Amnesty for Illegal Aliens essays

Amnesty for Illegal Aliens essays The additional amnesties proposed by the Mexican government should be rejected. Amnesties are never-ending, open-ended rewards for illegality. Amnesty for illegal immigrants world, rewards lawbreakers. Illegal aliens harm the American workforce. Illegal aliens displace an estimated 659,00 American workers every year, at a cost of 3.5 billion a year. The cheap labor that illegal immigration provides depresses the wages and working conditions of the working poor. Under a device invented by the courts, many illegal aliens are allowed to receive welfare without fear of deportation. Other illegal aliens get welfare the same way they get jobs, document fraud. In many cities, false documents can be bought on the street for as little as $40. With false documents, an illegal aliens right to work or welfare goes unquestioned. With the cost of displacing American workers, the cost of giving welfare to needy illegal aliens, and the cost of providing them general services, it is estimated that the annual cost of illegal immigrants is 19 billion. INS study after ten years in the united states, that average amnestied illegal alien had only a 7th grade education and an annual salary of less than 9,000 a year. Encourages more illegal immigration: amnesties always lead to more illegal immigration, and aliens around the world will sneak into the united states to be part of the next amnesty. We granted amnesty to 3 million illegal workers in 1986, only to see the number of illegal aliens rise to an estimated 11 million in 2000. Amnesty is not a cure for illegal immigration; it is a cause of illegal immigration. Rather than simply granting amnesty to millions of illegal immigrants, American policy should focus on incentives to illegal workers to return home. They arrived here with out our help; they will leave the same way if we dont dangle another amnesty before them. The interests of immigrants and the concerns of American busi ...

Pronouncing Words that Begin with WH

Pronouncing Words that Begin with WH Pronouncing Words that Begin with WH Pronouncing Words that Begin with WH By Maeve Maddox Maria Cypher wrote: Can you weigh in on whether the h in -wh- words (e.g., whether, white, overwhelmed) should be pronounced? This seems to be a regional thing, but I say yes, yes, yes! (And then my friends and relatives mock me.) Im with you, Maria. At least I am on many words that begin with the letter combination wh. Many of our wh words descend from Old English originals that began with the spelling hw: hwa (who) hwaem (whom) hwael (whale) hwaether (whether) hwit (white) The sound [hw] is an aspirate, rather like the sound one makes when blowing out a candle. Its a sound I teach for the phonogram wh. Even if one speaks a dialect that pronounces the spellng wh [hw] as [w] in words like white and whet, learning the wh as a phonogram distinct from the letter w and applying it as a spelling pronunciation is useful in learning to spell correctly. Not knowing the difference can result in writing that startles or misleads: By 1600, the British and Dutch had broken the Spanish and Portuguese naval hegemony, freeing up the spice trade. But trade in spices did not wet the North American palate for hot chili peppers.YaleGlobalOnline WordNavigator.com lists 941 English words that being with the wh spelling. Many of them are different forms of the same word, for example whistle and whistling. Many are words of interest only to Scrabble players. Eliminating the Scrabble words, multiple forms of the same word, and obsolete spellings, I narrowed the list to 70 or fewer. Of this short list, some are words in which the wh has mutated to an h sound (delabialization of /hw/), ex. who, whom, and whore. (I can remember the first time I came across that third wordI was in high schooland went around trying to pronounce it with a [hw]. Talk about being laughed at†¦) Words like white, whet, and whale belong to whats called the wine/whine merger. For most English speakers, the wh in these words is pronounced as a plain w [w]. Maria and I are in the minority. And Id guess that we dont pronounce the same wh words alike. In reviewing my short list of wh words, I find that Im not at all consistent. For example, I would pronounce whizz with the [hw] in this sentence†¦ The arrow whizzed through the air. †¦but Id probably pronounce it [w] in this sentence: Charlie stepped behind the hedge to take a whizz. The only reason I can think of is that I heard the second use of the word in conversation before seeing it written. Then theres whiz as in whiz kid. That, for me, would probably take a [w] sound. Here are some words that I know I pronounce with the breathy [hw] sound†¦ whale whinny whine while whether whisper whistle whiskers †¦but I think I may pronounce these words with a plain w sound: whisky whey whittle white Ah, the mystery of language! Heres a link to all you could ever want to know about The Phonological History of wh. Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Spelling category, check our popular posts, or choose a related post below:7 Types of Narrative ConflictList of 50 Great Word Games for Kids and AdultsI wish I were...

