Alternative Means of Transportation

Guilherme Cesa Academic Writing Sara Rayfield 04/18/2012 Instead of Horns, Voice Today, most of the big cities centralize interests in improving and encouraging the private means of transportation instead of public. Driving a car can be very comfortable and pleasant, but it causes serious problems. Because of this, we all must change our mind about the ways we move daily and find different ways for locomotion. Mobility is a very exciting thing; the feeling of freedom that it gives can be very rewarding.An example of that is the way society found to punish people: we put them in a prison and do not allow them to move for days, months or years. It is evident and natural that everybody needs to move around daily, whether it is to go to work or go to the supermarket. The most popular way of personal transportation in modern society is the car. A car represents much more than just a way of transportation. The idea of having a car these days transcends the basic idea of mobility; an automo bile represents status and wealth while using alternative ways for transport such as bus, train, or bicycle are depreciated by society as being worse.Looking at how society chooses to move within its territory can reveal a lot of things about what type of society it is. Giving priority to cars means not prioritizing the greater good; it is a selfish way of thinking. More cars being driven means more roads and parking lots, fewer public spaces and green areas, more traffic jams, and pollution. On the places that were supposed to have sidewalks, we now see a wide avenue, the park turned into a parking lot. Gradually, the cities are becoming a place adjusted for the cars instead of the dwellers.As many of the problems that vehicles may cause, the most discussed nowadays is the global warming. The air pollution made by cars and fossil fuel dependents increase the moisture level of the air, which causes the greenhouse effects. The pollution forms a layer around the atmosphere that makes the heat be reradiated from the surface to the atmosphere, causing the global warming. However, hope still exists for Planet Earth by the limitation of usage and dependency on fossil fuels.Besides the main problem that cars cause for the environment, cars nowadays are much cleaner than before, the problem is that we have a lot more cars being driven on the streets and polluting the earth. In addition, cars demand a large amount of raw material to be made and they produce a lot of waste. While driving the automobile, it is not only polluting gas that is being produced, it also affects the ground and water when the tires wear out and fluids, such as battery oil and gasoline, spill from the car.Alternative forms of transportation such as walking and bicycling for short distances, and train, subway, trolley, light rail, bus, and car pooling for longer distances may be a good solution to solve a lot of problems. It will not only help in the amount of pollution in the atmosphere but also would bring benefits in other aspects of our lives; we would save money, it would reduce other types of pollution such as water, land and noise, it would give us a better quality of life, we would spend less time in stressful traffic and the cities would become a more pleasant place to live in.Of course it is very difficult to convince people not to use their cars since we have an inexistent public transportation program; no buses, no trains, no bike lanes, and bad sidewalks. Once the authorities start improving the methods of transportation as well as promoting them, people will begin to see the advantages of changing one to another. Studies from the company EMBARQ have shown that cities can reduce up to 30% of the vehicular traffic over the next 3 to 5 years if improving the public transportation.A good example that this improvement can cause big effects in cities is the Los Angeles Metro promotion; their urban transportation system authorities are making an innovating campaign fo r the city. In order to reduce the traffic, clean the air and make their lives less stressful, Los Angeles’ transit authorities start trying to convince people about the benefits of using public transportation. The way they found to do so was improving as much as possible the service quality offered for metro and buses lines, making them cleaner and more comfortable.Then they worked to improve the image of it and get people out of their cars. They made buses appear more attractive with colorful paints and redesigned the metro stations with paint arts and music. At least, they started working on a marketing campaign to convince people to use their services and encouraging Angelinos to leave the car need. Another facet of public mobility that could replace the use of cars is cycling and walking. Better sidewalks and bike lines as well as providing free bikes rentals as many cities in Europe do would attract more people to use these means of transportation.Walking and cycling ca n be a very pleasant way to move from one place to another in short distances and the gains that it causes are numerous. It gives people a slower-pace routine, and using legs to ride a bike or walk is a very good exercise that improves a lot the body and mental health, it is free and can help to save a lot of money in gasoline and transport fares. It is also a pro-environment way of transportation that does not pollute, it helps to make a more attractive and green city where people can interact with others and with the city environment around them.As a conclusion, changing one way of transportation to another is an action that takes long to happen and it takes a lot of effort both from authorities and citizens. However, if it be done, it will bring positive results for the whole society. The cities would become a better place to live, with streets populated by people and not by cars. Work Cited Network, EMBARQ. â€Å"LA Metro: Promoting Mass Transport† Vimeo. 04 January 2010. Web. 19 April 2012. Pawley, Martin. â€Å"The War Against Car† Open Democracy. Globalization Transport. 8 May 2012. Web. 19 April 2012.

Dr Mccall Paper Essay

Jerry McCall is Dr. Williams’s office assistant. He has received professional training as both a medical assistant and a LPN. He is handling all the phone calls while the receptionist is at lunch. A patient calls and says he must have a prescription refill for Valium, an antidepressant medication, called in right away to his pharmacy, since he is leaving for the airport in thirty minutes. He says that Dr. Williams is a personal friend and always gives him a small supply of Valium when he has to fly. No one except Jerry is in the office at this time. What should he do? Resource: Ethics Case Study Grading Criteria on your student website Read the case study in Ch. 4 of Medical Law and Ethics that begins, â€Å"Jerry McCall is Dr. William’s office assistant. †Prepare a 700- to 1050-word paper in which you answer the following questions: †¢Does Jerry’s medical training qualify him to issue this refill order? Why or why not? †¢Would it make a difference if the medication requested were for control of high blood pressure that the patient critically needs on a daily basis? Why or why not? †¢If Jerry calls in the refill and the patient has an adverse reaction while flying, is Jerry protected from a lawsuit under the doctrine of respondent superior? †¢What is your advice to Jerry? †¢Identify major legal and ethical issues that may affect Jerry’s decision. †¢What problem-solving methods might be helpful to assist in making an ethical decision? Include at least two sources in your paper. Format your paper consistent with APA guidelines Describe ethical principles used in health care organizations. Explain the relationship between an organization’s culture and ethical decision-making. Recognize the role and importance of ethical values within an organization. an office assistant Jerry has certain duties and obligations to fulfill within his field of study, knowledge, and expertise. In this case as an office assistant Jerry has the authority and obligation to answer all phone calls and respond to them promptly, ethically, and efficiently. In this case the office assistant not only has administrative training but a limited amount of clinical training, the amount of clinical training that he does have does not qualify him to issue this refill. As an office assistant Jerry has the authority to call in only prescriptions or refills approved by the doctor. In this case as he is the only one in the office he should explain the situation to the patient and let him know that he will try his best to get in touch with Dr. Williams in order to have this prescription called in. He should let the patient know that it may not be possible to get it done within the time frame but that he will try and that he will call him back as soon as possible to let him know. Jerry as an assistant for Dr. Williams should have contact information for Dr. Williams, he should try calling the doctor and getting permission to call in this refill. However, if the doctor can not be reached then he must let the patient know that refilling this prescription at this†¦

Effects of Addition of Nitrogen on Ph and Availability of Soil Assignment

Effects of Addition of Nitrogen on Ph and Availability of Soil Nutrients - Assignment Example If biomass is divided into root components and the ones above the ground, we find the significant effect to be root biomass of the last generation composed of high N. These effects account for less than 0.1% of variance of root and dry biomass. As 50% of biomass above the ground and root materials are returned as litter to the system, the high N’s soil deposition get greater inputs of nitrogen and organic C. Therefore, a large quantity of N and C accumulate in the soil at the top of the deposition of high N microcosms, compared to deposition of low N microcosms. However, there are no effects in the composition of high N. If soil C is increased in the deposition of high N, it reflects significantly larger NEP. Varied measures reflects decomposer activity: invertase, b-xylosidase and collembolan density activity are significantly larger in deposition of high N microcosms: furthermore, there is no effect in the composition of high nitrogen on the measures. Rates of nitrogen miner alization do not differ in the combinations across, composition and though N leaching rates are a times greater in the deposition of high N. This effect is inconsistent and leaching rates are low. Storage of carbons in the POM fraction is greater under deposition of high nitrogen and is not affected by composition of high N. ... l percentage P value P value P value P value P value Above ground biomass(g/m sq) + 82.5

An exegetical study of Genesis 32 verses 22-32 Essay

An exegetical study of Genesis 32 verses 22-32 - Essay Example and have prevailed.† 29Then Jacob asked him and said, â€Å"Please tell me your name.† But he said, â€Å"Why is it that you ask my name?† And he blessed him there. 31Now the sun rose upon him just as he crossed over Penuel, and he was limping on his thigh. 32Therefore to this day, the sons of Israel do not eat the sinew of the hip which is on the socket of the thigh, because he touched the socket of Jacob’s thigh in the sinew of the hip. (New American Standard Bible) The account of Jacob’s wrestling match at the ford of Jabbok is, admittedly, a rather difficult passage to interpret because of the surrealism of the occurrence: In the middle of the night, Jacob decides to send his wives and children and their possessions over the ford (vv. 22-23); from out of nowhere, a man appears and wrestles with Jacob who, for some reason, is left behind or stays behind on the other side of the ford (v. 24); the match goes on for an extended period, that is, until daybreak (v. 24), and Jacob demands for a blessing when the man tries to disengage (v. 26); right there, Jacob’s name is changed to Israel, and the place is named Peniel as well (vv. 28, 30). On the surface, the meaning of the passage is not made immediately clear, for as one goes through it initially, it reads as though it is a dream sequence. However, there seems to be no concrete reason to suppose such. It seems fairly clear that there was an actual crossing that occurred (v. 22), an d that Jacob was physically hurt by the encounter (v. 31b â€Å"†¦and he was limping on his thigh.†). Hence, the passage indicates rather clearly a turning point not only in Jacob’s life, but in the consequent Israelite history, as evidenced by the effects of the nocturnal encounter (v. 32). At any rate, this particular analysis of the narrative focuses on the name changes that are apparent in the text, specifically the change of Jacob’s name to Israel, and the place of the struggle being named Peniel. Such name-changing has

Date (phoenix dactylifera L) Research Paper Example | Topics and Well Written Essays - 1500 words

Date (phoenix dactylifera L) - Research Paper Example A single bunch of date palms that weighs about 8 kg may contain as many as 1000 dates. â€Å"The dried fruit is more than 50% sugar by weight and contains about 2% each of protein, fat and mineral water† (online-family-doctor.com, n.d.). Date palm belongs to the Phoenix dactylifera tree in the palm family. The mt genome of P. dactylifera shows a variety of unique traits as it happens to be the first of the family plants of palm. It not only positions at the known monocot mt genomes’ roots, but also has a significantly low repeat content level while it exhibits the RNA editing events in abundance. Date palm shows â€Å"a high level of chloroplast sequence insertions as compared to other known angiosperm mt genomes† (Fang et al., 2012, p. 9). There is no objective record of the exact location where and time when the date palm originated as this information is believed to have been lost in antiquity, yet there are many records that suggest the cultivation of date palm in 4000 B.C. as the date palm was employed in the construction of the moon god’s temple in the Southern Iraq, Mesopotamia. Another proof of the antiquity of this fruit is the Nile Valley in Egypt where the date palm was adopted to symbolize a year in the Egyptian hieroglyphics whereas the frond of the date palm was used as a month’s symbol. â€Å"[This information] is confirmed by history, and corroborated by the archaeological research into ancient historical remains of the Sumerians, Akadians and Babylonians†¦Houses of these very ancient people were roofed with palm tree trunks and fronds. The uses of date for medicinal purposes, in addition to its food value, were also documented† (Zaid and Wet, n.d.). Date palms are believed to originate in Babel, Iraq, though there are also evidences of its origination in Harqan, and Dareen. Date is one of the most nutritious and delicious fruits that have been

