Introduction to campylobacter Literature review

Introduction to campylobacter - Literature review Example 163–189). Since campylobacter is present in large quantities in stool, isolation may be considered from this point. However, it is important to note that isolation requires certain conditions of microphilic atmosphere and a media that contains antibiotics. Several methods have been developed to isolate campylobacter. One of them is the membrane filtration. This is used in isolating the microorganism from low turbidity water. Filters of pore size of 0.45 microns are used, and the water is passed as the platting is done face down for the selective agar for the campylobacter. The selective agar is described below in another isolation method. The filters in this process are removed after an overnight incubation. The streaking of plate for isolation before re-incubation then follows this. Prior lab tests have indicated that in the presence of pre-filtration with filters of pore sizes of 6.0 and 5.0 has consistent results of recovery of about 30 jejuni CFU per 250 ml of the seeded water that is nat ural (Line 1711–1715). The other method of isolation is the conventional cultural method. In the laboratory, the sampled specimen is prepared for isolation. If, for example, the sample of raw chicken, a sample of filtrated, chicken rinse water may be used. The water is taken and centrifuged at a rate 16000 times the weight for a period of ten minutes in a minimum temperature of 4 degrees. With an enrichment media of Preston broth, the supernatant is discarded while the pellet is suspended. After the sampled pellet is re-suspended, incubation of the sample at a microbic atmosphere that has 10 percent carbon dioxide, 5 percent oxygen and 85 percent nitrogen. All this happens at a temperature of 3 degrees for 24 hours. The enrichment broth is made consistent with the nutrient broth with supplementation including trimethoprim 10 mg/l, cefoperazone 15 mg/l, rifampicin 5 mg/l, polymyxin B 2500 iu/l and amphotericin 2mg/l. This enriched culture is then placed in

Leadership management assignment 1 Essay Example | Topics and Well Written Essays - 1500 words

Leadership management assignment 1 - Essay Example This is in line with the company’s recruitment policy to help them get the most qualified at affordable remuneration (Luecke 2003). This is therefore done to ensure that the selected individual to fill the position of the manager is the best across the region. They received several applications for the position of the managing director; the group underwent a rigorous recruitment process and finally was left with an individual to negotiate with their starting salary on the job. The remaining individual was from Mexico. In the negotiation process different negotiation skills were outlined that resulted into a successful with a few instances of messing up. Its Human resource manager represented the company on the salary negotiation table while the other side was the individual whose starting salary was to be negotiated (Jacks 2011). Person Position Character A Human resource Manager He is a highly Sociable, Extrovert and democratic B Newly recruited employee Also quite extroverte d, friendly, polite, and highly conscious For new employees of any given firm it is normally safe to negotiate for higher starting salaries before accepting the job offer because after this the new employee will be subjected to the normal salary increase payment plans of the company, which depends on extraordinary performance (Young 1975). The new recruit therefore needed to negotiate for a higher pay than what they used to earn in their former position hence the need for the negotiation skills. The HR manager of company X also needs to be a good negotiator to make sure that they provide the company with manageable expenses and it is willing to negotiate the starting salary of the employee as a whole. The employee is though considering the option of first negotiating the basic pay because given their character they are likely to be confused if they combined the negotiations together with those for the other benefits. This would be to the disadvantage of the employee if the pre-deter mined salary were already advertised (Zartman 1978). A â€Å"Hello Mr. F, this is X company as we talked over the phone, I gaze you are here to talk about the remuneration package of the job offer that we just shortlisted you for the other day. According to the company policy, we would be glad to offer you a salary package of $60,000 yearly plus the benefits, which would vary depending on several variables. Would you be ok with that?† B :I am interested in the job yes but I would not mind if you offered me a salary package of $68,000 per year plus the packages as we would negotiate if it is at the best interests of the company,† A â€Å"$68,000 is not even the average industry rate leave alone what we normally start offering our employees. However, because of your skills and presumed competence, we would not mind offering you a $65,000 package yearly and the benefits as it would be negotiated. How about that?† B "Thank you for your offer and I am certainly intere sted in the position and Company. Can I get back to you later this afternoon or first thing in the morning" A â€Å"You are most welcome and highly appreciate the time that you took to present yourself for interviews. Please make a point of communicating tomorrow given that we need to fill the position immediately. Anyway, your positive response will be highly appreciated. Nice time.†

COPD Case Study Assignment

COPD Case Study Assignment 1) CASE SUMMARY Mr TLT is a 58 year old taxi driver who was admitted to Hospital Batu Pahat due to newly diagnosed chronic obstructive pulmonary disease. He has had hypertension for the past one year and is taking T Amlodipine 5mg od. He is also a chronic smoker for the past 40 years who smokes about 20 sticks of cigarettes a day. Mr TLT presented with shortness of breath which progressively increased in severity for the past 4 days. The shortness of breath was associated with a wheeze. There was also cough with production of mucoid sputum. The dyspnoea occurred after an episode of upper respiratory tract infection. Mr TLT has been having intermittent chronic cough associtaed with mucoid sputum for the past 3 years. He has also been having persistent breathlessness for the past 1 year especially on exertion. He has not sought treatment prior to this admission. On physical examination, Mr TLT was tacypnoiec with a respiratory rate of 28 breaths per minute. There was no cyanosis. Repiratory system examination showed use of accesory muscles as well as increased anterior posterior diameter of the chest and reduced cricosternal distance. On auscultation, vesicular