Teams at Kluster Case Study Example | Topics and Well Written Essays - 500 words

Teams at Kluster - Case Study Example Individual team members must develop long-term working relationships with other individuals within the group and form solid operational procedures in order to perform their tasks efficiently. Additionally, the company will provide all material external support in order for the team to accomplish their short and long term objectives effectively. In the case of Klusters â€Å"Illuminator Team† its basic format is of a team that runs things. It is also a type of virtual team since the many team members are all from different geographical locations and often meet using web based groupware instead of face to face. There are advantages and disadvantages to a team based work environment. Some advantages of a team based approach to problem solving is that unlike traditionally structured organizations all team members participate in the decision making process instead of top management making all the decisions. As a direct result all employees are empowered to participate creating a work environment that is more efficient and effective at dealing with complex organizational problems while giving a competitive edge over the competition. Some disadvantages of a team based approach is that in many teams individual achievement is not as easily determined as in a traditional hierarchical organization which is a factor in determining compensation. Team based companys tend to focus on team achievements rather than individual performance. The lack of centralized decision making of a team based organization can lead to some disorganization and as well as control and coordination issues for management (Sch ermerhorn & Hunt & Osborn). The Illuminator team has addressed some of these challenges by placing team member reward mechanisms in order to recognize top performing individuals and their contribution to the team effort. Their system is designed to provide them with financial as well as member

Anne Ingram, Viscountess Ingram's Ideas about women in An Epistle to Essay

Anne Ingram, Viscountess Ingram's Ideas about women in An Epistle to Mr. Pope - Essay Example Pope, at the time of Anne Ingram, was thought to hold these misogynistic views. He happened to have written many poems which depicted a woman in quite an inferior position and at times exalting the pope’s stature in relation to women. In her illustration, she turns the tables for the pope and ends up using his own verse technique and other principles that he held against him. As we can see in numerous couplets written by Pope, there are very sharp contrasts between the characters of men and those of women. However, in her writing, Ingram uses the form of couplet in placing huge emphasis on what the female and male gender do possess in common. In her argument, Ingram states clearly that there is not much difference, if any, since both man and woman desire to have one thing, which is common: love of power, and that this motivates both male and female sexes. Interestingly, Ingram chooses to use a positivist kind of model, in which she blatantly addresses Mr. Pope as an equal with little regard to his own perceived stature, in a verse similar to the ones he uses. The most exhilarating thing that comes out clearly in her poem is the fact that she proves similar modes of thinking inherent in both man and woman. They bo th simply think alike (Ingram 2604 -2607). She introduces her poem with a very harsh snarl†¦Ã¢â‚¬ Pernicious dwarf! The malice of thy tongue†Ã¢â‚¬ ¦.. This is truly a serious dent on the pope’s character. It shows the kind of hard feelings Ingram had for the pope following his character and writings against women. It demeans his thoughts and talk. When we look at the second line of her poem, we find an insight into the future. In her thinking, she argues that if the pope were to live in a different era, such a demeaning character would definitely see him executed. This she attributes to the ill rhymes the pope writes with what she considers as his ‘poison pen’! Ingram reads nothing from this more than the pope revealing himself as the very most miserable person among all men (Ingram 2604 -2607). Feminism and enlightenment ideas about women are fully expressed by Ingram. She spoke her mind with full authority and wit, something not characteristic of wo men at her time. She does foreshadow Wollstonecraft’s concept of having a complete education and she further asserts that when it comes to intellect, men and women have no difference. Thus, in â€Å"An Epistle to Mr. Pope† she says: †¦Ã¢â‚¬â„¢tis the same principle impels them both†¦. †¦what makes the difference then you may inquire†¦ †¦in education all the difference lies†¦ †¦.women, if taught, would be as bold and wise†¦Ã¢â‚¬  She challenges the patriarchal authority and Ingram asserts herself with expression of certain opinions she has over women in society. She thinks that women need to be treated with dignity and appreciated just like men. Her despise for poor treatment of ladies is seen when she says that pope admired Lady Mary yet when she returned, he treated her contrary to what was expected. And since then, the way Mary is referred to have always been †¦Ã¢â‚¬ disgraceful, venomous, and quite obscene†Ã¢â‚¬ ¦ . Ingram holds that pope fail to put into account the fact that women have a different mode of socialization when compared to men. In her argument defending women, she argues that it is not true to say women are empty vessels with no mind of their own. She