Current Research Paper Example | Topics and Well Written Essays - 1000 words

Current - Research Paper Example It there for means that Eli Lilly and company is basically the bedrock or pillar of Lilly Endowment. However, Lilly Endowment remains a motivator for the pharmaceutical company, and hence it affects some of its business and management strategies. Lilly Endowment entails some community and volunteer programs in the community. It is believed that its budget is greatly financed by Eli Lilly and company and this means that the pharmaceutical company would do anything to make gain, to put in a capacity to support Eli Endowment. This could mean cutting on expenses like reduction of labor, adoption of modern and effective digital management strategies like e-human resource management (E-hrm) to reduce the number of workers hence reduce on the labor expenses among others. Furthermore, the pharmaceutical company may have to organize some workshops and seminars to encourage the beneficiaries and officials from the Lilly endowment and this could mean some cost and time as well. Some senior management team are always required to mentor the youths and women in the Lilly Endowment and this means they have to forego their core roles in the Eli Lilly and company to encourage some members of the Lilly Endowment Inc. Lilly Endowment was founded by the core owner of Eli Lilly and company and his three core values revolved around community development, education and religion among others. This means that the same principles must be incorporated in the pharmaceutical management strategy. The element of community development could be related to its CSR which entails building schools for the locals, initiating clean water projects in the community, constructing health institutions and funding certain health related projects to eradicate epidemic like HIV and TB among others. The company is known to donating food and pharmaceuticals to the less fortunate like the street homes and elderly homes

Noteworthy Features of United Arab Emirates Research Paper - 1

Noteworthy Features of United Arab Emirates - Research Paper Example It is a vibrant civil society. The study also explores that folklore; education and sports play a vital role in society. UAE Architecture is an example of the combination of traditional and modern design. UAE society has built a new culture that is an example for different countries of the world. This new culture shows how a nonhomogeneous society builds a prosperous and rich country. The United Arab Emirates (UAE) is a diverse and multicultural society. It is home to different ethnic groups from different parts of the world. This article is about the important features of UAE society and culture. The article first gives a brief description of the concept of society and culture. Then it discusses the features of UAE society and culture thru this concept. The fundamental element of a society is a human being, an individual. A large number of individuals who live in a geographical area and share (â€Å"The cultural concept†) certain laws, customs, beliefs, norms, languages build a society. The individuals of a society may come from one ethnic group or diverse ethnic groups. If society consists of a diverse ethnic group of people, then the members of the society share different customs, beliefs, norms, and languages. The UAE society consists of diverse ethnic groups. How to define the culture of a society? There is no formal interpretation of culture. There ar e many understandings of the concept of culture. Some understanding of culture (â€Å"Culture and People†) relates to objects like music, art, food, and literature of a group of people. Edward B. Taylor (â€Å"What is culture†), an English Anthropologist, described culture as the behavior of the members of the society. Thru knowledge, belief, art, law, morals, custom, and habits members of the society express their behavior. According to Merriam Webster dictionary (â€Å"Culture†) culture is a set of customary beliefs, and material traits of a racial, religious, or social group.  

Critical Process Paper Term Example | Topics and Well Written Essays - 1000 words

Critical Process - Term Paper Example Due to this analysis the most truthful opinion is that videogames inspire and cultivate aggressive behaviour not any more or less than other forms of media like television or internet. This statement was a basis on which video games already received a First Amendment protection during the attempt of state government of California to forbid selling violent videogames to minors. Nevertheless despite the victory of videogames in that battle, though it gave them equal rights with other media, the main war is still raging on. Doctors, researchers and most of all immoderately and excessively careful and anxious parents seek to find right tactics to blame videogames in the wrong behaviour of their children. Such scenario slowly moves but still parents themselves are more responsible for any problems that they have with their children and videogames have nothing to do about it. As for the other types of media they are more independent and not so young as videogames. For those who don’t know it may be interesting that nowadays there is a serious discussion on the matter of giving videogames a status of art. This requires more significant and attentive look from the government, producers of videogames and customers. Books, movies and films are strictly categorized by the level of age and also a lot of other restrictions and requirements (for example aspersion and slander towards other person must not take place in any media). Therefore, by connecting with the world of real media and art videogames must be of a high level. The rate of the game is not similar to the rate of violence in it. Violence is just an extra option because a majority of all games need one player or a team of players to conquer, smash, beat or simply make lose the other player or team of players. Most of the games follow the jungle rule of the survival of the fittest (eat or be ea ten). Such parents` concern about the

Liverpool Street Essay Example for Free

Liverpool Street Essay London is a vast city, with people of various religions, cultures, traditions and backgrounds. It is a city, which allows people to have freedom and choice. London is the commercial centre of Great Britain with diverse institutions. It is also famous for tourism; millions of people come to London to experience what it can offer. It has many famous historical buildings, botanical gardens, and great landmarks, which are an essential when visiting London. It is an honoured country to be proud of. We studied and analysed two stories. A Christmas Carol by Charles Dickens, and a Kiss Miss Carol by Farrukh Dhondy. Both stories portray disadvantage. A Christmas Carol is about a man called Scrooge who has a mean character and sees no good in life, he never makes the best out of things. He hates poor people and thinks that Christmas is a humbug. A Kiss Miss Carol is about a young Bangladeshi boy named Jolil whose life is in monopoly control of his father. He has no free will whatsoever. Jolil is overwhelmed to be included in a Christmas play at school, but realises that his parents are not ready to support him. The poverty in London from the story A Christmas carol is described through depressing gloomy language. Dickens brings the settings to life by using adjectives like cold bleak dingy. These words give a poor effect to the climate, and make it seem dull and lifeless. Dickens describes houses using boring colours like black. He contrasts the black lifeless colours with the white sheet of snow so that the bleak depressing colours stand out more. These lifeless colours, make the atmosphere feel unhealthy, Dickens varies his sentence length for great effect and breaks them up by the use of colons and commas. His choice of words such as dirtier and dingy mist make the climate seem crowded and filthy. Dickens uses many methods of writing in detail. He makes the reader want to read on by his lengthy descriptions, extensive use of vocabulary, humorous style of writing and his use of dialogue, for the characters. Though some of the techniques Dickens used are tedious, but the humour and communicating with the reader (the dialogue) helps balance this out. The poverty in London from the story A Kiss Miss Carol is described in a lot of detail as we can create images of some of the scenes Jolil describes. The author describes corrugated estates, which looked like huge skulls, which had been picked out clean. The term skull signifies death, the estates are described as if all signs of life from the building have been extracted, as if the estates are completely dead, old, and a little haunted. When a Lion kills a Reindeer, it eats the parts he desires, the remaining carcass is then picked out clean by little insects, taking every bit they can, taking all the life and essence they can from the remains of the dead animal. Similarly, this shows how the building is savagely demolished; every essence of life from the estates has been picked out clean, and nothing if left of it. The area in which Jolil lives is portrayed as mixed and quite poor. Jolil has to save up his travel money to bribe his brother-no luxury pocket money there. (Lines 161-163). He watched the needle go in and out of the patches of grey clothes, like the beak of a bird pecking down a lines of crumbs. The grey cloth shows a dullness in the work that Jolil is doing, that there is absolutely no vitality, its shows the dull, dreary, depressed and deprived type of life Jolil is leading. The bird pecking crumbs show a state of desperacy that Jolils family is leading, that they work hard, but get paid very little money, and this also shows how desperate Jolil is to go and perform at the Christmas Concert. The wealth shown in the story A Christmas Carol is through describing the rich colourful, tasty textures of food. The wealth is emphasised through language. Dickens describes how round the chestnuts are, bringing them into life, tumbling out into the streets in their opulence. This word describes the wealth, affluence, and fortune in the chestnuts that taste so tender. The bunches of grapes which dangle from the shopkeepers hooks, that peoples mouth might water gratis. Gratis describes how peoples mouth would water without charge, and in as much freedom when passing by the round, green, squidgy sweet grapes, which taste absolutely exhilarating. Dickens describes the fragrance of the food market, the cool sensation, that sweet and pleasant odour, the aroma, which leads to the radiant fruits, those glowing lights, beaming brilliantly to sheer perfection. The gold and silver fish symbolise wealth, fortune and prosperity. Dickens can make the most awful fruits sound to sweet and sugary. This is how wealth is shown in London, through the rich, colourful, fragranced fruits in the market. The wealth shown in the story A Kiss Miss Carol is by many white businessmen wearing suits rushing towards Liverpool Street station. Thousands of white people hurrying towards the train station. Liverpool Street is an industrial area with many huge companies in competition. It is in the heart of London. These people flocking to and from the station are either going to or from work, which tells us that London is able to sustain itself as millions of people are earning money.

