Trim Store Sop

SOP for Trims & Stationary Store Trims & Stationary Store Objectives: * Storage of all the various trims and stationeries that comes with detailed data. * Ensure no short supply of various trims before bulk production. Activities: * Pre-Trims & Stationeries Receive Activities: The monthly planner for trims in-house should come to the store in-charge with the weekly updates and changes should be communicated at the very instant of the occurrence. The trims purchase team should make sure to in-house the planned trims at least before 20 days to carry out pilot run and for bulk maximum 5 days.After receiving the requirement list from the purchase team it is the duty of the trim store in charge to follow up the status of the ordered trims. If in case trim is late from the planned date of receiving then the same should be intimated to the planning, cutting, and merchandiser so that the necessary steps can be taken to acquire the trim before production starts. NOTE: The stock of stationerie s should be checked time to time so as to avoid any situation of shortage. * Trims/Stationary Receive: Unloading the trims: Unloading should be done in the presence of the store in charge/supervisor.The supplier invoice or the transporters copy of the Delivery Challan should be checked by the trims store in charge and then unloading should be done in the designated area. The received trims quantity should be cross checked against the supplier packing list while unloading and should be verified by the store incharge. If quantity is less, the transporters are informed and it is recorded on Delivery Challan. The Invoice copy should be filed in â€Å"Daily trims/stationary receive file† and at the end of the day material inward details should be updated by the store incharge.The information of trims received against the Purchase No. is informed to the purchase person and the concerned merchandiser. A swatch card of a trim of every kind received for a particular order should be se nt to the merchandiser handling that buyer for approval. Once approved it should be prominently displayed on the trim store board. * Trims Inspection * The trims should be kept on the inspection table before checking. * The trims should be inspected to cross check the purchased quantity to the actual quantity received. 100% inspection should be done for each trims received. * Make full use of the Count & Weight M/c to know the actual number of particular trims received. * In case of zippers the length of each should be measured and those not conforming should be separated and exchanged. * Keeping the trims in racks after Inspection: * Depending on the order quantity a rack box (upto 3500 garments), 2 rack boxes (3500-8000 garments) or a column(more than 8000 garments) in a rack is allotted for a particular style. A board should be attached to it clearly stating the style number. A stock card should also be affixed along with it duly filled with the required quantity for each trim in that order. * When the inspection for a trim for a particular order is completed and the received trim is â€Å"OK†, it should be kept in the rack allotted for that particular order. * All the trims being loaded on to the rack after inspection should be entered into the stock card carefully mentioning the order quantity received and date of receival. * If any trim is already available in stock the required quantity for that order is counted and kept on the rack dedicated for that order.On the swatch card it should be mentioned that the trim was â€Å"IN STOCK†. * All trims movement should be done carefully. * Issue trims to various departments * Trims should be issued only against the requisition slip. * Exact number of trims should be issued. No extra trims should be issued. * As soon as the copy of cut parts issued is received from the cutting room the required amount of trims for stitching that quantity of garments should be fetched from the respective racks. They should all be ready in one carton so that as soon as the line feeder comes with a requisition from bundling the trims are issued. The trims required for packing can be issued only three times a day in the allocated time slot. * As soon as some trim is taken off the rack for issuing, the issued quantity along with quantity left on the rack should be updated in the stock card. * Returned trims * The returned trims should be kept in the returned trims storage area only. * Records should be maintained about the returned trims along with the departments from where those are coming. * If those trims are style specific they should be disposed off 2 months after the shipment is sent with a consent from the merchandising department. Keeping of stationary * As soon as the stationary received it is cross checked with the order quantity. * It is then kept on the stationary rack segregated according to the type. * The same is recorded on the stock card mentioning the received quantity and date. * Issuing of Stationary Stationery should be issued only against a requisition slip. As soon as any kind of stationary is issued the stock card should be updated noting down the issued quantity and quantity left. As soon as the quantity left reaches the danger zone an order should be placed for it.

Accredited & Deluxe Hotels for Tourism Essay

1. Century Park Hotel 599 Pablo Ocampo Str. Manila 1004Â  2. Crowne Plaza Manila Galleria – Ortigas Avenue, Corner Asian Dev., Bank Avenue, Quezon City 3. Diamond Hotel Phillippines – Roxas Boulevard cor. Dr. J. Quintos St., Manila, Philippines 1000 4. Dusit Hotel Nikko Ayala Center Makati City Metro Manila, Makati, 1223, Philippines 5. EDSA Shangri- La Hotel – 1 Garden Way Ortigas Center, Mandaluyong City, Manila 1650 6. Holiday Inn galleria Manila – 1 Asia Development Bank Avenue, Ortigas Center, Pasig City, 7. Hotel Intercontinental Manila – 1 Ayala Avenue, Makati, Luzon 1226, Philippines 8. Hyatt Hotel and Casino Manila – 1588 Pedro Gil Corner MH Del Pilar, Malate, Manila 1004 9. Makati Shangri- La Manila – Ayala Avenue corner Makati Avenue, Makati City 1200 10. Mandarin Oriental Manila – Makati Ave, Makati City 1226 11. Pan Pacific Hotel – Gen M Malvar, Manila 1004Â  12. Renaissance Makati City hotel – Esperanza Street corner Makati Avenue, Ayala Center, Makati City 1228, Philippines, Manila 13. Sofitel Phillipine Plaza Manila – Ccp Complex Roxas Boulevard, Pasay – Manila 1099 14. The Bellevue Manila – North Bridgeway, Filinvest Corporate City, Alabang, Muntinlupa City, Philippines 1781 15. The Manila Hotel – One Rizal Park 0913 Manila Po Box 307 Philippines 16. Heritage Hotel – Manila – Roxas Boulevard corner Edsa Pasay City 1300 17. The Peninsula Manila – Ayala Museum, Makati Ave, 1226 See more:Â  First Poem for You Essay 18. Vivere Suites – 5102 Bridgeway Avenue corner ASEAN Drive, Filinvest Corporate City, Muntinlupa City 1781 Accredited First Class Hotels in the Philippines 1. CSB International Conference Center – Arellano cor Estrada Sts | Malate, Manila, Luzon 1004, Philippines 2. Discovery Suites – Ortigas Center, Pasig City 1600 Philippines 3. Great Eastern Hotel – 7842 Makati Avenue, 1200 Manila 4. Manila Pavilion hotel – United Nations Avenue, Corner Ma. Orosa Str Manila 1000 , Philippines 5. The Linden Suites Hotel – 37 San Miguel Avenue, Ortigas Centre Pasig City 1600 6. The Pearl Manila Hotel – General Luna Str., Corner Taft & United Nations Avenue, Ermita, Manila, Luzon 1000, 7. The richmonde Hotel – 21 San Miguel Avenue Pasig City‎ 8. Traders hotel Manila – 3001 Roxas Boulevard, Pasay, Manila, 1305 Philippines Accredited Standard Hotels in the Phillipines 1. Aloha Hotel – 2150 Roxas Boulevard, Cor. Quirino Ave.,Malate Manila, 1004 Philippines. 2. Bayview Park Hotel – 1118 Roxas Boulevard Cor., United Nations Avenue, 1000 Manila 3. Best Western hotel La Corona – 1166 M. H. Del Pilar St. cor. Arquiza St. Ermita, Manila, Philippines 4. Camelot Hotel 5. CEO Suites 6. Cherry Blossoms Hotel – 7. City Garden Suites – 8. Citystate Towe Hotel – 9. Garden Plaza Hotel – 10. Hotel Las Palmas –

