Anorexia Nervosa Essay Example for Free

Anorexia Nervosa Essay I. Introduction Anorexia nervosa has received a great deal of attention in the popular media in recent years. This disorder is listed under the category of disorders of childhood or adolescence in DSM-III. Anorexia consists of extreme weight loss due to a reduction in eating. It occurs most frequently in female adolescents; only about 1 in 10 people with anorexia are male. The disorder is believed to be rate, but one study found an incidence of 1 case out of 200 adolescent girls. Anorexia begins when the adolescent starts to diet. The person often has major problems in self-esteem and concerns about physical appearance. Weight reduction may be one way for the person to feel in control of her or his behavior, and to improve self-esteem ( Lager, 2003).   However, for anorexics, dieting gets out of hand. They develop an unreasonable fear of eating, and often suppress hunger by engaging in repetitive activity such as frequent exercising. When anorexics must eat because others (e.g., parent) demand it, they often will induce vomiting after meals to get rid of the food ingested. Even though the anorexic begins to waste away and develops such physical problems as cessation of menstruation (for girls), constipation, and imbalances in body chemistry, she or he is often unconcerned about the life-threatening aspect of the behavior (Darby, 2001). Anorexics continue to perceive themselves as heavier that they really are, and some continue to avoid eating until they die from starvation. Death may occur in up to 15 percent of anorexics. This paper intent to: (1) understand what anorexia nervosa really means and its effects; (2) know the measures for managing anorexia; (3) be aware of the use of pharmacologic agents to stimulate appetite in the terminally ill and; (4) be familiar of the factors influencing nutritional status in varied situations. II. Background Anorexia Nervosa is a psychiatric disorder characterized by an aversion to food and a resulting extreme loss of weight. It is most common in teenage girls and young women. The victims, although not necessarily overweight, become obsessed with a fear of obesity and deliberately subject themselves to a starvation diet (see â€Å"Anorexia Nervosa Overview.† eMedicineHeath. Emergency Care + Consumer Health). The resulting malnutrition typically leads to constipation, vomiting, low body temperature, low blood pressure, and amenorrhea (cessation of menstruation). Victims can lose up to 25 percent of their body weight and, if untreated, may die. Treatment for anorexia consists of hospitalization along with psychotherapy and counseling. Victims are either fed intravenously or are placed on a high-calorie, high-protein diet supplemented by large doses of vitamins. A. What are an anorexia nervosa and its effects? At the other end of the spectrum from obesity is anorexia nervosa, an eating disorder associated with self-imposed starvation. The already underweight person continues to restrict food intake, often to the point where death is a genuine concern. One of the most distinguishing traits of people who have anorexia nervosa is that they do not see themselves as thin (Halmi, 2004). When they look in a mirror, they actually perceive themselves to be overweight or gaining weight. In the latter case they may go out and jog 5 miles or stay up all night jumping jacks. The resulting weight loss and attendant physical stress often lead to an absence of menstruation among females, and the person may look pallid and gaunt. III. Discussion Anorexia is a puzzling disorder. Why would an otherwise healthy young person starve to death? Although some explanations of anorexia have focused on biological causes (a possible malfunction of the hypothalamus which could lead to a lack of desire for food), current views focus on problems in the family which may lead to anorexic behavior. The parents of anorexic adolescents are often very controlling and attempt to order their children’s lives to a greater extent than do parents of non-anorexics. Furthermore, the families are often filled with conflict between family members. Anorexic behavior may be an extreme, distorted attempt by the adolescent to control at least one aspect of her or his own behavior. Treatment of anorexia usually involves several different emphases. If the weight loss is life threatening, medical intervention (e.g., intravenous feeding) is necessary. The reinstitution of eating behavior and achieved using behavioral approaches; however, these gains are often short-lived. Most treatment programs report success rates