Patient with Congestive Heart Failure

Patient with Congestive Heart Failure Patient S.V. is a 54 years old female. She is a postmenopausal housewife and her family history is not being recorded. She is a non-smoker and does not drink alcohol at all. She has no-known drug allergic. The past medical history showed us that Madam S.V. is having, rheumatoid arthritis (RA), hypertension (HPT) for 10 years and diabetes mellitus (DM) for 7 years. She was admitted to the hospital on few weeks ago due to congestive heart failure. Madam S.V.s drugs history include: T. furosemide 40mg od Oedema HF T. perindopril 4mg od HF HPT T. spironolactone 25mg od HF T. Losec (Omeprazole) 20mg bd Duodenal ulceration P. Calcium lactate 1 puff od Calcium supplement T. Rocatriol 0.25mg bd Vitamin D supplement T. Metformin 500mg bd DM T. folate 5mg od Folate deficiency T. Methotrexate 20mg/week RA Clinical data The abnormal result of FBC may due to folate deficiency that caused by side effect of methotrexate. Besides that, patient was having high neutrophil number for his differential count which is 8.7 k/ µL (normal range 1.9-8.7 k/ µL). This may due to the long-term use of corticorsteroid. Patients total carbon dioxide in the blood was two times higher than normal range (23-27 Vol%). Prothrombin time and INR of the patient was low: PT =11.1 sec (normal range = 11.9-14.5 sec), INR = 0.82 (normal range 2-4). However, the reason is unknown. Diagnosis ECG and chest X-ray were carried out and the results showed that patient was having sinus tachycardia and cardiomegaly. Cardiovascular system of patient also had been checked. It found that the patient was having a 3rd heart sound. Hence, the patient was diagnosed with congestive heart failure (CHF). Clinical progress DAY 1 Patient is admitted to the hospital at 10.30am by ambulance. She is weak but conscious and alert. The patient complains that she is shortness of breath (SOB) and her sleep has been interrupted due to SOB. It can also be considered as paroxysmal nocturnal dyspnoea (PND) which is sudden, severe SOB at night that awakes a person from sleep, often coughing and wheezing. At the same time, she also experiences from chest discomfort and swelling leg. Besides that, the patient also shows the symptoms of cushings syndrome such as moonface and hirstuism. The blood pressure (BP) and pulse rate (PR) of Madam S.V. are found to be quite high as well, which is 118/87mm/Hg and 146b/min respectively. Test ordered include FBC, RP, LFT, ABG, Coagulation test, UE, CXR, ECG and random glucose test. Nebulizer is given to patient once she is admitted. She is also on high flow mask oxygen 15L/min at the same time to ease the problem of SOB. Salfasalazine 1g bd is added to patient. The management plan is to carry out lung function test, continue to on the face mask for oxygen supply, revise all test results, restrict fluid and continue with old medications. DAY 2 Patient still complain of minimal SOB and minimal chest pain. Another new complain, headache, has been recorded. Her BP and PR have been slowly decreased but they are still not within the normal range. T. bisoprolol 2.5mg od is added for a better control of HPT and HF. Management plan include restrict fluid DAY 3 Patient is no longer complaining for anything. She has no chest pain and SOB anymore. Her PR has back to normal range. However her BP is still slightly higher than normal range. Management plan is same as day 2. Sulphasalazine since the condition of RA is improved. DAY 4 Patient is feeling well, comfortable and tolerating orally. Her BP and PR are within the normal range. The management plan is to perform a CRX report, patient can be discharged if normal result is obtained and continue old medications. Pharmaceutical care issues There are few things need to be taken care of in this case. Firstly, the patient is having the problem of nausea and vomiting and no action is taken to solve this problem. Antiemetic drug (H1 receptor antagonist, cyclizine; D2 receptor antagonist, halopiridol) should be given. At the same time, underlying cause of nausea and vomiting has to be identified if possible. This may caused by side effect of perindopril. Secondly, patient is having cushings syndrome due to long-term usage of steroids for her rheumatoid arthritis. However, there is no any record about the steroids intake for patient in clinical notes. Hence, we have to ask GP or patient to make sure that whether she has stopped taking steroids or still continue with it. According to CSM, long-term corticosteroids therapy should be withdrew gradually. Abrupt discontinuation of corticosteroids therapy may cause severe symptoms because normal production of steroids by the body has been affected. The dose may be reduced rapidly down to physiological doses (prednisolone 7.5mg