Business Model Product Statement Health And Social Care Essay

The respiratory system consists of the respiratory musculuss, carry oning air passages, lungs, pneumonic vasculature, and environing tissues and constructions ( Fig. 1 ) . Each plays an of import function in act uponing respiratory responses. Figure 1. Respiratory Anatomy ( 1 )LungsThere are two lungs in the human thorax ; the right lung is composed of three uncomplete divisions called lobes, and the left lung has two, go forthing room for the bosom. The right lung histories for 55 % of entire gas volume and the left lung for 45 % . Lung tissue is squashy due to really little ( 200 to 300 – 10-6 m diameter in normal lungs at remainder ) gas-filled pits called air sac, which are the ultimate constructions for gas exchange. There are 250 million to 350 million air sac in the grownup lung, with a entire alveolar surface country of 50 to 100 M2s depending on the grade of lung rising prices ( 2 ) .Conducting Air passagesAir is transported from the ambiance to the air sac get downing with the unwritten and rhinal pits, through the throat ( in the pharynx ) , past the glottal gap, and into the windpipe or trachea. Conduction of air Begins at the voice box, or voice box, at the entryway to the windpipe, which is a fibromus cular tubing 10 to 12 centimeter in length and 1.4 to 2.0 centimeter in diameter. At a location called the Carina, the windpipe terminates and divides into the left and right bronchial tube. Each bronchial tube has a discontinuous cartilaginous support in its wall. Muscle fibres capable of commanding air passage diameter are incorporated into the walls of the bronchial tube, every bit good as in those of air transitions closer to the air sac. Smooth musculus is present throughout the respiratory bronchiolus and alveolar canals but is absent in the last alveolar canal, which terminates in one to several air sacs. The alveolar walls are shared by other air sacs and are composed of extremely fictile and collapsable squamous epithelial tissue cells. The bronchial tube subdivide into subbronchi, which farther subdivide into bronchioli, which further subdivide, and so on, until eventually making the alveolar degree. Each air passage is considered to ramify into two subairways. In the grownup homo there are considered to be 23 such ramifications, or coevalss, get downing at the windpipe and stoping in the air sac. Motion of gases in the respiratory airways occurs chiefly by majority flow ( convection ) throughout the part from the oral cavity to the olfactory organ to the 15th coevals. Beyond the 15th coevals, gas diffusion is comparatively more of import. With the low gas speeds that occur in diffusion, dimensions of the infinite over which diffusion occurs ( alveolar infinite ) must be little for equal O bringing into the walls ; smaller air sac are more efficient in the transportation of gas than are larger 1s ( 2 ) .AlveolussAlveoluss are the constructions through which gases diffuse to and from the organic structure. To guaran tee gas exchange occurs expeditiously, alveolar walls are highly thin. For illustration, the entire tissue thickness between the interior of the air sac to pneumonic capillary blood plasma is merely approximately 0.4 – 10-6 m. Consequently, the chief barrier to diffusion occurs at the plasma and ruddy blood cell degree, non at the alveolar membrane ( 2 ) .Motion of Air In and Out of the Lungs and the Pressures That Cause the MotionPleural PressureIs the force per unit area of the fluid in the thin infinite between the lung pleura and the chest wall pleura.Alveolar force per unit areaIs the force per unit area of the air inside the lung air sac. To do inward flow of air into the air sac during inspiration, the force per unit area in the air sac must fall to a value somewhat below atmospheric force per unit area.Transpulmonary force per unit areaIt is the force per unit area difference between that in the air sac and that on the outer surfaces of the lungs, and it is a step of the elastic forces in the lungs that tend to fall in the lungs at each blink of an eye of espiration, called the kick force per unit area.Conformity of the LungsThe extent to which the lungs will spread out for each unit addition in transpulmonary force per unit area ( if adequate clip is allowed to make equilibrium ) is called the lung conformity. The entire conformity of both lungs together in the normal grownup human being norms about 200 millilitres of air per centimetre of H2O transpulmonary force per unit area ( 3 ) . Figure 2. Conformity diagram of lungs in a healthy individual ( 3 ) .Pathophysiology of Weaning FailureReversible aetiologies for ablactating failure can be categorized in: Respiratory burden, cardiac burden, neuromuscular competency, critical unwellness neuromuscular abnormalcies ( CIMMA ) , neuropsychological factors, and metabolic and endocrinal upsets.Respiratory burdenThe determination to try discontinuance of mechanical airing has mostly been based on the clinician ‘s appraisal that the patient is haemodynamically stable, wake up, the disease procedure has been treated adequately and that indices of minimum ventilator dependence are present. The success of ablactating will be dependent on the ability of the respiratory musculus pump to digest the burden placed upon it. This respiratory burden is a map of the opposition and conformity of the ventilator pump. Excess work of take a breathing ( WOB ) may be imposed by inappropriate ventilator scenes ensuing in ventilator dysynchrony ( 4 ) . Reduced pneumonic conformity may be secondary to pneumonia, cardiogenic or noncardiogenic pneumonic hydrops, pneumonic fibrosis, pneumonic bleeding or other diseases doing diffuse pneumonic infiltrates ( 5 ) .Cardiac burdenMany patients have identified ischemic bosom disease, valvular bosom disease, systolic or diastolic disfunction prior to, or identified during, their critical unwellness. More elusive and less easy recognized are those patients with myocardial disfunction, which is merely evident when exposed to the work load of ablactating ( 5 ) .Neuromuscular competencyLiberation from mechanical airing requires the recommencement of neuromuscular activity to get the better of the electric resistance of the respiratory system, to run into metabolic demands and to keep C dioxide homeostasis. This requires an equal signal coevals in the cardinal nervous system, integral transmittal to spinal respiratory motor nerve cells, respiratory musculuss and neuromuscular junctions. Disruption of any part of this transmittal may lend to ablactating failure ( 5 ) .Critical unwellness neuromuscular abnormalciesCINMA are the most common peripheral neuromuscular upsets encountered in the ICU scene and normally affect both musculus and nervus ( 6 ) .Psychological disfunctionCraze, or acute encephalon disfunction: Is a perturbation of the degree of knowledge and rousing and, in ICU patients, has been associated with many modifiable hazard factors, including: usage