A comparison between cardiac CT scanning and cardiac digital subtraction angiography (DSA)

Abstract Coronary artery disease affects nearly one tenth of the UK population and remains the leading cause of death in the western world. To investigate and provide interventions for coronary artery disease, imaging of the coronary arteries to enable visualisation of atheromatous plaque is required. This review looked at the techniques of cardiac computed tomography scanning and cardiac digital subtraction angiography, and their contribution to the investigation of coronary artery disease. Comparison of the procedures considered technique, radiation exposure, contrast agent, clinical indications and efficacy in diagnosis of coronary artery stenosis. On comparison of the effectiveness of the techniques, both were shown to have been effective non-invasive procedures that may be used to rule out diagnoses and avoid inappropriate use of invasive angiography. The research shows mixed evidence for cardiac computed tomography angiography as a test of high specificity, however sensitivity and speci ficity of cardiac digital subtraction angiography is high, and therefore suggest that the techniques may be useful in low risk patients. Introduction Coronary artery disease remains the main cause of death in the UK and western world (Hacker, 2013; Liu et al., 2002) and contributes a substantial disease burden, affecting 7% of men and 5% of women in the UK in 1999 (Liu et al., 2002). Coronary artery disease results from the build up of atherosclerotic plaque within the arteries supplying the myocardium. This plaque limits the flow of blood through the arteries, and can cause ischaemia of the heart muscle. If the plaque becomes unstable and ruptures, this may lead to thrombus formation and the complete occlusion of an artery, resulting in a myocardial infarction (McClure et al., 2009). Acute coronary syndrome (ACS) is a sub-classification of coronary artery disease and encompasses unstable angina, non-ST elevation myocardial infarction and ST elevation myocardial infarction. ACS represents a range of conditions that result from thrombus formation in coronary arteries, and if untreated has poor prognosis and high mortality (NICE, 2010). To investigate and provide information for interventions for coronary artery disease and ACS, visualization of the coronary arteries and any lesions caused by atherosclerotic plaque is required. Advances in technology have given rise to several sophisticated perfusion analysis techniques, which provide greater prognostic value than morphological imaging (Hacker, 2013). Perfusion analysis allows the blood flow through the coronary vessels to be observed and any abnormalities in the perfusion can be interpreted as a functional consequence of atherosclerotic changes within the vessels (Hacker, 2013). Currently, UK guidelines (NICE, 2010a) recommend coronary angiogram as first line management for patients presenting with ACS. This enables imaging of the coronary arteries to assess perfusion. It is important to assess the circulation as arteries can be affected from the earliest stages of endothelial dysfunction to high-grade coronary artery stenoses (Hacker et al., 2010; Bugiardini et al. 2004; Kaufmann et al., 2000), and this provides the information necessary for prognosis and intervention. With the advances in technology, there are now various diagnostic tests available to assess coronary artery disease, including coronary angiography and computed tomography (CT) scanning (Gorenoi, Schonermark & Hagen, 2012). This review aims to review the literature on coronary CT scanning and digital subtraction angiography, their clinical applications, techniques and comparative value in coronary artery assessment and diagnosis. Cardiac Digital subtraction angiography Coronary angiography is the conventional diagnostic procedure used in coronary artery disease. It is a minimally invasive technique, whereby a catheter is placed into the radial or femoral artery and is advanced through the arterial system to the coronary arteries. A contrast agent is then injected at the aortic root and allows visualization of the arteries using x-ray in real time at up to 30 frames per second. This allows a view of the extent, location and severity of coronary obstructive lesions such as atherosclerosis and enables prognostic indication (Miller et al., 2008). Coronary angiography also enables catheter placement either side of the lesion to assess pressure changes and determines the degree of flow obstruction (Miller et al., 2008). . Digital subtraction angiography (DSA) again works by introducing a contrast agent into the coronary arteries and taking x-rays in real time, however a pre image is taken by x-ray. This allows for the post images to be subtracted from the original mask image, eliminating bone and soft tissue images, which would otherwise overlie the artery under study (Hasegawa, 1987). Unlike conventional angiography, it is possible to conduct DSA via the venous system, through accessing the superior vena cava via the basillic vein (Myerowitz, 1982). This removes the risks associated with arterial cannulation (Mancini & Higgins, 1985). The procedure can also be performed with a lower dose of contrast agent and be done more quickly therefore eliminating constraints of using too much contrast during a procedure (Myerowitz, 1982). Whilst DSA is the gold standard in arterial imaging of carotid artery stenosis (Herzig et al., 2004), the application of DSA to the coronary arteries is limited due to motion artefacts associated with each heartbeat and respiration (Yamamoto et al., 2009). There are numerous cardiac clinical applications of DSA, it can be used to assess coronary blood flow (Molloi et al., 1996), valvular regurgitation (Booth, Nissen & DeMaria, 1985), cardiac phase (Katritsis et al., 1988), congenital heart shunts (Myerowitz, Swanson, & Turnipseed, 1985), coronary bypass grafts and percutaneous coronary intervention outcomes (Katritsis et al, 1988; Guthaner, Wexler & Bradley, 1985). However, others have suggested that the coronary arteries are not visualized well due to their small size, movement, their position overlying the opacified aorta and left ventricle, and confusion with other structures such as the pulmonary veins (Myerowitz, 1982). Cardiac CT Scanning Development of CT scanning in the 1990s enabled an increase in temporal resolution that was sufficient to view the beating heart, and they now provide a non-invasive technique for diagnostic and prognostic purposes. Cardiac CT scans have clinical applications that go beyond perfusion investigation, and can be used to assess structure and function of the heart (for example in electrophysiology disorders or congenital heart disease) due to its ability to provide anatomical detail (Achenbach & Raggi, 2010). CT scans can be used to assess coronary artery disease with and without injection of contrast agent (Achenbach & Raggi, 2010) by calcium scan or CT angiography. Coronary calcium CT scanning uses the evidence base that coronary artery calcium is a correlate of atherosclerosis (Burke et al., 2003) and is a strong prognostic predictor of the future development of coronary artery disease and cardiac events (Arad et al., 2000; Budoff et al., 2009; Achenbach & Raggi, 2010). Calcium is easily depicted on CT scan due to its high CT attenuation, and is classified according to the Agatson score, which considers the density and area of the calcification (Hoffman, Brady & Muller, 2003). Coronary CT angiography (CTA) allows visualization of the coronary artery lumen to identify any atherosclerosis or stenosis within the vessels. Patients are injected intravenously with a contrast agent and then undergo a CT scan. There are limitations regarding the suitability of patients for coronary CTA due to prerequisites of sinus rhythm, low heart rate and ability to follow breath-holding commands. Additionally, obesity presents a problem for patients that cannot fit into the scanner and affects the accuracy of the procedure. (Achenbach & Raggi, 2010). Comparison of cardiac DSA and cardiac CT scanning The technical differences between cardiac DSA and cardiac CT scanning give rise to differences in the clinical indications for the procedures, their diagnostic efficacy and also different risks or relative benefits to the patients. Due to the nature of the images produced by coronary CTA and DSA, each lends itself to different indications for use. Whilst coronary DSA provides imaging of all aspects of perfusion, CTA used with contrast agent also provides this however has the additional advantage of being able to assess structure and function of the heart. Coronary CTA has been shown to have a high accuracy at detection and exclusion of coronary artery stenoses (Achenbach & Raggi, 2010). In a multicentre trial conducted by Miller et al. (2008), patients underwent coronary calcium scoring and CT angiography prior to conventional invasive coronary angiography. The diagnostic accuracy of coronary CTA at ruling out or detecting coronary stenoses of 50% was shown to have a sensitivity of 85% and a specificity of 90%. This showed that coronary CTA was particularly effective at ruling out non-significant stenoses. Additionally, coronary CTA was shown to be of equal efficacy as conventional coronary angiography at identifying the patients that subsequently went on to have revascularisation via percutaneous intervention. This was shown by an area under the curve (AUC), a measure of accuracy of 0.84 for coronary CTA and 0.82 for coronary angiography. Miller et al.’s (2008) study included a large number of patients at different study sites , and additionally represented a large variety of clinical patient characteristics. The author’s claim that these factors contribute to the strength and validity of the study findings, and suggest that in addition to using patients with clinical indications for anatomical coronary imaging, should be used as evidence that coronary CTA is accurate at identifying disease severity in coronary artery disease. Miller et al. (2008) did however,, find that positive predictive and negative predictive values of coronary CTA were 91% and 83% respectively and therefore suggested that