daily). Then, the progress of dose reducing can be slowed down. The patient is hirudism which is one of the symptoms of cushings syndrome. This problem can be overcome by local measures such as shaving, or depilation such as using wax or cream (eg: eflornithine). The dose of T.folate for patient which is 5mg once daily is indicated for treatment of megaloblastic anemia. However, the FBC test result does not show any symptoms of megaloblastic anemia. The dose of T.folate should be 5mg once daily if it is indicated for folate deficiency induced by mehtotrexate. Blood film should be carried out to make sure that whether the patient is having megaloblastic anemia or not. FBC, serum folate and serum B12 are reliable indicator of folate status. Real indication of T.folate has to be clarified with doctor before dispense the drug. Oedema problem never been improved since the day patient been admitted into the hospital. Restrict fluid intake and strict I/O charting is carried out. However, patient is not compliance to it. Some simple self-care techniques can be taught to patient to reduce the build up of fluid. Counsel the patient about the importance of following Strict I/O chart. Dose of furosemide can be increased if oedema doesnt improve. The blood pressure of patient is still not stable yet. Patient has to be counseled to improve her diet and lifestyle. It is also necessary to monitor BP of patient regularly. Increasing dose of ÃŽÂ ²-blocker can be considered if BP is not reducing. However, due to its negative inotropic effect, ÃŽÂ ²-blocker should be started in very low dose and increase gradually. Lastly, upon discharge, ensure all appropriate medications are prescribed and patient is counseled appropriately. We have to tell patient that Perindopril is added in and ensure patients compliance with medication. Patient should be told to avoid alcohol and cranberry juice and consult GP if anything goes wrong. Disease overview Incidence Heart failure (HF) affects 0.3-2% of general population. In 2001, officially there are 11500 deaths are recorded in the UK due to HF. The incidence rate increase by double each decade from age 45. It affects 3-5% of those over 65 years and 8-16% of those over 75 years. The Rotterdam study shows that prevalence is higher in men compared to women. Pathophysiology Heart failure can be defined as inability of the heart to supply sufficient blood flow to meet the bodys needs. HF can result from any disorder that reduces ventricular filling (diastolic dysfunction) and myocardial contractility (systolic dysfunction). The leading causes of HF are coronary artery disease and HPT. As cardiac function decreases after myocardiac injury, the heart relies on few compensatory mechanisms. Although those compensatory mechanisms can initially maintain the cardiac function, they are responsible for HF symptoms and contribute to disease progression. An initiating event such as acute MI can cause the HF state becomes a systemic disease whose progression is largely mediated by neurohormones and autocrine/paracrine factors such as agiotensin II, norepinephrine, aldosterone, natriuretic peptides, and so on. Some drugs may exacerbate HF due to their inotropic, cardiotoxic and sodium-/water- retention properties. Diagnosis A complete history, physical examination and appropriate lab testing are essential in initial evaluation of patients suspected from having HF. The signs and symptoms are the key for early detection. Breathlessness, angina, fatigue and wheeze are common signs and symptoms. Patient complains that she is having SOB and PND. Electrocardiogram (ECG) and B-type natriuretic peptides (BNP) are essential tests for every patient with suspected HF. ECG is carried out once the patient is admitted into the hospital. Madam S.V. was detected to have sinus tachycardia by ECG which is one for the common ECG abnormalities in HF. Others common ECG abnormalities include sinus bradycardia, atrial fibrillation, ventricular arrhythmias and so on. Plasma BNP is not measured in this case. Chest X-ray (CXR) is also an essential component of diagnostic work-out in HF. It is very useful for detection of cardiomegaly, pulmonary congestion and pleural fluid accumulation. It also demonstrates the presence of any pulmonary disease or infection that will lead to dyspnoea. Via CXR, patient is detected from having cardiomegaly which is also one of the abnormalities for HF. Echocardiography (ECHO) should be performed shortly if one or both ECG and BNP get an abnormal result. ECHO is widely available and safe and provides essential information on aetiology of HF. However, ECHO is not carried out in this case. Some other tests such as FBC, RP, LFT, ABG, UE and random glucose test have been carried out to exclude others possible conditions. Pharmacology basis of drug therapy Diuretics The most important function of diuretic drug is to act by decreasing Na+ reabsorption. Diuretic drugs can inhibit Na+ reabsorption by actions on different transport mechanism, which are located at different sites in nephron. All diuretics are acting on the luminal surface of the nephron. They are protein bound in blood and reach the tubular fluid by secretion