Battle of Coochs Bridge in the American Revolution

Battle of Cooch's Bridge in the American Revolution Battle of Coochs Bridge - Conflict Date: The Battle of Coochs Bridge was fought September 3, 1777, during the American Revolution (1775-1783). Battle of Coochs Bridge - Armies Commanders: Americans General George WashingtonBrigadier General William Maxwell450 men British General Sir William HoweLieutenant General Lord Charles CornwallisLieutenant Colonel Ludwig von Wurmb293 men Battle of Coochs Bridge - Background: Having captured New York in 1776, British campaign plans for the following year called for Major General John Burgoynes army to advance south from Canada with the goal of capturing the Hudson Valley and severing New England from the rest of the American colonies.   In commencing his operations, Burgoyne hoped that General Sir William Howe, the overall British commander in North America, would march north from New York City to support the campaign.   Uninterested in advancing up the Hudson, Howe instead set his sights on taking the American capital at Philadelphia.   To do so, he planned to embark the bulk of his army and sail south. Working with his brother, Admiral Richard Howe, Howe initially hoped to ascend the Delaware River and land below Philadelphia.   An assessment of the river forts in the Delaware deterred the Howes from this line of approach and they instead decided to sail further south before moving up the Chesapeake Bay.   Putting to sea in late July, the British were hampered by poor weather.   Though aware of Howes departure from New York, the American commander, General George Washington, remained in the dark regarding the enemys intentions.   Receiving sighting reports from along the coast, he increasingly determined that the target was Philadelphia.   As a result, he began moving his army south in late August.   Battle of Coochs Bridge - Coming Ashore: Moving up the Chesapeake Bay, Howe started landing his army at Head of Elk on August 25.   Moving inland, the British began concentrating their forces before beginning the march northeast toward Philadelphia.   Having encamped at Wilmington, DE, Washington, along with Major General Nathanael Greene and the Marquis de Lafayette, rode southwest on August 26 and reconnoitered the British from atop Iron Hill.   Assessing the situation, Lafayette recommended employing a force of light infantry to disrupt the British advance and give Washington time to choose suitable ground for blocking Howes army.   This duty normally would have fallen to Colonel Daniel Morgans riflemen, but this force had been sent north to reinforce Major General Horatio Gates who was opposing Burgoyne.   As a result, a new command of 1,100 handpicked men was quickly assembled under the leadership of Brigadier General William Maxwell. Battle of Coochs Bridge - Moving to Contact: On the morning of September 2, Howe directed Hessian General Wilhelm von Knyphausen to depart Cecil County Court House with the right wing of the army and move east toward Aikens Tavern.   This march was slowed by poor roads and foul weather.   The next day, Lieutenant General Lord Charles Cornwallis was ordered to break camp at Head of Elk and join Knyphausen at the tavern.   Advancing east over different roads, Howe and Cornwallis reached Aikens Tavern ahead of the delayed Hessian general and elected to turn north without waiting for the planned rendezvous.   To the north, Maxwell had positioned his force south of Coochs Bridge which spanned the Christina River as well as sent a light infantry company south to set an ambush along the road. Battle of Coochs Bridge - A Sharp Fight: Riding north, Cornwallis advance guard, which was comprised of a company of Hessian dragoons led by Captain Johann Ewald, fell into Maxwells trap.   Springing the ambush, the American light infantry broke up the Hessian column and Ewald retreated to obtain aid from Hessian and Ansbach jgers in Cornwallis command.   Advancing,  jgers led by Lieutenant Colonel Ludwig von Wurmb engaged the Maxwells men in a running fight north.   Deploying in a line with artillery support, Wurmbs men attempted to pin the Americans in place with bayonet charge in the center while sending a force to turn Maxwells flank.   Recognizing the danger, Maxwell continued to slowly retreat north towards the bridge (Map). Reaching Coochs Bridge, the Americans formed to make a stand on the east bank of the river.   Increasingly pressed by Wurmbs men, Maxwell retreated across the span to a new position on the west bank.   Breaking off the fight, the  jgers occupied nearby Iron Hill.   In an effort to take the bridge, a battalion of British light infantry crossed the river downstream and began moving north.   This effort was badly slowed by swampy terrain.   When this force finally arrived, it, along with the threat posed by Wurmbs command, compelled Maxwell to depart the field and retreat back to Washingtons camp outside Wilmington, DE. Battle of Coochs Bridge - Aftermath: Casualties for the Battle of Coochs Bridge are not known with certainty but are estimated at 20 killed and 20 wounded for Maxwell and 3-30 killed and 20-30 wounded for Cornwallis.   As Maxwell moved north, Howes army continued to be harassed by American militia forces.   That evening, Delaware militia, led by Caesar Rodney, struck the British near Aikens Tavern in a hit-and-run attack.   Over the next week, Washington marched north with the intention of blocking Howes advance near Chadds Ford, PA.   Taking a position behind the Brandywine River, he was defeated at the Battle of Brandywine on September 11.   In the days after the battle, Howe succeeded in occupying Philadelphia.   An American counterattack on October 4 was turned back at the Battle of Germantown.   The campaign season ended later that fall with Washingtons army going into winter quarters at Valley Forge.            Selected Sources DAR: Battle of Coochs BridgePHAA: Battle of Coochs BridgeHMDB: Battle of Coochs Bridge