of psychotropic drugs ; untreated hurting ; drawn-out immobilization ; hypoxaemia ; anemia ; sepsis ; and kip want ( 7 ) . Anxiety and depression: Many patients suffer important anxiousness during their ICU stay and the procedure of ablactating from mechanical airing. These memories of hurt may stay for old ages ( 8 ) .Metabolic perturbationsHypophosphataemia, hypomagnesaemia and hypokalaemia all cause musculus failing. Hypothyroidism and Addison's disease may besides lend to difficulty ablactating ( 5 ) .NutritionCorpulence: The mechanical effects of fleshiness with reduced respiratory conformity, high shutting volume/functional residuary capacity ratio and elevated WOB might be expected to impact on the continuance of mechanical airing ( 5 ) .Ventilator-induced stop disfunction and critical unwellness oxidative emphasisVentilator-induced stop disfunction and critical unwellness oxidative emphasis is defined as loss of diaphragm force-generating capacity that is specifically related to utilize of controlled mechanical airing ( 9 ) .Clinical Presentation of PatientsPatients can be classified into three g roups harmonizing to the trouble and length of the ablactation procedure. The simple ablactation, group 1, includes patients who successfully pass the initial self-generated take a breathing test ( SBT ) and are successfully extubated on the first effort. Group 2, hard ablactation, includes patients who require up to three SBT or every bit long as 7 yearss from the first SBT to accomplish successful ablactation. Group 3, prolonged ablactation, includes patients who require more than three SBT or more than 7 yearss of ablactation after the first SBT ( 5 ) .Clinical Outcomes and EpidemiologyThere is much grounds that ablactating tends to be delayed, exposing the patient to unneeded uncomfortableness and increased hazard of complications ( 5 ) . Time spent in the ablactation procedure represents 40-50 % of the entire continuance of mechanical airing ( 10 ) ( 11 ) . ESTEBAN et Al. ( 10 ) demonstrated that mortality additions with increasing continuance of mechanical airing, in portion because of complications of drawn-out mechanical airing, particularly ventil ator-associated pneumonia and airway injury ( 12 ) . The incidence of unplanned extubation ranges 0.3-16 % . In most instances ( 83 % ) , the unplanned extubation is initiated by the patient, while 17 % are inadvertent. Almost half of patients with self-extubation during the weaning period do non necessitate reintubation, proposing that many patients are maintained on mechanical airing longer than is necessary ( 5 ) . Addition in the extubation hold between readiness twenty-four hours and effectual extubation significantly increases mortality. In the survey by COPLIN et Al. ( 13 ) , mortality was 12 % if there was no hold in extubation and 27 % when extubation was delayed. Failure of extubation is associated with high mortality rate, either by choosing for bad patients or by bring oning hurtful effects such as aspiration, atelectasis and pneumonia ( 5 ) . Rate of ablactating failure after a individual SBT is reported to be 26- 42 % . Variation in the rate of ablactating failure among surveies is due to differences in the definition of ablactating failure. VALLVERDU et Al. ( 14 ) reported that ablactating failure occurred in every bit many as 61 % of COPD patients, in 41 % of neurological patients and in 38 % of hypoxaemic patients. Contradictory consequences exist sing the rate of ablactating success among neurological patients. The survey by COPLIN et Al. ( 13 ) demonstrated that 80 % of patients with a Glasgow coma mark of more than 8 and 91 % of patients with a Glasgow coma mark less than 4 were successfully extubated. In 2,486 patients from six surveies, 524 patients failed SBT and 252 failed extubation after go throughing SBT, taking to a entire w eaning failure rate of 31.2 % ( 5 ) . The huge bulk of patients who fail a SBT do so because of an instability between respiratory musculus capacity and the burden placed on the respiratory system. High air passage opposition and low respiratory system conformity contribute to the increased work of take a breathing necessary to take a breath and can take to unsuccessful release from mechanical airing ( 15 ) .Economic ImpactMechanical airing is largely used in the intensive attention units ( ICU ) of infirmaries. ICUs typically consume more than 20 % of the fiscal resources of a infirmary ( 16 ) . A survey that analyzed the incidence, cost, and payment of the Medicare intensive attention unit usage in the United States ( US ) reveled that mechanical airing costs a amount stopping point to US $ 2,200 per twenty-four hours ( 17 ) . One survey shows that patients in the ICUs having drawn-out mechanical airing represents 6 % of all ventilated patients but consume 37 % of intensive attent ion unit ( ICU ) resources ( 18 ) . Another survey corroborates this Numberss besides demoing that 5 % to 10 % of ICU patients require drawn-out mechanical airing, and this patient group consumes more than or every bit much as 50 % of ICU patient yearss and ICU resources. Prolonged ventilatory support and chronic ventilator dependence, both in the ICU and non-ICU scenes, have a important and turning impact on health care economic sciences ( 19 ) .DrumheadTreatment OptionWeaning FailureOverviewThe procedure of initial ablactating from the ventilator begins with an appraisal sing preparedness for ablactating. It is so followed by SBT as a diagnostic trial to find the possibility of a successful extubation. For the bulk of patients, the full ablactation procedure involves verification that the patient is ready for extubation. Patients who meet the standards in table 2 should be considered as being ready to ablactate from mechanical airing. These standards are cardinal to gauge the like liness of a successful SBT in order to avoid tests in patients with a high chance of failure ( 5 ) . Table 2 Standards for Measuring Readiness to Wean Clinical Appraisal Adequate cough Absence of inordinate tracheobronchial secernment Resolution of disease acute stage for which the patient was intubated Objective measurings Clinical stableness Stable cardiovascular position ( i.e. fC ?140 beats*min-1, systolic BP 90-160 mmHg, no or minimum vasopressors ) Stable metabolic position Adequate oxygenation Sa, O2 & A ; gt ; 90 % on ?FI, O2 0.4 ( or Pa, O2/FI, O2 ?150 mmHg ) PEEP ?8 cmH2O Adequate pneumonic map f ?35 breaths*min-1 PImax ?-20- -25 cmH2O Ve & A ; lt ; 10 l*min-1 P0.1/PImax & A ; lt ; 0.3 VT & A ; gt ; 5 mL*kg-1 VC & A ; gt ; 10 mL*kg-1 f/VT & A ; lt ; 105 breaths*min-1*L-1 CROP & A ; gt ; 13 ml*breaths-1*min-1 No important respiratory acidosis Adequate thinking No sedation or equal thinking on sedation ( or stable neurologic patient ) Taken from ( 5 ) and ( 15 ) . fC: cardiac frequence ; BP: blood force per unit area ; Sa, O2: arterial O impregnation ; FI, O2: inspiratory O fraction ; Pa, O2: arterial O tenseness ; PEEP: positive end-expiratory force per unit area ; degree Fahrenheit: respiratory frequence ; PImax: maximum inspiratory force per unit area ; VT: tidal volume ; VC: critical capacity ; CROP: integrative index of conformity. 