Management Of Acute Coronary Syndrome

Management Of Acute Coronary Syndrome Acute coronary syndrome encompasses a collection of three acute processes related to myocardial ischemia. These include: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). Myocardial ischemia is caused by inadequate perfusion within the myocardial tissue due to oxygen demand exceeding oxygen supply. In a healthy person the amount of oxygen required by the myocardium (O2 demand) is determined by heart rate, myocardial contractility, myocardial wall stress, and afterload. As explained by Antman, et al (2012), oxygen supply to the myocardium requires a satisfactory level of oxygen-carrying capacity of the blood (determined by the inspired level of oxygen, pulmonary function, and hemoglobin concentration and function) and an adequate level of coronary blood flow. The coronary vessels have the ability to adjust their level of resistance to adapt to the increased oxygen demand required by the myocardium during certain times (such as during physical exertion). Ischemic heart disease is typically caused by atherosclerosis, which is a buildup of plaque inside the lumen of the coronary vessels. The emergence of atherosclerosis in the vessels does not occur overnight. Antman, et al. (2012) found that atherogenesis in humans typically occurs over a period of many years, usually many decades and that growth of atherosclerotic plaques probably does not occur in a smooth, linear fashion but discontinuously, with periods of relative quiescence punctuated by periods of rapid evolution. The process of atherosclerosis begins with an abundance of lipoproteins in the blood stream. These lipoproteins bind to the walls of vessels and are eventually deposited within the intima of the arteries. To counteract this process, phagocytes are sent into the vessel to attack these foreign particles (Antman et al., 2012). Once the phagocytes are within the intima, they mature into macrophages and become lipid-laden foam cells (Antman et al., 2012). As these plaques advance calcification occurs. This process is thought to be a key step in the formation of atherosclerotic plaques (Antman et al., 2012). Normally this narrowing of the vessel lumen does not cause chest pain or discomfort. Eventually, however, these plaques may rupture. At this point platelet activation occurs, which eventually leads to clot formation at the sight of the plaque. This clot, or thrombus, may break off and lodge in a coronary vessel. These two processes are a common pathogenic finding with acute coronary syndrome (Lincoff, Califf, Anderson, Weisman, Aguirre, Kleiman, Harrington Topol, 1997). A partial occlusion of the coronary vessels due to a ruptured plaque/platelet complex causes unstable angina or a NSTEMI. In this case, the oxygen demands of the heart cannot be met. A complete occlusion causes a STEMI (Anderson, Adams, Antman, Bridges, Califf, Casey Jr, Chavey II Wright, 2011), which eventually leads to myocardial cell death. Discussion/Analysis The emergency department providers are often the first line of defense in the management of patients with chest pain. The ability to quickly evaluate whether or not the cause of chest pain is potentially fatal is of great importance. Critical chest pain can be broken down in to non-cardiac and cardiac causes. Non-cardiac causes include: pneumothorax, pulmonary embolism, and Boerhaaves syndrome. Acute coronary syndrome is among several cardiac causes of emergent chest pain. An accurate diagnosis of the cause of chest pain requires several key components. These include: patient history (including risk factors), physical examination, diagnostics, and labs. History History is instrumental during the evaluation of a patient with chest pain. Ischemic chest pain is often described as a severe pressure or squeezing and is classically described as the feeling of an elephant sitting on my chest. Typically this pain is described as substernal chest pain which radiates to the neck, jaw, or down the left arm. Additional details regarding the onset of chest pain can also serve as important clues. For example, pain on exertion that resolves with rest suggests stable angina, whereas new onset chest pain or chest pain at rest suggests unstable angina. A good method to differentiate cardiac from non-cardiac chest pain is whether the pain improves after administration of nitroglycerin (NTG). If the pain is relieved by NTG it is considered to be likely due to cardiac causes. Additional details suggesting cardiac origin are shortness of breath, nausea +/- vomiting, diaphoresis, and the presence of syncopal/near-syncopal episodes. It is important to note that a patient with chest pain often have a silent or atypical presentation. This is especially true in elderly men (Woon Lim, 2003) and diabetics (Tabibiazar Edelman, 2003). A patient with an atypical presentation may present with shortness of breath but lack the classical symptom of angina pectoris which radiates to the jaw or left arm. Commonly these patients complain of a feeling of indigestion or epigastric discomfort. Thus it is very important to consider ACS in these patients. The presence of risk factors plays an important role in the evaluation of chest pain, especially in a patient with known disease. The landmark Framingham Heart Study showed that cardiac risk can be influenced by diet, lifestyle, and familial risk factors (Oppenheimer, 2005). The more risk factors that a person carries, the greater their risk of developing ischemic heart disease. These risk factors are generally grouped into two categories: those that are modifiable and those that are not. Risk factors amendable are as follows: Tobacco smoke (American Heart Association, 2012) High blood cholesterol (AHA, 2012) High blood pressure (AHA, 2012) Physical inactivity (AHA, 2012) Obesity and overweight (AHA, 2012) Diabetes mellitus (AHA, 2012) Risk factors that cannot be changed include: Age- 82% of people who die of coronary heart disease are >65 (AHA, 2012) Male sex (AHA, 2012) Heredity- this includes both family history and race (AHA, 2012) Risk is higher among Mexican Americans, American Indians, native Hawaiians and some Asian Americans (AHA, 2012) Patients presenting with unstable angina or NSTEMI have variable levels of risk of cardiac death and ischemic cardiac events (Antman, Cohen, Bernink, McCabe, Horacek, Papuchis, Mautner Braunwald, 2000). The trial conducted by Antman et al. (2000) set out to develop a simple risk score that has broad applicability, is easily calculated at patient presentation, does not require a computer, and identifies patients with different responses to treatments for UA/NSTEMI. In doing so, the TIMI risk score was created. The scores are calculated using a score of 1 for each risk factor (7 total categories) assigned to a given patient. According to Antman, et al (2000) the score determines the patients risk of death, myocardial infarction, or severe ischemia. Antman, et al. (2000) found 7 prognostic variables that increase a patients risk. These are: Age 65 years or older At least 3 risk factors for coronary artery disease (male, dyslipidemia, smoking, hypertension, diabetes mellitus, obesity family history) Prior coronary stenosis of 50% or more ST-segment deviation on ECG at presentation At least 2 anginal events in prior 24 hours Use of aspirin in prior 7 days Elevated serum cardiac markers In TIMI 11B/ESSENCE, event rates increase significantly as the TIMI-score increases (Antman et al., 2000). A score of 0/1 showed a 4.7% event rate; 8.3% for 2; 13.2% for 3; 19.9% for 4; 26.2% for 5; and 40.9% for 6/7. This landmark pair of trials allows practitioners a quick assessment of a patients risk of suffering a serious cardiac event. Physical Exam Physical exam is also a key component in the evaluation of a patient with chest pain, as many clues can suggest acute coronary syndrome. Unstable vital signs can be an important hint that the patient has suffered an MI. A general examination may reveal a patient who is diaphoretic and/or using accessory respiratory muscles. The cardiovascular exam could reveal a new murmur, S3/S4 gallop, or JVD. Finally, during the pulmonary exam rales may be heard upon auscultation. Diagnostics Diagnostic testing is an essential part of the evaluation of a patient presenting with chest pain. Several important diagnostic tools were introduced to the emergency department in the latter half of the 20th century that greatly improved the diagnosis and care of acute coronary syndrome. Electrocardiogram The introduction of coronary care units in the 1960s allows physicians to utilize the electrocardiogram (ECG) to monitor potential fatal arrhythmias in patients with acute myocardial infarction (Julian, 1987). Shortly thereafter the portable electrocardiogram became commonplace within the emergency department to assist in diagnosing complications of acute coronary syndrome (Drew, et al, 2004). A patient presenting with myocardial ischemia will typically have symmetrically-inverted T waves in leads V2-V6 (Dubin, 2000). As the name suggests, a STEMI is an ST-segment elevation myocardial infarction, though ST-segment elevation can occur with Prinzmetals angina in absence of an infarction (Dubin, 2000). Additionally, the ECG allows us to evaluate necrosis of the heart in the form of the presence of Q-waves. Q-waves are the first downward deflection of the QRS complex (Dubin, 2000). As Dubin (2000) explains, a positive Q-wave MI must: Lack a preceding spike in the QRS complex Be at least 1 mm wide or Have an amplitude of 1/3 the QRS complex An additional benefit of the ECG is that it allows the practitioner to identify the location of an acute event. Each lead corresponds to a particular location of the heart. For example, leads II, III, and AvF are the inferior leads and reflect the inferior portion of the heart. Due to the relatively high specificity but low sensitivity of the 12 lead ECG in diagnosis of acute coronary syndrome, a group of researchers in Canada recently set out to enhance ischemia detection by conducted a trial which added a new criteria using a three vessel specific leads derived from the traditional 12 lead ECG (Horacek, Mirmoghisi, Warren, Wagner Wang, 2008). This trial showed a statistically significant improvement in the ability of the vessel specific lead protocol to detect ischemia (Horacek et al., 2008). Horacek et al. (2008) found the following sensitivity and specificity for conventional STEMI criteria versus that of the vessel specific leads (VSL): Vessel Sensitivity Specificity Left Anterior Descending 74% conventional, 91% VSL 97% conventional, 97% VSL Right Coronary Artery 60% conventional, 70% VSL 94% conventional, 94% VSL Left Circumflex Artery 36% conventional, 71% VSL 100% conventional, 100% VSL Totals Set 60% conventional, 76% VSL 96% conventional, 96% VSL Based on these results, Horacek et al. (2008) concluded that using vessel specific leads can identify acute ischemia better than existing STEMI criteria. While a STEMI criteria using vessel specific leads has yet to become a mainstay within the standard emergency room protocol, this study provides exciting new improvements in the detection and management of patients with ACS. Serum Biomarkers The use of biochemical markers to detect cardiac cell death significantly evolved in the 1980s and 1990s. Initially, nonspecific markers such as aspartate transaminase and total creatinine kinase were used to detect myocardial necrosis (Lewandrowski, Chen Januzzi, 2002). During the mid-1990s the more cardiac specific enzymes CK-MB became the gold standard for detection of myocardial injury (Lewandrowski et al., 2002). CK-MB, which commonly rises 4-9 hours after the onset of angina, was not without its shortcomings. CK-MB may be falsely elevated due to several different causes, including recent strenuous exercise or skeletal muscle damage, or renal failure (Vivekanandan Swaminathan, 2010). In the late 1990s a more predictable biomarker, troponin I, was introduced for more accurate detection of acute coronary syndrome (Heeschen, Goldmann, Moeller Hamm, 1998). According to Heeschen et al. (1998), Troponin I can be evaluated at the bedside in the emergency room and has a higher diagno stic sensitivity for the detection of acute myocardial infarction (60% vs 48%) when compared to CK-MB. The reason for this improvement in accuracy is that troponin I is not found in skeletal muscle tissue or renal failure (Heeschen et al., 1998). As Heeschen et al. (1998) demonstrated in a head to head study that cTnI test systems produced no positive results in patients with end-stage renal failure and acute or chronic skeletal muscle injury, whereas 30% and 71% of the patients, respectively, had increased CK-MB mass concentrations. One disadvantage of troponin I, however, is that it has a lower sensitivity for the detection of acute myocardial infarction compared to that of CK-MB (Heeschen et al., 1998). This is due to an increased level of cTnI in patients with unstable angina (Heeschen et al., 1998). For this reason, a typical workup for a patient with chest pain in the emergency room includes both cTnI and CK-MB assays, which are drawn at presentation and every 3-6 hours therea fter (Ross, Bever, Uddin Hockman, 2000). Imaging A common component of a chest pain protocol is a chest x-ray. This is normally either a standard AP/lateral series or a portable chest x-ray if the patient is unable to get out of bed. The chest x-ray is useful to eliminate other possible causes of chest pain, such as an aortic aneurism or a pneumothorax. Contrast-enhanced computed tomographic angiography, or CTA, has become an integral part of the management of acute coronary syndrome due to its high sensitivity and specificity (Hoffman, Truong, Schoenfeld, Chou, Woodard, Nagurney, Pope Udelson, 2012). According to the ROMICAT-I study performed by Hoffman et al., (2012), CTA is an effective way to rule out myocardial infarction or ischemia as well as major cardiovascular events over the next 2 years from presentation. The data presented in ROMICAT-I showed that patients undergoing CTA decreased their hospital stay by 7.6 hours compared to standard therapy (Hoffman et al., 2012). Additionally, 50% of CTA patients were discharged from the hospital within 8.6 hours of presentation versus only 10% of patients undergoing standard therapy (Hoffman et al., 2012). Finally, the mean time to diagnosis was significantly decreased with the CT group versus the standard group (Hoffman et al., 2012). Overall, CTA was shown to reduce time spent in the hospital and time to diagnosis when compared to standard therapy for acute coronary syndrome. This is important to note considering the importance of quick coronary reperfusion of STEMI patients (Trost Lange, 2011). An additional observation was that these benefits were achieved without an increase in the cost of care (Hoffman et al., 2012). There was no overall difference between the groups in incidence of myocardial infarction 30 days after initial presentation (Hoffman et al., 2012). It is important to note that a patient undergoing a CTA is exposed to increased radiation. Additionally, patients undergoing CTA were more likely to undergo invasive coronary procedures when compared to standard evaluation. Based on this data, a question arises as to whether every patient presenting with possible acute coronary syndrome should undergo a CTA. The population studied in ROMICAT-I consisted of low to