into proximal convoluted tubule utilizing the organic acid transport mechanism. They are mostly used to control symptoms of breathlessness and fluid retention. However, they do not alter disease progression or prolong survival. Thus they are not considered mandatory therapy for patients without fluid retention. Loop diuretics for example furosemide is most widely used if compared to other thiazide. It produces diuresis with NaCl loss. It also has vasodilator action which is partly mediated via prostaglandin. This will increase blood flow in the medulla and hence contributes to their natriuretic effect. Unlike thiazides, loop diuretics maintain their effectiveness in the presence of impaired renal function, although higher doses may be necessary. Thizide diuretics are relatively weak diuretics and used alone infrequently in HF. However, thiazide like metolazone can be used in the combination with loop diuretic to promote effective diuresis. Angiotensin-Converting Enzyme Inhibitors (ACEIs) ACE is binding to the plasma membrane and can also exist as a soluble enzyme. The ACEIs act by substrate competition by binding in the Leu-His binding pocket on ACE. Thus, action of angiotensin-I is inhibited. They also decrease the concentration of angiotensin II and aldosterone and attenuating many of their deleterious effects, including reducing ventricular remodelling, myocardial fibrosis, vasoconstriction and sodium and water retention. In addition, they also very helpful in reducing blood pressure due to arterial vasodilation. However, they will inhibit the breakdown of bradykinin which contributes to strong hypotensive action and cough. There are currently 11 ACEIs available for clinical use with similar structure and properties, including captopril, enalapril, lisinopril and others. ACEIs are indicated in all grades I to IV of heart failure which stated in NYHA. Potassium sparing diuretics should be stopped before starting ACEI. ACEIs may increase the risk of renal failure in patient with high dose diuretics, elderly, those with existing renal dysfunction and patients with grade IV HF. Hence regular renal function monitoring is required once patient has stabilized on drug. ÃŽÂ ²-blockers ÃŽÂ ²-blockers can be either selective for ÃŽÂ ²1-adrenoceptor which is cardioselective such as atenolol, bisoprolol and metoprolol or non-selective which can act on both ÃŽÂ ²1-and ÃŽÂ ²2-adrenocepors such as propranolol and timolol. Blockade of ÃŽÂ ²1-receptors will decrease rate and force of contraction of heart. Meanwhile, ÃŽÂ ²2-adrnoceptor blockade inhibits adrenaline-induced vasodilatation mediated by these receptors. Via these mechanisms, heart rate and cardiac output can be reduced. Beneficial effects of ÃŽÂ ²-blockers may result from antiarrhythmic effects, slowing ventricular remodelling, decrease myocyte death, improving LV systolic function, decreasing heart rate, and ventricular wall stress. The use of ÃŽÂ ²-blockers is not suitable for patients who have unstable HF. Patients should receive a ÃŽÂ ²-blocker even if symptoms are mild or well controlled with ACEI and diuretic therapy. Because of negative inotropic effects of ÃŽÂ ²-blockers, they should be started in very low doses with slow upward dose titration to avoid any symptomatic worsening. ÃŽÂ ²-blockers may worsen HF in the short term, but if use with caution they may be very useful in preventing long-term deterioration. Aldosterone antagonists Aldosterone antagonists such as spironolactone and eplerenone also can be called as potassium sparing diuretics. They act on aldosterone-sensitive portion of nephron (last part of distal convoluted tubule and first part of collecting tubule. They block the mineralcorticoid receptor and inhibit Na+ reabsoption and K+ excretion. Spironolactone can be added to ACEI, diuretic and digoxin to improve morbidity and mortality in patient with severe HF. Eplerenone is more specific compared to spirinolactone as inhibitor of aldosterone receptors and has been shown to reduce morbidity and mortality in patient with left ventricular dysfunction post-MI. However, the diuretic effects of aldosterone antagonists are minimal. Combination of aldosterone antagonist with thiazide or loop diuretics will potentiate the effect of thiazide or loop diuretics. This is a more effective alternative compared to potassium supplement. Angiotensin receptor blockers (ARBs) and Digoxin ARBs may be used as an alternative to ACEIs (eg: losartan) when patient is intolerant to ACEIs or may be used as adjunct therapy (eg: valsartan and cadesartan) in patient who remains symptomatic despite the dose of ACE and ÃŽÂ ²-blockers have been optimised. However, ARB is not given to the patient since she is well tolerated to ACEIs. Digoxin is one of the main drugs for HF treatment. However, digoxin is not recommended in this case. Digoxin can only been given if patients HF is worsening or patient is having atrial fibrillation at the same time. Hence, it is reasonable to exclude digoxin from treatment in this case. Evidence for treatment of the conditions Diuretics Diuretic is a very important drug for heart failure treatment especially for symptoms of fluid retention. A meta-analysis which includes 18 randomised controlled trials (RCT), n=982, had been carried out to study the role of diuretics (loop diuretics and thiazides) in patient with congestive heart failure (CHF). 