coronary CTA should not be used in place of the more accurate conventional coronary angiography. A low positive predictive value (in relation to the prevalence of disease) was proposed to be due to a tendency to overestimate stenosis degree as well as the presence of artefacts leading to false positive interpretation (Achenbach & Raggi, 2010). Other research providing comparison between coronary CTA and conventional coronary angiogram has highlighted variability in results. A meta-analysis conducted by Gorenoi, Schonermark and Hagen (2012) investigated the diagnostic capabilities of coronary CTA and invasive coronary angiography using intracoronary pressure measurement as the reference standard. The authors found that CT coronary angiography had a greater sensitivity than invasive coronary angiography (80% vs 67%), meaning that coronary CTA was more likely to identify functionally relevant coronary artery stenoses in patients. Despite this,, specificity of coronary CTA was 67%, compared to 75% in invasive coronary angiography, meaning that the technique was less effective at correctly excluding non-diagnoses than invasive coronary angiogram. This research appears to contradict the power of cardiac CTA at excluding diagnoses of coronary artery stenosis as suggested by Miller et al. (2008), he study did combine evidence from over 44 studies to provide their results and therefore had a large statistical power. The authors interpret the results in light of the clinical relevance of cardiac imaging, suggesting that patients with a higher pretest possibility of coronary heart disease will likely require invasive coronary angiography for revascularisation indicating that coronary CTA may be a helpful technique in those patients with an intermediate pre-test probability of coronary heart disease that will therefore not require invasive angiography. Goldberg et al. (1986) investigated the efficacy of DSA in comparison to conventional coronary angiography in 77 patients. They found that the two angiograms agreed within one grade of severity in 84% of single cases and 90% of multiple cases, identifying both patent and lesioned arteries. The results led the authors to conclude that there was no significant difference between the two methods and that DSA could be used in selective coronary angiography to find results comparable to that of conventional angiography. In addition to being a small study into the efficacy of DSA, the study also had several sources of inherent variability that should be considered when interpreting the results. These included differing sizes of digital imaging screen and non-use of calipers, meaning that the interpretation of the images could vary throughout the study. The authors also suggest that whilst showing strong support for the use of DSA in coronary artery disease, the technique may not actually p ermit better prognostic determinations or clinical judgements that are better than conventional angiography, and therefore the further implementation of the techniques may not be founded or necessitated. More recently, there has been further research looking at the effectiveness of DSA as a way of measuring coronary blood flow. Whilst motion artefacts have proven a problem in lots of past research (Marinus, Buis & Benthem, 1990; Hangiandreou, 1990), recent research has developed methods to minimise these. Moilloi and colleaues (1996) showed that using a motion-immune dual-energy digital subtraction angiography, absolute volumetric coronary blood flow could be measured accurately and thus provide an indication of the severity of any arterial stenosis.This may provide further suggestion for clinical implementation of DSA. Although these studies provide evidence for the efficacy of cardiac DSA and CTA, they often make comparisons to conventional angiography. This is useful as a baseline comparison, however it is difficult to make comparisons between the two procedures directly due to less available evidence making direct comparisons. Lupon-Roses et al. (1985) conducted a study investigating both coronary CTA and venous DSA. The study looked at the efficacy of both techniques at diagnosing patency of coronary artery grafts compared to the control conventional angiography. CT was shown to diagnose 93% of the patent grafts and 67% of the occluded grafts whereas DSA correctly diagnosed 98% and 100% of patent and occluded grafts respectively. Interestingly, the DSA picked up the 11 grafts that were misdiagnosed by CTA and the CTA picked up the 2 grafts misdiagnosed by the DSA. This data may suggest that individually, DSA has a better profile for diagnosis of coronary artery occlusion, however if the two procedures are used in combination exclusion of patent arteries and diagnosis of occluded arteries would be effective (Lupon-Roses et al., 1985). Coronary DSA and CTA are both non-invasive procedures (unlike the conventional coronary angiography where a wire is placed in the coronary vasculature). With the only invasive part of the procedure being the injection of the contrast material into a vein. This presents a significant advantage to both procedures over that of conventional angiography, and may even permit investigation on an outpatient basis (Meaney et al., 1980). Similarly, both DSA and coronary CTA are favoured because of their intravenous approach, eliminating the risks of bleeding or arterial injury from an intra-arterial catheterization and being able to be used in those with limited arterial access. However, although the intravenous approach used in cardiac DSA makes it favourable, it does lead to difficulty with visualisation of the coronary arteries due to the overlying iodinated pulmonary and cardiac structures (Mancini & Higgins, 1985). Therefore,, intra-arterial DSA is also sometimes used (Yamamoto et al., 20 09). As with all CT scanning, coronary CTA carries with it a dose of ionizing radiation (Brenner & Hall, 2007). Studies have estimated that for diagnostic CT scanning, patients are on average exposed to 12mSv of radiation during the procedure, the equivalent of 600 x-rays (Hausleiter et al., 2009). Estimates of radiation doses associated with conventional coronary angiography are lower than that of coronary CTA at 7mSv (Einstein et al., 2007). Additionally, DSA technique reduces the radiation dose from that of conventional coronary angiography as the vessels are visualised more clearly (Yamamoto et al., 2008). The dangers of radiation exposure are increased risk of developing cancer, skin injuries and cateracts (Einstein et al., 2007). It is therefore important that the benefits of conducting the procedure greatly outweigh the risk of radiation exposure. CT calcium scanning provides a low radiation dose at around 1mSv (Hunold et al., 2003). Cardiac CT calcium scanning does not require administration of a contrast agent, unlike in coronary CTA and DSA that use iodine based contrast agents. The risks associated with contrast agent include nephrotoxicity and risks of hives, allergic reactions and anaphylaxis (Maddox, 2002). The amount of contrast agent used is partly dependent on the length of the procedure and how clearly the arteries can be visualised. For this reason, both cardiac CTA and DSA use less contrast agent that conventional coronary angiography (Brant-Zawadzki, et al., 1983). CT calcium scanning of the coronary arteries is therefore recommended in those with less likelihood of coronary artery disease (NICE, 2010). Both coronary CTA and DSA require interpretation by trained physicians, and the importance of training and achieving intra-rater reliability should not be underestimated (Pugliese et al., 2009). Conclusion Overall, both coronary CT and DSA have been demonstrated as effective procedures for the imaging of the coronary arteries in CAD (Achenbach & Raggi, 2010; Miller et al., 2008; Moilloi et al., 1996; Goldberg et al., 1986). Whilst cardiac CT scanning does provide a wider range of clinical applications, allowing assessment of perfusion as well as cardiac structure and function (Achenbach & Raggi, 2010), coronary DSA has many applications that allow assessment of coronary blood flow (Molloi et al., 1996; Katritsis et al, 1988; Booth, Nissen & DeMaria, 1985; Guthaner, Wexler & Bradley, 1985; Myerowitz, Swanson, & Turnipseed, 198). Both cardiac DSA and CTA procedures have their advantages. As non-invasive procedures, these techniques pose less risk to patients, and enable the possibility of outpatient investigation, to be used to rule out diagnoses and to avoid inappropriate invasive coronary angiogram (Gorenori et al., 2012). Additionally, intravenous access is preferential to arterial cannulation for the contrast infusion, removing the risks associated with bleeding or intra-arterial injury. Cardiac DSA exposes the patient to a lower dose of radiation that coronary CTA (Hausleiter et al., 2009; Yamamoto et al., 2008; Einstein et al., 2007), which is beneficial at reducing the risk of genetic mutations and cancer. Cardiac CTA and DSA also have their common disadvantages. The use of contrast agent may present side effects for the patient including kidney damage and risk of allergic reactions and anaphylaxis (Maddox, 2002). For this reason, calcium CT scanning can be useful in patients that are not at high likelihood of coronary artery disease (NICE, 2010b). Additionally, both cardiac DSA and CTA are subject to motion artefacts from respiration and heart beats, which can cause difficulties with interpretation (Achenbach & Raggi, 2010; Yamamoto et al., 2009). In the case of cardiac CTA, this excludes a subset of patients that are unable to follow commands and those who have high heart rates. Overall, cardiac CTA and cardiac DSA are effective, non-invasive imaging techniques for assessment of coronary artery disease. Whilst they are not the gold standards in cardiac monitoring, they can provide important diagnostic information without exposing patients to the risks of invasive angiography. Due to this, their use should be weighted against clinical need, the risks of the procedures, and the suitability of the patient. Interpretation of cardiac CTA and DSA imaging should be by trained individuals. 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Conflicts by Pyong Gap Min