intermediate risk patients. Overall, CTA was shown to decrease the time to diagnosis and hospital stay for patients with possible ACS. In contrast, CTA increases a patients exposure to radiation and increases the likelihood that these patients will undergo an increase in invasive coronary procedures. These factors should all be considered when evaluating a patient presenting with chest pain. Treatment Pharmacologic Aspirin: Early aggressive aspirin (ASA) therapy (162-325mg followed by 81-162mg daily) is currently recommended for all patients with acute coronary syndrome, unless contraindicated (Kirk, Kontos Diercks, 2011). Plavix (Clopidogrel): According to the CURE trial Clopidogrel has been shown to provide a 20% reduction in cardiovascular death, MI, or stroke for NSTEMI patients with positive biomarkers or ischemic ECG changes (Kirk et al., 2011). It is important to note that the significant anti-platelet benefits of Clopidogrel administration should also be weighed against the increased risk of bleeding events if the patient may be a candidate for coronary artery bypass surgery. Antianginal Agents: Nitroglycerin (NTG): NTG is commonly administered by EMS respondents but can also be ordered once the patient arrives in the emergency department, typically sublingually or in the form of Nitropaste. Nitroglycerin dilates the coronary arteries, which reduces myocardial oxygen demand (Trost Lange, 2011). For this reason, it is important to evaluate the patients baseline blood pressure. If SBP is less than 100, caution should be used. Morphine: Intravenous morphine may be given in the event that chest pain is not relieved by NTG administration. Morphine reduces ventricular preload, thereby decreasing myocardial O2 demand (Trost Lange, 2011). Beta-Andrenergic Blockers: Beta-blockers decrease demand on the heart by decreasing heart rate, blood pressure, and myocardial contractility (Trost Lange, 2011). In a patient presenting with ACS, IV Lopressor is typically the agent of choice. These are especially effective agents in patients with elevated blood pressure or tachycardia. It is important to evaluate relevant contraindications to beta-blocker therapy, such as: HR Calcium-Channel Blockers: Diltiazem and Verapamil improve cardiac O2 supply by vasodilation of the coronary vessels, reduce O2 demand by reducing afterload, and reduce heart rate and contractility (Trost Lange, 2011). Calcium-channel blockers are 2nd line treatments for ACS and are typically reserved for patients who are unable to take a beta-blocker (Trost Lange, 2011). Contraindications include: sick sinus syndrome, 2Â ° or 3Â ° AV heart block, hypotension, acute MI with pulmonary congestion, atrial fibrillation or flutter with accessory bypass tract, and ventricular tachycardia, severe left ventricular dysfunction, and cardiogenic shock (Epocrates, 2012). Antithrombotic therapy: Antithrombotic therapy is recommended in a patient with suspected ACS, unless contraindicated (Trost Lange, 2011). Unfractionated heparin is easy to administer (IV) and is rapidly reversible with protamine in the event of bleeding. (Trost Lange, 2011). As with any antithrombotic, there is a risk of bleeding so these patients require close monitoring. Low molecular weight heparin is more predictable, has a lower incidence of thrombocytopenia, and does not require monitoring (Trost Lange, 2011). LMWH is the preferred agent for a more conservative, ischemia-guided strategy to prevent in hospital death or myocardial infarction (Trost Lange, 2011). Bivalirudin is an antithrombotic agent that does not cause thrombocytopenia (Trost Lange, 2011). It has been shown to be equally as effective as unfractionated heparin or LMWH but with a significantly lower rate of bleeding (Trost Lange, 2011). Oxygen administration should be administered for patients who are short of breath, showing signs of shock, or O2 saturation Next Step for NSTEMI or Unstable Angina Patients If a patient is considered to be high risk, such as a patient is at risk of future ischemia or infarction, an early invasive strategy is recommended (Trost Lange, 2011). For these patients, cardiac catheterization should be performed within 24-48 hours of admission (Trost Lange, 2011). In a low risk patient, a more conservative treatment is typically recommended. For these patients, catheterization is only recommended if recurrent or provocable ischemia occurs (Trost Lange, 2011). TIMI scores are a valuable tool to assess the patients risk and to guide the practitioner on the appropriate next step. Next Step for STEMI Patients Prompt coronary reperfusion is paramount in patients presenting with STEMI (Trost Lange, 2011). A door-to-balloon time of less than 90 minutes is considered to be the goal (Trost Lange, 2011). If the patient presents to a facility without a percutaneous coronary intervention facility the patient should be either: Treated with fibrinolytic therapy if not contraindicated (Trost Lange, 2011) Or Transferred to a nearby PCI facility (Trost Lange, 2011). Conclusion Acute coronary syndrome is spectrum of diseases typically caused by atherosclerotic disease. Emergency department practitioners must be able to rapidly diagnose and manage ACS patients in order to potentially preserve precious heart muscle. While treatments for ACS have improved dramatically over the past 30 years, several recent innovations have brought upon exciting new possibilities for the care of these patients. These include new vessel specific ECG leads, cardiac specific biomarkers, and the use of computed-tomographic angiography to assess patients with possible ACS. One component of the management algorithm that has not changed is the need for a strong history and physical examination to aid in diagnosis. Urgency in obtaining diagnosis cannot be stressed enough, and patients presenting with STEMI should be rapidly sent for PCI or transferred to a facility with PCI capabilities.

Discuss About Failure Essay

Q: ‘The word failure should never be used in education.’ Discuss. â€Å"Failure is not the end of the journey.† was an impactful phrase that Steve Jobs once said in his most eulogised moment of wit. I would dare to say that ‘failure’ is not a foreign word to anyone in the world and to the large majority, it is never viewed as a pleasant word to hear. In dictionaries, the word failure is often defined as the lack of skill or knowledge to succeed in accomplishing a task, yet ironically, the word failure is very often used in schools, where students attend to acquire skills and knowledge. Therefore, I strongly feel that the word ‘failure’ should not be used in today’s education system most of the time. Firstly, one reason why I feel that the word ‘failure’ should not be largely used in education is simply because of its demoralising effect. With the advancements in science and technology, education systems around the world have increased its difficulty by leaps and bounds. Hence, examination papers have changed and the syllabus only gets tougher. Students therefore are constantly bombarded with difficult and mind-boggling questions and tests, thus it is only natural that there are bound to be failures within a class. However, for the students that had studied very hard for the test, failing would only crush their confidence and pride. A research carried out by a group of students in Tokyo University had found out that 2 out of 7 students in Japanese High Schools are demoralised after failing their first few semestral assessments and their grades continue to suffer all year round as they had already lost the will to persevere and strive for excellence. This study supports my view that ‘failure’ demoralises people as it extinguishes the fiery will within students and their drive to excel. More often than not, being called a failure in schools may develop in students a form of self-fulfilling prophecy as their constant failures may have convinced them that they may indeed be useless and will never succeed in the future. Hence, I strongly feel that the word failure is too harsh a term to judge students based on their academic and holistic achievements alone as this will in fact demoralise them. Another reason why I feel that the word ‘failure’ should only be used to a bare minimum is because it creates more demanding parents. All parents have high hopes for their child, and I would dare to say that every parent wishes for their child to be able to successfully climb the rungs of the social ladder and stand at its peak. However to do that, excellent academic and holistic grades must be attained. A survey conducted by a group of students studying psychology in the National University of Singapore (NUS) in 2011 observed that 75% of Singaporean families display prejudice against failure and envisage their own child enrolling into the top medical courses of the local universities in Singapore. This study displays the stress that students in Singapore face as now not only do they have to excel in their studies to achieve a decent grade, but they are also expected to live up to their parent’s extremely high expectations. Such a scenario is ubiquitous in almost every Asian country and community, take the Asian families in Japan and the Asian communities in the United States for example, many Asian children fear showing their report cards to their parents if they had failed any subject as they fear the tongue-lashing that they receive upon showing their grades. Moreover, Asian families have been stereotyped to be very demanding as they demand that their child score straight ‘A’s for his or her examinations. This scenario is evident from the book ‘Battle Hymn of the Tiger Mother’ by Amy Chua which describes the typical strict Chinese upbringing where even an A- grade is not acceptable much less a ‘failure’ grade. To fail is to bring shame and dishonour to the family. Thus, I believe that the root of all these expectations branch from the very use of the word ‘failure’ as it somehow segregates the students based on their abilities into two groups – the successful and the failures, and parents would therefore want to push their child even harder to be able to enter the ranks of the successful and falling into the pits of failure is not favoured by most parents. Hence, I feel that the word ‘failure’ should not be used most of the time so that children would not need to fear failing and the ridiculously high expectations of parents can be somewhat mellowed. Lastly, as clichà © as it may sounds, the word ‘failure’ promotes a segregated community in schools. Very often, it is a common sight to see the students that excel in their studies form their own small cluster while the ostracised students that have consistently failed their examinations would form their own cliques. Such scenarios are especially evident in schools in the Western countries, such as the United States and the United Kingdom. Very often, students that fail their tests continuously would rather invest their time in beautifying their aesthetic appearances or in honing their skills in  their extra-curricular activities. While the students that score terrific grades, on the other hand, are labelled ‘muggers’ and ‘nerds’, hence this gave rise to the much stereotyped ‘popular’ and ‘unpopular’ kids in many American schools. This, thus, unconsciously created a segregated community in schools and as a result of this segregation bullying is rampant in schools as the more popular but academically weaker students would threaten the smarter ‘nerds’ to accomplish their work for them. This is supported by a documentary carried out by Discovery Channel, titled Bully, on the reasons behind bullying, which found out that one of the main reason why children resort to bullying is to achieve the much desired grades they wanted. Thus, ‘failure’ had unknowingly created a hierarchy within many schools and therefore, I strongly feel that the word ‘failure’ should not be used to a large extent. However, critics of my argument may argue that the word ‘failure’ may instil in students the need to improve and work harder, and motivates them to stretch themselves to their fullest potential. However, I believe that this is an extremely idealistic view as, not every student can remain optimistic upon receiving such dreadful grades. Moreover, such a argument also fails to take into consideration the students that had failed multiple times. Failing a couple of times may motivate one to try and work harder but the constant failure that some students experience would crush their determination and willingness to work hard. Hence I believe that if nothing is done to at the point of receiving the failure grade, and teachers allow things to go by its on course, the student may be badly sh aken and demoralised and as a result instead of improving his grades, he may actually worsen and score far worse grades. Thus, this brings me back to my point that ‘failure’ should not be used in our education systems most of our time as every student have differing levels of motivation and not everyone can take ‘failure’ so easily, and instead of improving themselves they end up despondent and unwilling to work hard. Critics of my argument may also claim that the competition that arises due the usage of ‘failure’ is beneficial to the students. However, this argument is flawed and the argument is too naive. This is because they fail to realise that is because of such intense competition that students may resort to cheating and other underhanded measures to attain a passable grade or their desired grades. In a study published in the Los Angeles Times, it was found that students cheat to  attain higher grades to meet with their parents expectations or to enter into a high paying job from the top Ivy League Universities. Moreover, with globalisation, the presence of scholars in schools contribute to the competition that local students face, and this has actually created such a stressful environment as the scholars contribute to the top scores of many major examinations and as a result the bell curve system that determine ones grade would shift to the right and students would require to score higher grades to attain their desired grades. This additional stress from the increase in competition if not managed properly would prove to be detrimental to ones mental fitness, and students that are unable to take such intense competition now, may just crumble under the immense stress that all students have to shoulder. Therefore, I strongly believe that the competition that ‘failure’ brings about brings more disadvantages than benefits and hence, I feel that ‘failure’ should not be used in our education most of the time. Therefore, in conclusion, does ‘failure’ necessarily bring more harm than good? While ‘failure’ does indeed have its good points, like bringing about differential learning, beneficial competition to those that require it, it brings about much more adverse effects to our community. The word ‘failure’ can badly demoralise students, create more ‘Tiger Mothers’ – a term used to describe more demanding parents, and a segregated community in many schools. Thus, I strongly feel that schools being the place that students attend to further improve themselves and acquire new knowledge, should not use the word ‘failure’ most of the time as it simply does not bring about much benefits. Therefore, I would like to reiterate that I strongly feel that the word ‘failure’ should not be used in today’s education system most of the time.