Chapter 10 Review Sheet Photosynthesis

Biol 1406, Instructor: Alice Zhou Updated 4/18/12 Chapter 10: Photosynthesis 1. Describe the energy transformation that occurs in photosynthesis. Solar energy to chemical energy specifically stored in sugar. SolarChemical energy (sugar) 2. Write the summary equation of photosynthesis. Solar + 6CO2 +6H2O C6H12O6+6O2 (simple)Complex 3. Photosynthesis produces organic sugar molecules. Where does the carbon come from in making the sugars? From carbon dioxide 4. Aerobic cellular respiration is catabolic, exergonic and oxygen requiring. What about photosynthesis?Anabolic, endergonic, O2-releasing 5. What is the difference between autotrophs and heterotrophs? Autotrophs create their own food by photosynthesis heterotrophs don’t. 6. Name some photoautotrophs. Plants Algae Photosynthetic Bacteria 7. Draw and label these parts of chloroplasts: thylakoid, granum, stroma, outer and inner membrane. 8. What type of cells in a plant will contain chloroplast? What type of cells contain mitoch ondria and why? Every single plant cell will have mitochondria, some plant cells only the green ones will contain chloroplasts. 9. The Nature of Light and Pigments . What wavelength range is the source of light for photosynthesis? Gamma X-RaysU. VVisible (VIBGYOR: ROYGBIV backwards)Infrared Radio Small wavelength350nm750nmWavelength b. What are photons? * Massless * Carry fixed amount of energy (packet of energy) * Travels at speed of light c. What are pigment molecules? Selectively absorbing visible light (chemical) -350-450nm d. Name three types of photosynthetic pigments found in green plants. Note which one is the main one, which ones are accessory pigments. * Chlorophyll A (MAIN) * Chlorophyll B (minor %) * Carotenoid (minor %) e.What makes chloroplasts or leaves green and why? Green is being reflected because it is not absorbed. f. How can you easily separate them out experimentally? Paper Chromatography g. Plot an absorption spectrum of chlorophyll a. Be sure to use correct p arameters on x and y axis. 10. Organization of pigments in photosystems. a) What is the concept of a photosystem? b) Photosystems are organized into two subcomponents: * antenna complex: Lots of pigments (A, B, and carotenoids) Pigments along with some proteins that organize some pigments about 200 found, scaffold proteins reaction center complex A pair of chlorophyll A are found proteins are organized and shape reactions. PEA are bound here. * (T/F? ) In either complex, membrane proteins are present to anchor and support the functions of pigment and other organic molecules. 11. Light interacts with pigments h. When photons strike the pigment molecules in the chloroplast, what immediately happens? _ Photoexcitation_____. After that, what can happen to the electrons in the photosystem? Describe two outcomes in diagrams. Electrons fall back to ground state Electrons transferred to PEAElectrons fall back to ground state Electrons transferred to PEA i. In outcome 1, electrons fall back to ground state. Inductive resonance: energy of the excited electron, but not the electron itself, is transferred to a neighboring pigment molecule, exciting the second pigment molecule. Very little energy is lost in this ENERGY transfer. j. In outcome 2, electrons are transferred to PEA (Primary Electron Acceptor): _________ reaction has occurred. The pigment molecule that has lost the electrons is___________, whereas the PEA is reduced because it gains an electron.This actually happens to two chlorophyll a pigments (RCCA) located at reaction center in a photosystem. k. Draw a diagram of photosystem to illustrates both outcomes as photons interact with pigments: 12. Light reactions l. Describe the events that have led to the redox reaction at the reaction center. 1) Photon strike Antenna Pigments 2) Photoexcitation of pigment electrons 3) Inductive resonance 4) Photoexcitation of another pigment eventually 5) Energy passed on to RCCA (reaction center chlorophyll A) 6) Photoexcitati on of RCCA 7) m.Electrons from PEA flow â€Å"downhill† in energy level through a series of electron carriers embedded in thylakoid membrane. Energy lost by the electrons is used to synthesize ____________ molecules through ______________________ process, similar in mechanisms to oxidative phosphorylation in mitochondria. n. Ultimately electrons are passed from the electron carriers to ___________ and reduce it to NADPH by the enzyme NADP+ reductase. o. Draw a diagram of the above events. Note the direction of pumping, diffusion and the site of ATP synthesis. p.Trace the electron flow in light reactions starting from the source of electrons. (non-cyclic electron flow) q. What supplies the source of all of the electrons in this electron flow to make sure that RCCA will not run out of electrons? What is the by-product of this donation of electrons to RCCA? r. Light reactions produce ATP and NADPH. Why is the synthesis of these two compounds necessary? s. Sum it up: What go into the light reaction and what come out of the light reaction? List all components. 13. Now let’s move onto the next stage: Calvin cycle t. What does it accomplish? . Where does Calvin cycle occur? v. What is the key enzyme? What is special about this enzyme? w. The immediate product of Calvin cycle is G3P _________________________. What other products can be made out of G3P? 14. Integrating Light Reaction with Calvin Cycle. (understand the relationship) x. What is the overall flow of electrons in photosynthesis? y. As you turn off the light in your room, the plant in your room ceases light reactions immediately, what about Calvin cycle reactions? z. If an inhibitor inhibits Calvin cycle, would the light reaction keep going?

Journey of a Man Essay Example | Topics and Well Written Essays - 1250 words

Journey of a Man - Essay Example Moreover, I was greatly intrigued by the way physical features of different groups evolved, and flattered that the male sex chromosome played an important part in this research. However, some of Wells’s sayings seemed contradictory to his views. Moreover, I did not like the way the host acted sometimes while conducting the research. Therefore, after watching this documentary, I had mixed opinions about it. During the beginning of the documentary, an explanation is given on Wells’s theory that the birthplace of all humans alive on this planet is the same-Africa. The pride I felt in my ethnicity after discovering this was immense. True, I do not completely associate myself with Africa as my nationality is ‘American’, but I am after all an ‘African American’. This realization also instilled a sense of shame in me due to not having even a bit of patriotism in me for the country where we African Americans are originally from; early in Americaâ€℠¢s history, Africans were brought to America from Africa as slaves but were later given freedom and equality, due to which we are now African Americans. This documentary has made me accept the fact that it does not matter which country I was born in or which country’s nationality I assume. What really matters is that all African Americans know that their great great grandfathers directly originated from Africa, but majority of them forget about this origin. I myself had forgotten this origin until I watched this documentary. This is not the only reason why I am so grateful to this documentary. Thanks to the ground-breaking discoveries made by Spencer Wells, one develops a new perspective of the concept of race. By stating that â€Å"we are all African under the skin†, Wells’s disregards all the old-fashioned concepts of race, such as thinking that people with the same color of skin or language are the same. Spencer puts this point across by exploring how African s migrated to different parts of the world and evolved in different ways, which is why people with similar physical characteristics started to associate themselves with one of these ‘different races’. The documentary disagrees with such associations and I highly agree with this point. I believe that by seeing an individual through ‘racial lenses’, assumptions about that individual would definitely be made according to his/her ‘race’. According to me, this is termed as a kind of discrimination. Being an African American, I myself have been a victim of having assumptions being made about me, such as the time when a grocery owner kept a watchful eye on me while I was buying groceries (just because majority of the shoplifters in that neighborhood are African American). Therefore I really approved of Wells’s opinion that everyone is the same, and not part of ‘different races’. As he says in his documentary, we have the same desce ndant, who was from Africa. However, something about this statement of his made me doubt his personal opinions a bit. By terming us all as ‘Africans’, Wells is in fact calling us a race-something which is contradictory to what his views throughout the documentary are. According to Wells, there is no such thing as a race, but implying that we are

Addiction Essay Example | Topics and Well Written Essays - 500 words

Addiction - Essay Example For example, I have a cousin who is interested in knowing and trying drugs in order to understand what addiction means. He is a teacher who takes his students to know all about addiction. I am rigorously opposed to this view and my claim is that people do not have to understand what addiction means; they have to understand what it is going to happen if any kind of addiction becomes part of their lives. Two of the most essential readings on the topic of addiction are â€Å"The 10 Most Important Things Known about Addiction† by Doug Sellman and â€Å"Injecting Rooms Benefit All, Not Just Drug Users† by Robert Power. This paper makes a reflective summary of these two articles in order to bring out the major arguments of these authors about addiction and its consequences. One of the most fundamental articles on the question of addiction, Doug Sellman’s â€Å"The 10 Most Important Things Known about Addiction† offers a list of ten important things or facts abou t addiction. These ten essential facts about addiction have emerged over the last three or four decades and an understanding of these important things will fundamentally help the people in addiction treatment as well as general public. Bringing together a body of knowledge across multiple domains,

