Relationship between technology and progress (or 2 other topics), Essay

Relationship between technology and progress (or 2 other topics), based on documents from book Thomas Edison and Modern America - Essay Example Therefore it has become necessary to ask this age old question once again. What exactly is the relationship between technology and progress? Is the change that is brought about by technology always positive? Is it at some point inevitable that once we accept the positive developments of technology we have at the same time have to accept its negative accompaniments? These are some of the questions that this paper shall seek to answer. There shall be a special focus on the book Thomas Edison and Modern America by Collins, Lisa and Gregory. There are three areas that I have identified in which the relationship between technology and progress is evident and straightforward. These areas are; an improvement in the quality of life, wealth creation, unemployment, the environment and transport and communication. I shall seek to discuss how technological inventions have brought about changes in the five named areas. This shall of course be done within the context of this book. Because it is ob vious that the perspective to be gained here is mostly from Edison’s day, I shall also include a few sentences to provide the modern context. This shall make up for an all rounded understanding of this relationship (Changing Times, p2). The first area to be looked at is the area of quality of life. This is also the most controversial area as far as the relationship between technology and progress is concerned. The reason that there is a controversy at the centre of this area is because there are varying views on what quality of life means. What constitutes an improvement in the quality of one person might be an unnecessary vexation to another (Not Just An Idea, p 28).. There are several inventions made during Edison’s time that improved the quality of life of the people then. The light bulb for instance comes to mind. Before Edison invented the light bulb, many people used other rudimentary forms of lighting like oil lamps. These were known for the chocking fumes they produced and also obviously because there were not bright enough. It can’t also be ignored that oil came at a cost (Edison's Sparks of Interest noted in the New York Sun). The other lighting that was used in the day was gas lighting. It was however seen a dangerous. Edison used his skills to homes located in a square mile around Pearl Street, Manhattan. It is important at this point to however state that Edison did not invent the light bulb. The light had been scientifically and technologically available half a century earlier. He merely made it commercially available. He also built an electrical system around which it could operate (pg 60). There are many technologies in the present day that have affected the lives of people as much as the light bulb and the electrical system did the. The most important thing about the light bulb is that it allowed people to have the access to lighting and energy in general. The electrical system on the other hand, was the basis for several other inventions. It provided inventors with a source of light and energy from which other inventions were made (Notice from the Edison Company for Isolated Lighting, November 1885). Today, there is one technology that I can think of that has made as much impact. It is the computer. The computer by itself has been an amazing invention. We can use it for typing documents e.t.c. However, that is not where the main significance of the computer is to be found. The