breathing was heard with generalised rhonchi and coarse early inspiratory crepitations at the lower zone of both lungs. The cardiovascular system examination was normal. There were no other abnormalities on physical examination. Investigations done include chest plain radiograph which showed a hyperinflated chest, tubular heart and absence of vascular markings at the peripheries. The ECG showed sinus rhythm with low voltage. No P pulmonale indicative of right atiral hypertrophy seen. A working diagnosis of acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection was made. Mr TLT was given nebulization of ipratropium bromide, salbutamol and normal saline for 2 times. His symptoms improved after being given the nebulization. He was discharged after three days when the dyspnoea had resolved. He was given metered dose inhaler of Ipratropium Bromide 40microgrammes tds and MDI salbutamol 200microgrammes PRN. He was given an appointment to assess his symptoms at the outpatient department in one month time. STUDENT NAME: Tan Hai Liang ID NO : M0409146 NAME OF SUPERVISOR : Prof Khin ROTATION: Internal Medicine PATIENTS DETAILS I/C NUMBER : 510912-01-6343 AGE : 58 SEX : Male DATE OF ADMISSION : 2 June 2009 R/N NUMBER : 1143451 2) CLINICAL HISTORY Chief complaint: Mr TLT is a 58 year old taxi driver who presented with shortness of breath for the past four days. History of present illness: Mr TLT is a chronic smoker for the past 40 years who has been smoking about twenty sticks of cigarettes a day. He had been diagnosed with hypertension for the past one year and is currently on T Amlodipine 5 mg od. Mr TLT has been having intermittent chronic cough for the past 3 years. The cough is productive at times. The sputum produced is mucoid in nature and about one tablespoonful in amount. There is no blood in the sputum. It is also not foul-smelling. Mr TLT then proceeded to have shortness of breath for the past one year. The dyspnoea is persistently present and described as requiring increased effort to breathe. It is worse on exertion and Mr TLT experinces reduced effort tolerance. He is now able to climb one and a half flights of stairs before becoming breathless. He has not consulted any doctors for these symptoms prior to admission. Mr TLT then developed symptoms of upper respiratory tract infection such as rhinorrhea and sore throat one week prior to admission. He had fever of 38 degress celcius at that time which resolved with paracetamol. He also had a productive cough with mucoid sputum at this time. Mr TLT then developed increasing shortness of breath 4 days prior to admission. The shortness of breath worsened over the 4 days and was associated with noisy breathing. He was breathless even at rest but was still able to speak in sentences. There was also an increase in cough as well as production of sputum. The sputum was mucoid and non purulent. He also did not notice any blueness around his lips or at his fingers. Systemic review: There was no loss of appetite or loss of weight. He had mild ankle oedema but no other signs of heart failure such as orthopnoea or paroxysmal nocturnal dyspnoea. Past medical history Mr TLT has not had any hospital admissions prior to this. He was diagnosed with hypertension last year as an incidental finding during a visit to the kilinik kesihatan for an upper respiratory tract infection. He is currently taking tablet Amlodipine 5 mg once daily. Family history Mr TLT is the eldest of 5 siblings. There is a strong family history of hypertension in that his mother as well as two other siblings are also hypertensive. There is no family history of asthma, diabetes or ischaemic heart disease. Social history Mr TLT used to work as a taxi driver but has stopped working full time 2 years ago. He still occasionally drives his taxi but spends more time at home with his family. He is a chronic smoker for the past 40 years and smokes about 20 sticks of cigarrettes a day. He drinks alcohol with his friends on weekends. He drinks one to two bottles of beer each time. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine ____________________________________________________________________________ 3) FINDINGS ON CLINICAL EXAMINATION On general examination, Mr TLT was well nourished and alert but was tachypnoiec. He was able to speak in sentences but there was use of his accessory muscles. There was no clubbing or cyanosis seen. There was also no peripheral oedema, pallor or jaundice. Vital signs: Pulse rate: 72 beats per minute, regular with good volume. No bounding pulse. Respiratory rate: 28 breaths per minute Blood pressure: 129/73 Temperature: 37 degrees Celsius SpO2: 95% under nasal prong oxygen 3 litres per minute Examination of the respiratory system: On inspection of the hands, there was no peripheral cyanosis or flapping tremors seen. There was also no clubbing, muscle wasting or palmar erythema seen. There was presence of nicotine stains. The jugular venous pressure is mildly elevated at 3.5 cm above the sternal angle. On palpation of the trachea, the trachea is central but the cricosternal distance is 2 fingers which is reduced. The apex beat could not be palpated. On inspection of the chest, there is an increased anterior posterior diameter giving rise to a barrel shaped chest. The chest moves equally with respiration and there is use of accessory mucles with intercostal, subcostal and suprasternal retraction. There are no chest wall deformities. On palpation, chest expansion is reduced on both sides. Tactile fremitus is equal on both sides. On percussion, there is hyperresonance over both lungs with loss of liver and cardiac dullness. On auscultation vesicular breathing is heard. There is generalised expiratory rhonchi. There is also fine early inspiratory crepitations heard at the lower zones of both lungs. Examination of the cardiovascular system: The apex beat could not be palpated. There were no parasternal heaves or thrills palpable. On auscultation, normal first and second heart sounds were heard. There was mild bilateral pitting oedema. Examination of the abdomen: On inspection, the abdomen is flat and moves with respiration. There was no guarding or tenderness. The liver and spleen were not palpable. There was no organomegaly. Examination of the neurological system was normal. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING Provisional diagnosis: Acute exacerbation of newly diagnosed chronic obstructive airway disease due to upper respiratory tract infection. Evidence for: Patients with chronic obstructive airway disease (COPD) usually present with a persistent dyspnoea and reduced effort tolerance which was present in the history given by Mr TLT. He is also at increased risk of developing COPD due to exposure to associated risk factors such as tobacco smoke. He has been a chronic smoker for the past 40 years. There is also the presence of chronic cough occasionally associated with mucoid sputum which further suggests COPD. Physical findings of a hyperinflated chest and vesicular breathing with generalised expiratory rhonchi also point to an obstructive airway disease. During this admission Mr TLT had increasing severity of shortness of breath even at rest. This was associated with a wheeze that was described as noisy breathing. Sudden worsening of symptoms suggest an episode of acute exacerbation. The history of upper respiratory tract infection symptoms suggest that it was the trigger for this episode of exacerbation. Differential diagnosis: 1) Congestive cardiac failure. Mr TLT may have developed congestive cardiac failure as a primary event or as a complication of chronic lung disease. There is history of reduced effort tolerance. Patients with congestive cardiac failure may also present with a wheeze and sudden increase in dyspnoea. Physical examination of fine crepitations at both bases of the lungs may also indicate congestive cardiac failure. There is also evidence of mildly raised JVP as well as mild pittint ankle oedema. Evidence against: There is no history of any cause of heart failure such as ischaemic heart disease or cardiac valve defect. Mr TLTs previous records during follow-up show well controlled blood pressure. Additional investigations need to be carried out in order to rule out this condition. A chest plain radiograph may be done in order to look for evidence of heart failure such as cardiomegaly. An ECG may be done to look for right atrial hypertrophy. An echocardiogram should also be performed in order to assess the function of the ventricles. 2) Bronchiectasis Patients with bronchiectasis have a history of chronic cough as well as production of copious amounts of sputum. They may also have persistent shortness of breath, reduced effort tolerance and wheeze. Evidence against: The sputum produced by Mr TLT is mucoid in nature and not purulent which is typical in bronchiectasis. It is also not copious and foul smelling in nature. On physical examination, coarse crepitations would be heard in bronchiectasis as opposed to the fine crepitations heard in Mr TLT. There is also no evidence of clubbing. Chest plain radiograph should be done in order to look for thickened bronchial walls or cystic shadows. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 5) IDENTIFY AND PRIORITISE THE PROBLEMS 1. Shortness of breath and reduced effort tolerance Mr TLTs chief complaint is shortness of breath. This may be attributed to the increase in number of goblet cells and later on fibrosis of the bronchial walls causing airway obstruction seen in chronic obstructive airway disease. The shortness of breath may be partially relieved with the use of nebulization of ipratropium bromide, salbutamol and normal saline or with the use of metered dose inhalers. Chest physiotherapy may also be useful. Mr TLT also has had reduced effort tolerance and persistent dyspnoea for the past a year. As such he may require the use of ipratropium bromide in a metered dose inhaler upon discharge in order to feel less breathless due to the bronchodilator effect of the ipratropium bromide. 2. Upper respiratory tract infection Mr TLT may require antibiotics as he still has symptoms of upper respiratory tract infection such as sore throat. Furthermore patients who present with an acute exacerbation are at greater risk of having a bacterial infection. This is because of the depressed immune state that the patient is in as a result of the acute illness as well as due to any steroids that would be given as part of the management plan. The appropriateness of usage of antibiotics in chronic obstructive airway disease will be further discussed below. 3. Adequate inhaler technique Mr TLT would need to be taught about the correct technique to be used when using metered dose inhalers. He would probably require daily use of ipratropium bromide metered dose inhalers to reduce his breathlessness. In the event that he is unable to learn proper technique, he may be encouraged to buy an aerochamber. 4. Smoking cessation Mr TLT should be counseled on smoking cessation as it has been proven that smoking cessation would alter the course of progression in COPD and is associated with lower all-cause mortality. He should be counseled on the various options of smoking cessation which will be discussed further below. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS 1) Full Blood Count Justification: In order to view the total white count as well as the differential count to see if there is an infection which has caused this episode of exacerbation. There may also be secondary polycythemia if the patient has chronic pulmonary hypertension. Results: White cell count : 7.91 X 109/L Red blood cell : 4.48 X 1012/L Haemoglobin : 133.00 g/dl Haematocrit : 42.00 ratio Mean cell volume : 93.80 fL Mean cell haemoglobin : 29.70 pg Mean cell haemoglobin conc. : 317.00 g/l Platelets : 141.00 X 109/L Differential count Neutrophils : 60.10% 4.76 X 109/L Lymphocytes : 25.30% 2.00 X 109/L Monocytes : 13.80% 1.09 X 109/L Eosinophils : 0.50% 0.04 X 109/L Basophils : 0.30% 0.02 X 109/L Interpretation: This is a normal full blood count result with normal total white count as well as normal haemoglobin levels. 2) Plain chest radiograph Justification: Done in order to look for evidence of chronic obstructive airway disease such as hyperinflated chest or evidence of congestive cardiac failure such as cardiomegaly and prominent upper lobe vessels. Results: Hyperinflation of the chest with the 7th anterior rib crossing the diaphragm. No other abnormalities seen. Interpretation: Hyperinflation of the lung fields is consistent with the provisional diagnosis of chronic obstructive airway disease. 3) Sputum FEME, culture and sensitivity (not done) Justification: In order to look for any bacteria which may have been the cause of the exacerbation . If there any organism cultured, proper antibiotics can be given based on the sensitivity test. 4) Arterial blood gas (not done) Justification: May be necessary in severe cases of breathlessness to look for respiratory failure and associated changes in blood pH. 5) Blood urea serum electrolytes and creatinine Justification: To look for renal impairment which may be present due to Mr TLT having hypertension. Renal impairment may also affect the dosage and type of antibiotics used. Results: Urea : 3.7mmol/L Sodium : 135 mmol/L Potassium : 3.7 mmol/L Creatinine : 65 umol/L Interpretation: Normal result. There is no renal impairment 6) Electrocardiogram Justification: To look for evidence of right ventricular hypertrophy or right atrial hypertrophy which may be seen in chronic lung disease. Results: ECG with sinus rhythm. There is no P pulmonale seen. There is low voltage seen. No ischaemic changes seen. No left ventricular hypertrophy. Interpretation: Normal ECG with low voltage is seen in a hyperinflated chest such as in patients with COPD STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION Working diagnosis: Acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection My proposed plan of management is as follows: Acute management 1. Provide supplemental oxygen via nasal prong 3L/min and maintain SpO2 above 90%. Arterial blood gas should be done in order to ensure adequate oxygenation without carbon dioxide retention of acidosis. 