Problem Of Failure To Thrive Health And Social Care Essay

Although the term failure to boom ( FTT ) has been in usage in the medical idiom for rather some clip now, its precise definition has remained debatable1. accordingly, other footings such as â€Å" undernutrition † 1 and â€Å" growing lack † 2 have been proposed as preferred. FTT is a descriptive term applied to immature kids physical growing is less than that of his or her peers.3 The growing failure may get down either in the neonatal period or after a period of normal physical development.4 The term FTT is non, in itself, a disease but a symptom or mark common to a broad assortment of upsets which may hold small in common except for their negative consequence on growth.5 In this respect, a cause must ever be sought. Frequently, the rating of kids who fail to boom present a hard diagnostic job. Some of the troubles result from the legion differential diagnosings, the definition used or misdirected inclination to seek sharply for underlying organic diseases while pretermiting aetiologies based on environmental deprivation.6 In add-on, early accusals and disaffection of the kid ‘s parents by the health-care supplier will do the rating and direction of the kid who has failed to boom more difficult.7 In general, factors that influence a kid ‘s growing include: ( I ) A kid ‘s nutritionary position ; ( two ) A kid ‘s wellness ; ( three ) Family issues ; and ( four ) The parent-child interactions.3,8,9 All these factors must be considered in rating and direction of kid who has failed to boom. This paper presents a simplified but elaborate attack to the rating and direction of the kid with FTT.DefinitionThe best definition for FTT is the 1 that refers to it as unequal physical growing diagnosed by observation of growing over clip utilizing a standard growing chart, such as the National Center for Health Statistics ( NCHS ) growing chart.10 All governments agree that merely by comparing tallness and weight on a growing chart over clip can FTT be assessed accurately.11 So far, no consensus has been reached refering the specific anthropometric standards to specify FTT.11 Consequently, where consecutive anthropometric records is non available, FTT has been diversely def ined statistically. For case, some writers defined FTT as weight below the 3rd percentile for age on the growing chart or more than two standard divergences below the mean for kids of the same age and sex1-3 or a weight-for-age ( weight-for-hieght ) Z-score less than subtractions two.1 Others cite a downward alteration in growing that has crossed two major growing percentiles in a short time.3 Still others, for diagnostic intents, defined FTT as a disproportional failure to derive weight in comparing to height without an evident aetiology.6 Brayden et al.,2 suggested that FTT should be considered if a kid less than 6 months old has non grown for two back-to-back months or a kid older than 6 months has non grown for three back-to-back months. Recent research has validated that the weight-for-age attack is the simplest and most sensible marker of FTT.12Pitfalls of these definitions:One restriction of utilizing the 3rd percentile for specifying FTT is that some kids whose weight autumn below this arbitrary statistical criterion of normal are non neglecting to boom but stand for the three per centum of normal population whose weight is less than the 3rd percentile.5,6 In the first 2 old ages of life, the kid ‘s weight alterations to follow the familial sensitivity of the parent ‘s tallness and weight.13,14 During this clip of passage, kids with familial short stature may traverse percentiles downward and still be considered normal.14 Most kids in this class happen their true curve by the age of 3 years.6,14 When the percentile bead is great, it is helpful to compare the kid ‘s weight percentile to tallness and caput perimeter percentiles. These should be consistent with the place of tallness and caput perimeter percentiles of the patient.5 Another restriction of the 3rd percentile as a standard to specify FTT is that babies can be neglecting to boom with pronounced slowing of weight addition, but they remain undiagnosed and hence, untreated until they have fallen below the arbitrary 3rd percentile.6 These normal little kids do non show the disproportional failure to derive weight that kids with FTT do.6 This attack attempts non merely to forestall normal little kids from being falsely labeled as neglecting to boom, but besides excludes kids with diseased proportionate short stature.14 Having excluded these easy distinguishable upsets from the differential diagnosing of FTT, simplifies the attack to rating of the kid who has failed to thrive.6 A more across-the-board definition of FTT includes any kid whose weight has fallen more than two standard divergences from a old growing curve.3,15,16 Normal displacements in growing curves in the first 2 old ages of life will ensue in less terrible diminution ( i.e, less than 2 SD ) .13 Some writers have even limited the definition of FTT to merely kids less than 3 old ages old17,18 A precise age restriction is arbitrary. However, most kids with FTT are under 3 old ages of age.6,8EpidemiologyIn immature kids, FTT which does non make the terrible classical syndrome of marasmus is common in all societies.19 However, the true incidence of FTT is non known as many babies with FTT are non identified, even in developed countries.20-22 It is estimated to impact 5 – 10 % of immature kids and about 3 – 5 % of kids admitted into learning hospitals.3,5,23 Mitchell et al,24 utilizing multiple standards found that about 10 % of under-fives go toing primary wellness attention Centre in the United States showed FTT. About 5 % of pediatric admittances in United Kingdom are for FTT.4 The prevalence is even higher in developing states with wide-spread poorness and high rates of malnutrition and/or HIV infections.3,19 Children Born to individual teenage female parents an d working female parents who work for long hours are at increased risk.22 The same is true of kids in establishments such as orphanhood places and places for the mentally retarded5,22 with an estimated incidence of 15 % as a group.5 Under-feeding is the individual commonest cause of FTT and consequences from parental poorness and/or ignorance.19,22,24 Ninety five per centum of instances of FTT are due to non plenty nutrient being offered or taken.25 The peak incidence of FTT occurs in kids between the age of 9 – 24 months with no important sex difference.22 Majority of kids who fail to boom are less than 18 months old.3 The syndrome of FTT is uncommon after the age of 5 years.3,22EtiologyTraditionally, causes of FTT have been classified as non-organic and organic. However, some writers have stated that this nomenclature is misleading.27 They based their sentiment on the fact that all instances of FTT are produced by unequal nutrient or undernutrition and in that context, is o rganically determined. In add-on, the differentiation based on organic and non-organic causes is no longer favoured because many instances of FTT are of assorted aetiologies.3 Based on pathophysiology ( the preferred categorization ) , FTT may be classified into those due to: ( I ) Inadequate thermal consumption ; ( two ) Inadequate soaking up ; ( three ) Increased thermal demand ; and ( four ) Defective use of Calories. This categorization leads to a logical organisation of the many conditions that cause or contribute to FTT.10Non – organic ( psychosocial ) failure to boomIn non-organic failure to boom ( NFTT ) , there is no known medical status doing the hapless growing. It is due to poverty, psychosocial jobs in the household, maternal want, deficiency of cognition and accomplishment in infant nutrition among the care-givers5,11. Other hazard factors include substance maltreatment by parents, individual parentage, general immatureness of one or both parents, economic emphasis and strain, impermanent emphasiss such as household calamities ( accidents, unwellnesss, deceases ) and matrimonial disharmony.6,8,22 Weston et al,28 reported that 66 % of f emale parents whose babies failed to boom has a positive history of holding been abused as kids themselves, compared to 26 % of controls from similar socioeconomic background. NFTT histories for over 70 % of instances of FTT.6 Of this figure, about one-third is due to care-giver ‘s ignorance such as wrong eating technique, improper readying of expression or misconception of the baby ‘s nutritionary needs,29 all of which are easy corrected. A close expression at these hazard factors for NFTT suggest that babies with growing failure may stand for a flag for serious societal and psychological jobs in the household. For illustration, a down female parent may non feed her baby adequately. The baby may, in bend, go withdrawn in response to female parent ‘s depression and provender less well.10 Extreme parental attending, either disregard or hypervigilance, can take to FTT.10Organic failure to boomIt occurs when there is a known implicit in medical cause. Organic upsets d oing FTT are most commonly infections ( e.g HIV infection, TB, enteric parasitosis ) , GI ( e.g. , chronic diarrhea, gastroesophageal reflux, pyloric stricture ) or neurologic ( e.g. , intellectual paralysis, mental deceleration ) disorders.6,19,22 Others include GU upsets ( e.g. , posterior urethral valve, nephritic cannular acidosis, chronic nephritic failure, UTI ) , inborn bosom disease, and chromosomal anomalies.6,7 Together neurologic and GI upsets account for 60 – 80 % of all organic causes of under nutrition in developed countries.30 An of import medical hazard factor for under nutrition in childhood is premature birth.1 Among preterm babies, those who are little for gestational age are peculiarly vulnerable since antenatal factors have already exerted hurtful consequence on bodily growth.1 In societies where lead toxic condition is common, it is a recognized hazard factor for hapless growth.5,31 Organic FTT virtually ne'er presents with stray growing failure, other m arks and symptoms are by and large apparent with a elaborate history and physical examination.32 Organic upsets histories for less than 20 % of instances of FTT.6Assorted failure to boomIn assorted FTT, organic and non organic causes coexist. Those with organic upsets may besides endure from environmental want. Likewise, those with terrible undernutrition from non-organic FTT can develop organic medical jobs.FTT with no specific aetiologyReappraisal of the literature on FTT indicate that in 12 – 32 % of instances of kids who have failed to boom, no specific aetiology could be established.23,33-34Causes of failure to boomA. Prenatal instances: ( I ) Prematureness with its complication ( two ) Toxic exposure in utero such as intoxicant, smoke, medicines, infections ( eg German measles, CMV ) ( three ) Intrauterine growing limitation from any cause ( four ) Chromosomal abnormalcies ( eg Down syndrome, Turner syndrome ) ( V ) Dysmorphogenic syndromes.B. Postnatal causes based on pathophysiology:A. Inadequate thermal consumption which may ensue from:I. Under feeding Incorrect readying of expression ( e.g. excessively dilute, excessively concentrated ) . Behaviour jobs impacting eating ( e.g. , kid ‘s disposition ) . Unsuitable feeding wonts ( e.g. , uncooperative kid ) Poverty taking to nutrient deficits. Child maltreatment and disregard. Mechanical eating troubles e.g. , inborn anomalousnesss ( dissected lip/palate ) , oromotor disfunction. Prolonged dyspnea of any causeB. Inadequate soaking up which may be associated with:Malabsorption syndromes e.g. Celiac disease, cystic fibrosis, cow ‘s milk protein allergic reaction, giardiasis, nutrient sensitivity/intolerance Vitamins and mineral lacks e.g. , Zn, vitamins A and C lacks. Hepatobiliary diseases e.g. , bilious atresia. Necrotizing enterocolitis Short intestine syndrome.C. Increased Caloric demand due toHyperthyroidism Chronic/recurrent infections