Nursing Home And Law Essay Example for Free

Nursing Home And Law Essay A report from the United Press International last December 19, 2007 reveals that between 2000 and 2006, there has been a significant increase in the number of serious reprimands for dangerous conditions among nursing homes in the United States. The report indicates that part of the reason to the increase is the rigorous enforcement of activities in handling patients. It has also been reported that citations of physical or sexual abuse of patients as well as insufficient medication have a significant role in the increase (Barbee, 1991). The issue of the increase in the number of serious reprimands has a strong relationship with the nature, sources and functions of the law. The increase in the number of causes for the serious reprimands have a large share in analyzing the legal measures relevant to the reprimands and preventive measures taken. If the number of causes are decreased or totally removed, then there is strong reason to believe that the reprimands will also be loosened as much as the situation requires. The known way for putting a decline to these reprimands is through the law. Apparently, the law does not only look after the serious reprimands; it also looks after the causes for these reprimands as we shall see (Barbee, 1991). Analysis In its entirety, the law seeks to provide security for the welfare of the people. It does not seek to promote an unfair advantage nor does it seek to jeopardize the lives of individuals regardless of age or gender. A large number of patients in nursing homes are the elderly who are nearing the dawn of their lives. Given their physical status, one cannot find it reasonable to handle the elderly with rashness or with rigorous enforcement of activities (Murtaugh, Kemper and Spillman, 1990). On the contrary, the elderly should receive TLC—tender, loving care. If there are no existing laws which specifically sanctions these behaviors, then it is about time that the legislative agenda of the nation include concerns for the elderly in nursing homes. Moreover, should the law zero-in on the issue pertaining to the handling of the elderly in nursing homes, the law should make clear any exclusion to the rule or other exceptions that may be granted. Otherwise, the legal sanctions may apply to cases which may not necessarily be attributed with the intention of causing more harm than doing any good to the elderly patient. For instance, the law should make it clear that there are cases where the family of the patient decides to give the employees or doctors of the nursing hospital full control of the situation of the patient (â€Å"Serious nursing home violations rise,† 2007). In certain extreme cases where the patient is unable to make rational decisions and where the family has very minimal or little knowledge on what best suits the patient, doctors are given the power to decide what is best for the patient. In this process, it is not impossible that the patient may be harmed. The law should also acknowledge the fact that there are also cases where the patients themselves are the cause of the harm that they experience. As hospital administrators, however, the employees and staff of the nursing hospitals have the responsibility to ascertain that the patients are safe from external harm and from harming themselves. Yet the probability of instances where patients cause harm to themselves is not far behind. For the law to address these possibilities, it should be narrow enough to pin down precise cases yet broad enough to encompass cases where negligence on the part of the hospital administrators can be charged and filed as a peripheral case (Barbee, 1991). Further, the law should also be clear in defining the terms involved, such as what counts as ‘rigorous enforcement of activities’ or what is to be classified as ‘proper nursing care for patients’. Although interpretation of the law, especially during court proceedings, has become integral in the due process of the law, it cannot be the case that there can be no coherent interpretation of what the law and its sanctions imply or the reasons why laws for nursing homes were or will be created. On the contrary, the very fact that a law is created indicates that it has its purpose, and legislators of such a law most likely know the purposes behind the legislation of these laws. Unless the very purpose of the law regarding the treatment patients receive in nursing homes become clearly defined or sufficiently explicated, several inconsistencies and vague pronouncements are most likely to follow (Murtaugh, Kemper and Spillman, 1990). Why is there the rigorous enforcement of activities in handling patients in nursing homes in the first place? There are many factors that can be considered. First, it can be the case that the staff of the nursing home may be new and unfamiliar with the ethics in professionally handling the needs and medications of the patients. Second, the employees may have a limited knowledge on the physical condition of the patient or on the sickness of the patient. Third, the records of the patients may have indicated that the patient needs certain types of activities without specifying the frequency of the activity. Lastly, the nursing home might be lacking in terms of advanced medical equipment and other medical machines. And to compensate for such a ‘lack’, the nursing home administrators may have reverted to increasing the amount of activities above normal (â€Å"Serious nursing home violations rise,† 2007). Why is there a need for laws which cover sanctions for certain ways of handling patients at nursing homes? Part of the reason to this is the observation that there are nursing home employees who take advantage of their patients in many ways; one having been reported is physical or sexual abuse. The laws provide a means not only to proscribe certain behaviors from nursing home employees but, more importantly, to draw the fine line between professionalism and abuse of work responsibilities. Conclusions and further remarks It is a fact that a number of laws are first proposed in the legislative body of the government. But even more basic to this is the fact that a number of these proposals come from the demands of the people such groups that as lobby for laws which can directly affect their cause (Barbee, 1991). Certain tends in the contemporary society can also prompt the legislative body of the government to create laws which address these trends. For instance, the massive boom of immigration in earlier times led numerous countries to pass laws which control immigration of individuals. As for the increase in the number of cases pertaining to the rigorous enforcement of activities in handling patients, it is no wonder that there has been a corresponding increase in the number of serious reprimands for dangerous conditions among nursing homes. The United Press International report divulges the critical increase in the number of serious reprimands for dangerous conditions among nursing homes in America (â€Å"Serious nursing home violations rise,† 2007). The rigorous enforcement of activities in handling patients has an undeniable contribution in the increase although what remains debatable is the question of whether the existing laws have enough coverage over the ways in which nursing home employees take care of their patients. The citations of physical or sexual abuse of patients as well as insufficient medication are clear indicators that the problem in nursing homes is real and requires attention from the legislative body of the government. The nature, sources and functions of the law have a role to fit in the case of the patients situated in many nursing homes in the country. The increasing number of patients in nursing homes is perhaps the strongest indicator that, while the nation may lack solid efforts in surmounting patient-related incidents of harm, the law is yet to efficiently and effectively be put into action. References Serious nursing home violations rise. (2007). Retrieved January 20, 2008, from http://www. upi. com/NewsTrack/Top_News/2007/12/19/serious_nursing_home_violations_rise/9034/ Barbee, G. C. (1991). The Nurse, the Nursing Home, and the Law. The American Journal of Nursing, 61(8), 84-86. Murtaugh, C. M. , Kemper, P. , Spillman, B. C. (1990). The Risk of Nursing Home Use in Later Life. Medical Care, 28(10), 952-962.