1 mmHg=0.133 kPa. Harmonizing to an adept panel, among these standards merely seven variables have some prognostic potency: minute airing ( VE ) , maximal inspiratory force per unit area ( PImax ) , tidal volume ( VT ) , take a breathing frequence ( degree Fahrenheit ) , the ratio of take a breathing frequence to tidal volume ( f/VT ) , P0.1/PImax ( ratio of airway occlusion force per unit area 0.1 s after the oncoming of inspiratory attempt to maximal inspiratory force per unit area ) , and CROP ( integrative index of conformity, rate, oxygenation, and force per unit area ) ( 20 ) .Minute VentilationMinute airing is the entire lung airing per minute, the merchandise of tidal volume and respiration rate ( 21 ) . It is step by measuring the sum of gas expired by the patients lungs. Mathematicly, minute airing can be calculated after this expression: It is reported that a VE less than 10 litres/minute is associated with ablactating success ( 22 ) . Other surveies found that VE values more than 15-20 litres/minute are helpful in placing if a patient is improbable to be liberated from mechanical airing but lower values were non helpful in foretelling successful release ( 15 ) . A more recent survey concluded that short VE recovery times ( 3-4 proceedingss ) after a 2-hour SBT can assist in finding respiratory modesty and predict the success of extubation ( 23 ) . When mechanical airing takes topographic point, this parametric quantity is calculated monitoring flow and force per unit area by the ventilator in usage itself or by an independent device attached to the air passage circulation system such as the Respironics NM3Â ® by Phillips Medical. Other ways to find minute airing are by mensurating the electric resistance across the thoracic pit ( 24 ) . This method though, is invasive and requires deep-rooted electrodes.Maximal Inspiratory PressureMaximal inspiration force per unit area is the maximal force per unit area within the air sac of the lungs that occurs during a full inspiration ( 21 ) . Is it normally used to prove respiratory musculus strength. On patients in the ICU or those non capable to collaborate, the PImax is measured by obstructing the terminal of the endotracheal tubing for a period of clip close to 22 seconds with a one-way valve that merely allows the patient to expire. This constellation leads to increasing inspirator y attempt mensurating PImax towards the terminal of the occlusion period. However PImax is non plenty to foretell faithfully the likelihood of successful ablactating due to low specifity ( 15 ) . The measuring of PImax can be performed by devices equipped with force per unit area detectors.Tidal VolumeTidal volume is the sum of air inhaled and exhaled during normal airing ( 21 ) . Spontaneous tidal volumes greater than 5 ml/kg can foretell ablactating result ( 25 ) . More recent surveies found that a technique that measures the sum of regularity in a series analysing approximative information of tidal volume and external respiration frequence forms is a utile index of reversibility of respiratory failure. A low approximate information that reflects regular tidal volume and respiratory frequence forms is a good index of ablactating success ( 26 ) . Tidal volume can be measured utilizing a pneumotachographic device.Breathing FrequencyThe grade of regularity in the form of the external respiration frequence shown by approximative information instead than the absolute value of the external respiration frequence is been proven to be utile in know aparting between ablactating success and failure ( 26 ) . The take a breathing rate or frequence is measured by numbering the external respiration rhythms per a defined period of clip.The Ratio of Breathing Frequency to Tidal VolumeYang and Tobin [ 18 ] so performed a prospective survey of 100 medical patients having mechanical airing in the ICU in which they demonstrated that the ratio of frequence to tidal volume ( rapid shoal take a breathing index ( RSBI ) ) obtained during the first 1 minute of a T-piece test and at a threshold value of ?105 breaths/minute/l was a significantly better forecaster of ablactating results However, there remains a rule defect in the RSBI: it can bring forth inordinate false positive anticipations ( that is, patients fail ablactating outcome even when RSBI is ?105 breaths/minute/l ) [ 35-36 ] Besides, the RSBI has less prognostic power in the attention of patients who need ventilatory support for more than 8 yearss and may be less utile in chronic clogging pneumonic disease ( COPD ) and aged patients [ 37-39 ] .The Ratio of Airway Occlusion Pressure to Maximal Inspiratory PressureThe airway occlusion force per unit area ( P0.1 ) is the force per unit area measured at the air passage opening 0.1 s after animating against an occluded air passage [ 42 ] . The P0.1 is attempt independent and correlates good with cardinal respiratory thrust. When combined with PImax, the P0.1/PImax ratio at a value of & A ; lt ; 0.3 has been found to be a good early forecaster of ablactating success [ 11,43 ] and may be more utile than either P0.1 or PImax entirely. Previously, the clinical usage of P0.1/PImax has been limited by the demand of particular instrumentality at the bedside ; nevertheless, new and modern ventilators are integrating respiratory mechanics faculties that provide nu merical and graphical shows of P0.1 and PImax.Air manner ResistanceCropThe CROP index is an integrative index that incorporates several steps of preparedness for release from mechanical airing, such as dynamic respiratory system conformity ( Crs ) , self-generated external respiration frequence ( degree Fahrenheit ) , arterial to alveolar oxygenation ( partial force per unit area of arterial O ( PaO2 ) /partial force per unit area of alveolar O ( PAO2 ) ) , and PImax in the undermentioned relationship: CROP = [ Crs – PImax – ( PaO2/PAO2 ) ] /f where: PAO2 = ( PB-47 ) – FiO2 – PaCO2/0.85 and PB is barometric force per unit area. The CROP index assesses the relationship between the demands placed on the respiratory system and the ability of the respiratory musculuss to manage them [ 18 ] . Yang and Tobin [ 18 ] reported that a CROP value & A ; gt ; 13 ml/breaths/minute offers a moderately accurate forecaster of ablactating mechanical airing result. In 81 COPD patients, Alvisi and co-workers [ 39 ] showed that a CROP index at a threshold value of & A ; gt ; 16 ml/breaths/minute is a good forecaster of ablactating result. However, one disadvantage of the CROP index is that it is slightly cumbrous to utilize in the clinical scene as it requires measurings of many variables with the possible hazard of mistakes in the measuring techniques or the measuring device, which can significantly impact the value of the CROP index.Clinical Treatment ProfilesCONCLUSIONS AND RECOMMENDATIONS