George Washington Essay Example | Topics and Well Written Essays - 750 words

George Washington - Essay Example Whether Gandhi was there or not, India would have won freedom in 1947 because Britain was setting all its colonies free following the Second World War. Even if Nelson Mandela was not there Apartheid would have been abolished in South Africa in the 1990s and indeed it is possible that if George Washington was not there, the United States would still have won independence in 1776. But therein lies the most important part. It is not that one event which defined those countries but numerous actions and inactions which happened since then. Indeed Gandhi may or may not have set the country free but his philosophy of non violence defines India. Nelson Mandela bought tolerance into a country where it did not seem possible that people of different colors could live together. George Washington was offered unlimited power to rule a country which had the potential to be the richest in the World and he turned it down. It is very important to understand what a monumental decision that was. Fidel C astro got power in a small island and hung to it till absolutely close to death. Stalin, Polpot, Idi Amin, This is a long list covered in blood. These people who at least for a time were heroes for their country and then the lust of power took them over. Indeed it is not our ability what defines us, it is our choices. George Washington w George Washington was a man, even in his lifetime, was considered a figure larger than life, and indeed he was credited with supernatural abilities like it was said of him that that bullets could not hit him. There was an aura of invincibility around him. Indeed lot of the legends were most likely made, like the Cherry tree episode which never happened. As a Soldier he was capable of rashness and poor judgment, he was addicted to gambling, indulged in a good deal of wrenching and was said to be a most horrid swearer2. Was this person who would be the commander in chief for the continental army Let us look at the events of the revolutionary war. When the war began, the British Colonists ("Americans") did not have a professional army or navy. Each colony provided for its own defenses through the use of local militia. Militiamen were lightly armed, slightly trained, and usually did not have uniforms. Their units served for only a few weeks or months at a time, were reluctant to go very far from home, and were thus generally unavailable for extended operations. Militia lacked the training and discipline of regular soldiers3. Each colony was its own little country and fiercely independent. To get them together to be one fighting force was a monumental task; But George Washington was able to do that. The Reason was very simple, everybody trusted him and everybody respected him and indeed he himself was very conscious of the responsibility which came with his character. The second reason why he was able to forge a successful army was his adaptability. While his background was of a professional soldier with single minded professional discipline, here he had to deal with a rag tag mixed outfit of varying loyalties and ambitions. George Washington combined all of that because he realized that all of it, the Militias, the army could be one fighting force without necessarily losing their individual identity. This was not easy, and indeed battles were lost because some comm anders would not take George Washington as their leader,

Report Essay Example | Topics and Well Written Essays - 750 words - 13

Report - Essay Example However, this earned Qays the nickname Majnun, which refers to a mad man (Russell and Cohn 16). In this regard, it can be argued that, in the society in which Qays and Layla came from, public display of affection or love was considered as madness, and as such, people who were deeply in love would not marry those they love, since, being considered mad would mean their marriage would be scandalous. For instance, Layla father refused to allow Majnun or Qays Layla’s hand in marriage, arguing that, such a marriage would only result in a scandal and that it would not be okay for his daughter Layla, to be married to a madman (Russell and Cohn 23). In this regard, it is clear that love was not considered as a requirement or foundation for marriage. Despite Layla being in love with Majnun, her father forced her to marry another person she did not love. This story of Layla and Majnun also depicts love as a very strong bond between two persons that if broken, is very devastating. Because Majnun loved Layla so much, failing to get her hand in marriage devastated Majnun to the extent that he was overcome with too much grief that he disappeared into the wilderness, abandoning his family, his home to lead a life of solitude that was miserable. Additionally, the story of Majnun and Layla depicts love as a feeling of emotion that lasts forever and binds people together, forever. Even though she was married to another person, both Majnun and Layla hoped that one day would be together. When Layla’s husband died, she thought that she would at last be with the one she loves, but the demands of tradition denied her this opportunity, and as a result of heartbreak and devastation, she gave up and died. On hearing of the death of Layla, the one he deeply and truly loved, Majnun travelled to the place where his beloved Layla had been buried; he cried, wept and wept in devastation and also gave up as a

Issue of gun control Essay Example | Topics and Well Written Essays - 2000 words

Issue of gun control - Essay Example This essay discusses the issue of gun control in the United States of America. Here gun related violence is one of the leading causes of bodily harm and fatalities in which many of the guns used in these crimes do not belong to the shooters. Ideally, the acquisition of these guns tends to be legal, but they end up falling in the hands of ill-motive individuals that avenge attacks on innocent civilians. On the other hand, proponents of gun control restrictions argue that citizens should not own guns either legally or illegally because owning a gun is one of the contributors to gun related violence. In Parma, major calls are on the ban on the licensing of handguns and assault weapons while the obtaining of the other types of guns should be within law requirements. As a way of ensuring that the Ohio state’s curbs the gun violence menace, advocates for the debate have decried the need to have an arms registry that would help in accounting for the weapons used in committing crime. Additionally, gun shows are also potential areas that aid in flooding the population with unlicensed firearms. Ideally, gun acquisitions at gun stores tend to have intense requirements, but firearm shows do not have the same because their intention is making sales and not in safeguarding the population.Also the problem also lies in the accessibility of firearm clips. This is because gun handlers that have high capacity clips tend to spray more bullets without having to stop to reload their weapons, which causes more damage. 3. Data that supports the debate A majority of those that commit gun related violence tend to be individuals that have had priors in crime that has led advocates on the restriction on gun ownership to influence the Ohio state to adopt the background check to be law. When passed, an individual that has a prior history of crime becomes non-illegible to obtaining a firearm because of the information obtained through the national registry. In the past, this measure w as strict, but gradually became non-applied by firearm sellers because it attracted minimal profits within this trade. Ideally, many argue that conducting of background checks on a purchaser of a gun contravenes ones privacy and that it is also discriminating because of the stereotyping associated with past offenders. 3.1 National data According to the Survey by the National crime victimization, almost five hundred people became victim to gun related violence in 2011. On the same year, data by the FBI showed that sixty eight percent of American murders drew influence from firearms (Carter, 351). Additionally, forty-one percent of robbery crimes and twenty one percent of

Week 1 Journal Essay Example | Topics and Well Written Essays - 500 words

Week 1 Journal - Essay Example The death of the four poor men, namely Daniel Brillhart, Enrique Rubio and Daniel Moore, has ignited the minds of the Americans and compelled them to ponder over this intricate problem that had existed since long in the country and especially in California. The various news agencies have covered the issue in their columns and drawn our attention towards the personal life and history of the four persons. All four of them reportedly were men of good social and moral character. Though deprived of social status or recognition in society, they were god-fearing men who worked sincerely to make a living. Each one of them had a family and some relatives. They had lived a very happy and productive life before they abandoned their homes and joined the homeless population of the nation. They supposedly left their homes and families owing to adverse financial circumstances or social abandonment or drug-issues. They finally landed up in the encampments across San Francisco and took up a job to meet the basic needs of life- food, clothes and a temporary shelter. This story applies not only to those four deceased men, but to the entire homeless population of the US. Driven by financial deprivation and societal seclusion, these people escape from home s and families, to ultimately join the already overcrowded encampments of the homeless in the Silicon Valley. They live their lives as nameless, faceless and identity-less individuals who put up with the drudgeries of daily life to barely make sustenance. Despite the presence of a network of numerous shelter homes in the country, hundreds of homeless people die every year due to extreme cold. They live and die in a world of anonymity and isolation. To help them get rid of their homeless condition, the government should allocate sufficient resources for building up permanent housing facilities for these people. This would include the allocation of both financial resources and

Economic and Monetary Union Essay Example | Topics and Well Written Essays - 5000 words

Economic and Monetary Union - Essay Example Nevertheless both developed quickly back to the former patterns. On the divergent, this paper would find evidence of a decline in the resolution of the inflation progression in the mid-1990s. This also would be evidenced due to a structural alteration in private inflationary prospect due to policies associated to the groundwork of EMU. Regression Model analysis also been adjusted for Statistical analysis using an OLS- and a 2SLS. Main focus of the paper has addressed the question - How joining the Economic and Monetary Union of the European Union affects Inflation Joining the Economic and Monetary Union of the European Union has great prospect on decision-making structure of monetary policymaking. The political culture of monetary union posed on stability from Inflation. Legitimately countries those who prefer price stability at the expense of growth have dominated monetary union. These preferences shaped the base of monetary union where various institutions intent to protect this interest through price stability. Supporting aspects of monetary integration have shaped it hard to strictly enforce. The battle for price stability in relation to growth continues to be waged despite has gained apparent victory. The inclusion of the joining countries will impact on the institutional structure of the European Central Bank (ECB). The alliances have formed to promote and block certain policies. The alliances would be bent based on the extent of their economies may benefit more. The continued emphasis of stability has a more flexible bargain for its faster growth rate. Similar decisions have a credibility impact on the efficiency of EMU to play a more vigorous role in international monetary arena. This study would go to investigate how joining the Economic and Monetary Union of the European Union affects Inflation among the existing member countries and contrasting the incentives for accession countries. This paper would go to represent the analysis within three aspects as - Econometric models. Focus on analysis of data, Statistical techniques, The determinants of EMU historically extraordinary improvements are numerous and complex. The main motivation for joining EMU was the desire of being part of an area of monetary stability for most participating countries after long period of high and variable inflation among themselves. The aim of this paper is to investigate the joining Europe's Economic and Monetary Union (EMU) had any effect on the dynamics of inflation in the countries involved. This question is very significant in quite a few respects. EMU involved the preface of a new currency 'euro' among 12 member countries and created the new central bank responsible for organising and implementing a single

New Original Programme Coursework Example | Topics and Well Written Essays - 2000 words