The book Changes and Conflicts by Pyong Gap Min gives us an analysis on how and why Korean migration to the United States has altered their traditional family system. Allyn and Bacon published the book in 1998. The book focuses on changes in gender roles and marital relations. Also Korean child socialization, adjustments of the elderly, and the nature of transnational families and kin ties are topics Min discusses in the book. Min uses results of several surveys as well as his own ethnographic research to back his claims. Min used his own personal family experiences, his observations of other Korean families, informal discussion with Korean school teachers and social workers, and Korean newspaper articles for insight on Korean immigrant families. He also interviewed 50 Koreans in N. Y. representing a broad range of Korean people. Finally, Min used census and survey data, including his own surveys of Koreans in New York, to provide statistical information about Korean immigrant families. Min starts his analysis of Korean immigrant family by providing some background information on the Korean community in N. Y. Min explains that recent Korean immigrants can be characterized as being highly educated, urbanized, and predominately Christian. Korean immigrants began to settle in New York after 1965. One reason is the need for medical professionals during the 1960s in the New York and New Jersey area. The demand for medical professionals attracted many Korean professionals to the area. These professionals later on became naturalized and were able to invite their relatives for permanent residence. A characteristic o f the contemporary Korean community living in N. Y. are their concentration in small business. Min explains that the vast majority of the Korean work force is segregated in the Korean sub-economy, either as business owners or as employees of co-ethnic businesses. Some Korean businesses include green groceries, trade business dealing, import business, dry-cleaning service, and nail salons. Min states that the segregation of Korean immigrants in the work place promotes the preservation of their Korean cultural traditions and social interactions with co-ethnic. Min then proceeds to examine the role Confucianism plays on the Korean family system. Min claims that Confucian values that emphasizes filial piety, family/kin ties, the patriarchal family order, and children†s education still have a powerful effect on the behavior and attitudes of all Koreans. For example, Korean government, school, and community encourage people to practice filial piety by rewarding those who are exceptional in showing loyalty, respect, and devotion to their parents and by punishing those who deviate far from the norm. Also the concept of patriarchy has helped establish a male dominated society in Korea. In Korea, boys are preferred and are treated more favorably than girls and more emphasis is placed on boys† education than girls are. Finally, the emphasis on child education can be seen in Korea where formal education is used as a means of social mobility. According to Min, the most significant change brought about by international migration is the phenomenal increase in wives† economic role coupled with the weakling of husbands† role as provider. Korean immigrant working women make an important income contribution to the family finances. Min claims that Korean wives play a more important role than their husbands do in many family business, particularly small dry cleaning shops and small restaurants. Also it is easier for Korean immigrant wives to find jobs compared to their husbands because of the demand for blue-collar jobs. Even though Korean wives play an important economic role, their power and status in Korean society does not increase. Min claims the status of a Korean woman as a â€Å"helper† in the family business rather than as a co-owner also diminishes her social status and influence in the Korean immigrant community. Also the segregation of Korean immigrants at economic and religious levels bolsters the patriarchal ideology they brought with them from Korea. However, reality still remains and Korean women†s increased economic role in many Korean immigrant families has reduced their husband†s patriarchal authority, creating new sources of marital conflict and sometimes leading to separation and divorce. Koreans† child care and child socialization patterns undergo significant changes when they move to the United States. The major reason Min gives is the increase in Korean Immigrant women†s participation in the labor force. In the U. S. Korean women who work and have pre-school children depend on private nurseries or an elderly mother or mother-in-law for child care while they continue to work. This is a contrast compared with life in Korea where women who have pre-school children usually do not participate in paid work, but instead focus on child care. Also because both Korean parents work long hours outside the home, many children are left unsupervised at home. Min believes that this has lead to juvenile delinquency among Korean children, and may cause problems in the psychological development of a child. Another change in Korean family lifestyle is in gender socialization. There has been a change from the preference of male children, and equal treatment in educational aspects between boys and girls. However, the emphasis on children†s success in education has not changed since Korean immigrants moved to New York. Korean par ents push their children to do academics so they can attend a prestigious college and choose a field that leads to a high-status more common for them to live with their daughters than with sons. Second, Korean elderly do not depend on their children for financial support or expect support from their children. This is due to the welfare programs for the elderly, which have made them independent from their children. Finally, Min states that the vast majority of Korean elderly are satisfied with their lives in N. Y. and plan to live here permanently. The reasons Min gives for Korean elderly life satisfaction are their economic and residential independence, involvement in strong . The Korean elderly have also been affected by the changes in the traditional family system. First, many Korean elderly live independently of their children, and it is friendship networks and access to ethnic services in Queens, low expectations for economic and occupational success, and their deeply religious lives. Finally, Min explains how new technology and improvements in international travel has helped Koreans maintain strong ties to friends and relatives in their home country. The advanced in these two areas of technology and travel has lead to improve communication between family members. For example, more Korean family members can keep in touch with their relatives in Korea because of the increased convenience and affordability. The increase in communication between Korea and the U. S. has lead to the creation of â€Å"international commuter marriages†. Min describes international commuter marriages as being marriages where the husband has returned to Korea for a better occupation while his wife and children remains in the U. S. to take advantage of educational opportunities. Th advance in communication and travel has helped international commuter marriages prosper because now spouses can visit each other several times a year and talk on the phone every week. Min provides a detailed analysis of the Korean family. Min†s book opens up the reader to a society that the public knows little about. He provides an understanding of norms and beliefs of Korean society. By doing so, Min dismisses the stereotypes that plague Korean society. The data used in the book is solidly backed up by experiences of Korean people making it valid and logical. Finally, the book was written in 1998 making Min†s ideas relevant for today†s Korean society.