Acute Hepatitis B

Acute Hepatitis B GNUR543 St. John Fisher College Mr. Wilson is a 47 year old man being evaluated for complaints of fatigue, anorexia and abdominal distention. On examination, it is noted that the skin is jaundiced and the liver enlarged. D. W. denies significant alcohol or drug use. He denies any known exposure to hepatitis and has never been vaccinated for hepatitis. He is taking no medication. Laboratory tests reveal the following and a diagnosis of acute hepatitis B is made: 1. Review and analyze the laboratory data. What diagnosis is supported by these values? Give your rationale. Mr.Wilson’s lab work is reviewed below: * AST142 IU/L * AST (Aspartate aminotransferase) is an enzyme and blood sample results can detect if there is liver damage. AST is found in the heart and liver with much lower levels in muscles and kidneys. In a healthy person the AST is between 10-40 IU/L. If the liver is damaged, AST is released into the blood stream (Hepatitis B, 2011). * ALT120 IU/L * ALT (Alanine aminotransferase), if elevated can also be an indication of liver damage. ALT is an enzyme that is normally in the liver and kidneys. If the individual is healthy, the ALT is low, between 7-56 IU/L.Elevated ALT is an early indicator of liver damage usually elevating prior to a patient becoming jaundice (Hepatitis B, 2011). * GGT 42 IU/L * GGT (Gamma-glutamyl transferase) is an enzyme that is found in the liver but may also be in the spleen, kidneys and pancreas. As with AST/ALT, GGT is elevated when there is liver damage. The normal test range is 0 – 51 IU/L. GGT will be elevated when there is acute damage to the liver (or bile ducts) (Hepatitis B, 2011). * Alk Phos 84 IU/L * Alk Phos (Alkaline Phosphatase or ALP) is an enzyme found in the liver, bone, kidney and GI tract. Normal range for this blood test is 44 – 147 IU/L.Alk Phos, if elevated generally indicates that there is a blockage in the bile ducts. Also, if it is found to be high this means the pat ient can either have kidney disease or bone disease. To differentiate, a GGT test is also taken. If that result is high as well, a liver disease is present; if the GGT is within normal limits then the patient has bone disease (Hepatitis B, 2011). * Total Bilirubin1. 0 mg/dl * Total bilirubin is the product of damaged or broken down red blood cells in the body. The bilirubin is processed through the liver and the normal levels in the body are; 0. 3 – 1. 9 mg/dL.If this level is increased, it means that the liver is not processing the bilirubin due to liver disease (Hepatitis, 2011). * Albumin4. 3 g/dl * Albumin (ALB) measures the level of albumin in the patient’s plasma. Albumin is a protein that is made in the liver and is sensitive to any changes in liver function. Albumin mainly ensures that the cells in the body don’t leak, keep the tissues nourished and transports vitamins, calcium, hormones through the body. The normal range for Albumin is 3. 4 – 5. 4 g/dL. Albumin will be lower than normal in the case of malnutrition or liver disease (Hepatitis, 2011). HBsAgpositive * Anti-HBSnegative * Anti-HCVnegative * HIVnegative Test Name| Mr. Wilson’s Result| Normal Ranges| | AST| 142 IU/L| 10-40 IU/L| Elevated| ALT| 120 IU/L| 7-56 IU/L| Elevated| GGT | 42 IU/L| 0 – 51 IU/L| Normal| Alk Phos | 84 IU/L| 44 – 147 IU/L| Normal| Total Bilirubin| 1. 0 mg/dl| 0. 3 – 1. 9 mg/dL| Normal| Albumin| 4. 3 g/dl| 3. 4 – 5. 4 g/dL| Normal| Mr. Wilson’s labs indicate that he has chronic Hepatitis B. This is chronic because the indicators for acute liver damage are within normal limits. For example, if the patient were having an acute onset of Hepatitis B his Albumin would be low.Albumin is made in the liver and is very sensitive to any changes in the liver. If there was acute damage to the liver the Albumin value would not be in normal range. Also, Mr. Wilson’s bilirubin would be higher if he was having a cute hepatitis B. For the skin to be noticeably jaundiced the bilirubin level would usually be >2. 0 mg/dL (Hepatitis, 2011). The patients GGT would be elevated also if he was experiencing an acute episode of hepatitis B. Additional tests that might be helpful to making an accurate diagnosis would be; IgG-anti-HBc and IgM-anti-HBc.These tests show if the hepatitis is acute or chronic. The IgG-anti-HBc is positive if the patient is chronically infected. The IgM-anti-HBc would show positive if the patient is acutely infected with hepatitis B. The HBs-Ag will be positive in both acute and chronic cases. See the table below for an overview of the assessment and tests that are generally given when a new Hepatitis B diagnosis is reached. (Lok A. S. , 2011) 2. Explain the hepatocellular changes that occur with the above diagnosis. The liver has many roles in the body that associate it with many systems.For example, it acts as a digestive organ by secreting bile for the breakdown of fat (Co pstead, 2010). The liver also removes bilirubin from the blood, temporarily stores blood and synthesizes the blood clotting factors (Copstead, 2010). Other functions of the liver are; removing toxins from the blood, metabolizing both sex hormones and steroid hormones. Any damage to the liver can in turn disrupt any of these processes and functions that it performs. Some of the processes and functions can be changed in the following ways: * Liver inflammation: Inflammation in chronic hepatitis is associated with scarring.Severe inflammation can bridge together portal tracts within the liver, this is called â€Å"bridging necrosis† (Mani & Kleiner, 2009). It can also bridge to central veins, confluent necrosis (Mani & Kleiner, 2009). This leads to scarring, the creation of fibrous strands and in many cases will lead to fibrosis. Throughout the liver cells are becoming damaged therefore blocking and limiting the livers functionality. Hormone secretion, chemicals and toxins in th e blood, clotting factors and other defense fighting macrophages are interrupted (Copstead, 2010).Along with the inflammation, the patient will feel fatigued and will have a lowered immunity. * Ascites and peripheral edema: Abdominal distention, ascites, is a result of the damaged cells within the liver and more specifically the membrane of the cell has been damaged. There is an intra-abdominal buildup of sodium, water and protein. The cells in the liver are unable to maintain the appropriate osmotic gradient across the pleura (Copstead, 2010). This extra fluid is likely to accumulate in the dependant areas of a person’s body, such as ankles, legs, and arms (Kukka, 2010). Jaundice: Red blood cells have a short life span and as they die and/or are damaged the body will break them down and dispose of them. This is referred to as bilirubin metabolism and this happens in three phases; pre, intra and posthepatic. (Copstead, 2010). The red blood cells should be broken down, deliver ed to the liver and then transported through the biliary system and thus be wasted via the kidney’s or the colon. With damaged liver cells, the bilirubin is not excreted from the liver and there is a buildup of the conjugated bilirubin and the result is jaundice (Copstead, 2010).Other changes due to the liver damage are portal hypertension, gastric and esophageal varacies, vitamin mal-absorption, poor blood clotting and altered mental status (Copstead, 2010). The liver has such far reaching effect on so many organs and systems in the body that any damage to the liver will result in decreased functioning of other systems. Immediate tests to determine the cause and extend of the damage would be imperative to managing the disease going forward. 