New Original Programme - Coursework Example Music programmes began to rise in the 1990s with the coming of many music genres. Most of them provided a countdown of hit songs as voted by fans. The 21st century came with numerous changes in the presentation of programmes. Few categories of programmes existed, and the shift has seen the inclusion of new categories of programmes. Specialization within the programming sector of TV can be attributed to the rising demand for new programmes. Design of programmes continues to change immensely in the aim to satisfy the growing number of viewers, and their needs. The producers of programmes can link the demographics of viewers with the increase in specialization. Specialization has also been extensively utilized in the TV channels. The channels continue to specialize as a way of cutting a market niche for themselves in the extremely competitive airwave market. MTV, for example, is a TV channel dedicated only to music. Specialization continues to be extremely attractive to numerous players in the industry. New programme According to Jevon Saba, 2011, the most popular programmes for 2010 were fiction series programmes. This was based on the international popularity assessment conducted in 2011. Around the globe, these programmes led in the number of views as well as popularity from persons questioned. Music programmes have not been popular owing to the fact that they target a specific group of viewers. This immensely affects their popularity with groups of different demographic. The new programme proposed in this report shall be an analysis and interpretation show. The set up proposed shall be of a talk show or panel show. The programme shall be analyzing music related issues and discussing the progress achieved in music. Over the years, musicians have continued to use talk shows as a way of popularizing themselves to the masses. A music talk show shall present a platform for music related matters to be discussed. The popularity of talk shows increases in relation to the content and the host. This field of shows continues to gain popularity in the 21st century due to their content (Banerjee et al 2006). Many viewers see them as avenues of collecting information about fundamental elements of interest in life. The new music talk show shall give an opportunity to producers of records a chance to be seen in public. Enough information shall be availed to the viewers from the interviews conducted during the talk show. The entertainment aspect in talk shows can be presented in the different elements involved in the show. The show shall be a 40 minute programme. The host shall introduce the guests for each show and ask the several questions. This shall form the first part of the show. The second part shall involve the audience in the studio asking questions to the guest while the last part shall be for viewers to ask their questions via telephone. Each part shall be ten minutes long and the two commercial breaks shall each be five minutes. The commercia l breaks shall allow for the sponsors and advertisers to run short commercials during the programme time. Talk show hosting Talk show hosting continues to be popular in the 21st century. Larry king and Oprah Winfrey are some of the best internationally recognized icons of talk show hosting. In the music industry however the talk shows have been very few. The new programme shall seek the services of a renowned personality within the industry. The proposed programme seeks to have Kabelo Ngakane hosting the talk show and conducting the

How Our Culture Glorifies One Sex Over the Other in Dating Essay Example for Free

How Our Culture Glorifies One Sex Over the Other in Dating Essay In his musings A Note on Vulnerability and Responsibility, Hugo Schywyzer comments, Men, it seems, cant distinguish being wanted as a partner and being needed as a protector and provider. Women have always been held in high regard when it comes to dating. This is because women, through time, have always been viewed as weak and in need of protection. This view has carried over to our new era of woman empowerment and independence. These views have slowly changed over the decades though and beginning in the 1960s, women have slowly evolved into an equal partnership with men. These days, women and men earn their place in their relationships. The glorification is no longer automatic even while you are simply dating one another. Men have traditionally held the more responsible role of being mature and more understanding in a relationship. These days though, maturity and respect in a relationship are considered a two-way street where a dating couple would rather find a common middle ground rather than the man letting the woman have her way in the relationship. Although a womans decision is still glorified in terms in dating, women today tend to use their prerogative to find an outlet that they both will enjoy. It is no longer just a woman who must enjoy a date these days and the women prefer it that way. Although, the continually evolving area of dating has proven that women do not necessarily have to date. It is perfectly acceptable for women to opt for independence and remain single. Women no longer like being placed on a pedestal where men seemingly glorify them for the sake of their egos. Women no longer respond in a resigned manner to sexist treatment. Women will no longer accept that she is inferior and, judged to be mentally inferior to the male. Women feel respected these days when a man listens to what she has to say and considers her suggestions. Men seem to prefer a woman who shares her thoughts because the responsibility for dating enjoyment and relationship building no longer falls squarely on the mans shoulders. Consider my personal situation as an example. I work in the Armed Services and yet it does not affect my relationship with men. Instead of being threatened by my position, which used to be solely a mans job, most men who know me admire me for my courage and sense of duty and responsibility. These are traits that I carry over into my personal relationships that produces a smooth flowing and open line of communication and understanding with my partner. Since we both have input into how to improve our relationship, we have built a strong bond that cannot be questioned and need not be doubted. We are equals and partners in everything we do. These days, a man is no longer relegated to the protector and provider role. This evens out the responsibility in a relationship and allows the woman to ask her man to treat her as an equal while still being vulnerable and in need of protection. It can be said that men now treat women as their equal in every way even with the limitations set in place not by man, but by Mother Nature herself. Our culture no longer dictates that we glorify one sex over the other when it comes to dating. A woman no longer needs to pretend to be vulnerable and like a porcelain doll just to make the man feel strong. Men now get their glorification by living up to their commitments and vows in a relationship. Glorification of one sex over the other is no longer the norm. The bible lectures women to be submissive to their husband, that has not been the case for decades now. These days, women have the right to say no if she feels a situation is not right for her. Men can no longer assume for example, that when he says he is moving to another state, his girlfriend or wife will automatically go with him. Women these days have more things to consider like their jobs, family, friends unlike before when she was simply a stay at home person who was expected to do a mans bidding. M These days, a womans opinion is recognized as needed and therefore must be considered. Dating these days are based on totally new sets of rules based on woman empowerment and independence. Certain sports like soccer, golf, tennis, and basketball now have equivalent female leagues. While activities such as rock climbing, handy work around the house, and car repairs, which used to be the sole realm of men have seen a fair share of women accomplishing the same tasks without the hindrances one may have ordinarily expected. Responsibility of making a relationship, or even just a simple date, work is now a shared task that no longer glorifies or spotlights one sex over the other. This I further reinforced by the mass media of today with shows such as Sex at the City, Friends, Greys Anatomy, and Alias. All the women on these shows equal their male counterparts in every way. The barriers of social enjoyment have been torn down by these shows and empowered women to become an active participant in choosing their life mate. These shows encourage woman to take the initiative for dating or any other companionship activity provided that she is comfortable doing so. It is okay for a woman to be aggressive to a certain degree. A woman asking a man out on a date is no longer frowned upon since men can sometimes be just as shy as the woman when asking for a date. It is okay for a woman to change her own flat tire. It is no longer an issue if a woman has more intellectual know how than men. Women like these gain the respect of the significant other who glorify the woman who earned the right to be treated equally and not because tradition and society has dictated it to be that way. Society now dictates the women prove themselves if they want to be respected. Women have proven it many times over. Women are now leading and formidable figures in the fields that were exclusively for men in the past such as politics (Hillary Clinton senator), and business (Oprah Winfrey Mass Media). Outline of How Our Culture Glorifies One Sex over the Other in Dating Lead-in There is a belief that our culture glorifies one sex over the other when it comes to dating. Thesis These days our culture no longer glorifies one sex over the other in dating because all responsibilities and tasks are now a shared effort on the part of the man and woman. Conclusion: Be it a male or female, the dating couple want to earn the respect of their partner and earn the respect and glorification that is accorded to them as a productive significant other in the dating relationship. Works Cited: Hugo Schwyzer. November 03, 2005 A Note On Vulnerability and Responsibility. Retrieved January 4, 2007 from http://hugoboy. typepad. com/hugo_schwyzer/2005/11/on_a_more_serio. html