Patient with Congestive Heart Failure

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

Narcissism as Liberation and Deep Play: Notes on a Balinese Cockfight E

Comparing Susan Douglas' Narcissism as Liberation and Clifford Greetz's Deep Play: Notes on a Balinese Cockfight The method used by Susan Douglas in her essay â€Å"Narcissism as Liberation† to describe the way a particular event to practice might have a deeper meaning seems to differ somewhat with that used by Clifford Greetz in â€Å"Deep Play: Notes on a Balinese Cockfight†. In the former, the author concentrates on the method which would be best described as â€Å"direct approach†. In her explanations of the themes behind different advertising practices and their implied meanings she makes it sound as though the ones responsible for the advertisements infuse these subliminal messages on purpose into the context. She describes the play on women’s feelings to cow them into thinking that they are never the ideal and should always be working to perfect their bodies (using the advertiser’s products) is an intentional subliminal message that is infused into every commercial advertisement is done because that method seems to be effective. She stresses that the media and corporations have shaped...

History of Brazil Essay

It is a matter of fact that Brazil is a country of contrasts. One can easily observe that the development of this nation is incredibly uneven. Taking into consideration their past experience, the Brazilians are seeing some very good times as a nation. Certainly, they have overcrowding problems. However, each country has its own difficulties and tries to overcome them. Thus, the diversity of this country and its amazing history has brought a â€Å"mixing bowl† of culture preparing a bright future for Brazil. It is widely known that four major groups make up the Brazilian population. They are the Portuguese, who colonized Brazil in the 16th century; Africans brought to the country as slaves; various European, Middle Eastern, and Asian immigrant peoples who have settled in Brazil since the mid-19th century; and indigenous people of Guarani and Tupi language. (Skidmore, 131) Brazil is the only Latin American nation that takes its language and culture mainly from Portugal. Intermarriage between indigenous people or slaves and the Portuguese was a common phenomenon. Despite the fact that the major European ethnic culture of Brazil was once Portuguese, waves of immigration have greatly contributed to a diverse ethnic and cultural heritage. Admiral Pedro Alvares Cabral claimed Brazilian territory for Portugal in 1500. The early explorers brought back a wood with them that produced a red dye, pau-brasil. This is where the land received its original name. Portugal began colonization in 1532 and made the area a royal colony in 1549. During the Napoleonic Wars, fearing the advancing French armies, King Joao VI left the country in 1808 and set up his court in Rio de Janeiro. He was brought home later in 1820 by a revolution, leaving his son as regent. When Portugal wanted to reduce Brazil to colonial status again, the prince declared Brazil’s independence on Sept. 7, 1822. Thus, he became Dom Pedro I, emperor of Brazil. Harassed by his Parliament, Pedro I resigned in 1831 in favor of his five-year-old son who became emperor Dom Pedro II in 1840. Emperor Pedro II ruled to 1889 when a federal republic was established as a result of a coup d’etat organized by Deodoro da Fonseca, marshal of the army. A year earlier, while Dom Pedro II was in Europe, the Regent Princess Isabel had abolished Slavery. Abreu, 311) Dom Pedro II was a popular monarch. Yet discontent grew up and, in 1889, he had to resign because of a military revolt. Although a republic was proclaimed at that time, Brazil was ruled by military dictatorships until a revolt allowed returning gradually to stability under civilian presidents. From 1889 to 1930, the government was a const itutional democracy. The