Reflection on Experience With Surgical Wound Care

Reflection on Experience With Surgical Wound Care Reflective Practice is something more than thoughtful practice. It is that form of practice which seeks to problematise many situations of professional performance so that they can become potential learning situations and so the practitioners can continue to learn, grow develop in and through practice (Jarvis 1992). Moon (2004) defines reflection as part of learning and thinking. We reflect in order to learn something, or we learn as a result of reflecting, and the term reflective learning emphasizes the intention to learn from current or prior experience. Using the Gibbs (1988) reflective model for analysis, I will be relaying my thoughts and feelings through this essay which talks about my experience in achieving my learning outcome on surgical wound care. DESCRIPTION As I started my adaptation program in the surgical ward, I am expected to be dealing so much with surgical wound care. To reinforce my knowledge skills on the management of surgical wounds, I studied on the similarities differences that I have observed from our practices back home and from what is practiced here. I noted the different types of dressings cleansing solutions used and the different practices protocols regarding management of wounds. I observed how my mentors changed the dressings, how they removed stitches and staples and how they cleaned the surgical wound. I also observed how complications are prevented by providing patient education and observing the principles of proper hand washing and infection control. During my whole adaptation stay, I was able to develop my skills in the management of surgical wounds. During my previous training back home, we were not given the chance to perform procedures such as changing dressings, cleansing surgical wounds, and removing stitches since it was the surgical resident doctors responsibility to do that. Although I know how to do it due to the numerous times Ive seen them perform these procedures, it still feels different when you do these procedures yourself because you will be able to enhance the skill and gain more confidence when you do it more often. FEELINGS The whole training program gave me the opportunity to apply what I know when performing procedures of managing surgical wounds. Every time I finish performing any procedure, I feel really relieved knowing that I am enhancing my skills in this aspect more more and knowing that I am more self-assured with the experiences Ive had. I also became more confident with providing patient education and focused on principles on wound care hygiene, bathing, and prevention of complications. Aseptic technique was always observed whenever I touched the patients wound to prevent infection. Every time I come in contact with the patients skin, I always kept these principles in mind. EVALUATION The whole experience gave a lot of positive outcomes for me. I understood more about topics such as tissue viability wound healing and I was more familiar with the different dressings commonly used. Another new experience for me was when I was able to witness how to change vacuum dressings for a patient who had a chronic wound in his foot. As defined by Thomas (2001), Vacuum assisted closure (also called vacuum therapy, vacuum sealing or topical negative pressure therapy) is a sophisticated development of a standard surgical procedure, the use of vacuum assisted drainage to remove blood or serous fluid from a wound or operation site. I was amazed with how vacuum could help in wound healing. ANALYSIS According to NHS report, 1998, Wound care has, in the past, not been well managed because of the limited understanding of the healing process and the inadequate range of dressing materials available. Wound management has now come full circle, back to Hippocrates principle and dressings are being developed to provide the ideal environment for nature to do its work. Most surgical wounds are categorised as acute wounds, healing without complication in an expected time frame (Bale and Jones, 1997). However, like all wounds, healing is affected by intrinsic and extrinsic factors that may result in complications (Baxter 2003). Surgical complications include infection, dehiscence, evisceration or bleeding at the surgical site. During the whole of my training, preventing complications was another priority in taking care of surgical patients. The whole experience made me alert at watching out for any sign of complications by making sure that frequent assessment is done, principles of infection control are observed at all times and patient education is being delivered. Looking at the whole experience made me conscious about the great deal of learning I have achieved. I have witnessed how much I have improved with my skills with the help and guidance of my mentor. CONCLUSION Through this experience, I have utilized reflection to aid me in attaining an optimum level of learning by not only focusing on my knowledge but most especially on the positive changes that Ive achieved with my skills. Due to this learning experience, my clinical skill on surgical wound management was further enhanced. If I were to make any changes during my whole learning experience, what I could have done was to grab any opportunity that would come my way. When we had a patient with a vacuum dressing, I was hesitant to change the dressings because I was afraid to make any errors especially that it was quite a complicated procedure. Now Ive realized how much opportunity Ive lost knowing that we did not have many patients who had that type of dressing. This realization makes it clearer to me that I should be more assertive when opportunities on new procedures arise. ACTION PLAN This experience made me promise to myself that whenever I would be faced with more opportunities for learning, I would not hesitate to grab them. I should learn to be more assertive the next time and try my best to find more ways of achieving professional development. In the future, I would want to continue my learning about surgical wound management by keeping myself up-to-date about this topic regularly reading new literature. I would also want to know more about other types of dressings that I am not familiar with and find more avenues of learning through seminars, trainings and knowledge updates. Moon, J. (2004) Reflection and Employability, LTSN http://www.heacademy.ac.uk /assets/York/documents/ourwork /tla/employability/id339 _reflection_and_employability.pdf NHS report on wound care www.nhsdirect.nhs.uk

Emerging Threat of Invasive Fungal Infections

Emerging Threat of Invasive Fungal Infections Introduction Emerging threat of Invasive Fungal Infections Invasive fungal infection continues to be a major problem associated with high morbidity and mortality mainly to immunocompromised patients as well as to immunocomptent patients but to a much lower extent. (1) Invasive fungal infection and fungemia are caused by a variety of fungal pathogens. The most commonly isolated yeasts are Candida species (spp.) and Cryptococcus spp. Aspergillus species remains the most common mould however, Fusarium spp., Scedosporium spp., Penicillium spp. and Zygomycetes are increasingly isolated.(2) Patients mostly become colonized during hospitalization however, very few patients who become colonized develop sever infection. Nosocomial fungal infections can represent up to 15% of all nosocomial infections.(3) The spectrum of opportunistic invasive fungal infections has increased substantially owing to the rapidly growing population of immunocompromised patients.(4) Due to lack of specificity of symptoms diagnosis of fungal infections can be challenging.(3 ) Candida infections are mostly prevalent in critically ill patients in intensive care units (ICUs) and very low birth weight infants. Candidaemia is highly fatal with a reported mortality in the range from 36% to 63%.(5) In the recent years, mortality rates in ICU patients have decreased substantially probably due to earlier initiation of antifungal therapy.(6) Conversely, aspergillosis is the most common fungal infection in immunocompromised most specifically in haematological malignancy and haematopoietic stem cell transplantation (HSCT) patients. Incidence of aspergillosis has increased considerably but mortality has decreased owing to better diagnosis and treatment.(7) Treatment of Invasive Fungal Infections Treatment and prophylaxis of invasive fungal infections involves systemic antifungal therapy. Historically amphotericin B and Flucytosine have been the only available antifungals; these were followed by the development of the older triazole antifungals; fluconazole and itraconazole in the late 1980s. More recent advances have led to the release of amphotericin lipid formulas, newer broad spectrum triazoles (voriconazole, posaconazole) and the newest class of echinocandins.(8) Amphotericin B either as a deoxycholate or in lipid formulations has been the backbone of antifungal therapy for many years. The triazole antifungals have also emerged as front-line treatment and prophylaxis for many systemic fungal infections. Triazole antifungals used systemically include fluconazole, itraconazole, posaconazole and voriconazole. Fluconazole has a major role in prophylaxis and treatment of both invasive and superficial fungal infection. Voriconazole is the drug of choice in invasive aspergillosis of the lung. Posaconazole is used as a salvage therapy for invasive aspergillosis as well as a prophylaxis in HSCT and neutropenic patients.(9) Itraconazole is active against most fungi except for Zygomycetes.(10) Terbinafine which is widely used in skin infections is also effective against systemic candidiasis including vulvovaginal candidiasis although less effective than fluconazole and itraconazole.(11,12) Flucytosine is used in combination with amphotericin B for treat ment of severe systemic mycoses and has also in combination with other antifungals for treatment of colorectal carcinoma.(13) Echinocandins Introduced Despite the advantages in medical practice and introduction of newer agents, mortality due to fungal infections remained high with mortality due to Aspergillus approaching 100% in HSCT patients.(14,15) There has also been a change in epidemiology of fungal infections with non-albicans species reaching up to 50% with no significant change in mortality in spite of these newer agents in two studies conducted 15 years apart.(16,17) Echinocandins is a newer class of systemic antifungals introduced after almost 15 years of no new agents. They work by inhibiting ÃŽ ²-D glucan in fungal cell wall. Echinocandins have favourable kinetics which allows their once daily dosing. (18) The first echinocandin product to be licensed is caspofungin (FDA approved in 2001), that was followed by micafungin (FDA approved in 2005), and anidulafungin (FDA approved in 2006). (19)The discovery of the echinocandin antifungals has provided a new alternative for patients with equal if not higher efficacy relative to older agents and apparently lower toxicity.(20,21) Echinocandins are extensively used in the treatment of invasive fungal infections mainly invasive candidiasis in neutropenic and critically ill patients.(22)They are also approved as a salvage treatment for invasive aspergillosis.(23) The major advantage of the echinocandins members is their higher efficacy against many candida species including C. glabrata and C. krusei res istant to fluconazole added to their lower toxicity rates compared to older antifungals.(20,21,24) The Infectious Diseases Society of America (IDSA) recommends echinocandins as first line treatment of Candidaemia while caspofungin is offered as an alternative to voriconazole for treatment of invasive aspergillosis.(22,23) Echinocandins showed equal efficacy to triazole antifungals and even superior efficacy in subgroup analysis since it demonstrates superior efficacy for prophylaxis in patients with hematologic malignancies and undergoing HSCT.(25) Echinocandins Safety Treatment of fungal infections is challenging and riddled with adverse events. (26,27) Echinocandins showed no difference in drug related adverse events and all-cause mortality as compared to triazole antifungals where both groups have shown to be generally well tolerated, nevertheless, echinocandins has significantly decreased adverse event related mortality compared to triazole antifungals.(25) Echinocandins have revealed hepatic toxicity in clinical trials yet the incidence is considered low.(28) The most commonly reported toxicities associated with echinocandins in clinical trials are rash, phlebitis, and nausea. The renal profile of this class appears to be superior to that of older agents.(29,30) Serious adverse events reported with echinocandins in the context of clinical trials are very few with atrial fibrillation and seizures in two cases treated with anidulafungin and disseminated intravascular coagulation in another one treated with micafungin.(31,32) Unfortunately, till now there is insufficient data on the frequency of hepatic and renal toxicities in normal clinical settings although they have already been reported in context of clinical trials. Moreover, as these agents became more widely used outside clinical trials, new adverse reactions are surfacing. Anidulafungin has been reported to be associated with alopecia in a female patient after several months of treatment.