e.g. , UTI, respiratory tract infection, TB, HIV infection Chronic anemiaD. Defective Utilization of Kilogram caloriesCongenital mistakes of metamorphosis e.g. , galactosaemia, aminoacidopathies, organic acidurias and storage diseases. Diabetess inspidus/mellitus Nephritic cannular acidosis Chronic hypoxaemiaClinical manifestations of FTT3,22Normally the parents/care-givers may kick that the kid is â€Å" non turning good † or â€Å" losing weight † or â€Å" non feeding good † or â€Å" non making good † or â€Å" non like his other siblings/age couples † . Usually FTT is discovered and diagnosed by the baby ‘s physician utilizing the birthweight and wellness clinic anthropometric records of the kid. The infant looks little for age. The kid may exhibit loss of hypodermic fat, reduced musculus mass, thin appendages, a narrow face, outstanding ribs, and wasted natess, Evidence of ignored hygiene such as nappy roseola, common tegument, overgrown and soiled fingernails or common vesture. Other findings may include turning away of oculus contact, deficiency of facial look, absence of snuggling response, hypotonus and premise of childish position with clinched fists. There may be marked preoccupation with thumb suction.EvaluationA. Initial ratingIt has been proposed that merely three initial probes are required to develop an economical, treatment-centred attack to the kid who presents with FTT and this include:35 ( I ) A thorough history including an itemized psychosocial reappraisal ; ( two ) Careful physical scrutiny including finding of the auxological parametric quantities ; and ( three ) Direct observation of the kid ‘s behavior and of parent-child interactions. The Psychosocial Review: The psychosocial history should be as thorough and systematic as a authoritative physical scrutiny Goldbloom35 suggested that the interviewers should inquire themselves three inquiries about every household: ( I ) How do they look ; ( two ) What do they say ; and ( three ) What do they make? a. History ( 1 ) Nutritional history Nutritional history should include: Detailss of chest eating to acquire an thought of figure of provenders, clip for each eating, whether both chests are given or one chest, whether the eating is continued at dark or non and how is the kid ‘s behavior before, after and in between the provenders. It would give an thought of the adequateness or insufficiency of female parents milk. If the baby is on expression eating: Is the expression prepared right? Dilute milk provender will be hapless in Calorie with extra H2O. Too concentrated milk provender may be unpalatable taking to refusal to imbibe. It is besides indispensable to cognize the entire measure of the expression consumed. Is it given by bottle or cup and spoon? Besides assess the feeling of the female parent e.g. , inquire â€Å" how make you experience when the babe does non feed good? † Time of debut of complementary provenders and any trouble should be noted. Vitamin and mineral addendum ; when started, type, sum, continuance. Solid nutrient ; when started, types, how taken. Appetite ; whether the appetency is temporarily or persistently impaired ( if necessary calculate the thermal consumption ) . For older kids enquire about nutrient likes and disfavors, allergic reactions or idiosyncracies. Is the kid Federal forcibly? It is desirable to cognize the feeding modus operandi from the clip the kid wakes up in the forenoon boulder clay he sleeps at dark, so that one can acquire an thought of the entire thermal consumption and the Calories supplied from protein, fat and saccharide every bit good as adequateness of vitamins and minerals intake. ( 2 ) Past and current medical history The history of antenatal attention, maternal unwellness during gestation, identified foetal growing jobs, prematureness and birth weight. Indexs of medical diseases such as emesis, diarrhea, febrility, respiratory symptoms and weariness should be noted. Past hospitalization, hurts, accidents to measure for kid maltreatment and disregard. Stool form, frequence, consistence, presence of blood or mucous secretion to except malabsorption syndromes, infection and allergic reaction. ( 3 ) Family and societal history Family and societal history should include the figure, ages and sex of siblings. Ascertain age of parents ( Down syndrome and Klinerfelter syndrome in kids of aged female parents ) and the kid ‘s topographic point in the household ( pyloric stricture ) . Family history should include growing parametric quantities of siblings. Are at that place other siblings with FTT ( e.g. , familial causes of FTT ) , household members with short stature ( e.g. familial short stature ) . Social history should find business of parents, income of the household, place those caring for the kid. Child factors ( e.g. , disposition, development ) , parental factors ( e.g. , depression, domestic force, societal isolation, mental deceleration, substance maltreatment ) and environmental and social factors ( e.g. , poorness, unemployment, illiteracy ) all may lend to growing failure.5 Historical rating of the kid with FTT is summarized in Table 1. ( B ) PHYSICAL EXAMINATION The four chief ends of physical scrutiny include ( one ) designation of dysmorphic characteristics suggestive of a familial upset hindering growing ; ( two ) sensing of under lying disease that may impair growing ; ( three ) appraisal for marks of possible kid maltreatment ; and ( four ) appraisal of the badness and possible effects of malnutrition.36,37 The basic growing parametric quantities such as weight, height / length, caput perimeter and mid-upper-arm perimeter must be measured carefully. Accumbent length is measured in kids below 2 old ages of age because standing measurings can be every bit much as 2cm shorter.36,37 Other anthropometric informations such as upper-segment-to-lower-segment ratio, sitting tallness and arm span should besides be noted. The anthropometric index used for FTT should be weight-for-length or height. Mid-parental tallness ( MPH ) should be determined utilizing the formula.40 For male childs, the expression is: MPH = [ FH + ( MH – 13 ) ] 2 For misss, the expression is: MPH = [ ( FH – 13 ) + MH ] 2 In both equations, FH is father ‘s tallness in centimeters and MH is mother ‘s tallness in centimeters. The mark scope is calculated as the MPH A ± 8.5cm, stand foring the two standard divergence ( 2SD ) assurance limits.14Appraisal of grade FTTThe grade of FTT is normally measured by ciphering each growing parametric quantity ( weight, tallness and weight/height ratio ) as a per centum of the average value for age based on appropriate growing charts3 ( See Table 3 )Table 3: Appraisal of grade of failure to boom ( FTT )Growth parametric quantityDegree of Failure to BoomMild Moderate Severe Weight 75-90 % 60 -74 % & lt ; 60 % Height 90 -95 % 85 – 89 % & lt ; 85 % Weight/height ratio 81-90 % 70 -80 % & lt ; 70 % Adapted from Baucher H.3 It should be noted that appropriate growing charts are frequently non available for kids with specific medical jobs, hence consecutive measurings are particularly of import for these children.3 For premature babies, rectification must be made for the extent of prematureness. Corrected age, instead than chronologic age, should be used in computations of their growing percentiles until 1-2 old ages of corrected age.3Table 2: Physical scrutiny of babies and kids with growing failure.AbnormalityDiagnostic ConsiderationCritical marks Hypotension High blood pressure Tachypnoea/Tachycardia Adrenal or thyroid inadequacy Nephritic diseases Increased metabolic demand Skin Lividness Poor hygiene Ecchymosiss Candidiasis Eczema Erythema nodosum Anaema Disregard Maltreatment Immunodeficiency, HIV infection Allergic disease Ulcerative inflammatory bowel disease, vasculitis HEENT Hair loss Chronic otitis media Cataracts Aphthous stomatitis Thyroid expansion Stress Immunodeficiency, structural oro- facial defect Congenital German measles syndrome, galactosaemia Crohn ‘s disease Hypothyroidism Chest Wheezes Cystic fibrosis, asthma Cardiovascular Mutter Congenital bosom disease ( CHD ) Abdomens Distension overactive Bowel sound Hepatosplenomegaly Malabsorption Liver disease, animal starch storage disease Genitourinary Diaper roseolas Diarrhoea, disregard Rectum Empty ampulla Hirschsprung ‘s disease Extremities Oedema Loss of musculus mass Clubing Hypoalbuminaemia Chronic malnutrition Chronic lung disease, Cyanotic CHD Nervous system Abnormal deep sinew Reflexes Developmental hold Cranial nervus paralysis Cerebral paralysis Altered thermal consumption or demands Dysphagia Behaviour and disposition Uncooperative Difficult to feed. Adapted from Collins et al 41 Growth charts should be evaluated for form of FTT. If weight, tallness and caput perimeter are all less than what is expected for age, this may propose an abuse during intrauterine life or genetic/chromosomal factors.2 If weight and tallness are delayed with a normal caput perimeter, endocrinopathies or constitutional growing should be suspected.2 When merely weight addition is delayed, this normally reflects recent energy ( thermal ) deprivation.2 Physical scrutiny in babies and kids with FTT is summarized in Table 2.Failure to boom due to environmental wantChild with environmental want chiefly demonstrate marks of failure to derive weight: loss of fat, prominence of ribs and musculuss blowing, particularly in big musculus groups such as the gluteals.6Developmental appraisalIt is of import to find the kid ‘s developmental position at the clip of diagnosing because kids with FTT have a higher incidence of developmental holds than the general population.36 With environmental wan t, all mileposts are normally delayed once the baby reaches 4 months of age.42 Areas dependant on environmental interactions such as linguistic communication development and societal version are frequently disproportionately delayed. Specific behavioral ratings ( e.g. , entering responses to near and backdown ) , have been developed to assist distinguish implicit in environmental want from organic disease.43 Assess the baby ‘s developmental position with a full Denver Developmental Standardized test.44Parent-child interaction:Evaluate interaction of the parents and the kid during the scrutiny. In environmental want, the parent frequently readily walks off from the scrutiny tabular array, looking to easy abandon the kid to the nurse or physician.6 There is small oculus contact between kid and parent and the baby is held distantly with small modeling to the parent ‘s body.6 Often the baby will non make out for the parent and small fond touching is noted.6 There is small pa rental show of pleasance towards the infant.6 Observation of eating is an built-in portion of the scrutiny, but it is ideally done when the parents are least cognizant that they are being observed. Breast-fed babies should be weighed before and after several eatings over a 24-hour period since volume of milk consumed may change with each repast. In environmental want, the parents frequently miss the babies cues and may deflect him during eating ; the baby may besides turn away from nutrient and look distressed.6 Unnecessary force may be used during feeding. Developing a portrayal of the child-parent relationship is a cardinal to steering intervention.11LABORATORY EVALUATIONThe function of research lab surveies in the rating of FTT is to look into for possible organic diagnosings suggested by the history and physical examination.33,34 If an organic aetiology is suggested, appropriate surveies should be undertaken. If history and physical scrutiny do non propose an organic aetiology, extended research lab trial is non indicated.6 However, on admittance full blood count, ESR, uranalysis, urine civilization, urea and electrolyte ( including Ca and P ) degrees should be carried out. Screen for infections such as HIV infection, TB and enteric parasitosis. Skeletal study is indicated if physical maltreatment is strongly suspected. In add-on