Poverty in Canada Essay

Poverty in Canada has been a long debate on the political and social fronts of the community. According to 2005 reports, an estimated over ten percent of the Canada population are living in poverty. Of much concern is the ever increasing rate of homelessness experienced in the nation over the past two decades (Lee, 2000). However, numerous reports have indicated that the measure of poverty in Canada is negated by the government’s failure to have a definite method of measuring poverty levels. True to the letter, Canadians are current faced with the debate on whether absolute or relative measure of poverty is the best in determining poverty levels in the nation. Nevertheless, numerous measures have been put in place to promote poverty reduction strategies in many provinces of Canada. In addition, non-governmental organizations are increasingly engaging in community based poverty reduction projects. This paper is written as a discussion on poverty in Canada. The author will in particular look at the statistics of poverty in the nation, how poverty is measured in Canada, and the current poverty reduction measures being implemented. Poverty in Canada Poverty in Canada has been an historical issue for many centuries. According to available statistical information, poverty in the nation remains a swing between economic growth and recession as well as numerous evolving initiatives by the government to assist low income members of the community (Raphael, 2002). This information still indicates the emergence of organized assistance to the poor in the twentieth century. True to available literature, most of the poor assistance programs are generally funded by the church. This is evident from the catholic encyclopedia, which funds approximated over eighty seven hospitals in the Canadian nation catering for the poor members of the community (Surhone, 2009). On the other hand, the government has been on the forefront in addressing poverty issues among its citizens. Such can be historically evident from the establishment of the Canada’s welfare state after the great depression as was initiated by Bennett and Mackenzie King. Nevertheless, the problem of poverty in Canada is still a major threat to the sustainable social and economic development of the Canadians. From a 2003 statistical reports, an estimated poverty rate of over 10% has been reported (Raphael, 2002). This percentage has been confirmed by the central intelligence agency as an official value although the absolute rate is undoubtedly expected to be higher. However, the Canadian federal government seems not to agree with this value and have published a current poverty rate to have gone down for the past sixty years to a value less than five percent (Raphael, 2002). This value was determined on the basis of the basic needs poverty measure and deviates very much from what is perceived to be real. Many organizations top on the list being the Fraser institute have not appreciated this value and depict the Canadian federal government as extremely exaggerative. The above contradiction between the government and these conservative organizations has been compounded by the fact that the Canadian federal government has failed to endorse any metric measure of poverty including but not limited to the low income cut off. Altogether, the Canadian federal government seems to have realized the impact of poverty to the society and have employed several measures to reduce it. This is evidenced by the continued decline of poverty in the recent time 1996 when recession which was marked with low income rates. For instance, statistics shows that the less fortunate people such as the physically disabled, mentally ill, and single parent mothers are experiencing higher income rates. Students and recent immigrants have at least higher or average low income rate hence they can afford the basic needs. Measures of poverty in Canada The establishment of an official poverty measuring system in America has been marked with many controversies top on the list being the fact that politicians have failed to agree on a precise definition of poverty (Groot-Maggett, 2002). The have therefore ignored the interest of statistics Canada of defining poverty by it unable and unworthy to determine what is necessary to be a basic necessity. The government and some research institutes use different methods to estimate the extent of poverty of poverty in Canada. However, a debate has emerged on the supremacy of absolute and relative methods of measuring the depth of poverty. The author of this paper discuses both the absolute and the relative measures of poverty. One of the absolute measures of poverty is the basic needs poverty measure. According to libertarian Fraser institute’s economist Chris sarlo, the basic needs poverty measure was conceived to be a poverty threshold (Groot-Maggett, 2002). According to this basic needs approach of poverty, basic needs are those things which are required by people for their physical goods over a long time depending on the current living standards of that particular society. This measure was designed based on different information obtained fro various sources which include but not limited to statistics Canada. An extensive assessment of how much a person can spend in the house was established to give this measure the originality and substance it deserves. This was accomplished by examining the cost of various things which where perceived to meet the above definition of basic need. This included food, clothing, shelter, personal care, transport and communication for different types of societies. Based on the above research and by putting inconsideration the family size, the number of families which had insufficient income to cater for those necessities were determined. Earlier on, the amount of income required to cater for the basic necessities was determined on the basis of gross income which was inclusive of old age pensions and employment insurances. Currently however, the net income has been used the financial ability of a family to sustain its basic requirements (Lee, 2000). A worthy noting point is that this net income is based on reports which can be marked with error such as unreported and underground means of earning income. Based on the basic needs poverty measure, have gone down with an appreciatable rate to a value less than 5% which is estimated to represent less than 2million Canadians. Another absolute measure of poverty is termed the market basket measure. This was designed and established in 2003 by the Canadian government through its department of human resources and skills development (Raphael, 2002). The market basket measure of poverty accommodated a wider range of basic needs than the basic need measure. For instance, it put in consideration the community size and location for at least 48 communities in Canadians and then estimated the sufficient amount of income required to meet those needs. This measure is still understudy and is expected to cover more than 400 communities. The main notable relative property measures is the income distribution measure commonly known as income inequality metrics, gives information regarding the variation of income in a given community. Its effectiveness is evidenced by the fact that when a given group of people increases their income rate then there is a high probability of those earning less to feel an increase in their income. Another often quoted as a relative measure of poverty is the low income cut off which has received many critics from the statistics Canada and they have disregarded it as not a measure of poverty by saying that it does not give reliable and accurate fingers. The low income cut off measure was based on the gross income but the statistics Canada have given reports of both the gross and the net income (Marseken, Timpledon, & Surhone, 2009). This measure was designed to give the lowest mark which when exceeded; a family will have to spend much to cater for basic needs such as food shelter and clothing. Recent results based on this measure showed that approximate of 9. 4% lives below the low the current threshold of 63% of the total family income. Poverty reduction measures Like any other country in the world which is conscious of the well being of its people, the Canadian government through the provinces has employed several measures to eliminate poverty and a gain to reduce its impact to the people. Top on the list of these important measures is reduction of tax burdens. This is evidenced by the progressive income tax system in Canada which has resulted to a difference of about 5% between the gross and net low income cut off (Pohl, 2002). Government social programs cannot go unmentioned here because of their importance and effectiveness in succumbing poverty. The Canadian government has come up with a broad range of social programs aimed at helping the law income people. These programs include but not limited to old age security and employment insurance which have seen through the reduction of chances of falling to poverty of people who were rendered unemployed. In addition to this, government funds have been channeled to subsidizing education and public health with an aim of improving the living standards of people with low income (Raphael, 2002). Another government measure which cannot escape this discussion is the introduction of the minimum wage laws. The constitution of Canada includes the minimum wage laws, which even though they vary for different provinces, they have confirmed there effectiveness in standardizing wages by making sure that people with law income are not exploited (Raphael, 2002). The minimum set minimum wage is $8. 00 per hour although it can go a bit down for unskilled workers. Conclusion In conclusion therefore, poverty is not well defined in Canada because of the failure of politicians to agree on the necessities which should be basic. However, the above discussion shows that a considerable number of people in Canada are poor and lacks the basic needs a defined by the basic needs measure of poverty. In addition to this, the government’s effort to eliminate poverty as well as reducing its impacts cannot fail to be appreciated. This is it has invested sufficiently in social programs and in the enforcement of the minimum law wages which have seen through the reduction of poverty and its effect to the people. It also safeguard the less fortunate people and ensured that the poor people are not exploited or robed there right of living a good life. References Groot-Maggetti, G. (2002). A measure if Poverty in Canada. A Guide to the Debate about Poverty. Retrieved August 1, 2010, from http://action. web. ca/home/cpj/attach/A_measure_of_poverty. pdf Lee, K. (2000). Urban Poverty in Canada: Statistical Profile. Retrieved August 2, 2010, from http://www.ccsd. ca/pubs/2000/up/ Marseken, S. , Timpledon, M. , & Surhone, L. (2009). Poverty in Canada: Poverty, Minimum Wage, Measuring Poverty, Income Taxes in Canada, Economic History of Canada, Great Depression in Canada, Basic Needs, Economic Inequality. Toronto: Betascript Publishers. Pohl, R. (2002). Poverty in Canada. Retrieved August 1, 2010, from http://www. streetlevelconsulting. ca/homepage/homelessness2InCanada_Part2. htm Raphael, D. (2002). Poverty, Income Inequality, and Health in Canada. Retrieved August 2, 2010, from http://www. povertyandhumanrights. org/docs/incomeHealth. pdf

Leadership and managment Assignment Example | Topics and Well Written Essays - 1500 words - 1

Leadership and managment - Assignment Example Being prepared to deal with conflicting staff allows management to implement several strategic tactics to dissolve conflict resolution and restore solace to the workplace. Diversity has emerged in the hiring practices of the work place in the areas of race, age, gender, religion and most recently culture. The globalization of the business world has jolted corporations to embrace diversity in order to maximize competitiveness and optimize human resources. However, the array of differences can lead to misunderstandings and unfortunately workplace contention. Supervision has to be well prepared to counteract confusion. Both authors Craig E. Runde and Tim A. Flanagan (2008: 92), authors of the book Effective Leadership Stems from Ability to Handle Conflict, believe that â€Å"most effective leaders are extraordinarily competent at handling conflict.† An example of such an experience is the feel-good movie Glory Road. The movie is based on The Texas Westerns college basketball team in 1966 who won the NCAA championship while promoting diversity. The coach of the team, Don Haskins, pioneered diversity by recruiting players deemed best for the positions and sidestepping traditional hiring practices. The hiring of the new folks in nontraditional roles is an exemplary example of effective leadership. These are attributes of a true leader as the attainment of the desired result outweighs skepticism and cynicism. Peter F. Drucker (1994: 100) article â€Å"The Theory of the Business† reveals that a valid theory of business suggests that the assumptions about environment, mission and core competencies must fit reality. The example of coach Haskin has to be the pinnacle of addressing conflict. Throughout the movie, strong interpersonal attitudes clashed among team members. Fights erupted and tempers boiled. In one particular scene, teammates squared off and the season

Distribution Pattern Analysis of Public Parks and accessibility in Essay

Distribution Pattern Analysis of Public Parks and accessibility in Madinah Using GIS Technique - Essay Example Distribution Pattern Analysis of Public Parks and accessibility in Madinah Using GIS Technique This research quantifies inequalities in green space accessibility to support long term spatial planning strategies that specifically address green space accessibility. The focus of this paper is the distribution and accessibility analysis of public parks with regard to all segments of the population. When there is a significant increase in population and urban growth in a region, the need for public places of recreation increases. For example, in Britain, the area dedicated to national parks and green areas is approximately 10,000 square miles, which represents 17% of England and Wales’ total area of. Increasing rates of urbanisation in Madinah have led to increased pressure on many of the services and facilities, especially green spaces and gardens which are a key requirement for high density neighbourhoods. Green space refers to an area of land or water mass that either remains in its natural form or is used for agricultural purposes . Green spaces are free from industrial, institutional, commercial and residential use and development. While most green spaces are publicly owned, others are private properties and consist of undeveloped coastal lands, undeveloped, scenic lands, public parks, forest lands and estuarine lands . In urban areas, however, where land development is predominant, green space may encompass areas such as wetlands, recreational areas, vacant lots or narrow corridors for walking or cycling. Cultural and historic resources also form part of green space in some countries. In addition, green space is crucial as it absorbs and expels pollutants from the environment, by acting as an urban heat sink thereby protecting urban biodiversity. As agricultural pressures on land increase through greater demands for land, green spaces are slowly becoming depleted (Forman 2005). However, as development becomes a key priority, more land that was previously set aside for agricultural purposes is being developed into residential or institution areas (Van, 2007). This has led to scarcity of green space, and access to the available few is hampered by the prospect of development. Access to green space is of paramount importance because of the unique contribution of green spaces to the quality of life, It is likely that they can then work to review development plans for gardens on an equitable basis to serve the citizens. Green spaces are important for improving the air quality during the day, ridding it of carbon dioxide and other pollutants; they also beautify the environment, create a soothing atmosphere, and protect people from the glare and heat of the sun (Kumagai.2011). For instance, green spaces allow for relaxation, way from the daily stresses of urban life such as hectic work schedules and traffic. Moreover, green spaces offer immense recreational opportunities like individual exercise and organised sports. Spending time in urban green spaces offers reprieve to urban dwellers. However, because of increasing urbanisation a nd access to green space and spatial planning policies with regard to densification, more urban dwellers face the prospect of living in areas with few or no green space resources. Governments and individual municipalities set up clear guidelines for access to green space (Smith et al.2002). The Green Belt is a policy for managing urban growth in the UK. The policy guidelines provide concise