(33) Anidulafungin has also been associated with life-threatening haemodynamic stability in another patient during administration.(34) Three cases has shown a considerable drop in their cardiac index or a worsening of the mean arterial pressure, one following caspofungin administration and the other two post anidulafungin administration.(35) Echinocandins has also been associated with a decrease in cardiac contractility in few case reports and in vitro studies which warrant further investigations.(36,37) Further studies seem to be mandatory to investigate this po tential risk. Limitations on Detecting Risk Pre-marketing studies are incapable of detecting rare events. In addition due to their short duration they are also unable to detect delayed toxicities. It’s worth noting that to detect doubling of a 0.1% event with 80% power; more than 50,000 subjects need to be studied. This leads to drugs being authorized without serious rare events are adequately studied. One cannot also be sure that the safety profile demonstrated in the pre-marketing clinical trials with limited number of subjects remains unchanged when used by millions of patients in normal settings. This difference in safety profile demonstrated is not only attributed to difference in number of users but may also be due to choosing of healthier subjects to participate in clinical trials, providing better care to clinical trials participants in addition to shorter duration of exposure in clinical trials as compared to normal settings. This difference in safety profile may as well be attributed to the fact that participa nts in clinical trials are rarely representative to the general patient population. (38,39) Post Marketing Risk Detection Pharmacovigilance is defined as the continuous process of detecting, evaluating, communicating and improving safety of medicines under normal conditions.(40) Post marketing data on adverse events include spontaneous case reports, medical record databases, and data collected in prospective postmarketing studies.(41) Spontaneous reports are unsolicited reports of clinical observations originating outside of a formal clinical trial and that are submitted to regulatory agencies or drug manufacturers.(42) The report is considered important if it involves an ADR that is new, rare, serious or occurring at a higher frequency than expected.(43) Spontaneous reporting systems have a potential for detecting or ‘signalling’ new ADRS that have not been previously recognized in clinical trials.(38) The most crucial factor that determines the value of spontaneous reports is the quality of submitted reports and whether it has a complete description of the ADR, patient demographics, baseline characteristics other confounding factors or medication and temporal relation.(42) Signal detection using large postmarketing ADRs databases is the first step in detecting unknown and unexpected associations between drug exposure and adverse events which has to be followed by qualitative case-by-case analysis to identify signals that may be of value or warrant further investigation.(44,45) Safety evaluators usually look at common trends or patterns or and potential causal relations. (42) Advantages and Limitations of Spontaneous Reporting In all countries, the nation pharmacovigilance system relies on spontaneous reporting by healthcare practitioners, patients and manufacturers to the national coordinating center.(46) Spontaneous reporting is the only source of pharmacovigilance that provides the highest volume of data at the lowest cost.(47) The most important function of spontaneous reporting is early detection of signals which helps in hypothesis formulation that may lead to initiation of confirmatory investigations or regulatory actions that may end up with warnings, label changes or product withdrawal.(48,49) Large postmarketing databases are the most important source for mining of drug safety data, however, analysing data from these databases is very challenging owing to the limitations of these unsolicited reporting systems.(50) One of the most important limitations of spontaneous reporting is the quality of data since cases are mostly poorly documented with no follow up data which necessitates contacting the reporter for more data.(42) Another limitation is under-reporting whose extent is very hard to estimate and which depends on many factors including the severity of the reported ADR among many other factors.(51,52) Reporting rate also undergoes fluctuation along the drug life cycle with higher rates noticed when the drug is newly introduced to the market (weber effect). Higher reporting rates are also noticed for serious medical events or after negative publicity. (53) It’s estimated that FDA receives only 1% of ADRs in one study and 8% in another of all occurring ADRs which affects is reflected on the inability of spontaneous reporting system to estimate incidence of a specified ADR. (54,55) Role of Data mining in Pharmacovigilance The role of data mining in the field of pharmacovigilance is evolving. At the outset, it’s worth noting that data mining methods involve identifying the observed relation between a drug and a certain ADR. These relation identification methods are based totally on the frequency with which the drug and event are reported. The relations identified using these data mining techniques cannot be used to prove or negate a causal relation.(50) Data mining methods can elucidate complex drug issues such as concomitant medications or conditions that may not be investigated using traditional methods. However, this is usually confronted by the non-systematic attainment of background rates of adverse events and drug exposure data which hinder estimation of risk based on spontaneous reporting databases.(56,57) In the context of data mining, the term ‘signal’ is used to refer to a quantitative association between a drug and an event which exceeds a certain threshold set by the investigator that warrant further evaluation. The ‘signal score’ is the number reflecting the strength of the quantitative association which reflects how much the observed frequency differs from that expected.(50,56,58) The application of computational and statistical methods to large drug safety databases for identifying drug-event pairs disproportionately reported at higher frequency than expected by a statistical independence model is referred to as ‘Safety data mining’ and ‘disproportionality analysis’. Many data-mining methods are applied to pharmacovigilance; the ones that are most commonly reported in the literature are the proportional reporting ratio (PRR) and the reporting odds ratio (ROR) in addition to the Bayesian and empirical Bayesian methods.(59–62) Signal Detection Methods Disproportionality analysis is the main concept behind computerized pharmacovigilance methods. Disproportionality analysis is dependent on the construction of a 22 contingency table as shown in table (1). (63) Disproportionality methods differ in how they are calculated and how they account for low counts. They are generally classified into Frequentist and Bayesian approaches. Drug of interestOther drugs Event of interestab Other event cd Table 1: Statistical significance in spontaneous reporting is calculated using the frequencies in the table above Frequentist approaches Frequentist approach usually accompanied by hypothesis testing of independence using chi-square or Fisher’s exact test.(64) Proportional reporting rate (PRR) or Case/Non-case design PRR can be considered as an approximation of conditional probability and is calculated using the following equation: PRR= = a/(a+c) à · b/(b+d). Where a/(a+c) can be perceived as the probability of developing the event of interest given that the drug of interest is taken and an event in turn, b/(b+d) can also be perceived as the probability of developing the event of interest given that another drug is received given that any other drug is taken and an event occurred.(63) PRR is a valuable aid to signal generation which is easy to calculate and interpret with various refinements made possible.(59) Reporting Odds Ratio ROR is a ratio of two ratios and is calculated according to the equation: ROR= a/bà ·c/d where a/b is the ratio of the patients who had the event of interest a divided by the number of patients who had the event while taking other medications. This ratio in turn is divided by c/d which is calculated by dividing all patients who had the drug of interest but did not have the event of interest by all other patients who did not have the event of interest given that they took any other drugs. (63) ROR is not affected by general under reporting for a specific drug or as specific event.(65) It has been proposed that ROR may be less biased than other disproportionality methods being considered as the case-control studies analysis.(66) Nevertheless, others believe that in practice there is no difference in performance between ROR and PRR.(60,67) Bayesian approaches Bayesian approaches tries to account for uncertainty in disproportionality measure calculated from small samples by shrinking the disproportionality measure towards baseline case of no association. This shrinking is a reduction of spurious associations when there are not enough data to support it and is proportional to the variability in the disproportionality statistics.(64) The Bayesian approaches include Multi-item Gamma Poisson Shrinker (MGPS) which is currently used by the FDA.(68,69) MGPS is based on an empirical Bayes framework and its computed measure is called empirical Bayes geometric mean (EBGM) which is the Bayesian version of the Relative Reporting Ratio (RRR). RRR is the ratio of the incidence of the observed incidence rate of a drug-event pair to its expected rate under the assumption that the drug and event are independent.(70) Another Bayesian approach adopted by the WHO is called Bayesian Confidence Propagation Neural Network (BCPNN), which estimates a Bayesian version of the Information Component (IC). A positive IC indicates that based on all reports in the database the drug-event pair is reported more often than expected. (61) Postmarketing Safety Databases for Signal Detection Databases utilized in drug safety data mining are postmarketing databases maintained by manufactures, regulators and different consortia. These databases are different in their reporting guidelines, coding dictionaries and rules for data entry. These databases vary in size and may reach millions of reports. The analysis of these databases may yield different results and so a single database available to all stakeholders is needed. Ideally this database will not have duplicate reports or missing data and is consistently coded for drug and event name. A number of databases are commonly available for signal detection activities, however; they differ in accessibility. These include the database of the WHO International Drug Monitoring Programme and the FDA’s public release safety database (AERS).(50) WHO Safety Database The WHO safety database is a large database receiving AEs from the national collaborating centers participating in the WHO Drug monitoring program.(71) It has the advantage of having the drug names coded according to the Anatomical Therapeutic Chemical (ATC) classification and ADRS are coded using the WHO Adverse Reaction Terminology. However, data is accessible by subscription only.(68) European Medicines Agency EudraVigilance database The EMEA pharmacovigilance system is called the EudraVigilance. It has 2 modules one for clinical trials and another for post marketing surveillance. It has analytical capabilities and performs signal detection in terms of PRR and ROR. It has restricted access even to manufacturers who can only see reports that they have submitted to the EMEA.(72) US FDA Adverse Event Reporting System (AERS) AERS is the FDA’s postmarketing safety database. AERS database is intended to support the FDAs post-marketing safety surveillance program for drugs. It relies on unsolicited reports submitted by healthcare professionals and patients on adverse events and medication error reports as well as required reports by manufacturers and so represents a useful resource for investigating drug safety.(73) The public-release version of AERS is available beginning with January 2004 as quarterly data directly downloadable from the FDA website. The new FDA FAERS was launched in the 10th September, 2012, and replaced the Adverse Event Reporting System (also known as Legacy AERS).(74) The main aim of the current study is to: Map the safety profile of echinocandins antifungals.as compared to other drugs. Compare the safety profile of echinocandins to that of other systemic antifungals. Assess the effect of changing the reference group on the top signals identified. To achieve these aims data mining methods and disproportionality analysis will be employed to the FDA AERS to achieve these aims. This study will therefore add to the knowledge on the safety profile of this newer class of antifungals.