2. Close monitoring of vital signs and SpO2 hourly until the patients breathlessness improves. Nursing staff to inform if patient deteriorates such as increased respiratory rate or drop in oxygen saturation below 92%. 3. Give nebulization of Ipratropium Bromide:Salbutamol:Normal Saline in ratio of 2:2:1 every four hours until breathlessness decreases. 4. Oral prednisolone 40mg once daily for 10 days 5. Postural drainage and chest physiotherapy may be performed. 6. Oral antibiotics such as T. Cefuroxime may be given. This was not given in this patient with further discussion below. Long term management 1. MDI ipratropium bromide 40 microgrammes tds 2. MDI salbutamol 200 microgrammes PRN 3. Counseling on proper inhaler technique. 4. Couseling on smoking cessation. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES) Mr TLT was warded for a total of 3 days. His breathlessness improved after nebulization with ipratropium bromide, salbutamol and normal saline for one day. He no longer required nebulization after one day. Mr TLT was also able to ambulate without feeling breathless. He was able to eat and to sleep well without being bothered by the dyspnoea. His vital signs were also normal and his respiratory rate improved to about 20 breaths per minute. There was still some ronchi heard on auscultation but it was much reduced. He was afebrile during his stay. Mr TLT was discharged after 3 days of admission and educated on chronic obstructive airway disease. He was also counseled on the importance of smoking cessation. He was given an appointment with the medical outpatient department in one month time in order to review his symptoms after being given MDI ipratropium bromide. He was told to return to the hospital if he had similar episodes. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION Discharge Plan 1. Medications: i. MDI Salbutamol 200 µg PRN ii. MDI Ipratropium Bromide 40 µg TDS iii. T. Amlodipine 5mg once daily iv. T. Prednisolone 20mg od for 7 days. 2. Counseling on COPD and use of metered dose inhaler Mr TLT should be taught about the correct technique in using a metered dose inhaler. The technique should then be assessed before discharge. In the event that Mr TLT is unable to coordinate well, he may be advised to purchase an aerochamber. 3. Counseling on smoking cessation The approach to counseling a patient on smoking cessation as well as various options will be further discussed below. 4. Education on the symptoms of an acute exacerbation and advise to return to the hospital if there is development of those symptoms. 5. For follow-up at the medical outpatient department for review of symptoms while on MDI ipratropium bromide. He should also be taught about pulmonary rehabilitation. A spirometry appointment may also be made. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 10) REFERRAL LETTER (MANDATORY) Dr Tan Hai Liang Medical Department, Hospital Batu Pahat Family physician, Klinik Kesihatan Batu Pahat, 83000 Batu Pahat, 10 June 2009 Dear esteemed colleague, Patients name: Teo Lai Thing Patients I/c number: 510912-01-6343 Problem: Chronic Obstructive Airway disease Thank you for seeing this 58 year old gentleman who is hypertensive for the past 1 year currently on T. Amlodipine 5mg once daily. He presented to Hospital Batu Pahat with shortness of breath for 4 days that was increasing in severity. A diagnosis of chronic obstructive airway disease was made. He was discharged uneventfully on the third day of admission with the following medication: MDI Salbutamol 200 µg PRN, MDI Ipratropium Bromide 40 µg TDS and T. Amlodipine 5mg once daily. Mr Teo has been a chronic smoker for the past 40 years and smokes up to 20 sticks of cigarettes a day. We have counselled him about the benefits of smoking cessation while in the ward. He is currently considering it and would like to learn more about the various options of smoking cessation. Kindly assess the patients keenness for smoking cessation as well as provide him with additional information on the options available to quit smoking. Thank you. Sincerely ____________ (Tan Hai Liang) Medical Department Hospital Batu Pahat STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 11) LEARNING ISSUES IN THE 8 IMU OUTCOMES 1) Communication skills What are the benefits of smoking cessation in COPD patients and how should counseling be done? Counseling for smoking cessation should play a significant role in the holistic management of a patient with chronic obstructive airway disease. This is because studies have shown that smoking cessation changes the clinical course of COPD by preserving lung function. One study of patients reviewed at 14.5 years after stopping smoking showed that smoking cessation intervention showed 18% reduction in all-cause mortality compared with usual care without smoking cessation intervention. Patients who had stopped smoking had lower rates of death due of coronary heart disease , cerebrovascular disease, lung cancer, and other respiratory disease as compared with those assigned to usual care who continue to smoke. [1] Fig. 4. Effect of smoking cessation on mortality cause at 14.5 years in the Lung Health Study. (A) Comparison of smoking cessation intervention with usual care. (B) Comparison according to smoking status. I therefore looked up for counseling methods for smoking cessation. The American College of Chest Physicians recommend that physicians should be the first line in introducing smoking cessation. [2] There are 5 As that a doctor should perform for a patient who is a smoker: †¢ Ask about tobacco use at every visit †¢ Advise tobacco users to quit †¢ Assess the willingness to attempt quitting †¢ Assist the patient with methods for quitting †¢ Arrange for follow-up contact via phone or face to face If the patient is not yet willing to quit, there are 5 Rs which should be identified together by the patient and the doctor: †¢ Relevance of quitting for the patient †¢ Risks of illness related to continued tobacco use †¢ Rewerds/benefits of smoking cessation †¢ Roadblocks for quitting, internal and external †¢ Repetition of the motivation intervention at each encounter There are two means of intervention in smoking cessation namely pharmacological and behavioural. The pharmacological means include nicotine replacement therapy or buproprion. Behavioural interventions include counseling programs that teach problem-solving skills and support groups. [3] In conclusion, I learned that doctors have an important role in actively encouraging patients who smoke to stop as there are many proven benefits of smoking cessation. The steps discussed above on techniques in the counseling of patients would be helpful to me in the future. 