Third world country Essay Example | Topics and Well Written Essays - 250 words

Third world country - Essay Example Kenya is an emerging nation, which predominantly produces agricultural trade outs. The nation has enormous economical labour, which supports agricultural activities. Furthermore, the state has lush land that supports an assortment of agricultural activities. As such, farmer incurs minimal firming relative to other states, which may require irrigation to sustain agriculture. Overall, the nation can produce agricultural products like coffee or tea cheaply owing to factors that favour firming of the above commodities notably cheap labour and apposite weather. Conversely, Kenya encounters multiple hurdles in manufacturing owing to soaring expenditure on inputs. Consequently, the merchandise manufacture in this country lack competitiveness. Conclusively, Kenya has a comparative benefit generating agricultural commodities relative to manufactured merchandise (Kenya Investment Authority, 2011). Germany constitutes the elite nation with a diverse economy. Notably, manufacturing make a sizeable contribution to the economy. The country prides in phenomenal level of technology. The country has apposite technology that support manufacturing. Specialization has allowed mechanization to replace human labour reducing expenditure thus boosting efficiency. Germany has enough natural resources that avail a required component that sustain industrialization. Evidently, this country also possesses the required expertise to support manufacturing. Manufacturing particularly in the automobile sector necessitates expertise. Accordingly, presence of the relevant expertise has enabled Germans to undertake exceedingly technical manufacturing. Evidently, Germany has relative lead in manufacturing. The advantage arises from certain trait that the country possesses. Consequently, Germany leads in automobile assembly in Europe. Conversely, the unfavourable environmental condition makes agriculture an unviable option. Conclusively, adhering to this model would culminate in

From a Name to a Number - A Holocaust Survivor's Autobiography by Essay

From a Name to a Number - A Holocaust Survivor's Autobiography by Alter Wiener - Essay Example This is a unique piece of writing not easily commendable. In this autobiography, Alter Wiener talks about how his adolescent was captured by disturbing recalls of the concentration camps of the Polish. It is traumatic and distressing compared to any situation one can face in his or her life. It is a heart taking narration of once again a dark chapter in the history of the world we all came across. We think we do know history, but all our ideas about history are shattered once we read about the debt of immortality and fear these people suffered. It is a firsthand account of the brutal events of the history which we sometimes don’t even want to know about (Wiener, 2008). The book is an unpolished and rough read for the post-holocaust period. This book is a proof of those disturbing events that were part of WWII. The message explains that prejudice can lead to such devastating events. Also, tolerance is very important part of each person’s life. It not only divulges the story of Wiener but also discloses many replies to his story. It reveals, wanders sexual adventures I don’t really want to know about. Considering it is a journal which was written by a person who was sent to a concentration camp at an early age and destitute from anything more than a grade school education until the time of his release. Even though the author talks about him being uneducated and deprived, if I read the book thoroughly I think that he is a well educated and very intelligent person (Wiener, 2008). But that is just my opinions. Regardless of them, I believe the book is a true recount of the concentration camps describing every minute detail. I do feel pain for the author, and for all the people who died or survived these camps. The trauma of the camps continued centuries and even today’s generation is adversely affected by its aftermaths.

Role of Fellowship in Christian Spiritual Healing Dissertation

Role of Fellowship in Christian Spiritual Healing - Dissertation Example PATHOLOGY: Science of bodily diseases including symptoms of a disease. ACCENTUATE: Emphasize SYMBOL: Something regarded by general content as naturally typifying or representing or recalling something by possession of analogous qualities or by association in fact or thought. THERAPY: Medical/treatment of a disease according to Oxford dictionary but in generally understanding refers to all measures taken to attain or restore optimal health of humanity SACRAMENT: Religious ceremony or act regarded as outward and visible sign of inward and spiritual grace. AUTHENTIC: Leadership especially one state. 1 INTRODUCTION Many therapy practices like medical intervention, counseling and prayer have received the attention of researchers. There are subjects on healing and fellowship which are studied by many authors as well, for example, Louw et al (1994); however there seems to be no studies which focus on role of fellowship in healing. Warren 2002:138 has captured the importance of fellowship as he states, â€Å"God intends for us to experience life together†. This concept of togetherness and shared experience is referred to as ‘fellowship’ in the bible. The focus of this research is to explore the role of fellowship in spiritual healing. Though the researcher is not really interested in doing research just for the sake of doing it but because of the personal attachment researcher has with the topic itself. The researcher is prepared and committed to the subject and has a passion in the said area which has made the researcher impatient to see the contribution this study will make to the existing body of literature as well as to the society. Muller (1999:3) rightly says â€Å"to do research is not an easy task...Warren 2002:138 has captured the importance of fellowship as he states, â€Å"God intends for us to experience life together†. This concept of togetherness and shared experience is referred to as ‘fellowship’ in the bible. The focus of this research is to explore the role of fellowship in spiritual healing. Though the researcher is not really interested in doing research just for the sake of doing it but because of the personal attachment researcher has with the topic itself. The researcher is prepared and committed to the subject and has a passion in the said area which has made the researcher impatient to see the contribution this study will make to the existing body of literature as well as to the society. Mà ¼ller (1999:3) rightly says â€Å"to do research is not an easy task because of curiosity I could venture into a world of the â€Å"unknown† where a treasure, surprise, or a shock might be hidden†. By using the narrative approach, this research intends to venture with fellow travelers into their known world which they never knew or seen before. Based on the statement, â€Å"Life is a journey† we journey both separately and collectively, this research aims to venture into the world of exploring the â€Å"Role of Fellowship in Christian Spiritual Healing†.

Retailing story Essay Example | Topics and Well Written Essays - 1000 words

Retailing story - Essay Example Often, he could split the food and the couple became so discontent with his living conditions (Keding 33). This made the couple to buy a wooden bowl, which they used to serve the old man food. One day when the couple was just sitting, their little son began to gather some wood in the ground. When his father asked what he was doing, the son responded that he was creating a wooden bowl for his parents to use in the future. Immediately, the couple began to cry and were ashamed that they were treating their father so cruelly, and from that day they decided to treat their father right. The plot details The main characters of the story are the old man, his son and wife, and grandson. At the beginning of the story, the author uses these characters to communicate his intended message to his audience. Basically, the elderly character portrays the qualities of the disability and lack of power to perform his daily duties and responsibilities. The son and his wife are arrogant and disrespect the ir father. However, their grandson honour the experience of the older generation and this explains why he is making a wooden bucket for their parents to use when he grows up. The mentioned characters create a strong ground for readers to understand the things that elderly people go through. They are often discriminated and disrespected by the younger generation. This story is important to our culture in that, it teaches parents on how to bring up their children in an upright way. This is because children are likely to imitate their parents’ conducts. This story is significant since it helps parents to understand that if they disrespect their elderly parents, their children are more likely to treat them meanly when they become old. The story continues to be told because it addresses a major concern in the society. The story is a wake up call for parents to correct their actions so that children begin to emulate true role models. This story is often narrated to create insights on why parents should cherish being role models to their children. This story means a lot to me in that it helps me articulate the importance of respecting the elderly. It reminds me of how the elderly are subject to discrimination from the younger generation. Further, this story shows the benefits of respecting the elderly as, preserving respect for personal and future generations. Various theories have been advanced by different theorists such as Maria Montessori, Jean Piaget, and Lev Vygotsky (Calvert and Barbara, 22). Although their theories differ greatly, these theorists have a similar concept of learning and children development. They believe that learning and development occur when children interact with the people around them and the environment (Pinter 28). The theorists affirm that young children are active learners and they tend to imitate those around them. SECTION TWO Retelling the story Once upon time, they lived a very old man in a small who lived in disability, His eyes had become dim, his knees trembled, and his ears were dull of hearing. His life was difficult in that he could hardly hold a spoon when eating and often he could split the food on the table. His son and his wife were disgusted at his father’s conduct and they served him food in the earthenware bowl. The poor man underwent a lot because of his age and his inability to perform chore duties. One day, his trembling hands could not hold