Meri Moken †Why Antibiotics Stop Working

Meri Moken – Why Antibiotics Stop Working Free Online Research Papers In 1993, when Meri Moken got recognized by various institutions for her research work on the effect of detergents on bacteria, a lot of her work was actually a reflection of a broader spectrum of research that had started as early as the 1960s. What Meri essentially discovered was the resistance of bacteria to household detergents and bleaches – a subset of the age-old capability by bacteria to adapt to harmful chemicals. Her discovery illuminated the ever-burgeoning problems that pathogens present: that, over time, they become harder to eradicate, as any chemicals used against them become ineffective. Pathogens present a huge problem in the medical world, because not only are they becoming more problematic despite advances in antibiotics, but also because the advances are actually making the problem worse. As an illustration, the Escherichia coli, an intestinal bacterium, grew resistant to all fluoroquinolone antibiotics administered against it within a decade. This high rate of adaptation presents a grave problem, since it implies that scientific advances would be hard-pressed to keep up with the bacteria. Then, in 1994, it was discovered that some strains of Streptococcus pneumonia were resistant to Penicillin, and that a full 25% of all people suffering from this Pneumonia were resistant to antibiotics. It was a further indication that the war against pathogen was slowly, but surely, being lost. There are several ways in which bacteria can gain mastery over any antibiotic thrown at them. Every new antibiotic essentially places a kind of selective pressure on them, and the most adapted amongst them survive down the generations. Sometimes, a spontaneous mutation in the bacterial DNA may result in an organism with a higher level of resistance. Other bacteria engage in a process called transformation – a microbial sex-like process in which DNAs are shuffled between two organisms. But most ominous of all adaptation methods is the one in which bacteria interchange a section of DNA called a plasmid amongst themselves. It is ominous since it presents a very efficient way of increasing the overall adaptability of bacteria, without incurring the unpredictability that mutation presents. The resistance that results from the DNA changes within the bacteria is expressed in several ways, at the molecular level. Some of the bacteria change the target molecule, essentially inactivating it and thus making it harmless. Others go a step further and decompose the molecule into its elements. Others simply sequester the offending drug, thus keeping it away from their warpaths. And finally, some bacteria keep the fatal chemicals out of the cells, and prevent their entrance to it. Since the bacterial problem is a serious menace, several solutions have been suggested to help keep bacteria in their rightful place within the biosphere. Firstly, antibiotics should only be used when absolutely necessary. Using them at any other time only increases chances of developing resistance in the microbes. Secondly, all antibiotics, once administered, should be taken until the entire dose is completed. Partially resistant bacteria are less likely to survive and multiply when doses are completed. Thirdly, narrow-spectrum antibiotics should be used, to avoid triggering adaptation mechanism in other bacteria within the vicinity. And finally, vaccines can be innovated to act on a preventative platform rather than a curative one. References Why files (1997) What doesn’t kill them makes them stronger Retrieved 21st January 2009 from Research Papers on Meri Moken - Why Antibiotics Stop WorkingGenetic EngineeringThe Effects of Illegal ImmigrationIncorporating Risk and Uncertainty Factor in CapitalResearch Process Part OneInfluences of Socio-Economic Status of Married MalesBionic Assembly System: A New Concept of Self19 Century Society: A Deeply Divided EraMarketing of Lifeboy Soap A Unilever ProductMind TravelOpen Architechture a white paper

Tax memo Essay Example | Topics and Well Written Essays - 500 words

Tax memo - Essay Example In the case of Acme Corporation and its shareholders, the redemption exercise may imply one or more tests, usually referred to as the three major tests. First is the complete redemption test. Here, there will be an absolute redemption of every stock possessed by the shareholder. Second is the substantially disproportionate test where the vending shareholder must not possess as much as 50 percent of the voting power following the redemption exercise. In addition, the owners voting stock in the company need to be not as much as 80 percent of the company’s aggregate voting stock after the redemption exercise. Third is what has been referred to as the â€Å"not essentially equivalent to a dividend test† (Ronald, 48). Here, the implication is that the redemptions need not be equal to the dividend issued by the company. It is important to note that the shareholder’s constructive, direct and indirect ownership can be considered in the above explained tests. If a shareho lder meets the above tests, the price that the company redeems the ownership will be treated like a normal exchange of sale and this will be recognized as if the owner was only passing this to another person or a third party. If the tests are not met, the company’s redemption price will be taken like the passing was made to another shareholder. Tax cost of a redemption to shareholders does start with if the transaction succeeds for sales or interchanged treatment, also Smith should confirm whether Acme Corporation has accrued return and earnings. If Acme does not have returns and earnings or the company has never acquired another company through merging, which had profit and earnings then the divided treatment cannot come into being from redemption. Normally dividends shared among its shareholders are usually treated as non-taxable return of capital to the point of accustomed foundation of stock, then capital growth from estimated nature of