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

Role of Social Media in Online Shopping Advertisements

Role of Social Media in Online Shopping Advertisements A study on perception towards Social media with special references to online shopping Ms. V. PAVITHRA, ASSISTANT PROFESSOR MBA, EASWARI ENGINEERING COLLEGE- CHENNAI Abstract: The rapid rise of social media has captured the attention of marketers and consumers on a global scale, and together with a rapidly changing communications environment marketers now confront new challenges in terms of our understanding of consumer behavior and consumption patterns in the new millennium. Internet and Information technology have made tremendous contribution for business transformation witnessed nowadays all over the world. The growth of this particular media attracts the attention of advertisers as a more productive source to bring in consumers. A clear idea, the consumers have with online advertisement is the control they have over the item, choosing whether to check it out or not. To broaden our understanding and assist in managing marketing communications effectively, this exploratory research investigates the role of social media within the broader advertising and communications mix. The capability of purchasing without leaving your place is of great interest to ma ny consumers. Not only does online shopping offer really good deals, but also brings optimum convenience to the consumers. For the aforesaid purpose, a survey was conducted in Chennai city covering 250 samples. Key words: Online marketing, Social media, Consumer perception, consumption pattern, Advertisers, convenience Introduction: Knowing that, currently, social networks, blogs, forums and sharing sites are the main centers of interest for Internet users, marketers have started to rethink their online communication strategies and adjust to the new trend. Many companies are realizing that having a website and making it visible and easy to find through search engines (SEO) is simply not enough anymore. Nowadays it is vital that their online presence includes a Social Media component on sites like Facebook, Google+, Hi5, MySpace or Twitter. According to the recent research on consumer behaviour  on the Internet users, there are four distinct consumer groups with different intentions and motivations: Exploration Entertainment Shopping Information Types of Internet marketing Internet marketing is broadly divided in to the following types: Display Advertising: the use of web banners or banner ads placed on a third-party website to drive traffic to a companys own website and increase product awareness. Search Engine Marketing (SEM): a form of marketing that seeks to promote websites by increasing their visibility in search engine result pages (SERPs) through the use of either paid placement, contextual advertising, and paid inclusion, or through the use of free search engine optimization techniques. Search Engine Optimization (SEO): the process of improving the visibility of a website or a web page in search engines via the natural or un-paid (organic or algorithmic) search results. Social Media Marketing: the process of gaining traffic or attention through social media sites. Email Marketing: involves directly marketing a commercial message to a group of people using electronic mail. Referral Marketing: a method of promoting products or services to new customers through  referrals, usually word of mouth. Affiliate Marketing: a marketing practice in which a business rewards one or more affiliates for each visitor or customer brought about by the affiliates own marketing efforts. Content Marketing: involves creating and freely sharing informative content as a means of converting prospects into customers and customers into repeat buyers. Objectives: To study the various attitude of consumers towards online shopping To find out preferences regarding the attitude on social media. To identify the various issues faced by users in social media towards online shopping To analyze the customer response to online advertisements and their impact on purchasing behavior. Methodology: Secondary Research: I first of all surveyed the available literature related to the problem. The published data from various sources like e-Journals, Internet, Books were studied. Quantitative research: After the collection of secondary data, the questionnaire was designed to collect the primary data. It is analyzed on the basis of suitable table by using – Bar technique and percentage analysis. Chi-Square test is applied to test the goodness of fit to verify the distribution of observed data. HYPOTHESIS 1. Analysis of Internet user’s perception of online advertisements. H0 – The six options (entertainment, in formativeness, irritation, credibility, interactivity and purchase) i.e perception behind the online advertisements is same for all people(each of these options have same influential value on the respondents). H1 The six options (entertainment, in formativeness, irritation, credibility, interactivity and purchase) i.e perception behind the online advertisements is different for all people(each of these options have different influential value on the respondents). 2. Analysis of the relationship between the websites that are most searched for Age of the respondents. H0 – Age of the respondents and the websites that are most clicked at, are independent. H1 Age of the respondents and the websites that are most clicked at, are dependent. ANALYSIS 1. Analysis of the relationship between Internet user’s perception of Internet advertisements and Age of the respondents. Relationship between Internet user’s perception and Age-Observed values Age Entertainment Informativeness Irritation Credibility Interactivity Purchase Total 3 7 5 5 3 2 25 30-40 1 7 6 5 5 2 29 41-50 5 5 5 0 5 6 30 >50 3 3 2 4 3 4 18 Total 12 22 18 14 16 18 100 2. Relationship between Internet user’s perception and Age- Expected values Particulars Entertainment Informativeness Irritation Credibility Interactivity Purchase Total 3 5.5 4.5 3.2 2.4 22 25 30-40 3.48 6.69 3 21 3.5 8.3 29 41-50 3.6 6.5 2.22 2.4 4.5 5.7 30 >50 1.92 3 5 2.1 4.5 6.6 18 Total 12 22 18 14 16 18 100 =(4-1)*(6-1)= 15 At 95% of confidence Table value of Chi Square at n=15 is 24.996 Chi Square value observed here is 10.82125416 which is lesser than table value. This proves the hypothesis H0 is accepted â€Å"Perception behind the online advertisements is same for all people† 3. Analysis of the relationship between Internet usage and the Age of the respondents Age Access E-Mail Downloading Net Surfing Window Shopping 12 6 5 10 30-40 6 8 9 7 41-50 3 5 10 3 >50 5 8 4 4 Total 33 22 22 23 4 . Relationship between age and the website usage-Expected values Age Access E-Mail Downloading Net Surfing Window Shopping Total 3.5 2.5 4.3 5.6 23 30-40 4 5 3 2.6 30 41-50 7 7 3.5 4 27 >50 2 4 3.8 8.6 20 Total 33 22 22 23 100 = (4-1)*(4-1) =9 At 95% of confidence Table value of Chi Square at n=9 is 16.911. Chi Square value observed here is 2.456560586 which is lesser than table value. This proves the hypothesis H0 is accepted â€Å"Age of the respondents and the websites that are most clicked at, are independent†. 5. Important elements for the success of promotional campaigns For most respondents (38%) the element of the greatest importance for the success of promotional campaigns through social networks is the originality, followed by a consistent and well transmitted message (for 25%), interactivity (16%), attractive design (15%) and animation (with only 6% of responses). 6. In which extent the brand, company name and company characteristics influences the Respondents For more than 50% of the Social Media users the brand, the company name and the company Characteristics are also very important for capturing their attention. Findings: According to The Nielsen Company’s study, published at the end of January 2010, global consumers spent, on average, more than five and a half hours on social networking sites like Face book and Twitter in December 2009. The study showed an 82% increase from the same month of 2008 when users spent just over three hours on social networks. In addition, the overall traffic to social networking sites has grown over the last four years. Specifically, two thirds of online visitors spend their time on social networks and blogs, placing them ahead of other online forms of engagement and interaction including games and instant messaging. The purchase of a product as a result of experiencing a form of online advertising through social networks was achieved by only 16% of respondents who said they had purchased clothing or accessories (sunglasses, jewelry), electronics (cell phones, cameras, laptops), IT products (software and hardware) or flight tickets. The research results showed that Facebook is the social network where most of the respondents own an user account (27.8% of responses), followed by Hi5 with (21.6%), YouTube with 14.7%, LinkedIn (7 %) and Twitter (6.6%). Conclusion: This study was accomplished to determine the customer perception on social media towards online shopping. Most respondents aged between 26 and 35 and all the respondents who have corporate leadership or decision making positions have a Twitter account, which may confirm the idea that the members of this site are opinion leaders or aspirational models, mature professional people, who have an important point of view to share with others. The research revealed another important finding, namely that users agree to the idea that promoting products or services through social networks can be useful and that advertisements appear in an acceptable number within these platforms. The study also shows that women tend to be more open and tolerant than men in these aspects. Many of the consumers are aware of the various online scams due to which they are very concerned and reluctant while providing their credit card information online. Also the online purchases take a longer time in shipments and deliveries. 65 million Face book members (almost one third of users), have accessed the website from a mobile phone, four times more than the same period in 2008, and in 2010 their number has exceeded 100 million persons. In addition, people who have accessed the site from their mobile phones were almost 50% more active than those not using mobile Internet. I analyze the relationship between Age of the respondents and the websites that are most clicked at, are independent. In a survey of 100 respondents, 33 people used internet for Access E-mail, 23 respondents used internet for window shopping, 22 respondents used internet for downloading, and similarly 22 respondents used net surfing. Finally I concluded that the social media is giving broad platform to consumers for having more choices with comfort shopping. REFERENCES 1. Belch, G., Belch, M., Kerr, G., Powell, I., 2009. Advertising and promotion: an integrated  Marketing communication perspective, McGraw Hill Australia, Sydney, New South Wales. 2. Engel, J.F., Blackwell, R.D. and Miniard, P.W., Consumer Behavior. Chicago: Dryden  Press, 1990. 3. Humphries, J., 2010. Social networking in business – Face book. CXO Europe, January 4,  2010. Retrieved June 14, 2010, from http://www.cxo.eu.com/news/social-networking-inbusiness- facebook/ 4. Kaplan, A., Haenlein, M., 2010. Users of the world, unite! The challenges and opportunities of Social Media. Business Horizons 53 (1), 59-68. 5. Muniz, A., O’Guinn, T., 2001. Brand community. Journal of Consumer Research 27 (4), 412- 432. 6. Zeng, F., Huang, L., Dou, W., 2009. Social factors in user perceptions and responses to  advertising in online social networking communities. Journal of Interactive Advertising 10  (1), 1-13.