Preventing vent acquired pneumonia (VAP) in the icu Essay

Preventing vent acquired pneumonia (VAP) in the icu - Essay Example Microbiological surveillance is important because it prevents emergence of multi-drug resistant bacteria and also in determining empirical therapy for patients with VAP. According to Babcock et al (2004), educating health professionals about prevention of VAP is critical for prevention of not only VAP, but also various nosocomial infections. Similar reports were delivered by Needleman et al (2002) and Cho et al (2003). Another important strategy for prevention of VAP is early extubation and this is possible by following certain extubation protocols like interruption of sedation every day. According to Cook et al (2000), decreased time of mechanical ventilation decreases the risk of aspiration and consequently decreases VAP risk. The third strategy useful to prevent VAP is prevention of aspiration. Nieuwenhoven et al (2006) have reported that evevation of bed at 45 degrees prevents aspiration. Timely drainage of secretions in the subglottic region which get contaminated easily (Bonten et al. 2004), avoiding manipulation of fluids in the ventilator circuits (Han and Liu, 2010) and use appropriate endotracheal cuff pressure (Valencia et al. 2007) also prevent aspiration of contaminated fluids and secretions. There are several decontamination strategies which have been advocated for prevention of VAP. Some drugs like chlorhexidine are useful for oral decontamination. Selective decontamination of the intestines is possible by using antibiotics like polymyxin which are non-absorbable (Bonten and Krueger, 2006). Babcock, H.M., Zack, J.E., Garrison, T., Trovillion, E., Jones, M., Fraser, V.J. et al. (2004) An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest, 125, 2224–2231. Tablan, O.C., Anderson, L.J., Besser, R., Bridges, C. and Hajjeh, R. (2004) Guidelines for preventing health-care–associated pneumonia, 2003:

Health History and Examination Essay Example for Free

Health History and Examination Essay Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): Patient is alert, awake and oriented. Denies headaches, head injuries, dizziness, seizures, tremors, migraine, difficulty in speech and swallowing. No history of falls. Patient does mention that he has numbness and tingling of fingers and toes occasionally. Takes Gabapentin 100mg orally three times a day. Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient denies neck or head injuries, denies swelling or lumps on neck and head, Denies neck pain or headaches. Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): Patient wears eyeglasses that are with him. Bilateral cataract surgery done in June 2013. Regular vision checks after surgery done in November 2013 and at present he is not on any medications at home. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): No complaints of ear pain, infection, surgery tinnitus due to noise, or vertigo noted. Not on any medications. Hard of hearing right ear but does not use a hearing aid. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): Denies discharge from nose and throat, denies presence of sores or lesions in the mouth. Denies nose bleeds, bleeding gums, or sore  throat. No known allergies noted. Has upper and lower dentures that patient cleans with Polident tablets daily. History of Tonsillectomy at age 7. Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): Patient’s skin color is ethnic. Has some gray hair but no alopecia. Has well groomed nails. Denies skin problems. Particular about usage of moisturizing lotions after bath. Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to b reast, mammography, breast self-exam, medications): Patient denies any problems with breasts and axilla. Does not perform self-breast examination. Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): Denies leg pain, cramps or discoloration of arms and legs. Complains of occasional swelling on ankles. Takes Lasix 40 mg orally once a day. Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): Denies any chest pain or tightness. Denies shortness of breath or weakness. Complains of occasional cough relieved by Robitussin DM 10ml orally every 6 hours as needed. Patient is hypertensive and had an MI in 2005 but denies any history of Congestive Heart Failure. Family history shows that his father died of heart attack at age 75. Patient had an echocardiogram and stress test done last year as outpatient and per patient results were normal. Patient is taking Aspirin 81mg orally daily, Lopressor 25mg orally daily, and Plav ix 75mg orally daily. Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): Has occasional cough that could be due to change of climate. Denies shortness of breath or pain with breathing. Denies smoking and no history of lung disease is noted. Immunized for Influenza and Pneumonia on 10/14/2013. Patient was in ER in March for cough and fever and x-ray of the chest showed no abnormalities at that time. Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain;  difficulty with activity of daily living, medications) Denies any symptoms of joint problems and does not take any medications at home. Patient is independent and requires no assistance for activities of daily living. His wife and he take walks on a daily basis for 20 minutes. Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications) Denies any gastro-intestinal disease, ulcers, or diabetes. Consumes low sodium diet with no added salt three times a day and a bedtime snack. Includes plenty of vegetables and fruits in his diet. No swallowing problems noted. No complaints of nausea, vomiting or diarrhea noted. Patient has daily bowel movement and reports that it is brown in color. Denies use of stool softener or laxative. An Endoscopy and Colonoscopy was done in January 2014 and no abnormalities noted at that time. Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, supra pubic region or low back) Denies pain or any urinary problems. Patient verbalizes increased frequency of urination due to Lasix. Patient wakes up twice at night to urinate but he is continent of bladder. Per patient no prostate problem noted. Last prostate exam was done in February 2014. Physical Examination (Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): Patient is awake, alert, and oriented with no memory loss. Patient is calm, cooperative and pleasant. Judgment is intact. Patients speaks clearly and in full sentences. No difficulty noted while speaking. No swallowing problems noted. Patient has a steady gait with full strength. Sensations present in all extremities. Complaints of occasional numbness and tingling of fingers and toes but denies upon examination. Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland): Skull and neck are normal on examination. No deformities or hematoma noted. No lymph nodes identified on palpation. Adam’s apple present. Trachea is normal on palpation. Eyes (test visual acuity, visual fields, extra ocular muscle  function, inspect external eye struct ures, inspect anterior eyeball structures, inspect ocular fundus): Patient has eyeglasses with him. Patient is able to open and close his eyelids. Pupil is round and reaction to light is constriction to both eyes. Denies any blurring, watering, or tearing of the eyes. No redness or infection noted. Ears (inspect external structure, otocopic examination, inspect tympanic membrane, test hearing acuity): Hard of hearing right ear with no hearing aid. As per patient the physician had recommended hearing aid for the right ear but patient did not wish to use it. Otoscopic examination revealed normal ear canals and eardrums with minimal amount of earwax. Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): Nose, mouth and throat are normal on examination. On palpation no pain noted to sinuses. The upper and lower dentures fit well on the patient and do not become loose while talking or chewing. Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach self-examination techniques): No skin break down or rashes or lesions noted on inspection of the skin. Color is normal to ethnicity. Skin is warm, dry an d intact. Mucus membranes are pink and moist. Hair is gray and no alopecia noted. Texture of hair is soft to touch, no split ends noted. Kept short and clean. No ingrown nails or cracked nails noted. Nails are well groomed and pink in color. Patient verbalizes examining the skin and nails everyday while taking a shower. Breasts and Axilla (deferred for purpose of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps): Bilateral upper extremities are warm, symmetrical with bilateral radial pulses 2+. Bilateral lower extremities are warm, symmetrical without any discoloration. No varicose veins noted. Bilateral pedal pulses 2+. A trace of edema is noted on both ankles and feet. Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur): Carotid arteries are normal with pulse 2+. No jugular vein distension noted. Apical pulse is 82 beats per minute, BP of 150/80 mm of Hg. Heart sounds S1 and S2 are on auscultation. No murmur or extra heart sound noted. EKG shows a  Normal Sinus Rhythm. Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): Thoracic cage is normal and symmetrical. No abnormality noted on palpation and percussion. Breath sounds are clear and equal on auscultation in all lung fields. Respirations are even, regular and unlabored. Patient has occasional nonproductive cough relieved by cough medicine. Respiratory rate is 18/minute and Oxygen saturation is 99% on room air. Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformi ty, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion): Cervical spines are normal in size, no pain or deformities noted with full range of motion. Bilateral shoulders are equal in size, no swelling or mass noted. No pain noted on movement of shoulders. Bilateral elbows, wrists and hands are equal in size, with full range of motion and equal in strength. No deformities noted on inspection. Bilateral hips are equal in strength, no swelling or mass noted. No evidence of redness or injury noted. Sacrum is intact. Bilateral lower extremities with full range of motion and equal strength noted. No swelling or deformity noted. Bilateral ankles and feet noted with trace of edema. Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): Abdomen is flat and non-distended. Bowels sounds present in all four quadrants. Abdomen soft and non-tender on palpation. Percussion revealed tympany in all four quadrants. Umbilicus is midline and inverted. Surface of abdomen smooth and even, with homogenous color. No lesions or surgical scars noted. Genitourinary System (deferred for purpose of this  class) FHP Assessment Cognitive-Perceptual Pattern: Patient is alert and oriented, no memory loss. Well educated, and has the ability to read, write and understand information. Patient uses eyeglasses for reading and is hard of hearing right ear. Nutritional-Metabolic Pattern: Patient eats a low sodium diet with no added salt three times a day with a bedtime snack. Home cooked food with vegetables and fruits included in the diet are his preferences. The patient or his wife prepares the food. The patient and his wife do the food shopping. Sexuality-Reproductive Pattern: The patient has three children and 5 grandchildren. He is not interested in sexual activities but loves to spend time with his wife. Pattern of Elimination Patient is continent of bladder and bowel. Urinary frequency is increased due to effect of medication (Lasix). Pattern of Activity and Exercise: Patient is independent in activities of daily living. He is not involved in vigorous exercise but walks daily for 20 minutes along with his wife. Pattern of Sleep and Rest: Patient usually sleeps for 6-7 hours at night with an afternoon nap for 30 minutes. Patient wakes up twice at night to urinate but goes right back to sleep with no difficulty. Patient denies use of sleeping pills. Pattern of Self-Perception and Self-Concept: Patient is well dressed and has self-respect and respects others too. He leads a disciplined life with the ability to take care of himself and his wife. He is friendly with his neighbors and is an active participant in church activities Summarize Your Findings (Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements): Name: Lawrence Kelly Age/Sex: 72 years/Male Presenting complaints: Increased swelling of ankles and feet, numbness and tingling of fingers and toes, and occasional cough. Background (health and family history, recent observations): History of present complaints: Patient complains of swelling of feet and ankles for 2 weeks with numbness and tingling of fingers and toes. Occasional cough for last one week. Past medical History: Hypertension, MI, Hard of hearing (Right Ear). Medication history: Lasix 40mg orally daily Aspirin 81mg orally daily Plavix 75mg orally daily Lopressor 25mg orally daily Gabapentin 100mg orally three times a day Assessment (assessment of health state or problems, nursing diagnosis): Mr. Lawrence Kelly 72 year old male presented with complaints of swelling of feet and ankles with numbness and tingling of fingers and toes for the past 2 weeks. Occasional cough for the past one week. He is alert, awake and oriented with steady gait. Hard of hearing in the right ear. His vital signs are BP150/80 mm of Hg, Pulse 82, RR 18/minute, and Temp of 98.4. No chest tightness or pain verbalized. Breath sounds are clear and equal in all lung fields. Abdomen soft, non-tender and non-distended. Bowels sounds present in all four quadrants. No difficulty in urination verbalized and color of urine is amber. Trace edema noted on feet and ankles. Pedal pulses is 2+. Nursing Diagnosis: Fluid Volume Excess manifested by edema of feet and ankles. Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): Blood tests should be done including Comprehensive Metabolic Panel, Vitamin B12 Level, and BNP. X-ray Chest is recommended to find out if patient has CHF Echocardiogram could be repeated as it was done more than 6 months ago Teach the patient to monitor BP, Pulse, Intake and Output, and Daily Weights. Advise the patient to elevate the lower extremities on pillows to reduce  dependent edema Encourage the patient to read food labels on the sodium content Avoid fried foods, canned and frozen foods (Nanda Nursing Interventions, 2012) Provide information about community services such as Heart Center at Barnabas Health, Phone No. 1-888-724-7123 (Barnabas Health, 2013). References: Barnabas Health. (2013). Barnabas Health Heart Centers. Retrieved from http://www.barnabashealth.org/services/cardiac/index.htmlLifestyle and home remedies. Retrieved from http://www.mayoclinic.com/health/heart-failure/DS00061/DSECTION=lifestyle-and-home-remediesNanda Nursing Interventions. (2012). Nursing Interventions for Fluid Volume Excess. Retrieved from http://nanda-nursinginterventions.blogspot.com/2012/04/nursing-interventions-for-fluid-volume.html