Family Autobiography Essay Example | Topics and Well Written Essays - 1750 words

Family Autobiography - Essay Example Family and consumer sciences are a set of aspects that combines social and natural sciences for better understanding of the relationship that an individual shares in a society (Enrique, Howk and Huitt 1-18). The essay elaborates on my family background and ideologies, which have an influence on my development. In addition, the section of economics and social class along with their impact on my development has been explained. Moreover, special emphasis has been provided on the different positive and negative impacts of parental care. A. I belong to a Persian family and am the youngest son of my parents. I am younger of the two sons of my parents. I am brought up under strict guidelines that are followed within an Islamic religion. I am 21 years old and am close to my parents. I belong to an upper middle class family and reside with my parents and my elder brother. On a scale of 0 to 10, I would rate myself 8 points in terms of happiness. The family I belong to is supportive and provides me with immense mental strengths to carry out my tasks. Furthermore, I have certain duties to carry out in my family by taking care of my parents as my elder brother is working outside and most of the time stays out. Owing to the fact that my brother stays out, I have to perform the major duties of my family and take care of my parents. Besides family responsibilities, I have been also efficiently performing the responsibilities that are to be undertaken in a society. These responsibilities include different relationship and bond ing that I have with my peers, teachers and other people I am associated with in the society. B. I am the youngest member of my family. I have an elder brother named Arash, who is 24 years old and is working in the UAE. Initially, I used to feel that being younger provides me with a lot of preferences and gives me all the freedom. Being the