as high as 86 percent. However, anorexia still results in death for some individuals. A. Measures for managing Anorexia Anorexia is a common problem in the seriously ill. The profound changes in the patient’s appearance and his or her concomitant lack of interest in the socially important rituals of mealtime are particularly disturbing to families. The approach to the problem varies depending on the patient’s stage of illness, level of disability associated with the illness, and desires. Although causes of anorexia may be controlled for a period of time; progressive anorexia is an expected and natural part of the dying process. Anorexia may be related to or exacerbated by situational variables (eg, the ability to have meals with the family versus eating alone in the â€Å"sick room†), progression of the disease, treatment for the disease, or psychological distress. The patient and family should be instructed in strategies to manage the variables associated with anorexia. B. Measures for Managing Anorexia There are many ways in how to manage the patient who suffers from anorexia nervosa and it is divided into two measures, the medical interventions and patient and family tips. a) Medical Interventions The medical group initiates measures to ensure adequate dietary intake without adding stress to the patient at mealtimes and assess the impact of medications (eg,chemotherapy, antiretroviral) or other therapies (radiation therapy, dialysis)that are being used to treat the underlying illness. It administers and monitors effects of prescribed treatment for nausea, vomiting, and delayed gastric emptying and encourages patient to eat when effects of medications have subsided and assess and modify environment to eliminate unpleasant odors and other factors that cause nausea, vomiting, and anorexia. Remove items that may reduce appetite (soiled tissues, bedpans, emesis basins, clutter). This medical group assesses and manages anxiety and depression to the extent possible (see â€Å"Anorexia Nervosa: Treatment.† Mental Health. MayoClinic.com). It also assesses for constipation and/or intestinal obstruction and prevents and manages constipation on an ongoing basis, even when the patient’s intake is minimal. Furthermore, it provides frequent mouth care, particularly following nourishment, ensure that dentures are properly taken care, and administer and monitor effects of topical systematic for oropharyngeal pain. b)  Ã‚  Ã‚  Ã‚   Patient and Family Teaching Tips The family reduces the focus on â€Å"balanced† meals; offer the same food as often as the patient desires it and increase the nutritional value of meals. For example, add dry milk powder to milk, and use this fortified milk to prepare cream soups, milkshakes, and gravies. Allow and encourage the patient to eat when hungry, regardless of usual meal times. Eliminate or reduce noxious cooking odors, pet odors, or other odors that may precipitate nausea, vomiting, or anorexia and keep patient’s environment clean, uncluttered and comfortable (Halmi, 2004). Make mealtime a shared experience away from the â€Å"sick† room whenever possible. Reduce stress at mealtimes. Avoid confrontations about the amount of food consumed. Reduce or eliminate routine weighing of the patient. Encourage patient to eat in a sitting position; elevate the head of the patient’s bed. The family plan meals (food selection and portion size) that the patient desires. Provide small frequent meals if they are easier for patient to eat. Encourage adequate fluid intake, dietary fiber, and use of bowel program to prevent constipation (Wrede-Seamn, 1999). C. Use of pharmacologic agents to stimulate appetite in the terminally ill A number of pharmacologic agents are commonly used to stimulate appetite in anorectic patients. Commonly used medications for appetite stimulation include dexamethasone (Decadron), cyproheptadine (Periactin), megestrol acetate (Megace), and dronabinol (Marinol). Dexamethasone initially increases appetite and may provide short-term weight gain in some patients. However, therapy may need to be discontinued in the patient with a longer life expectancy, as after 3 to 4 weeks corticosteroids interfere with the synthesis of muscle protein. Cyproheptadine may be used when corticosteroids are contraindicated, such as when the patient is diabetic. It promotes mild appetite increase but no appreciable weight gain. Megestrol acetate produces temporary weight gain of primarily fatty tissue, with little effect on protein balance. Because of the time required to see any effect from this agent, therapy should not be initiated if life expectancy is