Kite Runner Essay Essay Example for Free

Kite Runner Essay Essay Hitler was an undoubtedly deranged man with the desire to concur a nation, who used inhumane methods to achieve his goal of a ‘perfect’ society. The proud words of Assef about him were, â€Å"Now, there was a leader. A great leader. A man with a vision.† (39-40) In the novel The Kite Runner by Khaled Hosseini, Assef is characterized as a cruel sociopath; his character is created through Hosseini’s use of figurative language and connotative diction. Throughout the passage with Assef as a child Hosseini describes Assef with repetition. Repetition in a novel is a way to convey the point that an author is trying to make. Hosseini makes his statement about Assef very clear. He uses the words â€Å"relentless†, â€Å"ambush†, and â€Å"Savage† over and over to push the severity of Assef’s lunatic way of life. Even more words are used like â€Å"stainless steel brass knuckles† (38) and yelling out the prejudice slur, â€Å"Flat-Nose† (38), referring to the Hazara people. They were repeated because they show up later in the novel and foreshadow Amir’s journey back to Kabul. Also the author uses an epithet to describe Assef, as if he were an evil character of an old epic story. Amir proclaims him to be â€Å"Assef ‘the ear eater’† (38) and the gruesome name created a legacy from his actions. Assef’s character is also shaped by the way Hosseini uses connotative diction to support how crazy Assef is. His word choice clearly states how Assef dominates the other children in Kabul, as Amir says â€Å"blond-blue eyed towered over the other kids.† (38) Assef is a force to be reckoned with because of â€Å"his famous stainless steel brass knuckles† (38) He uses them as a way to prove his authority in the neighborhood. His obsession to be the leader is unusual and he is out of control as a child. The way Hosseini describes Assef there is no bright future for him as he is a corrupt boy with the drive to cause suffering. Assef plays the role of the antagonist in the story where he instigates all conflicts by creating turmoil in the novel, which the main character, Amir, has to overcome. His psychotic mindset leads him to become part of the unexpected climax of the story, and helps to develop the novel further in relation to all the obstacles Amir must face when dealing with his past.

Global Health and Issues in Disease Prevention

Global Health and Issues in Disease Prevention Application: The â€Å"Haves† and â€Å"Have Nots†: Why Are There Disparities? Bernard F. Richards Describe two health outcomes for which India and China have had different experiences in the last half century. It has long been an observation that socio-economic status influences health outcomes. Wilkinson and Pickett (2010) explain that the majority of health-related and social problems that plague nations and even sub-populations within nations are largely influenced by societal inequities (p. 173). Essentially, societies than have greater levels of inequity tend to have inferior health and social standings. This principle has been demonstrated by India and China which are nations with vast populations and shared influence from challenges brought on by globalization and urbanization. However, growing societal inequities in India served as the basis for recent dissimilarity in health status for citizens of said countries. The difference in health status of both countries can be seen in several health outcomes. According to Dummera and Cook (2008), both China and India experience similar infectious and chronic illnesses, the burden and prevalence of infectious maladies are significantly higher in India (p. 590). In India, the most common source of mortality is infectious and parasitic illnesses. Conversely, most deaths in China are secondary to chronic illnesses such as cancers. For every 1000 deaths in China, cancer is responsible for 119.7 of them. In India, this number lies at 71 out of every 1000 for cancers however, infectious causes of death lies at 420 out of every 1000 deaths (Dummera Cook, 2008, pp. 591-592). Chinese, both males and females, enjoy higher superior life expectancy at birth as compared to their Indian counterparts. In China, life expectancies for males and females in 2004 were 70.4 and 73.7 years respectively. On the other hand, that for Indian males and females was found to be male 63.3 and 64.8 years respectively. In general, China is found to be superior in almost all aspects of health-related demographics. China has better birth, mortality, fertility, and literacy rates. Additionally, there are more physicians and physical spaces within hospitals and other health facilities in China. This offers better service delivery and access to health services that are offered. These statistics suggests significant differences in policies and strategies to counteract sources of ill-health and brings to the fore the importance of social equality in ensuring population health (Dummera Cook, 2008, p. 592). Explain the reasons for the disparities noted. As previously mentioned previously, infectious diseases account for the vast majority of deaths in India as compared to chronic diseases in China. The contrast becomes even more apparent as infectious illnesses are general considered diseases of poverty. Chronic illnesses, on the other hand, are dubbed diseases of affluence. One explanation for this disparity between both nations is the difference in societal development. India has experienced less development which serves as a catalyst for population vulnerability. People live in more unhealthy environments which have been proved to increase the risk of communicable illnesses. China has experienced greater positive development which has diminished levels of social and health-related vulnerability. Chinese people are essentially living longer which predisposes to chronic conditions related to lifestyle behaviors and increased life expectancy. Additionally, the Chinese authorities have enforced strict limitations on reproduction and p opulation growth (Dummera Cook, 2008, pp. 590-592) Social division and inequality also accounts for health disparities in both countries. There is present in India a caste system called ‘jati’ which is based on segregation, marginalization and social stratification. At the summit of the social hierarchy is the Brahmins class (Priests) followed by the Kshatriyas (Warriors and rulers), Vaisyas (skilled workers, merchants, minor officials), Sudras (unskilled workers), and Pariah (outcasts, untouchables) in descending order. Hearne (2014) explains that as we progress down the caste hierarchy, social inequity and discrimination increases. An individual’s educational status, income and consequently health status are all dependent on the caste he is in. This system is culturally and historically entrenched in Indian way of life, society and even religion. This ‘legal’ segregation and discrimination has resulted in members of the society put at increased health risks as they lack the socio-economic wherewitha l to access health care and protect themselves against the negative social determinants of health. China’s people enjoy greater social equity which has been a major influence in decreasing health disparities in this territory. Describe the experience for those outcomes in Kerala and suggest reasons for why they are similar or different from the rest of India. The dynamic nature of health can be illustrated by Kerala which is a state in India. It is quite impressive to observe the wide disparity in this sub-population of India as compared to the country in general. Residents of Kerala experienced superior life expectancies when compared to the rest of the nation. Males and females in Kerala are expected to live for 71.67 years and 75.00 years respectively. In essence, Keralans live approximately 9 years more than the average Indian. Infant mortality rate is 68 per 1000 live births in the general Indian population while that for Kerala is 14 (Ministry of Health and Family Welfare, 2014). Mukherjee et al. (2011) further explains that Kerala demonstrates higher educational and income levels as well as birth, mortality, fertility, and literacy rates when compared to other Indian states (p. 2). According to Dilip (2002), Kerala has higher morbidity but less mortality rates when compared to other states. This phenomenon is due to higher life exp ectancies and increasing levels of chronic illnesses. Communicable diseases however, are found to be less prevalent than chronic illnesses in this sub-population. The differences in health outcomes when comparing Kerala to other Indian states is largely due to lower levels of inequality in educational attainment, health and social standing in spite of lower income levels (Mukherjee et al., 2011, p. 2). Although the caste system is present within Kerala, social discrimination is less pervasive. Kerala’s robust communist movement and policies directed to promote welfare has contributed. Greater social equity has resulted in greater access to health care and improved health statuses. This is evidence that removing social inequities has a positive influence on the social determinants of health. This lesson can undoubtedly benefit all nations as the world strives to achieve better health outcomes for this generation and those to come. References Dilip, T. R. (2002). Understanding levels of morbidity and hospitalization in Kerala, India. Retrieved from http://www.scielosp.org/scielo.php?pid=S0042-96862002000900012script=sci_arttext Dummera, T. J. B. Cook, I. G. (2008). Health in China and India: A cross-country comparison in a context of rapid globalization. Social Science Medicine, 67, 590–605 Hearne, T. (2014). Indias social justice minister says Christians do not deserve special caste. Retrieved from http://www.christiandaily.com/article/indias.social.justice.minister.says.christians.do.not.deserve.special.caste/49363.htm Ministry of Health and Family Welfare, India. (2014). Life expectancy and infant mortality rates for selected Indian states. Retrieved from http://infochangeindia.org/women/statistics/life-expectancy-and-infant-mortality-rates-for-selected-indian-states.html Mukherjee, S., Haddad, S. Narayana, D. (2011). Social class related inequalities in household health expenditure and economic burden: Evidence from Kerala, south India. International Journal for Equity in Health, 10(1), 1-13. Wilkinson, R., Pickett, K. (2010). The spirit level: Why greater equality makes societies stronger. New York, NY: Bloomsbury Press.