Free Essays on Kafkas Metamorphosis: A Response to Kafka :: Metamorphosis essays

   Gregor had alienated himself long before his metamorphosis into a beetle. His obsession with his job had dehumanized him, made him less personal and more mechanical. While on business trips, he began to lock his doors at night in the hotels. He carried this action back to his homelife. His family did not know him anymore partially because they took him for granted for making their money for them and partially because that was simply how he wanted in to be. Gregor's metamorphosis into a beetle only allowed his family and himself to consciously alienate him from society and the world.    As someone said to meI can't remember who it was-it is really remarkable that when you wake up in the morning you nearly always find everything in exactly the same place as the night before. For when asleep and dreaming you are, apparently at least, in as essentially different state from that of wakefulness; and therefore, as that man truly said, it requires enormous, presence of mind or rather quickness of wit, when opening your eyes to seize hold as it were of everything in the room at exactly the same place where you had let it go on the previous evening. That was why, he said, the moment of waking up was the riskiest moment of the say. Once that was well over without deflecting you from your orbit, you could take heart of grace for the rest of your day.    Gregor woke up one morning to find himself turned from a human being to a beetle. People found that to be extremely hard to grasp. Many felt as though Gregor should have been more shocked at this change, or at least less understanding towards it. But really, why should he? The only part about being a beetle that seemed to truly negatively shock Gregor was that he could no longer attend to his job at the office. Gregor's family life did not change drastically. His loss of relation with his family was nothing very new, there was a lacking of personal connection with his parents for quite awhile before hand. His parents treated him as a form of hired help since he had taken the job to pay for his

Sabiduría y enseñanza en la ciudad en crisis (Platón, Apología 18a7-20c3) :: Spanish Essays

"Sabidurà ­a" y "enseà ±anza" en la ciudad en crisis (Platà ³n, Apologà ­a 18a7-20c3) ABSTRACT: Con Platà ³n se produce el reconocimiento de la educacià ³n como el lugar en que una comunidad mantiene su peculiar instalacià ³n en la realidad y por ello como el terreno de la accià ³n politica eficaz. La problemà ¡tica, presente ya desde los textos socrà ¡ticos, es ubicada en el pasaje de la Apologia de Sà ³crates en que la mencià ³n de las ‘acusaciones antiguas’ permite ver el juego de distintos elementos-la paideà ­a, la opinià ³n pà ºblica, el saber-en un momento de crisis. Esta crisis, tanto de la base polà ­tica tradicional como de la polà ­tica pragmà ¡tica, se traduce en un oscurecimiento de que lo que son el hombre y la pà ³lis que da lugar a Sà ³crates y a su tarea como consciencia de la quiebra del mundo polà ­toco. Se desarrolla el alcance ontolà ³gico de ella y sus-paradà ³jicos-consecuencias polà ­ticas y educativas. Una usual caracterizacià ³n sociolà ³gica de la educacià ³n la define como los modos de reproduccià ³n de una sociedad. En el fondo, la educacià ³n està ¡ exigida por el hecho de que una comunidad determinada (asà ­ sean las grandes sociedades contemporà ¡neas) resulta el lugar primario del encuentro del hombre con la realidad, y esta apertura del mundo, por ser siempre concreta, es histà ³rica y finita, y por ello tiene que esforzarse permanentemente para mantenerse abierta, ya que en cualquier momento puede oscurecerse y quebrarse. La educacià ³n es parte decisiva de este esfuerzo. El nombre de Platà ³n parece ligado a una concepcià ³n que, lejos de encontrar un fundamento en la finitud, lo encuentra—si vale la palabra—en lo 'absoluto', dejando a lo finito en una regià ³n ontolà ³gicamente là ­mite. Y sin embargo esta comprensià ³n de la realidad—que el Platà ³n maduro traducirà ¡ en la doctrina de las Ideas—està ¡ ligada al intento de rescatar a su particular comunidad de un naufragio (rescate que Platà ³n cree todavà ­a desesperadamente posible, aunque en realidad ya era tarde). Ya los textos "socrà ¡ticos" (la Apologà ­a de Sà ³crates y el Crità ³n) marcan, en la compleja relacià ³n de Sà ³crates con su ciudad, el reconocimiento, a la vez, del carà ¡cter fundante de lo comunitario-polà ­tico y de la quiebra interna de ese fundamento; y es justamente esta quiebra la que permite reconocerlo como tal. Estos textos tambià ©n marcan el comienzo de la reflexià ³n platà ³nica sobre la educacià ³n, que el drama socrà ¡tico signa inicialmente de violencia. Sà ³crates es la và ­ctima ilustre de una realidad social fallida que se opone con toda su fuerza a quien seà ±ala esa quiebra de sus fundamentos y que aparece asà ­ como 'subversivo' mucho antes de cualquier propuesta de replantearlos o cambiarlos.