less than 30 days. Finally, dronabinol is not as effective as the other agents for appetite stimulation in most patients. Although the use of these agents may cause temporary weight gain, their use is not associated with an increase in lean body mass in the terminally ill. Therapy should be tapered or discontinued after 4 to 8 weeks if there is no response (Wrede-Seamn, 1999). D. Factors Influencing Nutritional Status in varied Situations. One sensitive indicator of the body’s gain or loss of protein is its nitrogen balance. An adult is said to be nitrogen equilibrium when the nitrogen intake (from food) equals the nitrogen output (in urine, feces, and perspiration); it is a sign of health. A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth, such as occurs during pregnancy, childhood, recovery from surgery, and rebuilding of wasted tissue. Negative nitrogen balance indicates that tissue is breaking down faster than it is being replaced. In the absence of an adequate intake of protein, the body converts protein to glucose for energy. This can occur with fever, starvation, surgery, burns, and debilitating diseases. Each gram of nitrogen loss in excess of intake represents the depletion of 6.25 g of protein or 25 g of muscle tissue. Therefore, a negative nitrogen balance of 10g/day for 10 days could mean the wasting of 2.5 kg (5.5 lb) of muscle tissue as it i s converted to glucose for energy. When conditions that result in negative nitrogen balance are coupled with anorexia (loss of appetite), they can lead to malnutrition. IV. Conclusion In conclusion, the prevailing belief among clinical psychologists has been that anorexia arises out of an unstable self-concept. Thus, the commitment to diet and weight control is seen as an attempt to establish a firm sense of identity (Bhanji, 1999). In addition, there is the possibility that this illness, which in about 85 percent of cases occurs in adolescent females, indicates a rejection of traditional feminine roles. Even career patterns play a role. In certain occupations where there is a premium on being thin—for example, ballet dancing—the incidence of clinical anorexia may be great as 50 percent. Further, it has been suggested that malfunctioning neurons in the hypothalamus may alter the metabolism and feeding patterns of people with anorexia nervosa (Leibowitz 2003).   At present, however, the empirical support for underlying neurological disturbances is scant (Logue, 1999).

Causes and Treatments of Sepsis

Causes and Treatments of Sepsis Sepsis is a major cause of morbidity and mortality in hospitals today. It has been defined as the bodys response to an infection when organisms invade the body (Baudouin 2008). Its an infection which is caused by micro organisms or bacterias that invade the body. Sepsis can lead to acute organ dysfunction followed by multi-organ failure and death. In the early stages of sepsis the immune response can be characterised as a systemic inflammatory response syndrome (SIRS) (Chamberlain 2008). This is the bodys response to a variety of severe clinical insults. It is characterised by the presence of two or more of the following features: Temperature >38ÂÂ °C or 90/min, Respiratory rate > 20/min or PaCO2 12 x 109/l altered mental status, blood glucose>7.7mmol/l in absence of diabetes (LTHTR Sepsis Care Pathway 2009).Sepsis is defined as SIRS in response to infection (I, Mackenzie 2001). The surviving Sepsis campaign was launched in October (2002) aiming to increase awareness of sepsis, severe sepsis and septic shock among healthcare staff and the general public, develop evidence based guidelines for the management of severe sepsis and ensure that guidelines are put to practice globally. In the Nice Clinical guideline 50- acutely ill patients in Hospital they made key recommendations to ensure early identification of the acutely ill patient and prevent deterioration of condition thus reduce patient mortality, morbidity and length of stay, to reduce ICU admissions and re admission. Initial management of a critically ill patient includes: Immediate assessment of the airway, breathing and circulation Baseline observations HR, RR, BP, O2 sats, capillary refill, EWS and AVPU to assess level of consciousness A brief history A limited examination of the relevant systems of the body. A secondary assessment after stabilisation of the patient including a more thorough history, detailed examination by system and appropriate investigations. The golden hour an early window of opportunity immediate resuscitation with oxygen and fluids prevents secondary injury to organs as a result of hypoxemia and