The Football Game Essays -- Descriptive Essay Examples

The Football Game In the beginning, there was football. The official said, Let the stadium lights come on, and they came on. The football players came onto the field, and they saw the light was good. Other teams started to show up and practice on the battle ground, otherwise known as the "playing field." Fans shouted, and cheerleaders went on about their playful acts. Parents, brothers, sisters, and close friends all piled into the stands to see the game of the year. The official stepped out onto the moist grass at Williams Stadium in Plano, Texas. The time was seven o'clock p.m. on a Thursday night. He paused for a moment, looked at his stopwatch, and blew his whistle. Gigantic muscular men came from out of nowhere as the fans began to cheer, waving various flags, and clanging cow bells. The bells sounded like a wind chime in an April shower, all different sounds at different times. The players ran out to the middle of the stadium. A smell of hatred and resentment came about in the air. The crowd came unglued from their seats. The sounds of various noisemakers filled the air once again. Parents and grandparents alike came to their feet in the stands. Cars stopped on the street in front of the stadium, as they honked their horns, and cheered for their team of choice. As the two burly men stood in the middle of the field, many thoughts ran through their heads. They both knew someone was going to die, but defeat was out of the question. The official tossed a polished silver quarter into the air. The coin hit the wet grass with a shiny face of George Washington clearly showing. The home team will receive the ball. Both anger infested players shook hands and ran back to their sideline. The fans began to cheer as the players t... ...e smile on my face was literally being pulled up by strings that wouldn't seem to let go. Our kicker went on to kick the extra point, as only one minute remained on the time clock. The Clark Cougars went on to beat the Williams Warriors. I could see it now on the front page of the town newspaper. "Clark demolishes Williams for the first time in 14 years!" We finally beat the best team in the world! As we celebrated, and jumped around on the soggy grass, a tear came to my eye. It was all hitting me now. I finally achieved the goal of my life! I could not control the tremendous smirk on my face. As I watched the coach from the opposing team cry in agony, I thought to myself, "That must be what they call the agony of defeat." I knew that the moment of my life I had long waited for, was gone. Only memories are left in my mind, and I cherish every single one of them. The Football Game Essays -- Descriptive Essay Examples The Football Game In the beginning, there was football. The official said, Let the stadium lights come on, and they came on. The football players came onto the field, and they saw the light was good. Other teams started to show up and practice on the battle ground, otherwise known as the "playing field." Fans shouted, and cheerleaders went on about their playful acts. Parents, brothers, sisters, and close friends all piled into the stands to see the game of the year. The official stepped out onto the moist grass at Williams Stadium in Plano, Texas. The time was seven o'clock p.m. on a Thursday night. He paused for a moment, looked at his stopwatch, and blew his whistle. Gigantic muscular men came from out of nowhere as the fans began to cheer, waving various flags, and clanging cow bells. The bells sounded like a wind chime in an April shower, all different sounds at different times. The players ran out to the middle of the stadium. A smell of hatred and resentment came about in the air. The crowd came unglued from their seats. The sounds of various noisemakers filled the air once again. Parents and grandparents alike came to their feet in the stands. Cars stopped on the street in front of the stadium, as they honked their horns, and cheered for their team of choice. As the two burly men stood in the middle of the field, many thoughts ran through their heads. They both knew someone was going to die, but defeat was out of the question. The official tossed a polished silver quarter into the air. The coin hit the wet grass with a shiny face of George Washington clearly showing. The home team will receive the ball. Both anger infested players shook hands and ran back to their sideline. The fans began to cheer as the players t... ...e smile on my face was literally being pulled up by strings that wouldn't seem to let go. Our kicker went on to kick the extra point, as only one minute remained on the time clock. The Clark Cougars went on to beat the Williams Warriors. I could see it now on the front page of the town newspaper. "Clark demolishes Williams for the first time in 14 years!" We finally beat the best team in the world! As we celebrated, and jumped around on the soggy grass, a tear came to my eye. It was all hitting me now. I finally achieved the goal of my life! I could not control the tremendous smirk on my face. As I watched the coach from the opposing team cry in agony, I thought to myself, "That must be what they call the agony of defeat." I knew that the moment of my life I had long waited for, was gone. Only memories are left in my mind, and I cherish every single one of them.