to being unproductive, unsighted research lab fishing expeditions should be avoided for the undermentioned reason:5,6 ( I ) they are expensive ; ( two ) they impair the kid ‘s ability to derive weight in a new environment both by scaring him/her with venepuncture, Ba surveies and other nerve-racking processs and the no unwritten provenders associated with some probes prevent him/her from acquiring adequate Calories ; ( three ) they can be misdirecting since a figure of laboratory abnormalcies are associated with psychosocial want ( e.g. , increased serum aminotransferases, transeunt abnormalcies of glucose tolerance, decreased growing endocrine and Fe lack ) ; 21 and ( f our ) they divert attending and resources from the more productive hunt for grounds of psychosocial want. In one survey, a sum of 2,607 research lab surveies were performed, with an norm of 14 trials per patient. With all trials considered, merely 10 ( 0.4 % ) served to set up a diagnosing and an extra 1 % were able to back up a diagnosis.34Further Evaluation( 1 ) Hospitalization: Although some writers province that most kids with failure to boom can be treated as outpatients,4,5,11,45 I think it is best to hospitalise the baby with FTT for 10 – 14 yearss. Hospitalization has both diagnostic and curative benefits. Diagnostic benefits of admittance may include observation for eating, parental-child interaction, and audience of sub-specialists. Curative benefits include disposal of endovenous fluids for desiccation, systemic antibiotic for infection, blood transfusion for anemia and perchance, parenteral nutrition, all of which are frequently in-hospital processs. In add-on, if an organic aetiology is discovered for the FTT, specific therapy can be initiated during hospitalization. In psychosocial FTT, hospitalization provides chance to educate parents about appropriate nutrients and feeding manners for babies. Hospitalization is necessary when the safety of the kid is a concern. In most state of affairss in our set up, there is no feasible option to hospitalization. ( 2 ) Quantitative appraisal of consumption: A prospective 3-day diet record should be a standard portion of the rating. This is utile in measuring under nutrition even when organic disease is present. A 24-hour nutrient callback is besides desirable. Having parents compose down the types of nutrient and amounts a kid eats over a three-day is one manner of quantifying thermal consumption. In some cases, it can do parents aware of how much the kid is or is non eating.11Table 4: Summary of hazard factors for the development of failure to boomBaby featuresAny chronic medical status ensuing in: – Inadequate consumption ( e.g, get downing disfunction, cardinal nervous system depression, or any status ensuing in anorexia ) – Increased metabolic rate ( e.g, bronchopulmonary dysplasia, inborn bosom disease, febrilities ) – Maldigestion or malabsorption ( e.g, AIDS, cystic fibrosis, short intestine, inflammatory intestine disease, celiac disease ) . – Infections ( e.g. , HIV, TB, Giardiasis ) Premature birth ( particularly with intrauterine growing limitation ) Developmental hold Congenital anomalousnesss Intrauterine toxin exposure ( e.g. intoxicant ) Plumbism and/or anemiaFamily featuresPoverty Unusual wellness and nutrition beliefs Social isolation Disordered eating techniques Substance maltreatment or other abnormal psychology ( include Muschausen syndrome by placeholder ) Violence or maltreatment Adapted from Kleinman RE.1Table 1: Summary of historical rating of babies and kids with growing failurePrenatalGeneral obstetrical history Recurrent abortions Was the gestation planned? Use of medicines, drugs, or coffin nailsLabour, bringing, and neonatal eventsNeonatal asphyxia or Apgar tonss Prematureness Small for gestational age Birth weight and length Congenital deformities or infections Maternal bonding at birth Length of hospitalization Breastfeeding support Feeding troubles during neonatal periodMedical history of kidRegular doctor Immunizations Development Medical or surgical unwellnesss Frequent infectionsGrowth historyPlot old pointsNutrition historyFeeding behaviour and environment Perceived sensitivenesss or allergic reactions to nutrients Quantitative appraisal of consumption ( 3-day diet record, 24-hour nutrient callback )Social historyAge and business of parents Who feeds the kid? Life emphasiss ( loss of occupation, divorce, decease in household ) Handiness of societal and economic support ( Particular Supplemental Nutrition Program for Womans, Babies and Children ; Aid for Families with Dependent Children ) Percept of growing failure as a job History of force or maltreatment by or of care-giverReview of systems/clues to organic diseaseAnorexia Change in mental position Dysphagia Stooling form and consistence Vomiting or gastroesophageal reflux Recurrent febrilities Dysuria, urinary frequence Activity degree, ability to maintain up with equals Beginning: Duggan C.46DIFFERENTIAL DIAGNOSIS OF FAILURE TO THRIVE1. Familial short stature Although kids with familial short stature frequently are in the 3rd percentile on the growing chart, they have normal weight-to-height ratio and growing speed bone ages equal to their chronological ages and they look happy and healthy.47 Their growing curve runs parallel to and merely below the normal curves.48 2. Constitutional growing hold In constitutional growing hold, weight and height lessening near the terminal of babyhood, parallel the norm through in-between childhood and speed up toward the terminal of adolescence.48 Growth speed during childhood is normal, bone age is delayed, pubescence is delayed, wellness is otherwise normal and normally they have household history of delayed growing and puberty.47 3. Early oncoming growing hold Approximately 25 % of normal babies will switch to take down growing percentile in the first two old ages of life and so follow that percentile.11,49 This should non be diagnosed as failure to boom. Smith DW et al13 reported that 30 % of healthy, full-term, white babies cross one percentile line and 23 % cross two lines as they move from birth to age of 2 old ages. In both the history and physical scrutiny, there are no singular findings except that similar characteristics may be found in other siblings in the family.23 Although in some kids puberty may be delayed, normal pubertal growing jet occur subsequently in adolescence.23 The bone age corresponds to the tallness age.23 4. Specific infant populations Preterm babies and those who suffered intrauterine growing limitation may show growing failure in the immediate postpartum period50,51 but catch-up growing has been reported to happen during the first 2 to 3 old ages of life.52,53 As long as the kid ‘s growing follows a curve with a normal interval growing rate, FTT should non be diagnosed.54 Over diagnosing of growing failure can be avoided by utilizing modified growing charts developed for specific populations such as preterm infants,55,56 entirely breast fed infants,57,58 specific ethnicities ( e.g. , Asians ) 59,60 and babies with familial syndromes such as Down61 and Turner62,63 syndromes. The usage of these charts can assist reassure the doctor that these kids are turning suitably. In preterm babies, their chronological age should be corrected by gestational age until age of 24 months for weight measurings, 40 months for length, and 18 months for caput circumference.1 This is a petroleum method because it does non capture the variableness in growing speed that really low birthweight babies demonstrate.48 Entirely breast-fed babies tend to plot higher for weight in the first 6 months of life but comparatively lower in the 2nd half of the first year.48 5. Diencephalic Syndrome This syndrome must be differentiated from psychosocial FTT. The Diencephalic syndrome usually presents in the first twelvemonth of life with failure to boom, bonyness, increased appetite, euphoric affect and nystagmoid oculus movements.64,65 Clinically they differ from FTT because in contrast to their hapless physical status they are watchful, happy, active, associate easy and are non depressed.65 The Diencephalic syndrome consequences from neoplasms in the country of the hypothalamus and the 3rd ventricle.64 6. Psychosocial short stature ( Psychosocial nanism ) Psychosocial nanism is a syndrome of slowing of additive growing combined with characteristic behavior perturbations ( sleep upset and eccentric eating wonts ) , both of which are reversible by a alteration in the psychosocial environment.66 Normally the age at oncoming is between 18 and 24 months.66 Affected kids are frequently diffident and inactive and typically down and socially with drawn.5 The short stature may or may non be associated with accompaniment FTT.5MANAGEMENT OF A CHILD WITH FAILURE TO THRIVETreatment of FTT is both immediate and long-run and should be directed at both the baby and the mother/family. A good intervention program must turn to the followers: 1. The kid ‘s diet and eating form 2. The kid ‘s developmental stimulation 3. Improvement in care-giver accomplishments 4. Nursing considerations in the intervention of FTT 5. Presence of any implicit in disease 6. Regular and effectual follow up 7. Consultation and referral to specializers 1. The kid ‘s diet and eating form The pillar of direction of failure to boom, irrespective of aetiology, is nutritionary intercession and feeding behaviour alterations. For breast-fed babies, feeding interval should non be greater than four-hourly and the maximal clip allowed for suckling should be 20 proceedingss. Beyond this clip the baby would pall. Behavioural alteration should center on bettering feeding techniques, avoiding big sum of juices and extinguishing distractions such as telecasting during meal times. Fruit juice is an of import subscriber to hapless growing by supplying comparatively empty saccharide Calories and decreasing a kid ‘s appetency for alimentary repasts, taking to decreased thermal intake.67 Successful direction of FTT is followed by catch-up growth19 Catch-up growing refers to deriving weight at greater than 50th percentile for age.68 For catch-up growing, kids with FTT require 1.5 to 2 times the expected Calorie intake for their age.25Calculation of catch-up requirement30Kcal or gm protein for weight age ten ideal organic structure weight Actual weightAgeKcal/kggram protein/kg0 – 6 months 115 2.2 6 – 12 months 105 2.0 1 – 3 old ages 100 1.8 4 – 6 old ages 85 1.5 Beginning: Vinton NE et al30 Age Weight 3rd Catch-up growing fiftieth 97th Figure 1: Failure to boom and catch-up growing related to weight centile Beginning: Poskitt EME19 Some kids with FTT are anorectic and finical feeders. They may, hence, non be able to devour this sum of Calories in volume and therefore necessitate calorie-dense provenders. Toddlers can have more Calories by adding taste-pleasing fats such as cheese or butter ( where non executable palm oil ) to common yearling nutrients. In add-on, vitamin and mineral supplementation is required. Although some practicians add Zn to cut down the energy cost of weight addition during catch-up growing, the informations about its benefit are mixed.69,70 Meals should be pleasant, on a regular basis scheduled, and the kid should non be fed excessively quickly or excessively easy. Get downing with little sum of nutrient and offering more is preferred to get downing with big measures. Bites need to be timed in between repasts so that the kid ‘s appetency will non be spoiled. The type of thermal supplementation must be based on the badness of FTT and the implicit in medical status. For case, the sum of protein in the diet must be carefully monitored in kids with nephritic failure.3 Children with terrible malnutrition must be re-fed carefully to forestall re-feeding syndrome.3,67 For older babies and immature kids with psychosocial FTT, repast times should be about 30 proceedingss, solid nutrients should be offered before liquids, environmental distraction should