3. How should the disease be managed and monitored? Explain your rationale.If pharmacotherapeutics are used, explain your rationale and their mechanism of action. First steps would be to order additional labs including, IgM-anti-HBc, IgG- anti-HBc, HBeAg, HBV DNA, CBC with PT and electrolytes. In cases of acute hepatitis B, symptoms sometimes go unnoticed. The virus will normally go away on its own and if treatment is given, it is for the symptoms and most adults recover fully (Hepatitis B, 2011). But in the case of chronic HBV, the patient will need to be monitored to see if the virus is replicating (Lok A. S. , 2011). In patients with chronic HBV, the treatment oals are to reduce the long term effects of liver damage, prevent the transmission of the virus to others and manage any complications along the way (Lok A. S. , 2011). A clear diagnosis of chronic hepatitis B is needed. Results of blood work will determine the course of treatment. In Mr. Wilson’s case, with only the first lab results, it appears that he is in the active chronic infection stage. At this point the liver damage is still minimal. Because there does not seem to be significant liver damage a liver biopsy would not be indicated at this poin t (Lok A. S. , 2011).As the practitioner, I would recommend more blood tests, as noted above, and ongoing monitoring of the virus every few months. This will help in determining the activity of the virus. The medications used to treat chronic hepatitis B tend to have serious side effects. The patient must be willing to make a commitment to continue the therapy and adhere to close monitoring during any drug treatments (Hepatitis B, 2011). Supportive medicines are important to assist in treating side effects of the virus. For example, diuretics are prescribed if edema is not resolving on its own.Vitamins and minerals are indicated if labs show deficiency due to decreased liver function. If it is determined that Mr. Wilson’s virus is active (meaning he is able to infect others) there are new drugs available to choose from. Antiviral treatments include (Hepatitis, 2011): 1. Entecavir – a. A pill taken once a day for up to a year b. Used when DNA viral cells are actively re plicating 2. Interferon Alpha c. Injection a few times per week for up to a year d. Used when patient has compensated liver disease 3. Pegylated Interferon e. Injection once per week for up to a year f.Used when patient had compensated liver disease and evidence of viral replication and liver inflammation 4. Lamivudine g. A pill taken once a day for a year or more h. Used when patient has active liver inflammation and active viral replicating 5. Adefovir Dipivoxil i. A pill taken once a day for a year or more j. Used in patients with chronic HBV 6. Telbivudine k. A pill taken once a day for a year or more l. Used in patients with active viral replication, persistent elevations in ALT or AST or histologically active disease 7. Tenofovir m. A pill taken once a day for a year or more n. Used in patients with chronic HBVThe medicines listed above are used alone or more likely in conjunction with others. These are currently the only hepatitis B drugs that are approved by the FDA (Lok & M cMahon, 2009). According to the American Association for the Study of Liver Diseases (AASLD) Practice Guidelines, the ultimate goal of therapy is to suppress the replication of the virus and put the liver disease into remission (Lok & McMahon, 2009). This is monitored by watching the patients ALT, AST and other liver, viral and blood tests. The viral tests are imperative to determine the proper adjustments in medications.For example, interferon has been shown to reduce the viral replication and inducing liver disease remission (Lok & McMahon, 2009). Also, a newer drug, tenovir has shown significant promise in reducing viral levels in patients as compared to adefovir (Lok & McMahon, 2009). Practitioners need to watch for resistance as well when using the anti-viral drugs. As noted, the drugs are used in combination as well and these have shown to be more effective than when they are used alone. The effects of combined usage are better antiviral effects and delayed resistance (Lok & M cMahon, 2009).Mr. Wilson’s ALT, HBeAg lab values and his HBV DNA will be a main determinate to the type of therapy he will receive. A liver biopsy will be indicated later on if his  HBsAg is positive for more than six months, his serum HBV DNA is greater than >20,000 IU/mL and he has persistent or intermittent elevations in his ALT/AST levels (Kukka, 2010). Summary Hepatitis B can be chronic or acute. When a person has acute hepatitis B they generally don’t even notice and never need treatment. If treatment is needed it is supportive treatment for the symptoms of the acute virus infection.Chronic hepatitis B patients are at risk for cirrhosis and HCC (hepatic cellular carcinoma) (Kukka, 2010). Patients that have chronic HBV need to be educated on the risk of infecting others and will, in some cases, need to alter their lifestyle to protect others from getting the virus. Treatment is dependent on the blood work up that is obtained. It is very important that a patient that goes on antiviral treatment remain on it to reduce drug resistant strains. Also, patients must be evaluated and treated for the side effects of the anti-virals as well as the symptoms of other affected organs and systems in the body.References Copstead, L. -E. C. (2010). Pathophysiology. St. Louis: Saunders. Hepatitis. (2011, July 6). Retrieved March 26, 2012, from Lab Tests Online: http://labtestsonline. org Hepatitis B. (2011, July 6). Retrieved March 25, 2012, from Lab Tests Online: http://labtestsonline. org Hepatitis B. (2011, September 1). Retrieved March 24, 2012, from Mayo Clinic: http://www. mayoclinic. com/health Kukka, C. M. (2010). Hepatitis B Fact Sheet. HCSP Publications. Lexicomp. (2012). Retrieved February 5, 2012, from Lexicomp: https://online-lexi. com Liver Blood Tests. (2012, March 28).Retrieved March 30, 2012, from e Medicine Health: http://www. emedicinehealth. com/ Lok, A. S. (2011, February 16). Overview of the management of hepatitis B. Retrieved March 24, 2012, from UpToDate: http://www. uptodate. com Lok, A. S. , & McMahon, B. J. (2009). Chronic Hepatitis B: Update 2009. Alexandria: American Association for the Study of Liver Diseases. Mani, H. , & Kleiner, D. E. (2009, May 1). Liver Biopsy Findings in Chronic Hepatitis B. Retrieved April 1, 2012, from University of Pennsylvania, Department of Medicine: http://webdev. med. upenn. edu