8 trials were placebo-controlled and another 10 were comparison between diuretics and other drugs such as ACEIs, digoxin and ibopamine. The results had shown that diuretics reduce the risk of deterioration of disease and mortality compared to placebo group. When compared to active controls, diuretics also showed significant improvement in patients exercise capacity. The beneficial effects of diuretics are further supported by Cochrane database which also indicated that diuretics cause significant reduction rate and improvement in patients morbidity. Another study also proved that the withdrawal of furosemide will cause increase in volume load and right ventricular pressure. There will lead to deterioration of CHF which include impaired quality of life, weight gain and walking distance reduced. Higher dose of furosemide will have more desirable effects such as increasing general well-being and reducing symptoms of disease. However, the inappropriate high dose of furosemide will lead to hypotension. The risk of hypotension will be increased if patient on ACEIs or vasodilators at the same time with diuretics. According to NICE guidelines, low dose should be prescribed for the initiation of therapy and titrated up according to patients condition. Furosemide is the most commonly used loop diuretic. However, some patients are more responsive to other loop diuretic such as torasemide. This may due to its longer duration of action and high absorption. Some pharmacoeconomic analyses also proved that torsemide reduces hospitalisation for patient with CHF. Hence, overall treatment costs are reduced although torasemide is more expensive than furosemide. Patients that treated with torasemide have improved their quality of life. The data also suggest torasemide to be used as first-line treatment for patients with CHF and for those who are not response to furosemide. Besides that, according to a double-blind study, n= 1663, additional of aldosterone antagonist, spironolactone with furosemide had significantly reduced mortality and morbidity rate of patients with severe HF Hence from the evidences above, we can conclude that furosemide 40mg od is rationale to be given to patient to treat the symptoms of her CHF. Angiotensin-Converting Enzyme Inhibitors (ACEIs) The patient is taking perindopril 4mg od for her HF. A clinical trial has been carried out to compare the effectiveness between ACEIs and placebo in patients with symptomatic CHF. The overall results showed the significant reduction in total rate of mortality and risk hospitalisation. The benefits of ACEIs are further supported by five long-term randomised trials which had recruited 12763 patients with heart failure or left-ventricular systolic dysfunction (LVSD) to compare the effectiveness between ACEIs and placebo. Results showed that mortality rate has been reduced by 23%, readmission rate of heart failure reduced by 35% and re-infarction rate had been reduced by 26% for the patients who assessed ACEIs compared to placebo group. The benefits of ACEIs were observed at the beginning of therapy and it persisted long term. In SOLVD investigation, n=4228, ACEIs (enalapril) reduced the rate of hospitalisations and also incidence of heart failure in patients with reduced left ventricular ejection fractions compared to placebo group. Some randomised controlled trials proved that ACEIs also improve the exercise capacity and quality of life in majority of the patients. Not all the patients with heart failure due to left-ventricular systolic dysfunction experienced the improvement of exercise capacity. However, ACEIs alone is not enough for the treatment of heart failure with pulmonary oedema. Diuretic is needed to maintain sodium balance and prevent any fluid retention. ACEIs are more often to be prescribed compared to vasodilators and angiotensin receptor blockers due to more evidence supports. ACEIs will cause hyperkalaemia, cough and deterioration of renal function. Hence, renal function and serum potassium level need to be checked before the treatment is initiated. The SOLVD data, a randomised, double-blind and placebo controlled trial with 3379 patients, proved that enalapril caused 33% increased in deterioration of renal function compared to control group (P = 0.03). There is another study (n=191) showed that 44% of patients taking ACEIs suffered from persistent cough compared to controls which is only 11.1% (P The studies above showed that ACEIs are rationale to be used as first-line treatment HF. ÃŽÂ ²-blockers ÃŽÂ ²-blockers should be included in the treatment of HF even though the patient is already well controlled by diuretics and ACEIs. The European Journal of Heart Failure suggested that ÃŽÂ ²-blockers should be prescribed to all patients with stable HF and when left-ventricular ejection fraction à ¢Ã¢â‚¬ °Ã‚ ¤ 40%. A lot of meta-analyses showed that ÃŽÂ ²-blockers play a role in increasing life expectancy in patients with HF due to LVSD. In a meta-analysis which