be minimized and kids should eat with other people and non be forced-fed.71 The primary doctor may see confer withing a pediatric dietitian to assist supply calorie-dense diet.Monitoring nutritionary therapyThe first precedence is to accomplish ideal weight-for-age. The 2nd end is to achieve catch-up in length to that expected for the age. Stairss in the intervention are directed towards both immediate and long-run normal growing of the child.72 Effectiveness of therapy is monitored by addition in weight. Weight addition is response to adequate thermal eatings normally establishes the diagnosing of psychosocial FTT.3,23 If FTT continues in infirmary despite equal dietetic input, supernatural organic disease is most likely and requires farther investigation.23 Adequacy of weight addition varies with age ( see Table 5 ) .Table 5: Acceptable weight addition for age per twenty-four hoursAge ( months )Weight addition ( gram/day )Birth to & lt ; 3 20 – 30 3 to & lt ; 6 15 – 22 6 to & lt ; 9 15 – 20 9 to & lt ; 12 6 – 11 12 to & lt ; 18 5 – 8 18 to 24 3 – 7 Beginning: Brayden et al 2 Calculation of day-to-day or monthly growing such as weight addition in gms per twenty-four hours ( see Table 5 ) allows more precise comparing of growing rate to the norm.48 Although length growing is harder to measure, it should be 0.2 to 0.4mm per twenty-four hours in most children.73 2. The kid ‘s developmental stimulation: Organized programme of intensive environmental stimulation and fondness during waking hours using parents, voluntaries and child-life ( societal ) workers is necessary.33 Temporary or lasting Foster place may be required to extinguish inauspicious psychosocial environment. Surveies have shown that appropriate psychosocial stimulation is of import for cognitive development, both early and later in the kid ‘s life.74,75 3. Improvement in care-giver accomplishment Parents should be counselled about household interactions that are damaging to the kid. Pay attending to the care-giver ability to acknowledge the kid ‘s cues, reactivity and parental heat and allow behavior towards the kid. Guaranting that the nutrient is suitably prepared and presented and doing allowances for any troubles that the kid has in masticating and get downing may all take to improvement.3 Introduction of solids in little frequent provenders is utile. Babies should be fed in semi-upright position.76 All members of staff must work constructively with the parents, progressively go throughing duty back to them. They should avoid judgmental vocalizations. Prosecuting the parents as co-investigator is indispensable. It helps further their self-esteem and avoids faulting those who may already experience defeated and quilty because of sensed inability to foster their kid. 4. Nursing considerations in the direction of FTT: A nursing-care program should include careful charting of consumption, weight, and observations of the female parent ‘s eating manner and interaction with the kid. The nursing staff should teach the female parent on how to better behaviours that may be deprivational, including instructions on how to keep the infant stopping point during eating. The female parent should be taught how to cook locally available nutrients. Feeds should be thickened to increase its thermal denseness and therefore consumption. Educate the parents about the kid ‘s nutritionary and psychological demands. The kid should be stimulated by maternal attention, fondness and societal interaction with playthings and equals. Home visits by a community wellness nurse to measure household kineticss and economic state of affairs is of import. Parental anxiousness about the kid ‘s FTT can be allayed by reassurance by the nurse. 5. Underliing organic disease: Treat smartly any identified implicit in organic disease. Often the implicit in cause of FTT syndrome remains ill-defined, and an empiric test of nutritionary therapy by a individual experienced in feeding babies along with careful observation and support of the household is necessary. Children with FTT must be evaluated treated quickly and adequately for infection. The interactive relationship between nutritionary position and infection are peculiarly evident during babyhood. 6. Regular follow up: Upon discharge, near follow up with place visits is indispensable to guarantee care of nutritionary position. In this respect, Wright CM et al77 have shown that place nursing visits is associated with better results. Follow up should guarantee that the kid is so now booming physically by detecting their growing parametric quantities, utilizing the appropriate growing charts. It besides ensures that the kid continues to have equal nutrition at place. Cognitive development should be monitored and, where necessary, extra stimulation provided at place or in a preschool installation. The period of recuperation which should embrace calorie-dense diet is indispensable for full recovery of kids with FTT. Regular effectual follow up is critical in that accomplishing nutritionary and growing recovery in infirmary is likely less hard than keeping equal long-run nutritionary consumption and developmental stimulation at home.37 Children with FTT should be followed up at least every 4 hebdomads un til catch-up is demonstrated and the positive tendency maintained. 7. Consultation and referral to specialist ( s ) : For kids who are non bettering because of undiagnosed medical status or a peculiarly ambitious societal state of affairs, a multidisciplinary attack may be required.10,78Algorithm of an attack to direction of the kid with FTTDetailed History ( including itemized psychosocial reappraisal )Child with FTTThorough Physical Examination ( including auxological parametric quantities )Admit to infirmary with primary caregiver/motherInitial probes include FBC, ESR, uranalysis, urine civilization, stool for egg cell, cyst of parasite. Screen for HIV infection, TerbiumTest of nutritionary therapy with calorie-dense dietFeeds goodFeeds illFeed goodPoor or no weight addition in 4-5 yearssReassess ( farther physical test and probe )Good weight addition infirmary in 4-5 yearssGood weight addition in infirmary in 4-5 yearss Poor or no weight addition in infirmary in 4-5 yearss inNo organic diseaseReassess ( farther physical test and probe )Organic diseasediagnosedNegativeconsequencesSee psychosocial job and interveneRegular followup with growing supervising e.g monthlyRegular followup with growing supervising e.g monthlyOrganic diseasediagnosedInvite appropriate specializer ( s ) for disease-specific interventionSee psychosocial job and interveneRegular followup with growing supervising e.g monthlyInvite appropriate specializer ( s ) for disease-specific interventionRegular followup with growing supervising e.g monthlyPrevention OF FAILURE TO THRIVEPromotion of sole chest eating for early babyhood followed by optimal complementary eating in the presence of good hygienic patterns diminishes the hazard of infections, promotes infant growing and prevents child undernutrition.79 Community attempt to educate and promote people to seek aid for their societal, emotional, economic and interpersonal jobs may assist cut down the incidence of psychosocial FTT. Promoting rearing instruction classs in secondary schools every bit good as educational community programmes may assist new parents enter parentage with an increased cognition of an baby ‘s nutritionary and other demands. Early sensing of FTT and intercession can cut down the badness of symptoms, heighten the procedure of normal growing and development and better the quality of life experience by babies and kids. Prevention of LBW ( a hazard factor for FTT ) through balanced energy-protein supplementation, micronutrient supplementation, intervention of infection/malaria, surcease of smoke and intoxicant consumption in gestation are major intercessions capable of forestalling LBW.80Complication1. Malnutrition-infection rhythm: Perennial infection exacerbate malnutrition, which in bend leads to greater susceptibleness to infection. Children with FTT must be evaluated and treated quickly for infection. 2. Re-feeding syndrome: Re-feeding syndrome is characterized by unstable keeping, hypophosphataemia, hypomagnesaemia and hypokalaemia.68 To avoid re-feeding syndrome, when nutritionary rehabilitation is initiated, Calories can safely be started at 20 % above the kid ‘s recent intake.68 If no estimation of thermal consumption is available, 50 to 75 % of the normal energy demand is safe.68 If tolerated, thermal consumption can be increased by 10 to 20 % per twenty-four hours with monitoring for electrolyte instabilities, hapless cardiac map, hydrops, or feeding intolerance.68 If any of these occurs, halt further thermal additions until the kid ‘s clinical position stabilizes. 3. Chronic, terrible undernutrition in babyhood may deject caput growing, an baleful forecaster of subsequently cognitive disability.3PrognosisThe timing of abuse, continuance and badness of the disease doing growing failure find the ultimate outcome.25,30 The extent to which full catch-up growing occurs is frequently debated. A short period of hapless growing is likely to decide wholly if sustained equal nutrition is supplied for accelerated growth.19 On the other manus, drawn-out period of hapless growing is likely to take to persistent little size, peculiarly if it occurs early in babyhood when it may be hard to do up the immense increases in size of the first 6 months of life.19 When growing wavering occurs during or merely prior to puberty, there is merely a limited period of clip during which catch-up growing can happen, finally taking to incomplete catch-up growth.19 Repeated episodes of growing wavering without catch-up growing will take to clinical marasmus if decease from overpowering infection does non intervene.19 There are a limited figure of outcome surveies on kids with FTT, each with different definitions and designs, so it is hard to notice with certainty on the long-run consequences of FTT.81 In a big case-control survey of kids aged 7 to 9 old ages from an industrial economic system who had FTT in babyhood, Drewett et al82 confirmed continued lower attainments in weight, tallness and caput perimeter but non important differences in intelligence quotient. Other systematic reappraisals concluded that the long-run result of FTT is a decrease in intelligence quotient ( I.Q. ) of approximately three points, which is non of clinical significance.83 Long-term effectsA on tallness and weight look more pronounced than on I.Q.84 Children with past history of non organic FTT have been found at the age of five twelvemonth to be shorter and lighter than their matched controls.85 Regardless of aetiology, FTT in the first twelvemonth of life is peculiarly baleful, because maximum postpartum encephalon growing occurs in the first 6 months of life.3 Approximately a 3rd of kids with psychosocial FTT are developmentally delayed and have societal and emotional problems.3 The forecast is mor e variable in organic FTT depending on the specific diagnosing and badness of FTT. Merely one tierce of kids with FTT are finally judged to be normal.86 A possible account is that making optimum potency may be hard given that the socioeconomic and cultural environment in which these kids live is non easy changed.DecisionAlthough definitions of FTT vary, most governments agree that merely by comparing tallness and weight on a growing chart over clip can FTT be assessed accurately. Laboratory rating should be guided by history and physical scrutiny findings merely. The direction of FTT should get down with a careful hunt for its aetiology. Nutritional intercession utilizing calorie-dense diet is the basis of intervention of FTT, irrespective of aetiology. Social issues of the household and associated medical jobs most be addressed. A careful and timely hunt for cause of FTT and aggressive caloric supplementation are of import in obtaining the best possible result in kids with FTT.