presidency was alternating between the dominant states of Sao Paulo and Minas Gerais. This period ended with a coup d’etat that placed a civilian, Getulio Vargas, in the presidency. He remained as a dictator until 1945. From 1945 to 1961, presidents of Brazil became Eurico Dutra, Vargas, Juscelino Kubitschek, and Janio Quadros. When Quadros abdicated in 1961, he was succeeded by Vice President Joao Goulart. (Abreu, 329) Goulart’s years in office were marked by high inflation, total economic failure, and the increasing influence of radical political parties. The armed forces alarmed by these developments organized a coup d’etat on March 31, 1964. The coup leaders chose Humberto Castello Branco a president, followed by Arthur da Costa e Silva (1967-69), Emilio Garrastazu Medici (1968-74), and then Ernesto Geisel (1974-79). All of them were senior army officers. Geisel began a liberalization that was carried further by his successor, General Joao Baptista de Oliveira Figueiredo (1979-85). In the last of a long series of military coups, General Joao Baptista de Oliveira Figueiredo became president in 1979. He pledged a return to democracy in 1985. Figueiredo not only allowed the return of politicians exiled or banned from political activity during the 1960s and 1970s, yet also permitted them to run for state and federal offices in 1982. (Alden, 284) However, at the same time, the Electoral College consisting of all members of Congress and also six delegates chosen from each state continued its activities of choosing the president. The election of Tancredo Neves on January 15, 1985, the first civilian president since 1964, brought a nationwide wave of optimism and activity. He was elected from the opposition Brazilian Democratic Movement Party (PMDB). (Alden, 287) However, when Neves died on April 21, Vice President Sarney became president. The latter was widely distrusted because he had previously been a devoted member of the military regime’s political party. Collor de Mello won the election of late 1989 with 53% of the vote in the first direct presidential election in his 29 years. (Abreu, 378) Mello promised to lower the persistent hyperinflation by following the path of free-market economics. Having faced impeachment by Congress because of a corruption scandal in December 1992, Mello finally resigned. Vice President Itamar Franco took his place and assumed the presidency. Fernando Cardoso, a former finance minister, won the presidency in the October 1994 election having 54% of the vote. He took office on January 1, 1995. (Skidmore, 232) Cardoso has organized the disposal of bad government-owned monopolies in the electrical power, telecommunication, port, railway, mining, and banking industries. His timely proposals to Congress included constitutional amendments in order to open the Brazilian economy to greater foreign participation and to implement such sweeping reforms as social security, government administration, and taxation so as to reduce excessive public sector spending and considerably improve government efficiency. Alden, 298) During his short time in the office, Cardoso’s economic wisdom has made a measurable progress in overcoming Brazil’s poverty level. It is remarkable to observe how the Brazilian government makes certain efforts in order to address basic needs of its people such as education, distribution of meals, health care, and the promotion of children’s rights. Co-signed by the President of Brazil and 24 state governors, the â€Å"Pact for the Children† is intended to fully implement the constitutional and legal obligations providing for protection of children and adolescents. Several federal agencies supervise the execution of government programs for children and adolescents aimed to give Brazilian youth opportunities for a better life, shelter, education, and love. Thus, if not forgetting about the past mistakes and taking care of its nation, the Brazilians will surely come to the brightest future.