Enhance Intrinsic Tendon Healing Health And Social Care Essay

To measure the functional result after flexor sinew fix with application of simple postoperative protocols that advice early controlled motion taking to heighten intrinsic sinew healing, minimising adhesion formation, and therefore bettering the functional result. METHODS. These survey was between June 2005 and May 2008, as a prospective survey that included 225 instances with flexor sinew hurts. All the injured sinews were repaired utilizing the Modified Kessler ‘s technique, so splinting of the carpus and metacarpophalangeal articulations was done in 20 and 40 degree flexure severally, and dynamic splinting of fingers was done. Early motion was induced get downing from the first postoperative twenty-four hours with hurting control. Evaluation of the result was assessed by the manus clasp strength and by mensurating the sum of active flexure of proximal and distal interphalangeal articulations. RESULTS. 11 patients did n't go to for follow up and were excluded from the concluding analysis. 205 patients out of 214 ( 95.8 % ) achieved an first-class to good functional class in the concluding result, while 9 patients ( 4.2 % ) achieved a just to hapless result. Merely 3 patients experient tendon rupture ( 1.4 % ) . Average follow up period was 5.2 months. CONCLUSION. The usage of proper technique for fix of flexor sinews of the manus, followed by early controlled motions as a method of pick that on scientific background should heighten intrinsic sinew healing is ; executable, safe, and has a good functional result.Cardinal words: flexor tendon – hurtIntroductionThere are many different protocols and research attacks to tendon direction. With so many picks, today ‘s manus healer must understand non merely what those picks are, but besides why and when to utilize them. The most of import difference between the assorted attacks to mend postoperative digital flexor sinew, is rehabilitation and how the repaired sinew is treated during the first three to six hebdomads, in the earliest phases of mending. The specializer who does non understand how current techniques evolved is ill-equipped to plan the appropriate intervention for a given patient ( 1 ) . Tendon fix began to be accepted on 1752, when Albercht Von Haller, a Swiss research worker concluded that sinewy construction was insensitive to trouble. In 1959, Verdan described the zones of flexor tendon fixs of the manus. In 1967. Potenza studied tendon mending based on extrinsic fibroblastic invasion and proliferation with adhesion formation. Lundborg explored intrinsic sinew mending based on synovial fluid nutrition. Strickland, Manske, Gelberman, and others studied the delicate balance between mending and tendon gesture, with respect to growing factors, fibronectin, the ration of extrinsic to intrinsic sinew healing, tendon sutura techniques, strength of fix, and the consequence of early active postoperative gesture on result ( 2 ) . The contentions in tendon fix may be as follows ; in the initial phases of sinew healing, the formation of functionally weak tissue can non defy the tensile forces that allow early active scope of gesture, and so, there is a hazard of rupture of the fix. In the same clip, immobilisation of the figure may advance healing, but necessarily consequences in the formation of adhesions between the sinew and tendon sheath, which leads to clash and decreased glide. Besides, lading during the healing stage is still critical to avoid these adhesions, but once more, it involves an increased hazard of rupture of the repaired sinew. It is clear that understanding the biological science and organisation of the native sinew and the procedure of morphogenesis of tendon tissue is necessary to better current intervention modes ( 3 ) . In our work, we managed flexor sinew hurts ; by one of the most popular sinew fix methods ( modified Kessler technique ) , so leting for early passive and controlled early active motion of the figures taking for heightening the intrinsic sinew healing and minimising adhesions formation, therefore giving the best opportunity for an first-class functional recovery for the repaired sinews.Flexor Tendon AnatomyThe flexor sinews of the carpus, flexor wrist radialis ( FCR ) and flexor wrist ulnaris ( FCU ) are strong and thick sinews, while the flexor pollicis longus ( FPL ) has a distal musculus belly. The flexor sinews of the fingers are arranged into three beds ; flexor digitorum supericialis ( FDS ) sinews of the center and ring fingers are most superficial ; superficialis sinews of the index and small fingers are in the center, while the deepest bed is composed of the FPL and the four sinews of the flexor digitorum profundi ( FDP ) . There is frequently a tendon faux pas from the FDP of the index to the FPL, which may necessitate deletion to forestall post-surgical complications ( 4, 5 ) .Clinical Tendon Zones of VerdanThese zones are used to depict flexor tendon hurts of the manus and carpus ; Zone I: extends from the finger tip to the midportion of the in-between phalanx ( the Green Zone ) . Zone II: extends from the midportion of the in-between phalanx to the distal palmar fold ( No-Man ‘s Land or the Red Zone ) . Zone III: extends from the distal fold to the distal part of the transverse carpal ligament. Zone IV: overlies the transverse carpal ligament ( carpal tunnel ) . Zone V: extend from the carpus fold to the degree of the musculotendinous junction of the flexor sinews. Zones III, IV, and V constitute the Yellow Zone ( 6 ) .Pulleys ‘ systemPulleies are inspissating along flexor sheaths lined with synovial membrane. They improve biomechanics of flexor sinews by forestalling bowstringing of sinews during flexure. Fingers have 5 annulate blocks and 3 cruciate blocks. Annular blocks are A1 at metacarpophalangeal articulation ( MPJ ) , A2 over the proximal phalanx, A3 at the proximal interphalangeal articulation ( PIPJ ) , A4 over in-between phalanx, and A5 at the distal interphalangeal articulation ( DIPJ ) . A2 and A4 are the most of import to forestall bowstringing. Cruciate blocks are between the annulate blocks, they are thinner and less biomechanically of import than annulate blocks. The pollex has 2 annulate blocks ; A1 at MPJ, A2 at interphalangeal articulation, and one oblique block, which is an extension of adductor pollicis fond regar d that lies between A1 and A2 and it is the most of import pollex block to forestall bowstringing ( 7 ) .Nutrition of Flexor sinewsTendons have two beginnings of nutrition, an internal beginning provided by vascular perfusion, and external beginning provided by synovial fluid ( 6 ) . Tendons without synovial sheath receive blood supply from longitudinal anastomotic capillary system, that receive segmental blood supply from ; Vessels in the perimysium and vass at the bony interpolations. The beginning of foods for the flexor sinews with synovial sheath is either ; vascular perfusion and synovial fluid diffusion. The segmental blood supply of the sinews is from vass from muscular subdivisions in the forearm, vass in the environing connective tissue via the mesotenon conduit â€Å" vincula † , vass from the bone, at the interpolation, and vass from periosteum near interpolation ( 8 ) . In the last decennaries, many surveies of synovial perfusion of the flexor sinews within the synovial sheath have been done ( 9 ) . Studies demonstrates that synovial fluid perfusion was more effectual than vascular perfusion, so when the sinew was isolated from its vascular connexions, diffusion could supply the entire nutrition demands to all sections. Synovial diffusion besides contributes in sinew healing as the longitudinal sinew vasculature may be easy occluded by suturas, therefore sheath fix or Reconstruction is indicated.Tendon MendingThree stages of sinew healing are present ; Inflammatory stage ( first hebdomad ) , Proliferative stage ( 2nd-4rth hebdomad ) , and Remodeling stage ( 2nd-6th month ) . Tendons exhibits two types of healing, with different ratios. Extrinsic healing: Fibroblasts migrate from the sheath into the injured site, and besides from adhesion. This type healing is enhanced by postoperative immobilisation ( 7 ) . This explains why immobilisation protocols to reconstruct tendon congruousness consequence in cicatrix formation at the fix site, instead than a additive hempen array, and peripheral adhesions that limit tendon motions ( 10 ) . Intrinsic healing: Tendon cells can migrate across closely approximated terminals and heal with foods from synovial fluid. Peripheral adhesions do non take part in intrinsic sinew mending. Although some writers believed that adhesions formation is indispensable in sinew healing, several surveies demonstrated the intrinsic ability of flexor sinews to mend via foods supplied by diffusion from the synovial fluid ( 11 ) .Patients AND METHODSThis prospective survey was performed in the Emergency Unit, Kasr Al-Aini Hospital ( Faculty of Medicine, Cairo University ) in the period between 6/2005 and 5/2008. Table ( 1 ) shows the human ecology of the included patients. The figure of instances included was 225 instances enduring from flexor sinew hurts in zones I, II, III, IV, and V, but 11 instances were excl uded from the concluding analysis as they were non present during the follow up period ( table 2 ) . Included instances were instances with flexor sinew hurts showing within less than 24 hours from the hurt. Exclusion standards were ; kids below 12 old ages for expected bad conformity, late presentation, infected, contused and crushed lesions, and shocked poly-trauma patients.Table ( 1 ) Demographic distribution of patientsNumber of patients214Sexual activity ( Male & A ; Female severally )153 ( 75 % ) & A ; 61 ( 25 % )Age in old agesBetween 12 and 63 old agesManual Workers122 ( 60 % )Table ( 2 ) Distribution harmonizing to zone hurtsZone I injury33 ( 15 % )Zone II hurt48 ( 22 % )Zone III hurt36 ( 17 % )Zone IV hurt38 ( 18 % )Zone V hurt59 ( 28 % )Entire214 First assistance was done for every instances, including guaranting of equal general position of the patients ( airway, take a breathing, circulation ) , followed by IV analgesia, IV antibiotics ( individual dosage of 3rd coevals cephalosporine ) , booster dosage of antitetanic anatoxin was administrated. Clinical appraisal of the manus hurt ( vascularity, diagnosing of injured sinews and associated injures ) . The lesion was washed by unfertile saline, bovidone I, IV explored under either general anesthesia or IV Bier ‘s block, and a pneumatic compression bandage was indispensable portion in all instances ( with monitoring of the tourniquet clip ) . Minimal handling of the sinews was deliberately done. Tendons were repaired by nucleus suturas by modified Kessler ‘s technique utilizing 4-0 polypropene suturas and peripheral suturas. The carpus was splinted in 20 grade of flexure, and metacarpophalangeal articulation at 40 grade of flexure. Dynamic splint was applied to th e fingers utilizing rubber bands. Early passive and active motions were done with the control of hurting. Motions started from the first postoperative twenty-four hours, hourly, for 10 repeats of active extension and flexure of fingers while the manus is in the splinted place, and passively the DIPJ is so to the full flexed. Curative ultrasound was applied for 19 instances to heighten intrinsic healing. Follow up was done twice hebdomadally for one month, and so weekly for two months, so every month. Follow up ranged between 6 months and 18 months.ConsequenceFrom the 225 patients, 11 patients did n't go to the follow up period and were excluded from the concluding analysis. All the included patients continue with the follow up for at least 3 months, while merely 193 completed a period of follow up of 6 months. So, the concluding analysis was based on consequences recorded after 3 months of follow up. Average follow up period was 5.2 months. Evaluation of the result was based upon manus map, and