Heart of Darkness Essay -- essays papers

Heart of Darkness Darkness permeates every circumstance, scene, and character in Joseph Conrad's novella, Heart of Darkness. Darkness symbolizes the moral confusion that Charlie Marlow encounters, as well as the moral reconciliation he has within himself while searching for Kurtz. Marlow's morals are challenged numerous times throughout the book; on the Congo river and when he returns to Brussels. Charlie Marlow characterizes the behavior of the colonialists with, "The flabby, pretending, weak-eyed devil of a rapacious and pitiless folly," (25). Marlow distinguishes "the devil" from violence, greed, and desire. He suggests that the basic evil of imperialism is not that it perpetrates violence against native peoples, or that it is motivated by greed. But that "the flabby, weak-eyed devil," the imperialists, seem to be distinguished by being foolish and unaware. Marlow is appalled by the apathetic attitude towards the sight of death, of the colonials aboard the Nellie. At the grove of the first station, Marlow is troubled by the sight of a man curled up, dying. "I saw a face near my hand†¦black bones†¦white flicker in the depth of the orbs, which died out quickly," (27). Marlow's horror at the grove suggests that the true evils of this colonial company are dehumanizing and deathly. Marlow offers a dying man a few pieces of a biscuit, and despite the fact tha t he is not particularly compassionate, the situation troubles him greatly. During section two of Heart of Darkness, Marlow's professional skills, morals, and work ethics are contrasted with those of the other company employees. To Marlow, work represents the fulfillment of a contract between himself and the company he is working for. Repairing the st... .... His dishonesty was sparked by having compassion for others. Although dishonesty was something Marlow found distasteful at the start of his journey, he felt no remorse in lying to the Intended in Brussels. It is obvious that Marlow can not fully accept the truth himself, and lets the Intended believe that her husband died with a noble purpose, helping the Africans, and uttering her name as his a last words. Fay Weldon believes that, "the writers who get a lasting response from the readers are the writers who offer a happy ending through moral development†¦." In, Heart of Darkness, this statement holds true. Charlie Marlow goes through a period of moral reconciliation throughout the novella. Instances throughout Heart of Darkness show different sides of Charlie Marlow's morals. It is evident that when Marlow has returned to Brussels, that his morals have changed. Heart of Darkness Essay -- essays papers Heart of Darkness Darkness permeates every circumstance, scene, and character in Joseph Conrad's novella, Heart of Darkness. Darkness symbolizes the moral confusion that Charlie Marlow encounters, as well as the moral reconciliation he has within himself while searching for Kurtz. Marlow's morals are challenged numerous times throughout the book; on the Congo river and when he returns to Brussels. Charlie Marlow characterizes the behavior of the colonialists with, "The flabby, pretending, weak-eyed devil of a rapacious and pitiless folly," (25). Marlow distinguishes "the devil" from violence, greed, and desire. He suggests that the basic evil of imperialism is not that it perpetrates violence against native peoples, or that it is motivated by greed. But that "the flabby, weak-eyed devil," the imperialists, seem to be distinguished by being foolish and unaware. Marlow is appalled by the apathetic attitude towards the sight of death, of the colonials aboard the Nellie. At the grove of the first station, Marlow is troubled by the sight of a man curled up, dying. "I saw a face near my hand†¦black bones†¦white flicker in the depth of the orbs, which died out quickly," (27). Marlow's horror at the grove suggests that the true evils of this colonial company are dehumanizing and deathly. Marlow offers a dying man a few pieces of a biscuit, and despite the fact tha t he is not particularly compassionate, the situation troubles him greatly. During section two of Heart of Darkness, Marlow's professional skills, morals, and work ethics are contrasted with those of the other company employees. To Marlow, work represents the fulfillment of a contract between himself and the company he is working for. Repairing the st... .... His dishonesty was sparked by having compassion for others. Although dishonesty was something Marlow found distasteful at the start of his journey, he felt no remorse in lying to the Intended in Brussels. It is obvious that Marlow can not fully accept the truth himself, and lets the Intended believe that her husband died with a noble purpose, helping the Africans, and uttering her name as his a last words. Fay Weldon believes that, "the writers who get a lasting response from the readers are the writers who offer a happy ending through moral development†¦." In, Heart of Darkness, this statement holds true. Charlie Marlow goes through a period of moral reconciliation throughout the novella. Instances throughout Heart of Darkness show different sides of Charlie Marlow's morals. It is evident that when Marlow has returned to Brussels, that his morals have changed.

The Transformation of Psychology

The Transformation of Pyschology From the 1920s to today, psychology has surely developed. Technological advancements as well as new ideas and ways of thinking about the subject helped to reform what psychology is today. Rather than completely changing, psychology has actually built up more and more through the decades. New branches were added to the field as those who studied it made new breakthroughs. Over the years many scientists and psychologists have contributed to the transformation of psychology. Up until the 1920’s, psychology was defined as the science of mental life.It wasn’t until then that the idea of behaviorism became more prominent in psychology. During the time period between the 1920’s and the 1960’s, American psychologists led by John Watson redefined the meaning of psychology into a science of mental life and observable behavior. Not only did Watson redefine psychology, he also started the psychological school of behaviorism. It was als o around this time that Watson and his partner Rosalie Rayner conducted their conditioning experiment. The idea of classical conditioning came into play when behaviorism became a major branch of psychology.Between the 1950’s and 1970s, the mental perspective of psychology came back, producing another new branch. This new branch was called cognitive psychology. Cognitive psychology focused mainly on mental processes such as thinking, problem solving, memory, decision making, and language. The term â€Å"cognitive psychology† was first used in 1967 by the American psychologist named Ulric Neisser. To go along with cognitive psychology is the topic of cognitive development. This theory was concerned with the development of a person’s thought process.Jean Piaget published The Moral Judgment of Children which began his popularity as a theorist in cognitive development. As a reaction to behaviorism and psychoanalysis (a type developed by Freud, before the 1920s) , ano ther new type of psychology called humanism arose. Humanistic psychology stressed the importance of self-actualization and growth, and focused mainly on one’s potential. This new view on psychology was created by Abraham Maslow in the 1950s. He published Toward a Psychology of Being, in which he described humanistic psychology as â€Å"the third force† in psychology (behind behavioral and psychoanalysis).After the emergence of these new branches, psychology started to become more technologically advanced. Scientists and psychologists became interested in exploring the brain without removing it from subjects. They started to develop new technology. An example of this was in 1981, when a team developed the PET scan, which enabled doctors to view a computer generated image of the brain and when it is most active during certain mental activities. Today, technology continues to improve, which help psychologists discover more. Through the decades, psychology has undergone so me great changes.As new ideas came into play, new ways of thinking molded and shaped psychology into what it is today. Not only did psychology become a science of behavioral and mental life, but it also gained new branches that go even deeper. Psychology will most likely continue to grow and develop over the years. As technology advances, scientists and psychologists will discover even more and psychology will continue to expand as it did from the 1920’s until now.

Ketamine Pain Mechanism

Pain is communicated from the brain to other parts of the body by the CNS (Central Nervous System) and nerve endings. (Mayer, Mao, Holt, Price, 7731-7736) The ligand-gated ion channels, also referred to as LGICs, or ionotropic receptors, are a group of intrinsic transmembrane ion channels that are opened in response to binding of a chemical messenger. (Collingridge, Singer, 290-296) (Dickenson, 307-309) (Dickenson, Chapman, Green, 633-638)The ion channel is regulated by a neurotransmitter ligand that is very selective to one or more ions like potassium, sodium, calcium, and chloride. (Kandel, Schwartz, Jessell, 178-180)   Such receptors located at synapses converting the chemical signal to an electric signal in the post-synaptic cell. (Connolly, Wafford, 529-534)   The NMDA receptor (N-methyl-D-aspartate) is such an ionotropic receptor for glutamate. (Dingledine, Borges, Bowie, Traynelis, 7-61) (Lodge, Johnson, 81-86) (Meller, 435-436)   By X-ray crystallography, the NMDA recep tors have an heterodimer subunits, which are involved in the binding of agonists and antagonists like Ketamine. (Hirota, Lambert, 441-444)This channel complex contributes to excitatory synaptic transmission at sites throughout the brain and the spinal cord, and is modulated by a number of endogenous and exogenous compounds. (Rabben, Skljelbred, Oye, 1060-1066)   NMDA receptors play a key role in a wide range of physiologic and pathologic processes. (Hoffman, Coppejans, Vercauteren, Adriemsen, 240-242) (Klepstadt, Maurset, Moberg, Oye, 513-518) (Coderre, Katz, Vaccarino, Melzack, 259-285) Ketamine is primarily a non-competitive antagonist, which opens in response to binding of glutamate. This NMDA receptor mediates the reduction of pain effects of ketamine at low doses. (Lofwall, Griffiths, Mintzer, 439-449)Evidence for this is reinforced by the fact that naxolone, an opioid antagonist, does not reverse the analgesia. Studies also seem to indicate that ketamine is ‘use depend ent' meaning it only initiates its blocking action once a glutamate binds to the NMDA receptor. (Sorensen, Bengtsson, Ahlner, Henriksson, Ekselius et al., 1615-1621)   At high level doses, ketamine has also been found to bind to opioid mu receptors and sigma receptors. Thus, loss of consciousness that occurs may be partially due to binding at the opioid mu and sigma receptors. (Lonnqvist, Norton, 617-621)(Menigaux, Fletcher, Dupont, Guignard, Guirimand, et al. 129-135) (Koppert, Sittl, Scheuber, Alsheimer, Schmelz, 152-159) (Bushell, Endoh, Simen, Ren, Bindokas, 55-64)Works CitedMayer DJ, Mao J, Holt J, Price DD. Cellular Mechanisms of Neuropathic Pain, Morphin Tolerance, and their Interactions. Proc. Natl Acac. Sci. USA. 1999, 96(14): 7731-7736.Collingridge G, Singer W. Excitatory Amino Acid Receptors and Synaptic Plasticity. Trends Pharmacol Sci. 1990 11: 290-296.Dickenson AH. A cure for wind-up: NMDA receptor antagonists as potential analgesics. Trends Pharmacol Sci 1990 11: 30 7-309Dickenson AH, Chapman V and Green GM. The pharmacology of excitatory and inhibitory amino acid-mediated events in the transmission and modulation of pain in the spinal cord. Gen Pharmacol 1997 28: 633-638Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill: New York, (2000), pp.178-180Connolly CN, Wafford KA. The Cys-Loop Superfamily of Ligand-Gated Ion Channels – the Impact of Receptor Structure on Function. Biochemical Society Transactions (2004) Vol. 32: 529-534.Dingledine R, Borges K, Bowie D, Taynelis SF. The Glutamate Receptors Ion Channels. Pharmacology Reviews, 1999 51(1): 7-61Lodge D and Johnson KM. Non-Competitive Excitatory Amino Acid Antagonists. Trends Pharmacol Sci 1990 11: 81-86Meller ST. Ketamine: Relief from Chronic Pain through Actions at the NMDA Receptor? Pain   1996 68: 435-436Hirota K, Lambert DG. Ketamine: Its Mechanism (s) of Action and its Unusual Clinical Uses. Br. J. Anesth. 1996, 77(4):441-444.Rabben T, Skjel bred P, Oye I. Prolonged Analgesic Effects of Ketamine, an N-Methyl-D-Aspartate Receptor Inhibitor, in Patients with Chronic Pain. The Journal of Pharmacology and Experimental Pharmaceutics. 1999, 289(2):1060-1066.Hoffmann V, Coppejans H, Vercauteren M and Adriaemsen H Successful Treatment of Postherpetic Neuralgia with Oral Ketamine. 1994 Clin J Pain 10: 240-242Klepstad P, Maurset A, Moberg ER and Oye I Evidence for a Role for NMDA Receptors in Pain Perception. Eur J Pharmacol   1990 187: 513-518Coderre TJ, Katz J, Vaccarino AL and Melzack R.   Contribution of Central Neuroplasticity to Pathological Pain: A Review of Clinical and Experimental Evidence. 1993 Pain 52: 259-285.Lofwall MR, Griffiths RR, Mintzer MZ. Cognitive and Subjective Acute Dose Effects of Intramuscular Ketamine in Healthy Adults. Ex. Clin. Psychopharmacol. (2006), 14(4):439-449Sorensen J, Bengtsson A, Ahlner J, Henriksson KG, Ekselius L and Bengtsson M.   Fibromyalgia. Are there different mechanisms in the processing of pain? A double Blind Crossover Comparison of analgesic Drugs. 1997 J Rheumatol 24: 1615-1621Lonnqvist PA, Norton NS. Pediatric Day-Case Anesthesia and Pain Control.   Curr. Opin. Anaest. (2006), 19(6): 617-621.Menigaux C, Fletcher D, Dupont X, Guignard B, Guirimand F, Chauvin M. The Benefits of Intraoperative Small-Dose Ketamine on Postoperative Pain after Anterior Cruciate Ligament Repair. Anesth. Analg. 2000 90(1): 129-135Koppert W, Sittl R, Scheuber K,Alsheimer M, Schmeltz M, Schuttler J. Differential Modulation of Remifentanil-Induced Analgesia and Post-Infusion Hyperalgesia by S-Ketamine and Clonidine in Humans. Anesthesiology. 2003, 99(1): 152-159.Bushell T, Endoh T, Simen AA, Ren D, Bindokas VP, Miller RJ. Molecular Components of Tolerance to Opiates In Single Hippocampal Neurons. Mol. Pharmacol. 2002, 61(1): 55-64.