2) Professionalism, ethics and personal development Should antibiotics be given for episodes of exacerbation of chronic obstructive airway disease? Mr TLT was not given antibiotics during this episode of exacerbation. Certain quarters support the use of prophylactic antibiotics in all exacerbations due to the knowledge that most exacerbations are caused by the common organisms of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), Pseudomonas aeruginosa (P. aeruginosa) and Moraxella catarrhalis (M. catarrhalis). Sputum culture may not be useful as even in the clinical stable state, some patients have sputum positive for bacteria. As such a broad spectrum antibiotic is usually used to cover different bacteria. However, is this use of antibiotics justified in that do patients benefit from it or is the overjudicious use of antibiotics merely promoting antibiotic resistant bacteria? Current Global initiative for chronic Lung Disease guidelines [4] recommend that antibiotics should be given in: i) patients with exacerbations of COPD and the three cardinal symptoms of increased dyspnoea, increased sputum volume and increased sputum purulence. ii) patients with exacerbation of COPD with two of the cardinal symptoms if increased purulence of sputum is one of the two symptoms iii) patients with severe exacerbations of COPD that requires mechanical ventilation A meta-analysis by Ram et al [5] of 11 placebo controlled RCTs with 917 patients attempted to analyse the value of antibiotics in the management of acute COPD exacerbations. The results show that there is a decrease in short-term mortality, treatment failure and sputum purulence with antibiotic therapy compared to placebo. The authors concluded that antibiotics therapy is appropriate in exacerbations of COPD associated with increased cough and sputum purulence. They further found that antibiotics have the greatest effect for patients with severe exacerbations who are admitted to the hospital. They were unable to comment on exacerbations with non-purulent sputum, what antibiotics were the best to be used and also the duration of therapy due to the lack of RCTs done on these aspects. In conclusion, it was appropriate that Mr TLT was not given antibiotics as he did not have the cardinal signs as mentioned by the GOLD guidelines and further supported by the systemic review. 3) Self directed life long learning What are extrapulmonary manifestations of COPD and what are its therapeutic implications? Chronic obstructive lung disease has long been known as a localized pulmonary disorder. However new evidence have shown that COPD may be a systemic disease that involves pathology in several extra-pulmonary systems. An article by Remels et al [6] summarized the extrapulmonary manifestations as well as its implications on the holistic management of chronic obstructive airway disease. The article showed that there is skeletal muscle dysfunction as well as systemic inflammation in chronic obstructive airway disease. There is loss of muscle mass associated with impaired protein metabolism. The loss of muscle mass which is called sarcopenia may progress to cachexia. Studies have also shown that there is increased apoptosis of muscle cells at the cellular level. Independent of the loss of muscle mass is the reduced muscle endurance. This finding has been attributed to abnormalities in mitochondria or to hypoxia. These findings have significant implications on management of a COPD patient which will be discussed below. Systemic inflammation is also seen in patients with COPD. This is evidenced by elevated levels of the proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-a), interleukin-6, interleukin-8, and TNF-a receptors. The origin of the systemic inflammation is thought to be independent of the pulmonary manifestation of COPD. One postulation is the increase systemic inflammatory mediators such as neutrophils and lymphocytes in the circulation of patients with COPD. Another proposed mechanism is increased cytokine production due to chronic hypoxia. The therapeutic implications of these findings is that muscle atrophy should be prevented by resistance exercise as well as combined strength and endurance exercise. Current Malaysian guidelines on the management of COPD [7] recommend pulmonary resistance including lower and upper limb exercises as well as inspiratory muscle training. This concurs with a Cochrane metaanalysis by Lacasse et al [8] which strongly support respiratory at least four weeks of exercise training as part of the of management for patients with COPD. The authors found that there was clinically and statistically significant improvements in quality of life as measured by dyspnea, fatigue and emotional function. 4. Critical thinking and research What is the efficacy of systemic corticosteroids for acute exacerbations of chronic obstructive airway disese? The use of systemic oral or intravenous corticosteroids is recommended by GOLD guidelines in the management of acute exacerbations of chronic obstructive airway disease. However the patient, Mr TLT was not given any systemic corticosteroids. This could be because he merely had a mild exacerbation. I therefore looked up a Cochrane metaanalysis on the use of systemic corticosteroids for acute exacerbations of chronic obstructive airway disease [9]. The authors reviewed randomized controlled trials comparing parenteral or oral corticosteroids with placebo for the treatment of exacerbation of COPD. The primary outcomes measured were treatment failure (hospital readmission, return to emergency department), relapse and mortality. The authors reviewed 11 studies involving 1081 participants. The results show a statistically significant difference between placebo and use of corticosteoids. There was less treatment failure in patients given corticosteroids. Relapse within 30 days were also reduced. However there was no statistically significant reduction in mortality. As such the authors concluded that administration of oral or parenteral corticosteroids in the treatment of acute exacerbations of COPD reduces the likelihood of treatment failure. This is associated with early and continuing improvement during treatment with corticosteroids in lung function, breathlessness and blood gases and with a shorter hospital stay. This in turn has a positve impact on the economic cost of treating exacerbations, with fewer follow-up visits and hospital admissions. The authors also found that although there is an increased incidence of corticosteroid side effects such as fluid retention, hypertension and adrenal suppression, the effects are unlikely to persist after treatment ceases. EVIDENCE BASED MEDICINE WORKSHEET FOR REVIEW OF THERAPY STUDIES ASKING QUESTION Patient (P): Patients who present with stable COPD Intervention (I): Oral corticosteroids Comparison (C): Placebo Outcome (O): Effects on health status ACCESSING EVIDENCE THE SEARCH PATH How was the article identified: The Cochrane Library Search keywords : corticosteroids, stable COPD Citation: Walters JAE,Walters EH,Wood-Baker R.Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 3. 1. Is