includes 21 trials (n= 5894), ÃŽÂ ²-blockers showed a significantly reduction of overall and cardiovascular mortality by 34-39%in patients with severe HF. Another meta-analysis of 16 clinical studies also showed the reduction of 24% for patients who were taking ÃŽÂ ²-blockers for their HF treatment rather than placebo. An interesting meta-analysis had been carried out to test the efficacy of ÃŽÂ ²-blockers in the patients with diabetes mellitus (DM) and CHF. The result of this meta-analysis showed that ÃŽÂ ²-blockers had reduced the mortality rate of patient with DM and CHF. However, the reduction was not significant (P=0.11) compared to CHF patients without DM. Most of the survival benefits for patient with NYHA class II and III are well documented. There is a meta-analysis had proven that ÃŽÂ ²-blockers are having the same improvement of survival rate among the patients with severe HF compared to patients with NYHA class II and III. However, further studies need to be carried out to evaluate overall benefits versus risks of treatment in NYHA class IV. There are three main studies, nà ¢Ã¢â‚¬ °Ã‹â€ 9000, had been carried out to compare the efficacy between ÃŽÂ ²-blockers (bisoprolol, metoprolol succinate CR, carvedilol) and placebo. Almost 90% of patients involve in there three randomised trials were on ACEIs or ARB. Most of them also took diuretics and digoxin. All trials showed the improvement of mortality rate (RRR= 34%), risk of hospitalisation (RRR= 28-36%) and self-reported well being. So far, there are no significant differences between selective and non-selective ÃŽÂ ²-blockers and those with or without vasodilating propert ies. In one randomised controlled trial (COMET), n=3029, carvedilol was used to compared with the efficacy and clinical outcome of metoprolol tartate. The result has shown that carvedilol reduced the mortality rate significantly among the patients compared to short-acting metoprolol tartate (P=0.0017). However, there is no any clinical trial about comparison between carvedilol and long-acting metoprolol succinate. There is little economic evidence can be found for ÃŽÂ ²-blockers. NICE guidelines suggested that ÃŽÂ ²-blockers are cost effective due to reduction of hospitalisation rate. Bisoprolol 2.5mg od had been added to the patient on second day since patient was admitted. The evidences above do support that the usage of ÃŽÂ ²-blocker should be included in patient with HF. Aldosterone antagonists Spironolactone is the most common aldosterone antagonist used in treatment of HF. In a double-blind study (RALES), 1663 patients with severe HF (NYHA class III and IV), left ventricular ejection fraction à ¢Ã¢â‚¬ °Ã‚ ¤ 35% and being treated with diuretics, ACEIs or digoxin were recruited to test the effectiveness of spironolactone on their morbidity and mortality. The result showed 30% reduction in mortality rate and 35% reduction of frequency of hospitalisation compared to placebo group. Addition of spironolactone to ACEIs, diuretics or digoxin had reduced the mortality rate in patients with severe HF. Additional of spironolactone may lead to hyperkalaemia. However the problem of hyperkalaemia can be solved by closing monitoring the potassium level of patients. Another study also showed that spironolactone reduced 30% mortality rate in patients with HF when it has been added to ÃŽÂ ²-blockers and digoxin. A selective aldosterone antagonist, eplerenone, has fewer side effects compared to spironolactone. A randomised controlled trial (EPHESUS), n=6633, proved that morbidity and mortality rate among patients with left ventricular dysfunction after acute myocardial infarction had been reduced with the addition of eplerenone compared to placebo group. There is no relevant economic evidence of aldosterone antagonist. Eplerenone is mostly used when patients cannot tolerate with spironolactone. Hence, spironolactone 25mg od is appropriate to used as adjunct to diuretics, ACEIs or maybe ÃŽÂ ²-blockers for patient in this case. Since the patient does not suffer any side-effects from spironolactone, it is not necessary to change to eplerenone. Conclusion As a conclusion, patients CHF has been appropriately treated by following the guidelines and also supported by numerous of clinical studies. From the clinical process, we can see that the condition of patient was gradually improved day by day. A ÃŽÂ ²-blocker, bisoprolol was added in the second day in order to achieve a better control of patients HF and also HPT. According to guidelines, the dose of bisoprolol should be initiated with 1.25mg, not 2.5mg. The potassium levels need to be monitored regularly due to the concomitant use of perindopril and spironolactone which may cause hyperkalaemia. ARB and digoxin are not prescribed to the patient because she is well tolerated with ACEIs and she does not have AF. Other treatment for HF such as vasodilators (hydrazine and ISDN) will only be considered when all of the treatment options above have failed to this patient. Non pharmacological treatment such as life-style modification, healthy diet, restrict fluid intake and salt intake als o play a very important in controlling patients HF and HPT for long-term.