How to Write a Good Motivation Letter

How to Write a Good Motivation Letter How to Write a Good Motivation Letter 5 August, 2019 How can define a motivation letter? Do you consider it to be the same as a cover letter? Does it have any peculiar standards of formatting and composition? A cover letter is needed only in case of job applications, while a letter ofmotivation is typically required for university enrollment as well as acceptance to particular educational programs or even volunteer organization projects. It is also important to know how to write a good motivation letter for a fresh graduate or a student without particular career achievements who has to demonstrate that he or she is genuinely interested in a certain position. The name of the letter makes the main aim of writing absolutely clear. You are expected to provide a description of the factors that motivate you to apply for a particular position or activity. In case of writing a motivation letter for a student program, it is necessary to give explanations of your reasons why participation in it is important for you. If you want to apply for some volunteering activities in a non-for-profit organization, it is essential to provide the needed details related to your volunteering experience, if any, and your interest in meaningful activities and helping others. It is a common mistake to mistake cover letters for letters of motivation. It is natural as both of the letters have an aim to make a reader believe that there is no other candidate or applicant who would be better for a certain position. However, one of the differences is that limitations related to cover letters are stricter. How to Make a Motivation Letter Successful? Typically, even having theoretical knowledge of how to write a good motivation letter, students do not find it easy to keep to recognized standards of internship letter writing or motivation letter writing. It is challenging to select the details that have to be included into the letter and excluded fro it to make it effective. Note that a perfect letter of motivation is supposed to address the following issues: professional plans and goals career objectives: both short-term and long-term desired position after graduation plans as for the contribution to political, social, technological, and cultural development of the community, area, state, city, or region after graduation plans as for the place to live and work after you get a degree benefits of the selected study courses for you in terms of the career goals specific reasons why the committee should opt for your application among hundreds of other ones Factually, a good motivation letter should always contain accurate details about how a new position you are applying for will benefit from your acquired knowledge, internship practice, experience, abilities and skills. Moreover, we recommend evaluating your own weak and strong points, skills, and expertise from your own point of view. For instance, it is reasonable to assess your leadership skills, willingness to work in a team, ability to cope with tight deadlines and work under pressure, and so on. What Are the Main Constituent Parts of a Motivation Letter? All types of motivation letter writing imply covering the following fundamental aspects: Your first name and your last name along with the contact details: telephone number, email. The name of the company you want to work for and the name of the position you want. Valid reasons why you want to apply: it will be appropriate to mention your personal qualities here and explain why they will be beneficial for the development of this particular company. How to Turn Your Motivation Letter into an Outstanding Piece of Writing? Your constant focus while writing a motivation letter should be on the coherence of the content, correct language, and importance of mentioning your qualifications and intentions in terms of your application. Try to avoid flowery phrases and vague explanations. The dominant voice of the letter should be active. No specific terms. No clichs. You should sound persuasive and creative at the same time. Even if you believe that a certain clich will be the most appropriate way to express your thought, it is highly recommended to consider the aspects of how and why and opt for evidence and examples that overdo the flat phrases everybody is tired of. No plagiarism. Using certain facts and details from the previous researches or your own papers, you cannot take word-for-word parts of the texts. Moreover, never copy paste pars of the program in your letters. No copied forms. Have a look at some bright samples of the letters but do not base your own on the ideas taken from there. Blind copying will do no good and will never produce a good impression. Make your tone as positive as possible as there should be no focus on any negative aspects. Even if you want to tell about challenges or problems you had to overcome, it is better to point out not the hardships themselves, but the way you coped with them. Even if you mention your weaknesses, do not emphasize them. The main purpose of your motivation is to sell what you can do and how advantageous you are as a candidate. Most probably, they will ask you about your weak points when you are invited to the interview, but for now concentrate on the future. Present your previous qualifications, but also emphasize the prospects you want to have. You may lack experience in a particular area, but it will be right to tell not about this but about your eagerness to learn. Read a lot about how to write a good motivation letter, but also remember that the most important principle of writing is to be honest. Exaggerations are not welcome. They are looking for the most qualified candidate, but they need to know about your actual abilities and skills. You will still remain competitive if you tell the truth about what you can do instead of lying. Have a Look at the Following Valuable Tips Keep it brief It is not necessary to tell a lot. It will be much more beneficial just to point out your achievements and experience in the professional and academic spheres. You should realize the scope of work committees have in the seasons of admissions. Having thousands of applications daily, they want to see detailed information presented in a concise form. It sounds as a paradox, but it is true. They skim through the lines, and you should be able to present the main aspects without any vagueness or wordiness. Choose the achievements that are the noticeable and relevant. Professionalism and personality combined There is a certain similarity between a personal statement and a motivation letter. You have to cover the most practical details and keep the text coherent and concise. No boasting! No tedious flow of repetitions! Good luck!