Painting Analysis at the National Gallery of Canada Essay Example for Free

Painting Analysis at the National Gallery of Canada Essay On a recent field trip to the National Art Gallery in Ottawa, as a class, we looked at some paintings. The painting that stood out to me was Simone Martini’s painting titled St. Catherine of Alexandria. We have been studying the Renaissance period and this one was identifiable instantly. For our class assignment, we are required to identify the time period or style the painting might belong to, identify its stylistic features, the date it was created, the artist, mediums used, as well as the significance of its subject matter and its importance in the exhibition. By studying Simone Martini’s painting of St. Catherine of Alexandria I was able to compare it with some of the images seen in class, and from Janson’s History of Art textbook. When I first looked at Simone Martini painting of St. Catherine of Alexandria, I noticed many things. I noticed how her face gesture, the position of the subjects head, and arm size hinted naturalism; however, the proportions are not yet perfected. The subject is also being identified through the broach she is wearing around her neck, which is a wheel indicating she is St. Catherine of Alexandria. I noticed the subject has a gold halo and seems to be in a narrative; these techniques are seen in many paintings during the Renaissance period (as seen in image 1-4 in appendix). Being the left hand panel to the Madonna and Child, I also knew that this piece would have significance in the history of Art. The use of gold (gilding- seen in image 1-4 in appendix) and materials used (tempera on wood) also led me to believe that this is a Renaissance painting. Research has helped me determine that this beautiful golden painting by Simone Martini (St. Catherine of Alexandria) was made during the early Italian Renaissance period. This is because of the style and techniques that are used within the painting. The style of the renaissance period consisted of techniques using geometry and perspective, chiaroscuro, contraposto, naturalism, and classical themes. The main characteristics of the early include the use of one-point perspective, which creates the illusion of a three-dimensional space. The use of geometry is also typically seen in the composition of figures laid out in a triangular form to create a sense of balance (Reznichenko, 2013 para. 2 ). During the early Italian Renaissance period the artist attempts to represent figures and nature more realistically than previously during the medieval period. They studied nature and the human body to learn more about the anatomy of humans and animals (Reznichenko, 2013 para. 3). In Simone Martini’s painting of St. Catherine of Alexandria, you can see examples of this in the face gesture, the position of the subjects head, and the detail in her eye-lashes (Humanism/naturalism seen in images 3 and 5 in appendix). Early Italian Renaissance artists also used contrast between gradations of light and dark and shading, which is the technique they used to create a three-dimensional sense of space (Reznichenko 2013 para. 4). (shading seen in images 1 and 2 in appendix). In St. Catherine of Alexandria, you can see the shadows and shading throughout the painting; this is especially evident in the subjects face, neck, arms and hands. The subject matter in early Italian Renaissance included some classical themes of Greek and Roman mythology as well as depicting portraits and other worldly subjects. (Reznichenko, 2013, para. 5). In Martini’s painting, you see that it is both secular and sacred, but religion stands out a little more because of the subject portrayed is St. Catherine of Alexandra. Contropposto is a word that represents a the stance of the figure which ones’ weight rests on one foot; this technique was used to create a twist in the figures body, thus, making the hip and shoulders no longer parallel (seen in images 3 and 5 in appendix) . The use of contropposto had been seen before but not used since the classical period. (Reznichenko, 2013, para. 6) Simone Martini’s painting of St. Catherine of Alexandria does not show the subjects stance, but it does show a twist in the body (one point perspective) which creates the same idea of technique. Simone Martini, St. Catherine of Alexandria, was created in 1322–23, using tempera on wood. The size of the wood panel is 32 3/4 Ãâ€" 17 1/8 inches (with frame). It is part of the Collection of the National Gallery of Canada. The painting of St. Catherine of Alexandria is part of a triptych; and is the left panel of the altarpiece. The specific term used for this type of painting is called a polyptych. This is a three panel system with â€Å"wings† or side panels; Madonna and Child are represented in the centre piece which was the largest section (Wikipedia, 2013, para. 1 2). The significance of the subject matter in Simone Martini painting of St. Catherine of Alexandria is the changes that were seen during the renaissance, and the preservation of the tempera painting itself. The techniques seen during this period are very important. One being in order to depict the human figure properly, artists needed to study the anatomy. With the studying of the human body, artists used the technique of shading to create the volume and a better sense of perspective. During the restoration of St. Catherine of Alexandria, many parts were left untouched while others were carefully re-painted (Brink, 2001, para. 7); in my opinion, this says a lot about the quality of work Martini presented. In other words, this painting is significant because of the stylistic breakthrough of its time, as well as the care and quality of the painting itselfas well as the materials used. The titling of this period â€Å"re-birth† or â€Å"Renaissance† hints this time involved a breakthrough in art history. Through the use of geometry and perspective, chiaroscuro, contraposto, naturalism, classical themes, and the materials used, I was able to determine the stylistic period that Simone Martini, St. Catherine of Alexandria, was created during the renaissance period. Further research helped me determine that this painting was in fact a creation of the Early Italian Renaissance period. Without the use of these techniques and materials, the significance of this time in art history would probably not be recognized as the â€Å"renaissance, or â€Å"re-birth† of classical learning, literature and art. Studying this type of work has helped me realize why it is important to cherish certain works and learn about why they are significant. Without the renaissance period we would still be seeing bland, flat images without volume, and a lack of proportion. Works Cited: Brink, J. (n.d.). Annual Bulletin 3, Simone Martinis St Catherine of Alexandria An Orvietan Altarpiece and the Mystical Theology of St Bonaventure by Joel Brink. National Gallery of Canada . Retrieved February 11, 2013, from http://www.gallery.ca/bulletin/num3a/brink1.html Cimabue Wikipedia, the free encyclopedia. (2013, January 31). Wikipedia, the free encyclopedia. Retrieved February 11, 2013, from http://en.wikipedia.org/wiki/Cimabue Janson, H. W., Davies, P. J. (2007). The High Renaissance in Itali. Jansons history of art: the western tradition (7th ed., p. 567). Upper Saddle River, N.J.: Pearson Prentice Hall. Janson, H. W., Davies, P. J. (2007). The Early Renaissance in Fifteenth-Century Italy. Jansons history of art: the western tradition (7th ed., p. 545). Upper Saddle River, N.J.: Pearson Prentice Hall. Polyptych Wikipedia, the free encyclopedia. (2012, February 7).Wikipedia, the free encyclopedia. Retrieved February 11, 2013, from http://en.wikipedia.org/wiki/Polyptych Reznichenko, T. (n.d.). Characteristics of Italian Renaissance Art | eHow.com.eHow | How to Videos, Articles More Discover the expert in you. | eHow.com. Retrieved February 11, 2013, from http://www.ehow.com/list_6459200_characteristics-italianrenaissance-art.html Simone Martini Wikipedia, the free encyclopedia. (2013, February 3). Wikipedia, the free encyclopedia. Retrieved February 11, 2013, from http://en.wikipedia.org/wiki/Simone_Martini Steinhart, J. (n.d.). St. Catherine of Alexandria by Simone Martini at National Gallery of Canada. Ottawa, ON.. Travel Photo Base World Image Collection Visual Travel Planner. Retrieved February 11, 2013, from http://travelphotobase.com/v/CDNON/ONOG30 Tribute Money Wikipedia, the free encyclopedia. (2012, August 3). Wikipedia, the free encyclopedia. Retrieved February 11, 2013, from http://en.wikipedia.org/wiki/Tribute_Money

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.