this is the of import issue in tendon fix, and besides it is impossible to measure the sum of intrinsic healing to the sum of intrinsic healing in a life homo. So, the consequences of the fix were assessed by clinical rating of sinews ‘ map. This was done by measuring the manus clasp strength and by proving for the sum of active flexure of the distal interphalangeal articulations and proximal interphalangeal articulations, so deducting the sum of active extension shortage at these articulations during active extension. The consequences were graded as Angstrom: excellent ( & gt ; 132 grade entire gesture ) , B: good ( 88- 131 grade ) , C: just ( 44- 87 grade ) , and D: hapless ( & lt ; 44 grade ) . In patients with multiple flexor sinew hurts, the norm of the concluding functional result of all sinews was done. Concluding manus clasp strength norm was 80 % in comparing to the un-injured manus, with 15 % shortage, that is after taking in history the 10 % regulation. In measuring the concluding result, 205 out of 214 ( 94.1 % ) achieved an first-class to good functional class ( A or B ) , while 9 patients ( 4.2 % ) achieved a just to hapless result ( C or D ) . Functional result of grade C or D was related more to district II hurt ( 4 instances, stand foring 8.3 % of zone II hurts ) . The other 5 instances of grade C or D functional result were as follows ; two instances of zone I, two instances in zone V and a individual instance in zone IV. That ‘s average 6 % of hurts in zone I, 3.4 % of hurts in zone V, and 2.6 % of hurts in zone IV. All instances of zone III hurt had either rate A or B functional result. Minor complications related to the tegument lesion and that did non impact the concluding result occurred in 12 patients ( 5.6 % ) , that ‘s including mild wound infection that was self-controlled, haematoma that may hold required aspiration, hypertrophic cicatrix in which Si spot was applied, and an disciple cicatrix occurred in individual patient. Entire failure of the fix occurred merely in 3 patients, whom experienced tendon rupture ( 1.4 % ) and necessitate re-suturing ( two instances in zone II and one instance in zone I, and concluding result of such instances was added to the old consequences ) .Table ( 3 ) Final result harmonizing to the injured zone.Injured zoneEntire figureExcellent- Good resultFair- hapless resultZone I( Green ) 33 ( 14 % ) 31 ( 93.9 % ) 2 ( 6.1 % )Zone II( Red ) 48 ( 23 % ) 44 ( 92.7 % ) 4 ( 8.3 % )Zone III( Yellow ) 36 ( 17 % ) 36 ( 100 % )––Zone IV( Yellow ) 38 ( 18 % ) 37 ( 97.4 % ) 1 ( 2.6 % )Zone V( Yellow ) 59 ( 28 % ) 57 ( 96.6 % ) 2 ( 3.4 % )Entire214 ( 100 % ) 205 ( 95.8 % ) 9 ( 4.2 % )DiscussionTreatment of sinew hurts is an of import portion of manus surgery pattern worldwide. Adhesion formation, rupture of the fixs, stiffness of finger articulations, remain the chief jobs of primary sinew fixs. Tendon hurts happen in all parts of the manus and forearm, but the sinew hurts in the digital flexor sheath country ( zones 1 and 2 ) are the most hard to handle and stay a focal point of both clinical attending and basic probes ( 12 ) . There is now ample grounds to confirm several of import facts. As an illustration, intrasynovial sinews receive their nutrition via both intrinsic vascular supply and perfusion of synovial fluid. This means that the sinews do non necessitate to organize adhesions to environing sinews to have nutrition adequate for mending ( 1 ) . In our survey, we designed a program for mending injured flexor sinews that was wholly based on the background known from the physiology of sinew healing. We included instances in which we could execute primary sinews fix, as there is no uncertainty that primary sinews repair gives better functional recovery than secondary tendon fix or transplant ( 13 ) . In respect the timing of fix, Swiontkowski, 2001 ( 6 ) stated that acute sinew hurts require pressing attention, ideally within 24 hours of hurt. Zidel, 2007 ( 4 ) considered that primary fix can be done within 24 hours and considered delayed primary fix with the 1st twenty-four hours up to the fourteenth twenty-four hours. In our survey, we included instances that were showing to the exigency unit within less than 24 hours. Assortment of methods may be used for tendon fix, but the modified Kessler fix is still widely used for the nucleus sinew sutura ( 14 ) . Besides, modified Kessler fix is a good illustration of high-strength, low-friction fixs that minimizes clash between the sinew and flexor sheath while keeping sufficient strength to the fix ( 15 ) . We used the modified Kessler fix in all of our instances as the criterion nucleus sutura in add-on to peripheral suturas. Managing sinews was atruamatic to minimise mobilisation as possible during readying, and suturas were preferentially placed nearer to the palmar surface to least interfere with intratendinous circulation that enter dorsally. Appropriate direction of tendon sheath and block is concern of manus sawboness in covering with tendon hurts in digital sheath country. Suturing the sheath is controversial. Avoiding compaction of the repaired sinew by the tightly closed sheath is considered of primary importance in handling the injured sheath ( 16 ) . Closing of the synovial sheath is still controversial. Some writers mention that it is indicated, based on the fact that since intrinsic sinew vasculature is easy occluded by suturas and so, synovial nutrition may be required for mending ( 8 ) . In other ‘s sentiment, it is no longer considered indispensable ( 17 ) . Based on the fact of that the synovial nutrition has a function in tendon healing and that it may be plenty for mending even without the demand of intrinsic sinew vasculature, the sheath was sutured in all instances, taking for heightening intrinsic sinew healing and therefore minimising adhesions ( 18 ) . Our direction protocol for the block was as prescribe by Tang, et Al, 1996 ( 19 ) , which is the saving of a sufficient figure of blocks is critical to tendon gesture. Loss of an single annular block ( including a portion of A2 block or the full A4 block ) when other blocks are integral does non ensue in loss of map. Therefore, loss of a individual block ( A1, A3, or A4 ) or a portion of the A2 block does non necessitate fix. In instance of sinew fixs within narrow A2 or A4 blocks, some sawboness advocate venting a portion of the A2 or full A4 block to let go of the compaction of the repaired sinews ( 20 ) . Postoperative sinew gesture exercising is popularly employed after primary sinew fix, but exact protocols for rehabilitation vary greatly among states or even among manus surgery centres in the same state. Protocols for inactive flexure ( active extension of the fingers with gum elastic set grip ) are still in usage in some manus units. However, over the last 5-10 old ages, there has been a tendency towards combined active-passive finger flexure without gum elastic set grip, because gum elastic set grip bounds full extension of the finger ; while extension loss is a frequent complication ( 21 ) . In Duran and Houser, 1975 protocol, a dorsal splint or dramatis personae holds the carpus in 20 grades of flexure and the finger in a relaxed unspecified place of protective flexure by agencies of a gum elastic set attached to a sutura through the fingernail, to maintain the sinew on slack. Two times a twenty-four hours, the patient performs six to eight repeats of two exercisings. Both exer cises push flexor sinews proximally and so draw them distally: inactive flexure and extension of the DIP articulation while the PIP and MP are held in flexure, and inactive flexure and extension of the PIP while the DIP and MP are held in flexure. Through intraoperative observations, it was observed that these exercisings imparted 3 to 5 millimeters of inactive semivowel to the sinew, and they considered this to be sufficient to forestall formation of restrictive adhesions. Strickland and Glogovac, 1980 introduced the modified Duran attack which is in usage by many healers today: a dorsal splint holds the carpus and MP articulations flexed, and the interphalangeal ( IP ) articulations are strapped in extension between exercising Sessionss. The original Duran exercisings are supplemented by composite inactive flexure and active extension every bit far as allowed by the splint. Both logic and clinical surveies tell us that including composite inactive flexure will bring forth greater inactive flexor sinew motion. Some of the best consequences with an early inactive mobilisation protocol are in patients who unwittingly or consciously flex their fingers actively. This makes great sense logically. Passive flexure efforts to force the sinew proximally, but the sinew is designed to draw, non to force. Edema is a normal portion of mending after fix, even if the sinew is cut flawlessly, with minimum hurt to next tissues, and is repaired efficiently and good. Any fix is bulkier than an uninjured sinew. Any associated hurt will bring forth extra hydrops. All of these factors produce opposition to tendon motion. Some have noted †buckling † of the sinew instead than gliding with inactive motion. Obviously, carefully controlled active flexure should bring forth greater sinew motion than does inactive flexure. These active mobilisation protocols are possible merely because of the development of surgical techniques. It is good established that the strength of the nucleus sutura is related to the figure of strands traversing the fix ) and that a strong peripheral sutura both improves gliding and additions suture strength ( 22 ) . In our survey, farther direction was based on the fact of that early mobilisation will heighten the intrinsic healing of the sinew, minimizes adhesions, stiffness, and therefore minimizes the restrictions of motion. And in the same clip, immobilisation helps extrinsic sinew healing and adhesion formation. So, we splinted the carpus in 20 grade of flexure and MPJ at 40 grade ( 23 ) , we planned for dynamic splinting of involved figures with early passive and active but controlled gestures to avoid possible jobs related to early motion such as rupture of the repaired sinew. Controlled active motion ( CAM ) after flexor sinew fix was advised by several writers since the last decennaries till now ( 24, 25, 26, 27, 28 ) . We found that the CAM protocol that was described by Elliott, 2002 ( 23 ) easy to be described to and to be applied even by the patient him/her ego. The protocol starts the CAM from the first postoperative twenty-four hours, every hr for 10 repeats active extension and f lexure of fingers while the manus is in the splinted place, and passively the DIPJ is so to the full flexed. In our application, we waited till postoperative hurting subsided during which the patient may be hospitalized as describe besides by Elliot, et Al, 1994 ( 29 ) . The usage of Postoperative curative ultrasound from the fifth twenty-four hours, was done for a limited figure of instances, taking of cut downing hurting during finger motion, cut downing hydrops, and heighten ripening of the collagen fibres and intrinsic sinew healing. That was based on the survey done by Gabriel and Dicky, 2007 ( 30 ) who used curative ultrasound on sinew Achilles. In decision, immediate active mobilisation following fixs of complete subdivisions of the flexor sinews is, at present, a challenge in manus surgery which faces two major faltering blocks.. On one manus, sawbones has to obtain a sufficiently solid fix to allow active finger flexure and, on the other manus, to find a sector of mobilisation which would let maximum jaunt of the fix site without extra hazard of early rupture ( 18 ) . The tensile strength and glide maps are greater in the postoperatively mobilized sinews, whereas adhesion formation is greater in immobilized sinews ( 11 ) . We found our protocol is a safe, simple, scientifically accepted protocol and gives an first-class functional consequences for a repaired sinew with no or at least minimum morbidity.