The United States should drill for oil in the ANWR - Alaskan National Wildlife Reserve :: essays research papers

Proposition: The United States should drill for oil in the ANWR. Significance: Right now, The United States of America languishes in an economic decline. Jobs are being lost. Drilling in the ANWR will create hundreds of thousands of jobs. Also, 80% of Alaska’s state revenues are oil. With the North Slope oil fields in decline, Alaskans could lose jobs. Drilling in the ANWR will create jobs for Alaskans. As Jennie Wodkowski, who has lived in Alaska for 34 years said, â€Å"Oil’s important. We don’t have anything else going on here.† Rationale: 1. Harms the Environment 2. Costs Billions 3. Nobody willing to Drill 4. Not much Oil 5. Won’t create jobs 6. Not worth the time My opponents 1st/2nd/3rd contention was the drilling in the ANWR will harm the environment. This is absolutely incorrect. Lets put this into perspective, the ANWR is 19.6 million acres out of Alaska, which is 240 million acres. The proposed drilling in the coastal plain will be 1.5 million acres. Now, with the new technology we have today, we can tap into the 1.5 million acre oil supply with an oil area that is 2000 acres. 2000 acres is 1/10000 or .0001% of the ANWR. 1.5 million acres of oil and a minuscule possibility of harming at max, 1/10000, I repeat 1/10000th if the ANWR. (Arctic Power) Also, drilling in Alaska will not harm the wildlife. Take Prudhoe Bay for example. The Central Arctic Caribou Herd that occupies Prudhoe Bay has grown from a population of 6000 in 1978 to 27000 today. This is a 450% growth over 26 years at an average of 17.3% growth per year. (Arctic Power) That’s quite an increase. Furthermore, the ANWR is not a pristine wilderness with magnificent wilderness and beautiful wildlife at every corner. That is a illusion generated by anti – drilling supporters. The truth is that in the wintertime, the ANWR is 60 degrees below and 99 degrees below if you count the wind-chill factor. As Senator Ted Stevens of Alaska said â€Å"It (the ANWR) is hell in the wintertime. This is not some pristine place that should be protected.† Drilling will not harm wildlife or the environment. My opponents 1st/2nd/3rd contention was that drilling in Alaska will cost billions. True, drilling in Alaska will cost billions but the positive impact on the U.S. economy far outweighs the cost. Also, the billions of dollars it will cost to drill in the ANWR will be mostly paid by companies who want to develop into the ANWR, not the U.

One word that has changed the world

Do you love apples? Well, Ido love apples! However, it is not because it's nutritious, instead, it haschanged world. Why? You may ask, or you may come to realize that Job's productsof apple brand have indeed brought us dramatic changes. You're partially right! Actually, in the longprocess of history, there are three apples that have exerted significant impacton us. One was bitten by Eva, one fell on Newton's head, and another on is inthe hand of Steven Jobs. The three great apples have shaped a brand-new worldwith a fire-new outlook.The three great apples have signified a usion of curiosity,intelligence, innovation and technology. The three great apples have endowed uswith a window to look through an unknown world, to explore, to innovate, toprogress and to advance. Eva's apple is a metaphor of human's curiosity. Curiosity is a child-like sense of wonder, making usquestion things that others do not even notice. Einstein once put it â€Å"I'mneither especially clever nor especially g ifted, I'm only very, very curious. † Hewent on to say that, â€Å"the important thing is not to stop questioning. Withthis regard, he proposed the relativity theory, a milestone in hysics, aleapfrog of human development. Stories like this happen all the time. Becauseof curiosity, we have been eager to explore the outer space, is there anyliving creature in outer space, is there any possibility to live on otherplanets so that helping release huge burden of congestion, climate variationand other knotty issues. Curiosity drives us to the Journey of exploration ofthis mysterious and unfathomable world. Curiosity propels us to fgure out allthe truths and facts.Newton's apple is amanifestation of human's intelligence. We can speak, we can create, we can makea ifference. All these features have distinguished us as a unique creature, Justa saying goes† there's nothing as precious as humans in the world†. Thanks tointelligence, our ancient ancestors have created a brillia nt civilization thatinspired the world for centuries. Due to their intelligence and endeavor, wehave transferred from a primitive society to a modern one. Intelligence is thesource of our development. Apple intelligence leads us to advance. Jobs' apple is a symbol of dailyupgrading technology.In retrospect, we'll fgure out that we have been livingin a orld tightly connected with technology, particularly, after the 1990s. Becauseof technology, our life now is strikingly different. With TV, we are immersedin extensive entertainment and relaxation, with telephones, we are delighted inconvenient and efficient contact with families and friends, with MP3, we areenchanted in melodic music at anytime anywhere, with internet, we are involvedin a wide range of activities—chatting online, sending mails, shopping,getting information and so forth. Every day, we're marveled at fabulous giftsfavored by technology.Apple technology akes us to innovation andtransformation. Whether you're holdi ng anipod 4 or you're holding 4 packs of apples. World is waiting for us to make a differenceand the three great apples have spured the most unparalleled and tremendouschanges for the world. The great apples, namely, curiosity, intelligence andtechnology are the source of strength of enterprising, pioneering andprogressing. Apple, is more than anapple. It is a word that has changed the world and it's my solid convictionthat another apple is to change the world! One word that has changed the world By gluttonysJt