Strategies of General Motors and Toyota Motor Corporation Case Study

Strategies of General Motors and Toyota Motor Corporation - Case Study Example Strategies are usually tailored to take advantage of the various opportunities in the firm's environment while harnessing its strengths and competencies. Currently, General Motors Corporation (GM) leads the automotive industry with total revenue of US$192.60 billion during 2005. This is amidst the US$2.6 billion loses incurred during the same year which is due to the weak demand in North America. Following GM is Ford Motor Corporation (US$178.10 billion), Daimler Chrysler AG (US$177.37billion), and Toyota Motor Corporation (US$162.92 billion). Even though smaller in terms of revenue, it is notable that Toyota recorded the largest net income at US$10.61 billion during 2005 (Yahoo Finance 2006). It is apparent that there is an intense competition between the four largest players in the industry. Toyota was able to dislodge the Ford during 2003 and is widely regarded to as having the aspirations to become the future industry leader next to GM. From here, we can see a struggle between the companies as they are both challenged to devise winning strategies. For GM, the challenge is to craft and implement an effective strategy to maintain its position in the global market, while for Toyota a strategy to battle head-on with GM and increasing its market share. The company has a wide array of product line under the brands Chevrolet, Pontiac, GMC, Oldsmobile, Buick, Cadillac, Saturn, and HUMMER. The company's marketing arm is supported by retail dealers and distributors in the United States, Canada, and Mexico as well as dealers overseas. GM is recognized as the largest vehicle manufacturer selling 8.5 billion cars in 2001 while its sales in 2002 account for 15% of the trucks and vehicles sold globally (Yahoo Finance 2006). Traditionally, GM's approach to marketing its products is targeting a specific market segment for a specific brand so that the company's products do not compete with each other. These were profitable for the automotive firm as the brand's shared components and common corporate management gave way to substantial economies of scale while the distinctions between the brands created an "orderly upgrade path." Before 1995, the company has a full range of products ranging from Chevrolet which is offered to an entry-level buyer who is more concerned on a more practical and economical vehicle to the upscale Cadillac which is targeted to the elite market as it is regarded as the "standard of luxury (General Motors 2006)." Nevertheless, this strategy did not persist as the GM started to implement a gradual blurring of its divisions during 1995. This strategy leads to cannibalization in the market share of GM as each division competes with each other (General Motors 2006). During 2004, the company has announced a new strategy for its product lines which is apart from the traditional marketing and positioning it employs. This shift in brand strategy is targeted at â€Å"building sales, cutting costs, and bolstering brand identity (Garsten 2005).†Ã‚  Ã‚  