Competitive Strategic Management a Case Study of Virgin Atlantics Essay

Introduction: Today, competition in international markets has become severe and in order to sustain relevant position, organizations need to assume competitive strategies so that they can gain competitive advantages. (Rao, pp.185, 2011) The dynamic condition of markets has made it complicated for the organizations to achieve higher level of success without using experts’ promulgated models and literatures. (Flouris, Oswald, pp.19, 2006) Hence, researches have made it simple for the organizations to compete at broader level yet these researches merely gives way to these organizations and they need to develop the strategic plans on their own. Different companies adopt different kind of competitive strategies in order to get higher position in competitive market and for this purpose, it used to perform different activities than the competing firms. (Daft, pp.65, 2009)Virgin Airlines is one of the organizations who have assumed authentic strategies in order to satisfy customer’s need and ultimately got exceptional position. This paper is basically an analysis of the competitive strategy of Virgin Atlantics which it has used in order to gain competitive advantage. The first section analyzes the competitive strategy of Virgin Atlantics, second part deals with advantages and limitations and third part give certain recommendations to Virgin Atlantics in order to better its services. Competitive strategy of Virgin Atlantics: Porter has identified four different strategic options which an organization can use in order to gain competitive advantage keeping the contemporary internal and external environment under consideration. (Griffin, pp.244, 2010) Differentiation strategy is one of those competitive strategies promulgated by Porters In his Generic Strategic model. (Eldring, pp.6, 2009)Virgin Atlantic has based its strategic plan keeping differentiation strategy under consideration. However, if its strategy is scrutinized, it indicates that this strategy has been developed after doing thorough internal and external analysis. As far as internal analysis is concerned, this analysis demonstrates strengths and weaknesses of the organizations and for this purpose, different models like SWOT analysis can be utilized since it allows the organizations to analyze strengths and weaknesses of the organization. (Dibb, Simkin, pp.28, 2008) Virgin Atlantic has also based its strategy keeping internal analysis under consideration since its analysis demonstrate how internal analysis aids in having differentiation portfolio and potential customers. (Strauss, pp.106, 2010) The basic strength of Virgin Atlantic is the financial affiliation which it has with Singapore airline. (Reynolds, Lancaste, 2012) However, its financial information is not disclosed publicly yet it can be found out that the service has been differentiated by the company through identifying the core strengths and cost effectiveness is one of them. As far as weaknesses are concerned, Virgin Atlantic is though providing exceptional services to its customers yet for customers, it is costly. A normal customer cannot have first class or premium class service with this Airline. However, the solution has been provided in the form of three different classes and the average customers can utilize economy class for traveling to different destinations. Similarly, the external analysis has been done through doing market analysis, customer analysis, industry analysis and above all competitive analysis in order to gain competitive advantages. For this purpose, usually PESTEL analysis is done which identifies political, economic, social, technological, environmental and legal aspects of the provided services. (Henry, pp.51, 2008) Virgin Atlantic also does PESTEL analysis at macro level in order to gain complete competitive advantage through identifying all essential factors and after doing this analysis, it has developed its differentiation strategy for international market. Porter’s differentiation strategy can be observed from all the perspectives including packages, offers, services etc. For example, it has been offering services for more than 30 different destinations with 43 outstanding aircrafts including airbuses, Boeings and aircrafts. Similarly, this airline has bases in Manchester and London’s Heathrow and Gatwick airports and offers services for thirty different destinations including Dubai, Mauritius, Delhi, Sydney and Cape Town, the tourist favorite areas. Moreover, normally airlines offer business and economy class but Virgin Atlantic has three different classes including upper, premium economy and economy classes. In addition, it has infused differentiation strategy through providing Virgin Atlantic Cargo and Holiday services which offers instant and urgent shipments to different destinations of the world. Similarly, different travel packages with outclass offers have also been facilitated to customers in order to gain competitive advantages through dissimilar features. All these examples indicate how differentiation strategy of Porter’s Generic model aids an organization to gain benefits but for this purpose, organizations usually charge premium prices as well. Virgin Atlantic is also costly from other airlines in the market but its unique services have made it ample popular that more than five million customers use its services worldwide and all of them are ready to pay high prices for premium services. The competitive strategy of Virgin Atlantics has been developed keeping the market trends and contemporary needs of the customers under consideration and not only unique and different facilities have been provided but also basic requirements have been fulfilled. Hence, the competitive strategy of Virgin Atlantics has made it successful and preferable for the customers among all large air service providers. For using differentiation competitive strategy, this organization has been cherishing exceptional advantages and some of them are as followed: Advantages: If the analysis of advantages for using differentiations competitive strategy is scrutinized from the perspective of The Strategy Clock, it would appear that the organizations, who utilize this competitive strategy, gain high benefits investing low amount. Source: (Johnson, pp.243, 2008) This thing can be seen from the example of Virgin Atlantics since it has been using different sources to differentiate its services from others in order to gain competitive advantage and hence, achieved high profit in low amount as well. In current markets, the first advantage which Virgin Atlantics has been cherishing is the distinctive position due to providing unique services. Differentiation strategy allows Virgin Atlantics to have distinctive market position that makes it different from other competitors in the market and compels customers to prefer it on other competitors in the market providing similar service. (Thompson, Martin, pp.191, 2010) Second advantage of using this strategy is that it enables Virgin Atlantics to have sustainability in current market environment through gaining competitive advantage. For example, through providing unique services with exceptional features like multi-destination services, entertainment and customer care, shipping service, holiday packages, Virgin Atlantics invested little amount as compared to others but gained double benefits which enables it to have remarkable position in the market. The third major benefit of this differentiation strategy is flexibility which the organization provides. (Doise, pp.82, 2008) Virgin Atlantics also provides ample flexibility to customers in order to allow them to choose from multiple options. For instance, the customer can choose travel class from offered three classes according to his requirements. Suppose if customer has normal budget, he can select economy class whereas if he wants luxurious travel, he can select upper class. Flexibility is offered in packages and customers can choose relevant holiday packages of Virgin Holidays as well. Hence, this thing also proved ample lucrative for the company to achieve competitive advantage in contemporary markets and its environments. Limitations: In current dynamic business environment, using differentiation strategy is though beneficial but only to some extent since there are certain limitations cling to this competitive strategy, some of them are as followed: †¢It is very difficult to sustain elements of differentiation in current business environment since there are potential competitors in the market who try to assume better strategy in order to compete with Virgin Atlantics. These competitors might offer better services and add-ons that might affect core strategy of Virgin Atlantics †¢Changing services and making it unique is often costly. Though core strategy never costs high but sustainability of differentiations strategy usually costs high because the organizations have to spend a major amount in competing with opponents which ultimately compel the organizations to invest more and more for sustaining its position. (Sornarajah, pp.173, 2010) Virgin Atlantics has also faces this situation and spent a large amount on routes and aircrafts in order to differentiate its services from others. †¢Third limitation is the difficult which Virgin Atlantics has confronted in order to achieve differentiation. Since the current market is highly competitive and every organization has been trying to find out the best sources for gaining customer loyalty, this thing has made it ample complicated for the organizations to differentiate their services from others. Hence, differentiation competitive strategy is ample lucrative but these limitations makes it difficult for the organizations to sustain this strategy. However, in order to cope with these dynamic situations, different steps can be taken and the next part of the paper will promulgate all key steps which can augment profitability ratio. Recommendations: Virgin Atlantics can sustain its contemporary position in international markets taking different steps and for this purpose, it has to do analysis time and again in order to assess whether the implemented competitive strategy is compatible with current business environment or not. Following are some recommendations which can be used by Virgin Atlantics for sustaining its current position. Constant analysis: Virgin Atlantics should do constant internal and external analysis and amend the strategy or develop change management strategy according to the market requirements so that it can gain competitive advantages and beat its potential competitors. Additionally, these analyses would also enable the company to assess strengths and weaknesses of the company itself and through overpowering these shortcomings; it can develop its competitive strategic plan. Hybrid strategy: Though differentiation strategy is ample lucrative for providing sophisticated services and gaining customer loyalty yet it cannot be determined easily. Moreover, it might give high market share but market growth is possible only if this strategy is amalgamated with some additional strategy. This strategy can be cost-leadership strategy or focus strategy. Through focusing on differentiation strategy, Virgin Atlantics can obtain not only high market share but also market growth as well. as far as cost leadership strategy is concerned, it can be amalgamated with differentiation strategy in order to double the profit ratio since different researchers have provided combined competitive strategies as the solution of dynamic situation. (Marti, pp.100, 2007) Nevertheless, this hybrid strategy might also affect in a negative way. Competitive prices: Customers usually prefer exceptional services in affordable prices. So, Virgin Atlantics can gain advantages from cheap prices as well. Through providing low cost fleets to different customers, other then the facilitated, this organization could double its profit. However, the budget can be maintained through minimizing provided services during the flights. This thing would enable this organization to have market growth with low price strategy as well. Value added services: Value added services are often referred to as secondary services which are used for attracting customers and sustaining their loyalty with organization (Thurau and Hansen, p.112, 2000) No one can deny the significance of Value added services and marketing and this is the reason why it has remained inseparable part of every marketing plan and differentiation strategy. (Singh, pp.22, 2012) Virgin Atlantics can also gain competitive advantages via value added marketing and for this purpose; it can facilitate its customers with value holiday packages, discounted tickets and packages, lottery system and so on. These techniques would also attract a lot of customers and augment profitability and market share of the company as well. Conclusion: To conclude, it can be stated that this organization has been cherishing top positions on international level only because of using differentiation strategy and for this purpose, it has also invested capital through having partnership with Singapore airline. All its services including multiple destinations, holiday services, cargo services and in-flight entertainment, demonstrate its successful usage of differentiation strategy. However, Virgin Atlantics should also keep the advantages and limitations of using this strategy since there are certain times when this strategy needs slight amendments or changes in order to deal with contemporary circumstances. Virgin Atlantics can use different change management strategies in order to cope with limitations of this competitive strategy. In addition, this organization can also double its profit through taking different steps including value added marketing, competitive pricing and hybrid strategic development. These add-ons can maximize its profitability as well as worldwide recognitions and ultimately it would be able to compete with potential organizations like Emirates and Gulf Air. References: Daft, R. L. (2009) Organization Theory and Design. Mason, OH: South-Western Cengage Learning. Dibb, S., Lyndon S. (2008) Marketing Planning: A Workbook for Marketing Managers. London: South-Western Cengage Learning. Doise, M. L. (2008) An Integration of Corporate Culture and Strategy: The Interrelationships and Impact on Firm Performance. US: ProQuest. Eldring, J. (2009) Porter’s (1980) Generic Strategies, Performance and Risk an Empirical Investigation with German Data. Hamburg: Diplomica-Verl. Flouris, T. G.,Sharon L. O.(2006) Designing and Executing Strategy in Aviation Management. Aldershot, England: Ashgate. Griffin, R. W. (2011) Management. Mason, OH: South-Western Cengage Learning. Henry, A. (2008) Understanding Strategic Management. Oxford: Oxford UP. Johnson. (2008)Exploring Corporate Strategy: Text & Cases, 7/E. Dehli: Pearson Education India. Lancaste, G., Reynolds, P. (2012)Marketing. NY: CRC. Marti, M. (2007)Complexity Management Optimizing Product Architecture of Industrial Products. Wiesbaden: Deutscher Universitäts-Verlag. Rao, R. M. (2011)Services Marketing. Dehli: Pearson Education India. Singh, M. (2012)Building Customer Loyalty through Value Added Services: A Case of Telecom Sector. NY: GRIN Verlag. Sornarajah, M. (2012) The International Law on Foreign Investment. Cambridge: Cambridge UP. Strauss, R. (2010)Marketing Planning by Design: Systematic Planning for Successful Marketing Strategy. London: John Wiley & Sons. Thompson, J. L., Frank M. (2010) Strategic Management: Awareness & Change. Andover: South-Western Cengage Learning. Thurau, T, Ursula H. (2000) Relationship Marketing: Gaining Competitive Advantage through Customer Satisfaction and Customer Retention. Berlin: Springer.