Lab Report Conclusion

Conclusion In this experiment, we measured the mass of 4 gasses; oxygen, carbon dioxide, helium, and lab gas. We took a Ziplock bag, and turned into a non-stretchy balloon, and filled with each gas and measured the apparent mass then calculated the actual mass, then find a ratio between the mass of oxygen and the other gasses. We tried to keep the pressure about the same each time so our calculations would be more accurate. We found out that the heaviest was carbon dioxide, and the lightest was helium.In fact, helium and lab gas had a density below 0. Anyways, it turned out that our apparent masses were very different from our actual mass calculations; for example oxygen’s apparent mass was 28. 33g but its actual mass was 4. 10g. We also found the ratios, and after collecting class data, our carbon dioxide ratio was 1. 39/1g, our helium ratio was . 21/1g, and our lab gas ratio was . 59/1g. Then we had to come up with two hypotheses to figure out why one gas is heavier (denser) than another?Well, we came up with hypothesis #1: The different molecule mass hypothesis, and hypothesis #2: The more molecules in the same volume hypothesis. After having a class discussion, turns out that hypothesis one is more reliable due to Avogadro’s hypothesis; if two gasses at the same temperature and equal volume contain equal amount of molecules. So according to the statement above, the carbon dioxide molecules must be 1. 39x bigger than an oxygen molecule, a helium molecule must be . 21x bigger, and . 59x bigger than an oxygen molecule.

Tartuffe by Jean-Baptiste Poquelin Moliere Essay Example

Tartuffe by Jean Tartuffe by Jean-Baptiste Poquelin Moliere Paper Tartuffe by Jean-Baptiste Poquelin Moliere Paper Essay Topic: Literature Tartuffe, a play by Jean-Baptiste Poquelin Moliere, is a poignant story about a man, Orgon, who is totally and completely taken in and blinded by a scoundrel named Tartuffe. Orgon has utter faith and shows unconditional love for this poor pious man, Tartuffe. Orgon is willing to sacrifice everything his wife, his family, his daughters happiness and even his large estate. Orgon believes that under Tratuffes tutelage my souls been freed from earthly loves, and every human tie:/ My mother, children, brother and wife could die, /And Id not feel a single moments pain (I, v, 18-20). This story of deceit leads the reader to believe that all will be lost and that evil will triumph over good. The events that occur in the play and the emotions that the characters experience parallel the events in our everyday lives. Such events include the power struggle between Orgon (the parent) and his children, about secret agreements, about reverse psychology and about relationships in general. Orgon has agreed to give his daughter Mariane to Valere in marriage but is now having second thoughts. He has decided that Mariane should wed Tartuffe. He believes that Tartuffe is the most suitable husband and tries to convince her. Youre a sweet girl Whom I hold dear, and think most highly of (II, i, 7). You can repay me, if youll cheerfully obey me (II, i, 9-10). Although everyone in the family is against this union he says I shall defy you all, and make it clear/ That Im the one who gives the orders here (III, vi, 57-58). Its a fathers privilege (II, i, 30). But beyond his threats he supports his feelings when he tells Mariane Daughter, well disregard this dunderhead. Just trust your fathers judgment. Oh, Im aware/ That I once promised you to young Valere; /But now I hear he gambles, which greatly shocks me; /Whats more, Ive doubts about his orthodoxy. /His visits to church, I note, are very few (II, ii, 65-70). Mariane is distraught and turns to Dorine, her ladys maid and friend. Dorine encourages Mariane to tell her father that one cannot love at a fathers whim; /That you shall marry for yourself, not him: /That since its you who are to be the bride, / Its you, not he, who must be satisfied; (II, iii, 8-11). But Mariane is afraid to go against her fathers wishes and answers Dorine, Ive bowed so long to Fathers strict control, I couldnt oppose him now, to save my soul (II, iii, 13-14). When I read this part of the play it was like I was reading a page from my own life. Like Mariane, I have a great deal of respect and love for my mother and stepdad who have always guided me down a safe and stable path. But we disagree strongly about the boy I am dating. Tom is a kind and thoughtful person. He is a good friend and can be trusted with confidences. He and I enjoy many of the same things but each of us is willing to learn about the others interests and hobbies. My mom and stepdad see things differently. They pointed out that Tom and I are of different religions and from very different backgrounds. My best friend Melissa, like Dorine, can see my side of the story and agrees that I should follow my heart. But I guess ultimately I am the one who will have to live with the consequences of my actions. Am I ready to do that? Tartuffe has completely seduced Orgon into believing that he is the most religious and devout human being in existence and believes that his charm will work on all members of Orgons family. Tartuffe makes a pass at Elmire, Orgons wife, it floods my heart with bliss/ To find myself alone with you like this. / For just this chance Ive prayed with all my power/ theres nothing I had rather do Than bare my inmost heart and soul to you (III, iii, 21-23, 27-28). Having professed his feelings he takes hold of her hands and presses her fingertips. When rebuked, he places his hand on her knee. Damis, Orgons son, tells his father of Tartuffes overtures. Father Let us advise you / that I surprised him with your wife, and heard His whole adulterous offer (III, vi, 1, 7-8). As the scene was unfolding I could feel the lecherous actions of this ungodly man. When I was at Nassau Community College last fall and then again in the spring I was stalked by a young man in my English class. Nothing has ever made me feel more uncomfortable or scared in my entire life. This guy would be standing near my car and would just stare at me. He would stand by my classroom and would just stare at me. He even once had the nerve to follow me into the Ladies Room. I told my English Professor and the campus security police. They said they would keep an eye out but could do nothing unless he actually physically attacked me or spoke to me directly. That was not very comforting because it seemed that they did not quite believe