Essays and Essay Planning Guidance Essay Example

Essays and Essay Planning Guidance Essay Example Essays and Essay Planning Guidance Essay Essays and Essay Planning Guidance Essay political ideas. 7. Impractical: Who decides? How is it to be done? Is it not impossible to be correct? Any decision has to be arbitrary Case for censorship 10 1. Sex is private and precious: it should not be demeaned by representations of it in public. 2. Sex can be offensive: some people may find it so and should not have to risk being exposed to what they would find pornographic. . Corruption can be progressive: can begin with sex and continue until all decent values are eventually destroyed. 4. Participants might be corrupted: especially true of young children. 5. Violence can encourage imitation: by displaying violence even while condemning it -it can be legitimised and can also encourage imitation amongst a dangerous minority. 6. Violence is often glorified: encourages callous attitudes. Conclusion Case against censorship much stronger. No necessary connection between the two topics. From: mantex. co. uk/samples/plan. htm : 11 Planning Guide to Essay Planning 3 Strategy Many students, after having analysed an essay topic, may go straight to the library and read extensively on the subject. It is only after doing this research that they feel confident enough to start thinking and planning out their answer. Such an approach can be a mistake, however. They may find themselves producing a myriad of notes and then being at a loss to figure how these notes can be transformed into a coherent piece of writing. Before you read too much (or if possible, before you read anything at all), it is a good idea to do as much thinking and planning around the topic as you can. The benefit of this approach is that right from the start you can begin to get a sense of the shape your essay will take. It also means you can be more strategic in your reading, allowing you to search for specific reading materials rather than collecting a mass of material that may ultimately have limited relevance to your work. The task of writing is usually much easier if you create a set of notes which outline the points you are going to make. Using this approach, you will create a basic structure on which your ideas can be built. Plan This is a part of the essay-writing process that is best carried out using plenty of scrap paper. Get used to the idea of shaping and re-shaping your ideas before you start writing, editing and rearranging your arguments as you give them more thought. Planning onscreen using a word-processor is possible, but its a fairly advanced technique, and it doesn’t allow as much freedom to move ideas around and see them in relation to each other. Analyse the question Make sure you understand what the question is asking for. What is it giving you the chance to write about? What is its central issue? Analyse any of its key terms and any instructions. If you are in any doubt, ask your tutor to explain what is required. Generate ideas You need to assemble ideas for the essay. One way is to take a sheet of paper and make a note of anything which might be relevant to your answer. These might be topics, ideas, observations, or instances from your study materials. Put down anything you think of at this stage. Decide on topics On another sheet of paper, extract from your brainstorm listings those topics and points of argument which are of greatest relevance to the question and its central issue. Throw out anything which cannot be directly related to the essay question. Put topics in order On a third sheet of paper, put these chosen topics in some logical sequence. At this stage you should be formulating a basic response to the question, even if it is provisional and 12 may later be changed. Try to arrange the points so that they form a persuasive and coherent argument. Arrange your evidence All the major points in your argument need to be supported by some sort of evidence. On any further sheets of paper, compile a list of brief quotations from other sources (together with page references) which will be offered as your evidence. Compile a reference list as you collect sources. Use a recognised referencing style such as the Harvard â€Å"author/date† method. Make necessary changes While you have been engaged in the first stages of planning, new ideas may have come to mind. Alternate evidence may have occurred to you, or the line of your argument may have shifted somewhat. Be prepared at this stage to rearrange your plan so that it incorporates any of these new materials or ideas. Try out different arrangements of your essay topics until you are sure they form the most convincing and logical sequence. Finalise essay plan The structure of most essay plans can be summarised as Introduction Arguments Conclusion. State your case as briefly and rapidly as possible, present the evidence for this case in the body of your essay, then sum up and try to lift the argument to a higher level in your conclusion. Your final plan should be something like a list of six to ten major points of argument. Each one of these points will be expanded to a paragraph of around 100-200 words minimum in length (never one sentence! ). Relevance At all stages of essay planning, and even when writing the essay, you should keep the question in mind. Keep asking yourself Is this evidence directly relevant to the topic I have been asked to discuss? If in doubt, be prepared to scrap plans and formulate new ones which is much easier than scrapping finished essays. At all times aim for clarity and logic in your argument From: clpd. bbk. ac. uk/students/essayplanning 13 Sample Essay Plan 1 Critically examine the view that voting behaviour in the United Kingdom during the last thirty years has been increasingly influenced by factors other than social class. 1. Introduction You first need to identify the view that is being questioned. This is the theory of dealignment, which claims that the class–party relationship has broken down. This view, and the question itself, assumes that voting behaviour more than thirty years ago was influenced mainly by social class. You may want to question this assumption. You will need, therefore, to take a historical approach to the question, looking at trends over time. You should say that you will look at the traditional view and that you will then consider the case for and against dealignment. 2. The class–party relationship. class– This section will look at the argument that there has been a strong relationship between class and party. The work of Butler and Stokes was a classic statement of this, showing that working-class voters supported the Labour Party and middle-class voters supported the Conservative Party. Butler and Stokes noted that this relationship was not perfect: there were ‘deviant’ voters who voted in the opposite way. You will get more credit if you can give examples: for example, the manual workers with ‘deferential’ attitudes. They also pointed to the tendency for the elderly and for women to be more Conservative than their class background would suggest. 3. Dealignment It has been suggested that a process of dealignment has been occurring since at least the 1970s. There are two aspects to this alleged dealignment- partisan dealignment and class dealignment- and you should define each of these. You will gain extra marks if you can show that this is a deep-seated trend and is not unique to Britain. Behind this argument is the claim that ‘issue voting’ is now more important than class commitment. People are seen as making rational choices about which party is most likely to pursue appropriate policies on issues that concern them. Voters are, therefore, more ‘instrumental’. This also leads, so Heath et al. have argued, to more ‘tactical’ voting and, therefore, to less predictability in elections. 4. The New Right and centre politics Some commentators (for example, Stuart Hall) see the decline of class voting as, in part, a consequence of the rise of ‘authoritarian populism’ during the 1980s. This move to the right undermined Labour support in Britain and saw Labour defeats in 1983, 1987, and 1992. Labour’s response to these changes was to move closer to the centre of the political divide in order to recapture the more instrumental, issueoriented voters. You could conclude your discussion by saying that New Labour won the election in 1997 because it no longer relied on the declining foundations of its traditional, class-based support. You should make the point that political change cannot be explained in terms of political factors alone. There have been a number of important social and economic changes in Britain, and these have affected the old class allegiances. Factors pointed to have been the rise in the employment of women, the declining manufacturing base, the increasing number of service-sector jobs, the decline in the trade-union movement, and the break-up of old communities. You could draw on various evidence of these factors and how they have undermined the significance of class. 14 6. Conclusion An examination of the evidence seems to indicate that there has been a change in voting behaviour and that this can usefully be seen as involving a decline in class alignment and a strengthening of factors other than class. You might also like to conclude, however, that class remains an important factor alongside these other factors and that class dealignment is not the same thing as the emergence of a classless society. 15 Sample Sample essay plan 2 Should the government leave house prices to market forces, or actively intervene to prevent a house price crash? Justify your answer. Evaluation might consider some of these questions: What does a house price crash actually mean? What is the case for leaving house prices to market forces? What is the case for some form of intervention? What are the options for intervention? What are the problems with such intervention? Will house prices crash as the question implies – this can and should be challenged in your answer A housing crash / market correction might be exactly what the arket needs after a ten year boom! The case for leaving house prices to market forces? Ultimately house prices are determined by what homebuyers are willing and able to pay for a property and also the number of properties (new and existing) made available for sale Demand is driven by Incomes Unemployment The cost of a mortgage The availability of mortgage finance (including the loans to income multiple) Expectations of future price movements Supply is driven by Costs of construction Availability of land for housing development and its price Expectations of future price movements The number of properties existing homeowners decide to sell at a given price case The case for leaving it to the market is that Eventually if prices rise too far, demand will fall off and prices will adjust Higher prices will stimulate an increase in new house-building which will help the market reach equilibrium Private sector agents are often better judges of what the market needs than the government There is no certainty that the market will crash – it might experience a slowdown over a number of years The case for government intervention is that The booming market has created an inequitable (unfair) allocation of resources Major problems for housing affordability / impact on mobility of labour A housing crash would create difficulties for the economy and risk causing a collapse in consumer spending / recession Options for intervention: 16 Interest rates n ot an option – these are set independently by the Bank of England! Changes in stamp duty e. g. ower stamp duty for the lower end of the housing market New schemes to promote part ownership – part rent to increase affordability Relaxation of planning controls to stimulate new house building Increase in investment spending in new social housing to give people more choice of housing types What are the problems with such intervention? Risk of government failure Ineffective policies – government policies might actually do very little given the power of market forces Time lags – it takes a long time for government policies to work, by which time the market might already have started to adjust or a major housing correction might have happened. 17

buy custom The Advances in DNA Technology essay

buy custom The Advances in DNA Technology essay Introduction: The study of geneticdiseasebegan longago. In thepastpeople that suffered geneticdiseasewere leftalone. Theywere despisedand often separated from the rest of the community. Genetic diseases are highlyunpredictable. Despite the fact that genetic diseaseshave been studiedin the past, the studies done have still not reached a bottom line on the symptoms and treatment of diseases. Researchers havetherefore, sunkdeepto study genetic diseases. The target of the study is to findpossibletreatment and modes of managing such conditions. Further studies have also been done on ways of handling people with genetic diseases. These studies areoftendone by medical practitioners especially nurses. They include forums and medical courses thatassistthem to understand and such patients and be able to help them together with their families. Genetic diseases: The human bodyis madeof cells. In each cell, there are significant structures called DNA (deoxyribonucleic acid). DNA occurs in small bits on a chromosome. The chromosomeis composedof DNA strands. Genes are then the segments of DNA thatare foundon the chromosome. These genescarrythecharacteristicof an individual. Every person has 23 pairs of chromosomes. In rare occasions, these genesgetdefects that result in genetic disorders and diseases. A genetic disease is anillnessthat comes as a result of defects in the human chromosomes or genes. It is usually caused byvariationor alteration (mutation) of a gene. The genetherefore, codes for a protein that forms acharacterof a person.The defective genes lead to the making proteins withpoorstability which is not, three dimensional.These are the folded proteins. These proteinsare eliminatedfrom thecellthat later result in to a disease due to impaired cellular function. In other cases, the cell may fail toeliminatethe defective proteins which ac cumulate and result in genetic disorders (Gendel 2000). These diseases are eitherhereditaryor environmental. These diseases come invariousways. Genetic disorders can result from an abnormal number of chromosomes. That is the chromosomes could be less or more than thenormalnumberwhich is 23 chromosomes in each cell e.g. Down syndrome. The chromosomes can alsoexpandorrepeatitself in the cell.This results in tomutationof chromosomes.The resulting chromosome isdefectiveand causes disorders e.g. Huntingtons disease. A person cangetgenetic disease by inheriting defective genes from his or her parents. One of the parents could have a defective gene which theypassto the child duringconceptionof pregnancy (Mehta2010). Most of these diseases are rare. They canhardbe found incommonsettings. However, cystic fibrosis is one of the most common genetic disorders. Technological advances in genetic diseases the existing demands on genetic patient care, researchers have found out ways through which they can detect genetic diseases. These tests can detect both the inherited and the non-inherited disorders. The tests candetectwhether a person is a carrier of the disease. Prenataltestcan also be done to detect whether the unborn child willcontracta genetic disorder or not. Genetictestinvolve theanalysisof body tissues, blood and body fluids to detect the presence offaultyDNA. These genes couldhave been lost, misplaced in the body cell, inactivated, or over expressed in the cell. DNA testing can be done by two ways: Using DNA probes.These are short strings that have complementary sequence to the gene muted in the cell. Thisprobeis injectedinto the patient. If it finds the mutated gene, it binds to it and can be detected. The genetypecan also be detected by comparing the sequences. The DNA sequence that is faultyis comparedto a normalsequencetodetectthe fault in the sequence. The key proteins