feeding on a dead carcass scattered over my head. A man was standing on the oth er side of the bridge, with a shiny piece of metal in his hand. I didn’t understand, but my Mom knew that we were in danger, she knew what he held was a knife. â€Å"LubDUB.† My heart screamed out. I knew something was wrong now. The man yelled and screamed word that I had never heard. My Mother secured herself as a barrier between the man and me. His black eyes met my confused scared eyes. â€Å"Don’t hurt my mommy!† I screamed. There was no reaction, no movement. The only sound was the crows cawing below. Then the man said, â€Å"How would you like to take a swim,† in a quaint, barely audible voice. For a split second there was no movement, and then the man lunged at my Mother, and with the knife at her neck tipped me into the pond. I felt as if ... ...need air quite yet. There would be plenty of breathing after this Slam! My competitor and I seemed to slam our hands into the wall simultaneously. I didn’t know who won. I looked at the score board. Looked at the scoreboard and it read, â€Å"Lane:3 Swimmer:Meier,usa TIME:44.9 Place:1.† Victory. That was the first race of the rest of my life. In my junior year, my third year of high school, I was defeated by the member of the Greenwich Black Crows, but I still received third place in the state. Exactly three years after my second place performance earned me a spot on a collegiate swim team, it was me on the podium at trials. My victory wasn’t over my competitors, but the water, the water that beat me so many times before, it came down to a 43 second race in the Olympic trials and the three elements, one hydrogen, two oxygen, that I battled for so long.

Quantitative and Qaulity Research

Quantitative & Qualitative Research COMPARISON OF QUANTITATIVE AND QUALITATIVE RESEARCH METHODS Introduction This paper compares and contrasts qualitative and quantitative research methods in three basic areas. These are the of their: epistemological foundations, data collection methods, and data analysis methods. The paper ends with a brief summary of the primary points made. ComparisonGall, Borg and Gall (1996) discuss several similarities and differences between qualitative and quantitative research methods. With respect to similarities, both kinds of research formulate epistemological positions regarding the nature of causation and reality and both comprise a set of methods for designing research, collecting data, analyzing data, and deriving information from data collection and analysis.However, they differ in terms of the epistemological positions they advocate and in the methods they hold to be appropriate for meaningful scientific inquiry. One primary difference between the t wo research methods according to Gall, Borg and Gall (1996) involves their epistemological assumptions about the nature that causality. The quantitative method, according to the authors, rests on a view of causation as an external, measurable force that occurs independently of the observer and can be used to explain diverse phenomena.On the other hand, the conceptual foundation of qualitative research holds that causation itself is predominately a human interpretive process. The foregoing assumptions have implications for how scientists should study reality. Quantitative research roots its methods of acquiring information in a view that holds that reality is external to the observer whereas the qualitative method grounds its methodological principles and practices in the notion of reality as an interpretative construct.This point has been discussed by Wainwright (1997) who states that typically qualitative research seeks to discover information about any given phenomenon by obtainin g an in-depth understanding of the meanings and definitions of the phenomenon that are conceptualized by informants; moreover, these need not be many informants; a simple case study of one individual is said to yield much given the subjective element of reality.Quantitative research, based on its assumptions of causation and reality, attempts to arrive at an in-depth understanding of the phenomenon by measuring â€Å"it† in some fairly objective manner with results that can be established as valid by a set of formal scientific/methodological principles of inquiry and set criteria for reliability and validity. It seeks for results that are stable across time.Thus, while qualitative research aims at discovering how a very small collective interpret a phenomenon, quantitative research looks at some objective index of the phenomenon attempting to produce information that is stable and valid for large populations and samples. Gall, Borg and Gall (1996) note that for some domains s uch as education, the existing knowledge base consists of information obtained by both quantitative and qualitative research.The authors point out that many research experts believe it is quite acceptable to use both kinds of research to collect information about a given phenomenon despite their differing assumptions—-provided that the two methods are assigned differing roles in terms of the contribution they make to understanding the phenomenon being studied. With respect to the foregoing, qualitative methods are assigned the role of intensively observing some small sample and conceptualizing possible themes, patterns, processes, and/or structures as being involved in the phenomenon of interest.Quantitative methods are then called upon to determine whether the conceptualized constructs are supportable or confirmed. For example, a quantitative study might be conducted of three special education students' responses to inclusion with possible patterns of response being conceptu alized based on this small sample. Quantitative methods would then be used to determine whether this pattern of response is present in a much larger collective of special education students.Thus, qualitative and quantitative research can be seen as working together in complementary fashion. Gall, Borg and Gall (1996) report that the extent to which the two types of research can work to complement each other, in actual practice, is dependent on two contingencies. First, the phenomena being studied must be stable across time. Second, qualitative researchers must provide constructs that can be operationalized which is to say that can be measured in some objective way using a numerical system of some sort.If these conditions are satisfied, quantitative measures can then be used to support whether what is present at the individual or case level is also present for larger populations and samples. Gall, Borg and Gall (1996) further report that some researchers do not believe the two resear ch approaches can actually work together in a complementary fashion; this because of their differing epistemological views of causation and reality — views which make for not only conceptual but also profound methodological differences.For example, quantitative research stipulates that a researcher must state what can be expected to be revealed by his data analysis based on existing research (hypothesis formulation and testing). Qualitative researchers, however, believe that theories and concepts are only meaningfully derived AFTER the data has been collected. Similarly, the two research types differ in the methods they use to derive meaningful information from the data. Quantitative methods hold that the data should be analyzed statistically while quantitative research holds that it should be analyzed using formal methods of