Anne Carson Essay

Kiersten Baxley Professor Shirokova English 1102 12 September 2012 Anne Carson’s Lessons Anne Carson is a very intelligent and well rounded writer. When I first read Anne Carson’s â€Å"Short Talks†, I was seriously confused. At first, Ithought she was an abstract writer that wrote just to write. But then I took a second look at her work and realized there was much more to it than just crazy jumbled ideas. â€Å"Short Talks† is a mixture of many elements. It has argumentation, facts, personal opinions, and an unconventional way of writing. As I was rereading the â€Å"Short Talks†, I noticed names, facts, and a lesson to go along with each â€Å"Short Talk. This persuaded me to do some research so the stories would start to make more sense. After completing my research, I have come to the conclusion that â€Å"Short Talks† has been created to teach the reader a lesson, teach them about a historical figure, and to enable the reader to think outside of the box. I do not like reading something and have no idea what is being discussed; and that is what I liked about Anne Carson’s â€Å"Short Talks†, she prompts the reader to think in a critical manner thus persuading them to want to learn about what they are reading. For the reader to fully understand this style of reading, one needs to research Anne Carson’s background. Next the reader needs to research the main topics of each short talk. Anne Carson truly enables the reader to think outside of the box when she uses this less conventional way of writing since most authors do not use this style of writing. Most writers use a more â€Å"normal† approach to their writings. â€Å"Short Talks† seem to teach the reader some sort of lesson when they read them. Take the short talk â€Å"On Major and Minor† for example, Anne states, â€Å" There are more major things than minor things†¦I believe that she is portraying that there are people all around the world that turn very small things into much larger issues than it should be (Bartholomae and Petrosky 264-270). Carson uses the fictional character Elektra as an example in this short talk. Elektra’s mother and step-father murdered Elektra’s father. Elektra took this very hard, so she and her brother Orestes plotted revenge against her mother and step-father. Elektra’s father had been against things like this, but Elektra became so bitter she began to commit many crimes. So this short talk helps us decide between what is major and minor in our life. This helps to keep from overreacting over the small things in life. Another lesson comes from the short talk â€Å"On Reading. † This takes the reader back to their childhood. No, not everyone enjoys reading, but it is also great for you. In this short talk I got the imagery that this little girl was on a road trip with her parents, her father does not enjoy reading but she does. So while on the way to their destination, she reads Madame Bovary. While reading she takes a moment to look around at the sights passing through the window. This just gets the reader to truly think and assess the way they perceive the way they view reading. Having someone who enjoys reading, and someone who finds no pleasure in reading is what makes the world go round. Not everyone appreciates, or finds interest in the same things, but do not discourage anyone if you have no interest in it. If I were to write some short talks I could use an Anne Carson-like writing style, or writing that flows eloquently. I would try to help the reader to understand what is being said, but to also think about what is before them. I would include an introduction in my short talks to help guide the flow of the short talks. An example of my short talks would be: Every day starts the same way. Get up, get dressed, go to class. You see sleepy students stumbling to class, some even skip class. Never enough sleep. This is the life of a college student preparing for the future. You never know what life has in-store for you today, tomorrow, and all the days before you. Cheerleading When you see a cheerleader, you see a peppy smile. Energetic. This is an athlete in many many ways. Athlete’s in skirts! Tumbling, Stunting, Jumping,. Can you throw someone in the air? Never boring when were around. Love How do you explain love? Do you even know where it is or even how to find it? Is it a passion, a sport, a car, or a lover? Expression. Show it in your own way. Never give it up for anything. Adventure How does someone find adventure? One might sky dive, hike a nature trail, bungee jump. Not everyone is adventurous. Not everyone will find adventure in the same way. Riddle me this, when does your big adventure start? Anne Carson did a great job on â€Å"Short Talks. † I thoroughly enjoyed reading herâ€Å"Short Talks. †I also liked how I was challenged and pushed to think critically about â€Å"Short Talks. † That is what makes a great writer.

Solving The Low Performance Problem Caused By The Un...

I. INTRODUCTION In this article, the authors proposed to use a new technique – â€Å"resource bricolage† to solve the low performance problem caused by the un-balanced workloads in parallel database systems. When a parallel database system is first constructed, the set of machines are made identical, therefore, the default data partitioning strategy for this parallel database is uniform data partitioning, and will ignore the differences among machines. In this case, all these identical machines will have the same workload, which will end up with similar performance efficiency. However, when time goes by, in this parallel database system, new machines that are different from the original ones will be added; old machines will be reconfigured/upgraded or replaced. These changes will result in a heterogeneous parallel database (the set of machines varies a lot from each other, such as having different disk, CPU, memory and network resources). When this happens, the default uniform data partitioning method will still allocate data evenly onto each machine. Due to the heterogeneous feature of each machine, the same amount of data will be processed with varying amounts of time: same workload ma y overload the slow machines and under-utilize the powerful machine. Based on the fact that the slowest machine will determine the processing time in a parallel database system, the situation, described above, will significantly harm the overall database performance and at the same time, wasteShow MoreRelatedOperational Risk Management50825 Words   |  204 PagesDepending on the size and complexity of a bank, the response to operational risks may require considerable changes, such as the adaptation of systems and processes as well as, above all, the further development and integration of risk management methods. 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