Los Angeles in the 30's & 40's versus today Essay

Los Angeles in the 30's & 40's versus today - Essay Example Although LAX is currently a world renowned airport, it wasn’t always the center of attention. Prior to its inception, the primary airports for Los Angeles were Burbank and Grand Central Airport in Glendale. It wasn’t until 1946 that they started serving LAX, because it was just too far out of the way. At that time, it was located east of Sepulveda Boulevard, which ended up being rerouted to the west to loop around the new runways that were created in 1950. Nowadays, LAX is considered one of the busiest airports in the world, with nearly 60 million passengers using the airport each year. They also have a dual function as a civil-military base, providing the U. S. Coast Guard an area to launch, operate and repair their HH-65 Dolphin helicopters. (Delta Mike Airfield, 2008). Although the birth of LAX is a notable part of history in L.A., it was only the beginning of many not-so-good firsts for the city. In 1934, Upton Sinclair decided to run for the governor’s seat of California. He was a famous writer and activist, but he was also a socialist who happened to be California’s first celebrity politician. It gave birth to smear politics on a grand scale. Sinclair easily gained the Democratic primary for governor, after which the L. A. Times criticized his â€Å"maggot-like horde† of supporters (Huffington Post, 2008), while others warned that if elected, the state would become communist. This realization ignited an all-out political revolution. With help from Hollywood and the papers, Sinclair’s opposition practically invented the modern media campaign. They made unparalleled use of mail, radio, film, fund raising and opinion polls to create the most astounding smear campaign ever seen. The best was the new ability to manipulate film, using fake newsreels with Hollywood actors to destroy Sinclair’s candidacy. The L.A. Times had attacked Sinclair unmercifully for weeks, which ultimately destroyed his chances. President Roosevelt couldn’t do anything to help him as he was barely into his New Deal and was struggling himself. He couldn’t endorse him, because he would be seen as endorsing socialism, but on the same token, if he didn’t endorse him, others would call him cowardly for not endorsing a candidate of his party. With FDR’s refusal to endorse him, and the fake newsreels hit the big screen, current Governor Merriam won his re-election. This was the precursor to a variety of things that we now have in use across the country. Sinclair is credited with helping with inspiration to many of FDR’s New Deal programs, including Social Security and certainly was the first victim of smear campaigning and dirty politics. Today, when we have any election forthcoming, all of the newspapers, radio stations and television stations carry smear ads, one party against the other to convince us that the skeletons in the other parties’ closets outweigh their own. It’s odd to think that this all started with a well-known author who wanted to run for Governor of California. His muckraking books got the best of him, as while he was for FDR’s New Deal, he also led a movement called EPIC (End Poverty in California), the platform on which he was running for Governor. This also helped to move the Democratic Party further to the left where they continue to be today. Most Californians have at

To what extent would the smoking ban affect the pub industry in Wales Essay

To what extent would the smoking ban affect the pub industry in Wales - Essay Example In 1974, 51% of men and 41% of women smoked cigarettes - nearly half the adult population of the UK. Now just over one-quarter smoke, but the decline in recent years has been heavily concentrated in older age groups: i.e., almost as many young people are taking up smoking but more established smokers are quitting. Adult smoking rates vary only slightly between different parts of the country, as defined by the Government Office Regions. For example, in the East of England 25% of people smoke, in the North West, 30%. In Scotland 31% of the population smokes; in Wales the prevalence is 27%. (Smoking statistics 2005) About 48 million people in the United States smoke an estimated total of 430 billion cigarettes each year. Until the 1940s, smoking was considered harmless, but laboratory and clinical research has since confirmed that tobacco smoke presents a hazard to health. Smoke from the average cigarette contains around 4,000 chemicals, some of which are highly toxic and at least 43 of which cause cancer. Nicotine, a major constituent of tobacco smoke, is both poisonous and highly addictive. Nicotine is an oily liquid substance found in tobacco leaves that acts as a stimulant and also contributes to smoking addiction. When extracted from the leaves, nicotine is colorless, but quickly turns brown when exposed to air. It has an acrid, burning taste. Nicotine is a very powerful poison, and it forms the base of many insecticides. Cigarette tobacco contains only a small amount of nicotine and most of this nicotine is destroyed by the heat of burning so that the actual concentration of nicotine in smoke is low. However, even a small amount of nicotine is sufficient to be addictive. The amount of nicotine absorbed by the body from inhaling smoke depends on many factors including the type of tobacco, whether the smoke is inhaled, and whether a filter is used. Nicotine has various effects on the body. In small doses nicotine serves as a nerve stimulant, entering the bloodstream and promoting the flow of adrenaline, a stimulating hormone. It speeds up the heartbeat and may cause it to become irregular. It also raises the blood pressure and reduces the appetite, and it may cause nausea and vomiting. The known health risks associated with cigarette smoking, such as damage to the lungs and lung cancer, are thought to be caused by other components of cigarettes such as tars and other by-products of smoking, and by the irritating effects of smoke on the lung tissue. Addiction to smoking is caused by nicotine itself. Stopping smoking produces withdrawal symptoms within 24 to 48 hours, which commonly include irritability, headaches, and anxiety, in addition to the strong desire to smoke. Ban on smoking in pubs Smoking bans are government prohibitions or voluntary bans decided by establishment management on tobacco smoking in public or quasi-public indoor areas such as offices, restaurants, hotels, or even outdoor public areas such as parks and sports stadiums. In most jurisdictions the sale of tobacco to minors, or minors under a certain age, is prohibited. Such laws have been introduced by many countries in various forms over the years, with legislators citing health statistics that show tobacco smoking is often