reasoning and interpretation.Gall, Borg and Gall (1996) have also listed some of the differences between qualitative and quantitative research methods i n terms of the reports each side outputs following their investigations. In this regard, the authors state that the reports of quantitative research tend to be impersonal and objective write-ups of research findings. Qualitative research reports, on the other hand, are said to reflect the researcher's analytical reconstruction and interpretation of data provided to readers with an awareness that the readers themselves will, in fact, reinterpret what is reported.However, since it is likely that the epistemological structures of both research methods have some truth and some error in their epistemological frameworks, Gall, Borg and Gall (1996) state that it is quite possible that both methods can contribute valid data and so edify scientists' attempts to understand a given phenomena when used together in a complementary fashion. Given the foregoing, it seems reasonable to suggest that the determination as to whether a given researcher should use qualitative or quantitative methods, or use both conjointly, may depend upon the nature of information he desires and the use to which it shall be put.For example, Crowl (1996) states that if a researcher desires to focus on some complex issue and to use it in a pragmatic way, then it is wise to conduct research using both qualitative and quantitative methods. Both methods are said to provide a broader examination of the phenomenon and thus yield a fuller understanding of its complex structure. This broader look, in turn, is said to foster greater insight into the ways the information can be practically applied. Mertes (1998) states that there are certain kinds of information needs that are better suited to being answered using qualitative methods than quantitative methods.These are said to include: (1) the need to understand in detail why an individual does something; (2) the need to determine what aspects, components, or elements of a given issue or phenomenon are important and why they are important; (3) the need to i dentify a full range of responses or opinions existing in a given collective; and (4) the need to find areas of consensus in patterns of response. On the other hand, Mertes (1998) states that quantitative research is probably the best choice if there is a need to determine â€Å"how many† or to measure some volume-related characteristic of a collective.In other words, quantitative research should be used when there is an interest in how many people in a population have a particular characteristic or response. Further, Mertes (1998) reports that quantitative research is appropriate for measuring attitudes and behaviors, for profiling certain groups, and for formulating predictions. One particularly interesting point about qualitative and quantitative research methods is to note that the distinguishing characteristics are actual differences only to a certain extent.For example, McKereghan (1998) notes that qualitative and quantitative research can be distinguished in several wa ys and goes on to list some of these differences. Specifically, it is noted that quantitative research is objective; qualitative research is subjective. Quantitative research seeks explanatory laws; qualitative research aims at in-depth description. Quantitative research measures what it assumes to be a static reality in hopes of developing universal laws. Qualitative research is an exploration of what is assumed to be a dynamic reality.It does not claim that what is discovered in the process is universal and, thus, replicable. However, what McKereghan (1998) points out is that when actual research studies are examined in methodological detail, they seldom fit the sharp clear models of differences that are provided in written discussions of the two research approaches. Rather, in most any given study, elements of quantitative and qualitative procedures can be found. Because of this, McKereghan argues that discussing research using this dichotomy may not be especially applicable to w hat actually goes on in the world of research.Thus, while the two methods can be distinguished, it is probably important to note that this clarity of distinction is present far more in theory than in practice. Finally, it can be noted that quantitative methods help to make generalizations to larger groups and follow a well-established and respected set of statistical procedures, of which the properties are well-understood. However, in terms of practice, there is again an important issue related to whether practice actually meets the standards set for this research approach.As noted by Gall, Borg and Gall (1996), many studies are designed poorly, i. e. , many studies cannot find a significant difference when one exists, due to insufficient sample sizes or to extremely small effect sizes. Further, quantitative methods are often misinterpreted. Summary In this paper's comparison of qualitative and quantitative research methods, several points were made. It was noted that the two resear ch approaches differ in terms of their epistemological positions on causation and reality and this in turn makes for a number of methodological differences in the approaches.For example, it was noted that qualitative research typically entails in-depth analysis of relatively few subjects for which a rich set of data is collected and organized. Quantitative research, on the other hand, was said to entail the proper application of statistics to typically a large number of subjects. Further, the points were made that while quantitative research is objective; qualitative research is subjective. Also, it was noted that quantitative research seeks explanatory laws; qualitative research aims at in-depth description.In addition, quantitative research was said to measures what it assumes to be a static reality in hopes of developing universal laws while qualitative research is an exploration of what is assumed to be a dynamic, shifting, interpretative reality. It was noted that due to the di ffering nature of the two research approaches, it is likely that the selection of which to use will depend upon the nature of the information sought by the researcher and the use to which this information will be put. Examples were offered showing the kind of research to which each method or a combination of methods are particularly suited.Finally, the point was made that while there appear to be large differences between the approach from a philosophical/conceptual position, in actual research, methods from both approaches are often used. Further, the standards set for conducting each particular type of research, especially quantitative research, are often not met. References Crowl, T. K. (1996). Fundamentals of educational research (2nd ed. ) Madison, WI: Brown and Benchmark. Gall, M. D. , Borg, W. R. & Gall, J. P. (1996). Educational research: An introduction (6th ed. White Plains, NY: Longman. McKereghan, D. L. (1998). Quantitative versus qualitative research: An attempt to clar ify the problem. Document available at:http://socrates. fortunecity. com/qvq. html. Mertes, D. M. (1998). Research methods in education and psychology: Integrating diversity with quantitative and qualitative approaches. Thousand Oaks, CA: Sage. Wainwright, D. (1997). Can sociological research be qualitative, critical and valid? The Qualitative Report, 3(2). Document available: http://nova. edu/ssss/QR/QR3-2/wain. html.