college essay type b :: essays research papers

  Ã‚  Ã‚  Ã‚  Ã‚  Throughout the many ages that the world has partaken, several cultures have been contrived among the almost seemingly abundant human race. Due to this extravagant collage amongst the world as a whole, many different views of the world have been created. Things such as race, religion, ethnicity, language, and personality as well are all things that contribute to the division of individual philosophy and belief.   Ã‚  Ã‚  Ã‚  Ã‚  If there is a place here on earth that signifies, or emphasizes, the collage of culture, then a college would have to be it. People of several various dissimilarities will eventually have to communicate with one or another on a day to day basis for educational matters. These students have lived completely different cultural, economic, and academic lives as well as having physical dissimilarities.   Ã‚  Ã‚  Ã‚  Ã‚  Though growth of the state of mind may be a result of time spent in college amongst the culture of the world, the way a person has lived their life may also be a contributing factor in individual philosophy as well. There are many people in today’s society that have significant setbacks amongst their lives that cause them to stop and think about what life is really about.   Ã‚  Ã‚  Ã‚  Ã‚  A potential classmate that I believe I could learn a significant amount from either within or outside a formal classroom would definitely have to be someone of moral Islamic background. I believe that it would be an exquisite adventure to extend my philosophy with that of an Islam. As you can see, I’m not too worried about the problems associated with terrorism or Al-Qaeda, so therefore I can easily blend with someone of that nature.   Ã‚  Ã‚  Ã‚  Ã‚  President George Bush made a decision to imbuke war on Iraq with only the best intentions of ending terrorism among the United States of America, not with the anger and lust for revenge that the majority of Americans seemed to react with.   Ã‚  Ã‚  Ã‚  Ã‚  Back on subject, both Baptist and Islam have their similarities as well as their differences. I would mostly like to learn about what an Iraqi ethnicity must venture through in their life rather than their extravagant religion.

Essay --

The pharmaceutical companies continue to be accused of many unethical practices so the story of pharmaCARE comes as no surprise. The company started with good intentions but went down because of greed. It was a well-established company already famous for its integrity and high quality products. In the beginning, they were believed to enhance the quality of life around the world. The company continued to succeed due to its research and capitalized on a new breakthrough of a diabetes drug that they believed would help slow down the terrible progression of the Alzheimer’s disease. So after a few years, they created a subsidiary called CompCARE to be the â€Å"compounding pharmacy† to make the new drug named AD23. Because of the â€Å"supposed† success of this drug, it was in such high demand that CompCARE became to engage in methods outside the scope of what a compounding pharmacy is allowed to do, their practices pushed the limits and the end result was over 200 cardiac related deaths due to AD23. PharmaCare had several groups of people with stakes in what they had intended to achieve. These stakeholders in this scenario include PharmaCARE and CompCARE, one of its subsidiaries; both companies had high financial stakes in the success of AD23. There was also Wellco, a large drugstore chain, the employees of these 3 companies, the nation of Colberia and its citizens because their livelihood was tied to the success of AD23. Many of the social problems Colberia experienced like the destruction of its environment and consequently endangering of its native species through the company’s extensive activities and business practices came from PharmaCare. The company took advantage of the country’s low standard of living and its economic predicame... ...ng mean. When people are able to make that distinction, they’ll take the time to question themselves, and then question others’ actions including their reasoning and in this case, data rather than blindly accepting their decisions until the true situation comes to light. The failure with pharmaCARE started long before people started dying. PharmaCARE began to fail as soon the company felt it was ok to pay just a dollar a day to the Colberian people who didn’t know and felt they were being helped but instead were being exploited for their knowledge while their environment was being polluted. When CompCARE began to use unethical methods to get AD23 manufactured eventually leading to the deaths of more 200 people. It takes more than a statement â€Å"We CARE about YOUR world ®Ã¢â‚¬  to right the wrongs that all of this greed caused. Their actions must speak louder than words.

Eyes in Steinbeck’s The Snake Essay -- Essays Papers

Eyes in Steinbeck’s The Snake Eyes, both human and animal, appear as a predominant motif in John Steinbeck’s â€Å"The Snake.† Eyes serve not only a descriptive function, but signify two different modes of looking. One mode, embodied by Doctor Phillips, is scientific; the other, embodied by his female visitor, is bestial. Doctor Phillips uses sight to exert control over his environment; the woman’s way of looking proves more powerful, however, by achieving a truer understanding of the irrational impulses that govern the natural world. The description of Dr. Phillips’ eyes and the eyes of the woman qualify the two opposing worlds they represent. Dr. Phillips, who represents the scientific world, has â€Å"mild† eyes (74). The adjective â€Å"mild† suggests a lack of emotion; the scientific point of view employed by the doctor is wholly rational, and thus negates irrational emotion. Dr. Phillips’ refusal to acknowledge his emotions is evident in the phrase, â€Å"[he could] not [kill] an insect for pleasure† (80). If the doctor’s â€Å"mild† eyes connote a lack of emotion, then the â€Å"glitter† in the woman’s eyes suggest excitement, arousal, and an embrace of the irrational emotions that the doctor denies (75). The description of the woman’s eyes also indicates the doctor’s inability to comprehend the woman’s mode of looking. The story, though written from a third person perspective, is limited to what the doctor sees, thin ks, and feels; thus, the description of the woman’s eyes arise from his interpretations. Words such as â€Å"dark,† â€Å"veiled,† and â€Å"dusty† (78) are attached to the woman’s eyes in order to suggest mystery. The woman’s eyes seem mysterious to Dr. Phillips because her mode of looking is alien to him. In his first interaction... ...heir eyes and body movements; the doctor is likened to the rat through his â€Å"slight† build and fair hair (74). The rat sees the snake, but remains â€Å"unconcern[ed]† (83). Just as the rat fails to recognize the danger of the snake, Dr. Phillips initially fails to recognize the danger of the woman. He presumes, incorrectly, that she is just like his other visitors. Only too late does he realize that he can neither determine how she â€Å"sees,† nor exert his own mode of looking over her. She forces him to acknowledge a point of view not only different from his own, but more attuned to the essential temperament of the natural world. This temperament is defined by the irrational urges that exist in every living thing, including the doctor himself. Note 1. All references to â€Å"The Snake† are from John Steinbeck, The Long Valley (New York, NY: Viking, 1938): 73-86.