Information Technology Term Paper Example | Topics and Well Written Essays - 5000 words

Information Technology - Term Paper Example of the future that will guide how various pieces of new technology are either successfully integrated within the scope of any given project, or are discarded as being unnecessarily and waste of resources. As you know, Magnum Enterprises has enlisted my to head the information technology management team. As such, I wish to outline my understanding of what this important role entails, and how such an effective management of new software and hardware to implemented company wide can help to facilitate a more streamlined and profitable business model in the end. Not all software and hardware is created equal. Software developers and hardware engineers, for example, do not necessarily concern themselves with the practical applications of their various inventions. Instead, they are tunnel visioned on creating the best product they can, regardless of the end user or industry that will eventually make use of them. These individuals are sorely needed in the information technology realm of the modern age, yet recent history has shown us that they are not necessarily equipped to adequately manage the effective implementation of such products with the scheme and scope that defines Magnum Enterpri ses. In fact, some software packages and hardware tools may the best available, yet be determined to be inefficient within the working organisation that we ourselves have created. As such, it will be my role to work with my team to determine the very best products on the market that will truly push us forward with maximum efficiency and productivity. In my estimation, that is the role of the information technology manager. The first task our team should accomplish is to analyze the needs and priorities that we have in each division at Magnum. We need to ensure that we understand these critical areas in order to effectively manage the software and hardware that we incorporate into these areas to meet the objectives of each respective team (Benamai, 2007). In essence, the

Why does communsim work in some developing countries and democracy in Essay

Why does communsim work in some developing countries and democracy in others - Essay Example It intrudes further into the lives of people than socialism does. For example, some communist countries do not allow their citizens to practice certain religions, change jobs, or move to the town of their choice (Margonis, 1993). According to Nowotny (1997), communism has been perennially perceived to have been but a -- certainly disastrous -- evolutionary accident on the road of progress. Once this error would have been corrected and once the communist system was removed, the countries concerned would, without any great difficulties, resume their rightful place on the ladder of economic and political progress. This would occur spontaneously. Errors could stunt or thwart the development. But, on the other hand, no special measures would be necessary to promote it. Markets and with them wealth; civic society and political institutions and with them democracy would install themselves without further ado. Some even claimed that this step back unto the ladder of political and economic evolution would be easier (Nowotny, 1997). Although communism is always seen as ‘the big bad wolf’, there are still studies that suggest that it is much better that developing communist countries to embrace communism f irst before venturing into capitalism. Numerous researches argue towards the success of shifting governments from communism to democracy. McFaul (2005) cited the Serbian, Georgian, and Ukrainian cases of democratic breakthrough resemble one another-and differ from other democratic transitions or revolutions-in four critical respects. First, in all three cases, the spark for regime change was a fraudulent national election, not a war, an economic crisis, a split between ruling elites, an external shock or international factor, or the death of a dictator. Second, the democratic challengers deployed extra-constitutional means solely to defend the existing, democratic constitution rather than to achieve a fundamental rewriting of the rules of the political

Strategic Assessment of Wal-Mart for an ITM class Essay

Strategic Assessment of Wal-Mart for an ITM class - Essay Example Many others are of the view that the current problems were because of Wal-Mart’s failure to incorporate state-of-the-art IS/IT technologies in its operations. Being a business technology consultant hired by Wal-Mart, I do believe that Wal-Mart is in trouble mainly because of its failure to incorporate suitable IS/IT technologies in its activities. Offline businesses are currently giving way for online businesses or e-commerce. It is important for Wal-Mart to give more attention to online businesses. â€Å"Wal-Mart has assembled a team of 70 developers, computer engineers and researchers — dubbed @WalmartLabs — in an aggressive attempt to position itself at the forefront of social and mobile commerce† (Wal-Mart: The Next Tech Giant?). However, its e-commerce platform still needs more fine tuning to attract more visitors. Just like Amazon and Google, it is better for Wal-Mart to enter into the search engine business so that it can expand its business portfolios as well as enhance its retail business. Shopperception is a new IT related technology evolved out in recent times to check the consumer behaviours and buying habits. â€Å"Shopperception recognizes the customers when they check-in and it remembers previous buying habits and can predict what the customer is likely to want on this visit† (Israel). Wal-Mart should use this technology extensively in its retail outlets to help the consumers. â€Å"The Wal-Mart network, connecting more than 2,400 stores and 100 distribution centers worldwide. At Wal-Mart, we dont implement technology for its own sake," says David Flanagin, Director of Network Engineering† (The Wal-Mart Story, p.1). From the words of David, it is evident that Wal-Mart is not much keen in using technologies to improve the efficiency of its global activities. It should be noted that efficient working of a supply chain is necessary for Wal-Mart to

Financial Decision Making Assignment Example | Topics and Well Written Essays - 500 words

Financial Decision Making - Assignment Example 3. The fundamental role of the financial market is to enable companies to raise money. a) The money markets deal with bonds, while the capital markets deal with stocks. b) The primary market occurs when a company issues a stock for the first time in an initial public offering (IPO). The selling and buying of stocks on Wall Street by investors represents the secondary market c) A spot market is a market in which commodities and securities are sold for cash and are delivered immediately, while a future market deals with contracts that give the buyer the right to a buy a predetermined amount of stocks or bonds at a future point in time (Altiusdirectory, 2011). 4. Capital budgeting deals with the financing of company projects. For example if a company wants to open a second manufacturing facility the financing for such a venture would be consider a capital budgeting project. 5. One of the goals of a company’s governance system is to maximize shareholder wealth. The particular fina ncial incentives offered by a firm are not consider a part of its governance system. Usually all financial incentives are known by the employees, but at times companies pay the employees special bonuses which are not a part of the traditional incentive system. This occurs when a company has a very good accounting period. 6.