in the cell of the patient can also be detected. Some of these defective proteinsproducemalfunctioned genes. There are more advanced technologies that have come up to detect genetic disorders. According to Gendel (2000), researchers have sought out atherapyused to detect and correct misfolded proteins. This therapy uses a molecule drug called Pharmacological chaperones. The molecule binds to themisfoldedprotein and makes its three dimensionalform. Once the protein has formed the three-dimensionalformit takes itspositionin thecelland performs its function. The method can be used for other conditions that are a result ofmisfoldedproteins. Reason for genetic testing There are several reasons as to why anindividualcan go for genetic testing. Genetic testing canhelpin the determination of whether anindividualhasdefectivegenes in his or her body. This is in the context of those that already have the defective genes, but have not shown any signs for genetic disorders. For instance, a person can be tested for breast cancer, or olon. Genetic testing can be used to determine if an individual is a carrier of the defective genes. Carriers do notgetto have symptoms of the disease. They do not get infected by the disease, but can pass thediseaseto their children. This is in the cases of individuals that have adiseasethat is rotating in the family. Prenatal testing also includes genetic tests in which the mother of the unborn childis screenedfor genetic disorders such as cystic fibrosis, Spina Bifida, and Down syndrome. This test eliminates the chances of the unborn child tocontractthe disease. Samples of amniotic fluidare takenfor analysis of the disease (Daar 2008) these advances in genetic studies have also influenced nursing practices. The nursesgettrainingto become professionals in taking care of patients suffering from genetic disorders. The roles of nurses havehencebeen increased. It is theroleif nurses to ensure that the patients suffering from genetic diseasemakethe right choices andundergothecorrecttreatment and counseling (Smith, Ladd, Pasquerella 93). The nurses roles have also changed in with the rise in technology. The nurses roles include: Access hereditary and nonhereditary disease. This includes theassessmentof presence of diseases in the individual. Takedetailedfamily history of thepatientthat could be suffering from genetic disorders.This will help in the prediction of dominant or recessive genes in the individual tested. Interpret laboratory results for genetic disorders. This is one of thecrucialroles that involveconclusionof laboratory investigations. From these results, the nurse canconcludediagnosis and treatment. Provide genetic counseling, and consultation for genetic health care. This is beneficial for patients that are undergoingstressfulmoments as they undergo treatment of these disorders. There was anexpectantwoman overwhelmed by the news of a having a potentially aneuploid fetus. The woman had a fetus that had to be tested of geneticdefectivediseaseusing amniocentesis.She also had to go through the test, todetermineherfateand that of her unborn child.She had to make the decision in a short time frame. This is because the test has to be done before the child has developedfully. This would help the doctors determine ways through which they can help the unborn child be born without the expected disease. This situation puts the patient in a stress mode. The patient undergoes atoughmoment as she tries to make decisions about her unborn child with limited finance. In addition, she did not have social support. Such patients oftenresulttocrisis. The patient finds themselves withanxietyandconfusion. In some cases, they have atendencyof forgetfulness. She also has to deal with thethoughtthat her pregnancy may notsurvive. If the babyis born, she may have tobearthe child with the fatal geneticillnessof Huntington disease. In such a situation, the nurses role is crucial. The nurse to whom theladyis attending should play herpartso as to assist the patient tomanagethe situation. The nurse cantakethe patient through counseling session so as tolowerthe negative pressure that the patient is undergoing. On such a situation the nurseshould: Build a relationship between the patient and herself. This willeasetheatmospherebetween them, and the patient will be able to open up. She or he should assess the condition of thepatientandmakeaplanon how the goalswill be accomplished. The nurse should collect information from thepatientthat can be used in the diagnosis and treatment of the disease. During this phase, the nurse shouldbreakdown thecrisistoidentifywith the situation of the patient.At leastexplorethesituationin every point from the patients perspective.This way it will be easy for the patient to set goals. Theactionphaseinvolves the collection ofdatanecessary for the plan set in the beginning phase. The nurse should bekeentoeliminateall hindrances that willjeopardizetheaccomplishmentof the goals. These hindrances include lack of finances and lack of social support. He or she should capitalize on the strong points that willencouragethe patient to go through the therapy. After settling these details, and the information obtained is sufficient, the implementation process can commence. Terminationphasethis is thephasein which the nurse takes time toreviewon the progress of the patient. He or she will countercheck theprogressof the patient against the goals they hadsetat the start of therapy. Once theprogressis satisfactory, the nurse can thenreleasethe patient and terminate the counseling sessions. In case the goals set in thebuildingphase have not been accomplished, then the goals are reset. The patientis observedfurther until he or she recovers from the crisis. The ccanceller is careful when ending the counseling session with patients on his or her feelings.The woman that had difficulty in the decision making about the Huntington disease testing, agreed to do the test. The following are points to consider while handling apatientwith indecision on genetic disease. Ensure aneutralatmosphere between the patient and the counselor. The counselor should not impose his or her personal values to the patient; rathertakethe patient step by step until they have realized the problem in their perspective. The counselor should bekeennot to usedirectivenesson the patient.The counselor should use non defectiveness which willcapture, attention of the patient.However, in some cases he or she can usedirectivenessin the interrogation process but with an apologetic tone (West Student 2002). Crisis management Much often than not peoplegetin to difficult situations.In such timesit ishardto decide on the way forward. A person mayoptto find a counselor to assist them in decision making. It is usuallybetterbeingin a position, to make a decision early than to wait for some time. The situation maygetdepressive to handle. According to France (2007), there are three faces that encircle crisis management. 1. Phase one: impact phase: this is the reaction of an individual towards a certainsituationthat he or she have encountered. In such aninstanceoften theimmediatesolutions employed will not have worked out thesituation. Therefore, it turns out to be a problem that weighs heavy on the person. Anindividualmay notacceptbeing in thesituationthat they have found themselves engaged in at that time. A person mayreachanextentasking of themselves why he or she have gotten in to the problem.There are three dimensions which people may respond to a situation. Internal- external: this category clouds the person who feels that he or she is thecauseof the problem he or she is facing. Such anindividualmay be clouded by low-self esteem. Stable-unstable: this reaction refers to the decisions that arepermanentor temporary. A person may respond to an impact by picking on a decision that islong-lastingwhile another person may choose aplanthat is notpermanent. This category reactsfasttogetsolutions that will solve the situation fast. Global-specific: global attributions involve perceiving similarities across morenarrowapplications. 2. Phase two: coping phase: when a person has gotten overwhelmed by a situation and the firstapproachhas not worked, the person tends tofinda secondary solution. This is the way forward to deal with the situation. If the situation is not changing with the solution employed in the first instance, the individual tends to find a way to eliminate the problem completely. 3. Phase three: withdrawal: this phase comes in when thesolutionused do not work as planned by the person in the situation. In this phase, the individual maydecideto withdraw from the situation. Hence in this instance, the person finds out ways of getting rid of thesituationwithout solving it. In the case, of people suffering from genetic diseasescrisismanagement can be applied. Most patients, who are diagnoses by the disease, oftengetdepressed. This is because of the fact that they have contracted a fatal diseasee.g. in the case of Huntingtons disease. Some may overcome thefearof contracting the disease. The patient who can afford medication tries to get treatment. In other cases, patients without financialsupportmay find it more difficult. If the challenges and barriers become overwhelming for the patient, he or she mayresolvetowithdrawal. The patient then chooses to give up fighting theillness. At this point, the patient survives without any drugs or patientcareas he or she waits forfate. In conclusion, genetic disorders are notpredictable. They can behereditaryor non hereditary. Most of these diseases arefatalandrenderanindividualhelpless. In some cases, they cause premature deaths. As a result, it isbeneficialfor patients suffering from genetic disorders, to undergo treatment andtherapy. On the other hand, for anindividualthat has had family members dying sequentially of a certain disease, shouldresolvefor genetic testing. This can help them know if they have adominantor recessive defective gene which they are passing to other generations. Expectant mothers should also consider genetic testing for the good of the unborn child and the family as a unit. Medical personnel also need to come up in large numbers to find ways of improving patient care in hospitals. These personnel play acrucialrole in the recovery of patients suffering from genetic diseases. They shouldimprovethe patient care service to assist patients with such disease, and their family memberstoo. Genetic counseling plays a significant role in the management of these diseases (Ethobey 2010).Hence it is a worth course in building better medical services geared towards a healthy people. Buy custom The Advances in DNA Technology essay

Accounting Scandal Research Paper Example | Topics and Well Written Essays - 1250 words

Accounting Scandal - Research Paper Example â€Å"In 2000, Enron donated $1.76 million to the presidential campaign of the Republican George W Bush† (Davis, 2007, p83). This showed an unhealthy connection between the public sector and the private sector and this came back to haunt the firm and attempt to tarnish the image of some public figures. Kenneth Lay, the chairman of the board of directors and founder of Enron contributed more to George Bushs campaign more than any other person. Although no evidence was found that proved that there was direct bribery from the staff and management of Enron to public officials, many of them were found guilty for their involvement in what became a scandal. This is mainly connected to the overrides of the reporting requirements and expectations that were put in place. Enron maintained a complicated account structure and there was the difficulty of external stakeholders to demand more information and transparency. The management therefore got away with a lot of issues that were unreported and the scandal was eventually exposed by a whistleblower who reported the issue and matter to the authorities for prompt action. Enron used very inappropriate and wrong methods and procedures to record its accounts. Due to the fact that the firm had an influence over the political arena, Enron was able to get away with a lot of its poor and negative accounting practices. Enron used various techniques to provide misleading reports and information about their trading position. Basically, they used the revenue model and this sought to record revenue only and did very little concerning other important and relevant aspects of reporting (Campbell, 2008). This is know as the â€Å"agent† and â€Å"merchant† models of accounting. To this end, Enron created a system through which they set up false and other puppet entities to act as their agents. In this quest, the â€Å"agents† signed contracts and undertook very risky ventures in the name of Enron. These

Geography of Desire Essay Example | Topics and Well Written Essays - 1000 words

Geography of Desire - Essay Example With this on hand, it is then essential to analyze the relationship of Silicon Valley, which is the San Francisco Bay Area, to its culture with the influence of technology. Prior to discussing the relationship of the geographical location and culture in Silicon Valley, it is vital to gain an overview of technology and its importance. In essence, technology is defined as the manner of constructing machines and attributing to it their capabilities and efficiency while being used by an individual (McLoughlin 6-7). With this on hand, it can be inferred that the importance of technology can be determined in perspective of the user of the said technological machinery. Moreover, technology then can be considered as a great influencing factor to the user and even the environment of the user, which had occurred in Silicon Valley. Silicon Valley, in the past 40 years, has been considered as the â€Å"birthplace of many of the largest and fastest growing electronics firms in the world† ( Garud and Karnoe 127). In the past, there have been many technological experiments conducted in Silicon Valley, but one of the most crucial deciding factors for the technological hub was the establishment of the IBM laboratory in San Jose. With this action done, Silicon Valley was able to open its doors to the different technological firms, including Zilog, a semiconductor fir, and the Xerox Palo Alto Research Center (Garud and Karnoe). These fostered the beginning and the continuous of the technological innovation in the Valley. In addition, as the firms have been increasing in the Valley, it had also influenced the cultural activity in the area. As industrialization paved its way to Silicon Valley, it had also changed, and eventually broke the barrier between managers, employees, and function of corporations in the different technological sector present in the valley. The culture of start-ups became the trend in Silicon Valley, which was anchored on the â€Å"trust in individual a high degree of professional autonomy, and generous benefits† (Saxenian 50). This type of corporate culture allowed the managers, supervisors, and the heads of the department to create a normal working environment in the organizational system. This meant that employees can easily approach their managers in an informal manner in the hallway, and even have a small lunch time with their coworkers and bosses. The culture in Silicon Valley mostly anchored in the abolishment of organizational hierarchy in order to foster teamwork, camaraderie, and creativity (Saxenian 50-51). Aside from this, according to Martin Kenney â€Å"the Silicon Valley culture is based on establishing a company and then selling it to either public or a corporate acquirer† (â€Å"Lessons from the Development† 58). Therefore, aside from the non-hierarchical culture, Silicon Valley also became a breeding ground for entrepreneurs in the industry or technology. The culture born from the economic ac tivities in Silicon Valley is not considered as a unique one, but it is considered by many as â€Å"extreme entrepreneurship† (Kenney, â€Å"Lessons from the Development† 59). Looking back, in the beginning of the Silicon Valley, most of the employees were riskful and was able to pull through by transferring from one job to another. However, as the start-up