me. This sexual harassment was seduction at its worst. Tartuffe plays the scoundrel well. When given gifts by Orgon he insists he should Give him less I dont deserve it. The half, Sir, would suffice (I, v, 38). But Orgon does not see through these false words. Even when his son tells him of Tartuffes inappropriate behavior with his wife Orgon believes what he wants to. Tartuffe tells him Believe his story: the boy deserves your trust/ dont be deceived by hollow shows: /Im far, from being what men suppose (III, vi, 19, 24, 26). But Orgon insists that Tartuffe, is the honest and fair person he believes him to be and even gives him Clear deed and title to everything I own (III, vii, 38). This reverse psychology worked on Orgon and I hoped would work on my mom. One day when I was shopping with my mother, I badly wanted a pair of shoes that I saw in a fashion magazine and were expensive. I knew that my mom would not pay for them and would suggest that I get another pair of shoes that was more reasonably priced. When we got to the store she did exactly as I thought. She said no to the pair that I wanted because she really disliked them and picked out a different pair that she thought I might like. I said fine, whatever, and put a pout on my face because I was not getting the pair that I wanted. They really were not that bad and fit better than the expensive ones but they were not the trendy new expensive ones that I had my heart set on. But she was the one using reverse psychology. She told me that I could have the more expensive ones if I really wanted them. When she relented, I felt a little guilty. I put things into perspective and smiled. I agreed to the ones she picked out because they were more comfortable and I knew that after all the other things she had gotten me for school this would add another financial burden. However, after we paid for the pair of sneakers that was less money, she surprised me by offering to buy me a special pair of designer sandals that I desperately wanted, something she was planning all along. When Orgon finally accepts the truth about Tartuffe he must also accept the consequences of his actions. He is about to lose his estate and go to jail for keeping treasonous papers. He has decided that no one can be trusted. Cleante, Orgons brother-in-law, begs him not to jump between absurd extremes and to earn to distinguish virtue from pretense, / Be cautious in bestowing admiration, / And cultivate a sober moderation to err, if err one must,/ As you have done, upon the side of trust (V, ii, 37, 50-52, 56-57). My mom was a single parent for more than ten years and raised three children. Every decision rested on her shoulders. There were many times when she proved to be the stabilizing force in our lives by making difficult decisions about school, dating, driving and the like. We knew we could unconditionally count on her for love and guidance. She did, however, instill in all three of us the ability to make decisions. When I first started college I enrolled at SUNY Oswego. During the summer break I was very unhappy and torn about returning to school. There were not many Long Island kids at Oswego and fewer Jewish ones. I am the kind of student who needs to meet with my professors to help me get on track and some would not offer alternate office hours that would not conflict with my classes. Even so, I was more worried if my mom would be disappointed in me? Would I make new friends? Would my friends that that I had to come home? Would I be embarrassed about failing? I expected her to order me home because my grades were not as good as I had achieved in the past. On the other hand, I thought she might order me to stay since she had spent so much time, effort, and money getting me ready for out-of-town school. Instead, she ordered me to weigh the pros and cons and make a decision on my own. I insisted that she tell me what to do, but she held fast and offered no answer. She told me that the decision had to be mine. But having been raised in a household with her at the helm I had the ability to make a difficult grown-up decision. I decided to come hoe. She supported my decision and that decision turned out to be exactly right for me. I know I found my niche here at C. W. Post. Secrets can sometimes be troublesome and sometimes they are just meant to be shared between two people. When Tartuffe makes his sexual overture to Elmire, she asks him Arent you afraid that I may take a notion/ To tell my husband of your warm devotion. / But I shall be discreet about your lapse;/ Ill tell my husband nothing of whats occurred/If, in return, youll give your solemn word/ To advocate as forcefully as you can/ the marriage of Valere and Mariane (III, iii, 125-126, 136-140). When I came home from camp my mom and I entered into a secret agreement. My parents decided that I should help pay for half of the repairs on my car. It needed new tires, an inspection, and a new alarm. My mom knew how hard I worked all summer and that these repairs would take a big chunk out of my salary. We agreed that I would write out a check for the amount that was due and that she would reimburse me. She knew that if I paid for the repairs that I would not be able to take care of my personal needs and school expenses and that either way she would have to subsidize me. Orgon and his mother, Madame Pernelle, are each subjected to family pressure. Both believe in Tartuffe and will not listen to reason. As shown all along, Orgon does not want to hear any negatives about Tartuffe until his wife absolutely convinces him. But even Orgon cannot change his mothers mind. Madame Pernelle defends Tartuffe. She will not be swayed and insists that Till his guilt is clear, / A man deserves the benefit of the doubt. / You should have waited, to see how things turned out (V, iii, 45-47). Peer pressure is difficult to overcome. My first real experience with peer pressure was when I was away at school. My roommate was into marijuana and tried to convince me that a joint would enhance my outlook and I would begin to relax. My other friends tried to convince me that the bar scene was cool and that drinking would make me less up tight. But I know for me that drugs and alcohol are not for me. I am pleased to say that I did not give into peer pressure and Yes, I am the designated driver. As one can see, the events that the characters encounter in Molieres play Tartuffe are as timely today as when they were written. We can all identify and empathize in one way or another with his characters and the situations they find themselves in. Even though Orgon seems like a weak, uncaring father and husband, he ultimately shows his true love for his family and apologizes for his poor judgment. The play is a wonderful example of family life.