Nursing Pressure Sore

What are pressure sores? Pressure sores are areas of injured skin and tissue. They are usually caused by sitting or lying in one position for too long. This puts pressure on certain areas of the body. The pressure can reduce the blood supply to the skin and the tissues under the skin. When a change in position doesn't occur often enough and the blood supply gets too low, a sore may form. Pressure sores are also called bedsores, pressure ulcers and decubitus ulcers. What are the symptoms of a pressure sore? There are 4 stages of pressure sores. Symptoms at each stage include the following: Stage 1.The affected skin looks red and may feel warm to the touch. The area may also burn, hurt or itch. In people who have dark skin, the pressure sore may have a blue or purple tint. Stage 2. The affected skin is more damaged in a stage 2 pressure sore, which can result in an open sore that looks like an abrasion or a blister. The skin around the wound may discolored. The area is very painful. St age 3. These types of pressure sores usually have a crater-like appearance due to increased damage to the tissue below the skin's surface. This makes the wound deeper. Stage 4.This is most serious type of pressure sore. The skin and tissue is severely damaged, causing a large wound. Infection can occur at this stage. Muscles, bones, tendons and joints can be affected by stage 4 pressure sores. Who gets pressure sores? Anyone who sits or lies in one position for a long time might get pressure sores. You are more likely to get pressure sores if you are paralyzed, use a wheelchair or spend most of your time in bed. However, even people who are able to walk can develop pressure sores when they must stay in bed because of an illness or an injury.Some chronic diseases, such as diabetes and hardening of the arteries, make it hard for pressure sores to heal because of poor blood circulation. Peripheral vascular disease,MI, Stroke,Multiple trauma,Musculoskeletal disorders/fractures/contractu res,Gibleed , Spinal cord injury (e. g. , decreased sensory perception, muscle spasms),Neurological disorders (e. g. , Guillain-Barre', multiple sclerosis),Unstable and/or chronic medical conditions (e. g. , diabetes, renal disease, cancer, chronic obstructive pulmonary disease, congestive heart failure),History of previous ressure ulcer,Preterm neonates, Dementia, Recent surgical patient. Where on the body can you get pressure sores? Pressure sores usually develop over bony parts of the body that don't have much fat to pad them. Pressure sores are most common on the heels and on the hips. Other areas at risk for pressure sores include the base of the spine (tail bone), the shoulder blades, the backs and sides of the knees, and the back of the head. How are pressure sores treated? There are several things you can do to help pressure sores heal: * Relieving the pressure that caused the sore * Treating the sore itself Improving nutrition and other conditions to help the sore heal What can be done to reduce pressure on the sore? Don't lie on pressure sores. Use foam pads or pillows to take pressure off the sore. Special mattresses, mattress covers, foam wedges or seat cushions can help support you in bed or in a chair to reduce or relieve pressure. Try to avoid resting directly on your hip bone when you're lying on your side. Use pillows under one side so that your weight rests on the fleshy part of your buttock instead of on your hip bone. Also, use pillows to keep your knees and ankles apart.When lying on your back, place a pillow under your lower calves to lift your ankles slightly off the bed. When lying in bed, change your position at least every 2 hours. When sitting in a chair or wheelchair, sit upright and straight. An upright, straight position will allow you to move more easily and help prevent new sores. You should change positions every 15 minutes when sitting in a chair or wheelchair. If you cannot move by yourself, have your caregiver help you shift your position. How should the pressure sore be kept clean? In order to heal, pressure sores must be kept clean and free of dead tissue.Stage 1 sores can be cleaned with mild soap and water. You can clean stage 3 sores by rinsing the area with a salt and water solution. The saltwater removes extra fluid and loose material. Your doctor or nurse can show you how to clean your pressure sore. Pressure sores should be kept covered with a bandage or dressing. Sometimes gauze is used. The gauze is kept moist and must be changed at least once a day. Newer kinds of dressings include a see-through film and a hydrocolloid dressing. A hydrocolloid dressing is a bandage made of a gel that molds to the pressure sore and helps promote healing and skin growth.These dressings can stay on for several days at a time. Dead tissue (which may look like a scab) in the sore can interfere with healing and lead to infection. There are many ways to remove dead tissue from the pressure sore. Rinsing the sore e very time you change the bandage is helpful. Special dressings that help your body dissolve the dead tissue can also be used. They are left in place for several days. Another way to remove dead tissue is to put wet gauze bandages on the sore and allow them to dry. The dead tissue sticks to the gauze and is removed when the gauze is pulled off.For more severe pressure sores, dead tissue must be removed surgically. Removing dead tissue and cleaning the sore can hurt. Your doctor can suggest a pain reliever for you to take 30 to 60 minutes before your dressing is changed to help reduce pain. Why is good nutrition important for healing sores? Good nutrition is important because it helps your body heal the sore. If you don't get enough calories, protein and other nutrients (especially vitamin C and zinc, which can help heal wounds like pressure sores), your body won't be able to heal, no matter how well you care for the pressure sore.Your doctor, nurse or a dietitian can give you advice about a healthy diet. Be sure to tell your doctor if you have lost or gained weight recently. What if the sore gets infected? Pressure sores that become infected heal more slowly and can spread a dangerous infection to the rest of your body. If you notice any of the signs of infection listed below, call your doctor right away. Signs of an infected pressure sore include the following: * Thick yellow or green pus * A bad smell from the sore * Redness or warmth around the sore * Swelling around the sore * Tenderness around the soreSigns that the infection may have spread include the following: * Fever * Chills * Mental confusion or difficulty concentrating * Rapid heartbeat * Weakness How are infected pressure sores treated? The treatment of an infected pressure sore depends on how bad the infection is. If only the sore itself is infected, an antibiotic ointment can be put on the sore. When bone or deeper tissue is infected, antibiotics are often required. They can be given intravenous ly (through a needle put in a vein) or orally (by mouth). How can I tell if the sore is getting better? As a pressure sore heals, it slowly gets smaller.Less fluid drains from it. New, healthy tissue starts growing at the bottom of the sore. This new tissue is light red or pink and looks lumpy and shiny. It may take 2 to 4 weeks of treatment before you see these signs of healing. How can pressure sores be prevented? The most important step to prevent pressure sores is to avoid prolonged pressure on one part of your body, especially the pressure points mentioned previously. It's also important to keep your skin healthy. Keep your skin clean and dry. Use a mild soap and warm (not hot) water. Apply moisturizers so your skin doesn't get too dry.If you must spend a lot of time in bed or in a wheelchair, check your whole body every day for spots, color changes or other signs of sores. Pay special attention to the pressure points where sores are most likely to occur. If you smoke, you shou ld quit. People who smoke are more likely to develop pressure sores. Exercise can help improve blood flow, strengthen your muscles and improve your overall health. Talk to your doctor if physical activity is hard for you. He or she can suggest exercises that can work for you, or refer you to physical therapist that can help. Pressure Sore PreventionRelieving pressure: Position must be changed on a regular basis, at least every two hours, and in the very frail at least every hour. Good Diet: A good and balanced diet contributes to healing, as well as avoiding severe nutritional and weight loss Skin Care: Keep the skin clean. Moisture should be minimized. Skin care products should be used that moisturize the skin but do not make it wet or soggy. Use continence aids if a person is unable to control their bladder or bowels. Pads, diapers, convenes or catheterizing. Inspect the skin to see if any redness or breaks in the skin are developing.Use products to relieve and treat pressure sore s; airbeds, foam bed, bed and chair protectors, chair products, continence aids can all contribute to avoiding of bed sores. Clean skin with warm water and minimal friction. Apply lotion often. ————————————————- Avoid direct pressure to bony areas such as ankles and hips. Use pillows and padded protectors to support arms, legs and vulnerable areas. Change the position of a bed-bound person every two hours. Handle and move carefully to avoid skin tears and scrapes.Change the position of a chair-bound person hourly. Discourage the bed-bound or chair-bound person from sitting with the head elevated more than 30 degrees, except for short periods of time. Check and change bed linens as often as necessary Use continence management products if necessary to reduce exposure to moisture. Padded supports, such as doughnut cushions may, themselves, become a source of pressure. Do not massage bony areas of the body. Do not massage pressure sores. Do not use remedies such as iodine, peroxide and cornstarch that may further irritate the skin.Pressure sores (bedsores, decubitus ulcers, pressure ulcers) are areas of skin damage resulting from a lack of blood flow due to pressure. †¢ Sores often result from pressure but may also result from pulling on the skin or friction, particularly over bony areas. †¢ The diagnosis is usually based on a physical examination. †¢ Treatment includes cleansing, removal of pressure from the affected area, special dressings, and, sometimes, surgery. Pressure sores can occur in people of any age who are bedbound, chairbound, or unable to reposition themselves. They are more common among older people.They tend to occur over bony projections where pressure on skin can be concentrated, such as over the hip bones, tailbone, heels, ankles, and elbows. They occur where there is pressure on the skin from a bed, wheelchair, cast, splint, or other hard object . Pressure sores lengthen the time spent in hospitals or nursing homes and increase the cost of care. Pressure sores can be life threatening if they are untreated or if underlying health conditions prevent them from healing. Causes Causes that contribute to the development of pressure sores include: †¢ Pressure Traction †¢ Friction †¢ Moisture †¢ Inadequate nutrition Pressure on skin, especially when over bony areas, reduces or cuts off blood flow to the skin. If blood flow is cut off for more than 1 or 2 hours, the skin dies, beginning with its outer layer (epidermis). The dead skin breaks down and forms an open sore (ulcer). Most people do not develop pressure sores because they constantly shift position without thinking, even when they are asleep. However, some people cannot move normally and are therefore at greater risk of developing pressure sores.They include people who are paralyzed, comatose, very weak, sedated, or restrained . Paralyzed and comatose people are at particular risk because they also may be unable to move or feel pain (pain normally motivates people to move or to ask to be moved). Traction also reduces blood flow to the skin. Traction occurs when the skin is stretched by being wedged against something or when it sticks to something, often bed linens. When the skin is stretched, the effect is much like pressure. Friction can lead to or worsen pressure sores. Repeated friction may wear away the top layers of skin.Such skin friction may occur if people are pulled repeatedly across a bed. Moisture can increase skin friction and weaken or damage the protective outer layer of skin if the skin is exposed to it a long time. For example, the skin may be in prolonged contact with perspiration, urine, or feces. Inadequate nutrition increases the risk of developing pressure sores and slows the healing process of sores that do develop. Malnourished people may not have enough body fat to pad the skin and bones or to keep the blood vessels from being squeezed shut.Also, skin repair is impaired in people whose diets are deficient in protein, vitamin C, or zinc. Did You Know†¦? †¢ Inadequate nutrition increases the chances of developing pressure sores and slows the healing of sores that do develop. †¢ Repositioning people who cannot move themselves at least every 1 to 2 hours can help prevent pressure sores. Symptoms For most people, pressure sores cause some pain and itching. However, in people whose senses are dulled, even severe sores may be painless. Pressure sores are categorized into four stages according to the severity of damage: †¢ Stage I: Redness and inflammation Stage II: Some shallow skin loss, including abrasions, blisters or both †¢ Stage III: Full-thickness skin loss down to the layer of fat. †¢ Stage IV: Full-thickness skin loss with exposure of underlying muscle, tendon, or bone Pressure sores do not always progress from mild to severe s tages. Sometimes the first noticeable sign is a late-stage sore. If pressure sores become infected, they may have an unpleasant odor. Pus may be visible in or around the sore. The area around the pressure sore may become red or feel warm, and pain may worsen if the infection spreads to the surrounding skin (causing cellulitis).Infection delays healing of shallow sores and can be life threatening in deeper sores. Infection can even penetrate the bone (osteomyelitis), requiring weeks of treatment with antibiotics. In the most severe cases, infection can spread into the bloodstream (sepsis), causing fever or shaking chills. Spotlight on Aging Aging itself does not cause pressure sores. But it causes changes in tissues that make pressure sores more likely to develop. As people age, the outer layers of the skin thin. Many older people have less fat and muscle, which helps absorb pressure.The number of blood vessels decreases and blood vessels rupture more easily. All wounds, including pr essure sores, heal more slowly. Certain conditions make pressure sores more likely to develop: †¢ Being unable to move normally because of a disorder such as stroke †¢ Having to stay in bed for a long time, for example, because of surgery †¢ Being excessively sleepy (such people are less likely to change position or ask someone to reposition them) †¢ Losing sensation because of nerve damage (such people do not feel discomfort or pain, which would prompt them to change ositions) †¢ Becoming less responsive to what is happening in and around them, including their own discomfort or pain, because of a disorder such as dementia Diagnosis Doctors can usually diagnose pressure sores by doing a physical examination. A doctor or nurse usually measures the size and depth of a sore to determine its stage and plan treatment. If the damage is severe, radionuclide bone scanning or gadolinium-enhanced MRI (magnetic resonance imaging) may be done to check whether infection has spread from the sore to bone—a disorder called osteomyelitis.To diagnose osteomyelitis, doctors may need to take a small sample (biopsy) of bone to see if bacteria grow from it (culture). Prevention Prevention is the best strategy for dealing with pressure sores. In most cases, pressure sores can be prevented by meticulous attention from all caregivers, including nurses, nurses' aides, and family members. Close daily inspection of a bedridden or chairbound person's skin can detect early redness or discoloration. Any sign of redness or discoloration at pressure areas is a signal that the person needs to be repositioned and kept from lying or sitting on the discolored area until it returns to normal.Because shifting position is necessary to keep the blood flowing to the skin, oversedation should be avoided and activity encouraged. People who cannot move themselves should be repositioned every 2 hours if they are in bed and every hour if they are in a chair—more often if possible. The skin must be kept clean and dry because moisture increases the risk of developing pressure sores. Dry skin is less likely to stick to fabrics and cause friction or traction. For people confined to bed, sheets should be changed frequently to make sure they are clean and dry.Applying noncaking body powder to skin in areas where two parts of the body press against each other (such as the buttocks and groin) can help keep the skin in these areas dry. Bony projections (such as heels and elbows) can be protected with soft materials, such as foam wedges and heel protectors. Donut-shaped devices and sheepskins should be avoided as they only shift pressure or friction from one vulnerable site to another. Special beds, mattresses, and seat cushions can be used to reduce pressure in people who are wheelchair-bound or bedridden.These products can reduce pressure and offer extra relief. A doctor or nurse can recommend the most appropriate mattress surface or seat cushion. It is important to remember that none of these devices eliminate pressure completely or are a substitute for frequent repositioning. Treatment Treating a pressure sore is much more difficult than preventing one. The main goals of treatment are to relieve pressure on the sores, keep them clean and free of infection, and provide adequate nutrition. Adequate nutrition is important in helping pressure sores heal and in preventing new sores from forming.A well-balanced, high-protein diet is recommended as well as a daily high-potency vitamin and mineral supplement. Supplemental vitamin C and zinc may help with healing as well. Electrical stimulation, heat therapy, massage therapy, and hyperbaric O2 therapy have not proven helpful. In the earliest stage, pressure sores usually heal by themselves once pressure is removed. When the skin is broken, a doctor or nurse considers the location and condition of the pressure sore when recommending a dressing. Film (see-through) dressings help protect ea rly-stage pressure sores and allow them to heal more quickly.Hydrocolloid (oxygen- and moisture-retaining) patches protect, keep the skin appropriately moist, and provide a healthy environment for deep sores. Other types of dressings may be used for deeper sores, those that ooze a lot of fluids, and those that are infected. If the sore appears infected or oozes, rinsing with saline and dabbing gently with a gauze pad are helpful. A doctor may need to remove (debride) dead tissue with a scalpel or a chemical solution. Removal of dead tissue is usually painless, because pain is not felt in dead tissue. Some pain may be felt because healthy tissue is nearby.Health care practitioners may flood (irrigate) the sore, particularly its deep crevices, with a sterile solution to help clean away hidden debris. Sometimes a bed that circulates air (an air-fluidized bed) is used in hospitals and nursing homes. This special bed helps reduce or redistribute pressure on the body. ——â₠¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€- Deep pressure sores are difficult to treat. Sometimes they require skin and muscle flaps, in which healthy, thicker tissue with a good blood supply is surgically repositioned to cover the damaged area.This type of surgery is not always successful, however, especially for frail older people who are malnourished. Often, when infections develop deep within a sore, antibiotics are given. When bones beneath a sore become infected, the bone infection (osteomyelitis) is extremely difficult to cure and may spread through the bloodstream, requiring many weeks of treatment with an antibiotic (see Bone and Joint Infections: Osteomyelitis). ————————————————- The terms decubitus ulcer and pressure sore often are used interchangeably in the medical community.Decubitus, from the Latin decumbere, means â€Å"to lie down. † Decubitus ulcer, therefore, does not adequately describe ulceration that occurs in other positions, such as prolonged sitting (eg, the commonly encountered ischial tuberosity ulcer). Because the common denominator of all such ulcerations is pressure, pressure sore is the better term to describe this condition. Pressure is exerted on the skin, soft tissue, muscle, and bone by the weight of an individual against a surface beneath.These pressures are often in excess of capillary filling pressure, approximately 32 mm Hg. In patients with normal sensitivity, mobility, and mental faculty, pressure sores do not occur. Feedback, conscious and unconscious, from the areas of compression leads inIndividuals who are unable to avoid long periods of uninterrupted pressure over bony prominences—a group of patients that typically includes elderly individuals, persons who are neurologically impaired, and patients who are acutely hospitalizedà ¢â‚¬â€are at increased risk for the development of necrosis and ulceration.These individuals cannot protect themselves from the pressure exerted on their body unless they consciously change position or have assistance in doing so. Even the most conscientious patient with an extensive support group and unlimited financial resources may develop ulceration resulting from a brief lapse in avoidance of the ill effects of pressure. [2, 3] dividuals to change body position. These changes shift the pressure prior to any irreversible tissue damage. The inciting event for a pressure sore is compression of the tissues by an external force, such as a mattress, wheelchair pad, or bed rail.Other traumatic forces that may be present include shear forces and friction. These forces cause microcirculatory occlusion as pressures rise above capillary filling pressure, resulting in ischemia. Ischemia leads to inflammation and tissue anoxia. Tissue anoxia leads to cell death, necrosis, and ulceration. à ¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€Ã¢â‚¬â€- Irreversible changes may occur after as little as 2 hours of uninterrupted preSpecialized support surfaces are available for bedding and wheelchairs, which can maintain tissues at pressures below 30 mm Hgssure. urning and repositioning the patient remain the cornerstones of prevention and treatment. The wound and surrounding skin must be kept clean and free A new international guideline with regard to the prevention of pressure ulcers was released in 2009. [11] A collaboration between the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel, the guideline covers the latest evidence-based recommendations for all patients in all healthcare settings.Clinical practice recommendations in regard to prevention will include: * Current definitions and classification of pressure ulcers; * Risk assessment, including the role of nutrit ion; * Skin inspection and skin care; * Positioning and repositioning patients; * Evidence for use of various support surfaces (air-fluidized beds; alternating air mattresses and cushions; foam-, gel-, or fluid-filled mattresses; overlays for operating tables; turning beds; and other aids for pressure redistribution); * Protective devices used for pressure ulcer prevention; and * Education and training for healthcare providers.