hypovalaemia helping to reduce mortality and morbidity. The timing of clinical intervention is essential to the survival of septic patients (Chamberlain 2008). Respiratory failure is common and may develop at any stage so repeated assessments are necessary. A depressed conscious level is the most common cause of airway obstruction (I, Mackenzie 2001). A clear airway does not indicate effective breathing. Failure of gas exchange may be caused by lung problems (pneumonia, lung collapse, pulmonary oedema), failure of the mechanics of ventilation. Respiratory failure is suggested by signs of respiratory distress including dyspnoea, increased respiratory rate, use of accessory muscles, cyanosis, confusion, tachycardia, sweating. The diagnosis is made clinically but may be confirmed by pulse oximetry and arterial blood gases. Patients with a depressed conscious level may not react normally to hypoxia and signs of respiratory failure may be difficult to detect. Patients with inadequate ventilation, gas exchange or both require ventilatory support. This usually necessitates intubation and mechanical ventilation although in some patients gas exchang e and oxygenation can be improved by the application of continuous positive airway pressure (CPAP) by face mask or non-invasive ventilation. As per LTHTR sepsis care pathway (2009) high flow oxygen to be given to maintain a target of >94% using a non rebreath mask. Oxygen to be reduced when patient stable. In critically ill patients, high concentration oxygen should be administered immediately and this should be recorded afterwards in the patients health record (BTS guideline for emergency oxygen use in adult patients 2008). Tachycardia and hypotension are almost universal findings in the septic patient and result from a number of cardiovascular problems. In early sepsis, and in patients who have been partially or fully fluid resuscitated, the low blood pressure and high heart rate are associated with a high cardiac output and a low peripheral vascular resistance with warm peripheries and bounding pulses. In contrast, patients who have not been significantly resuscitated or have presented late in the course of their illness have a low cardiac output and high systemic vascular resistance. These patients are peripherally cold, sweaty, with weak, thready pulses and they need urgent resuscitation. However resuscitation aims to restore circulating volume, cardiac output and reversal of hypotension (I, Mackenzie 2001). Initially infuse i/v crystalloid or colloid rapidly guided by the clinical response. The optimal resuscitation fluid however, remains the subject of debate. Fluid resuscitation of severe sepsis may consist of natural or artificial colloids or crystalloids. Fluid challenge should be administered and repeated based on response (increase in blood pressure and urine output) and tolerance (V, Jean-louis 2004). Administering large volumes of fluid to patients with known cardiac disease or myocardial dysfunction related to their acute illness is a problem. Ronco, C et al (2004) argued that it is the quantity of fluid given rather than the type of fluid explaining that more crystalloid is needed to achieve the same effect as colloid but colloids are more expensive and carry their own risks. Adequacy of fluid infusion can be facilitated by repeated fluid challenges in which a pre defined amount of fluid e.g. 250 or 500mls is in fused over a set time. Sherman et al (2007) states that aggressiv e volume resuscitation and administering broad spectrum antibiotics should be given early to all septic patients using 2-4litres of normal saline. All patients should be monitored closely to see the response to resuscitation (urine output mental status, BP). If the patients blood pressure is 40mmgh lower than the patients normal BP fluid challenges nacl 0.9% 500ml given over 5-10mins (ALERT 2003). LTHTR Sepsis Care Pathway 2009 states if patient hypotensive give up to 3 boluses of 500ml (0.9% Saline) to maintain MAP>65/systolic 100mmgh. Urinary catheter hourly urine measurements. Perform investigations to confirm or clarify problems that are clinically evident, or to look for complications that are likely. Bloods including FBC, coagulation screen, UE, Liver function, Amylase, cardiac enzymes, Glucose, lactate and ABGs. Other tests may include a blood glucose, ECG and chest x-ray. You may consider sending samples for microbiology to confirm the presence of infection, i.e. blood cultures should be taken, sputum if suspecting chest infection and mid-stream urine (MSU) or catheter specimen of urine f suspecting urine infection. Blood cultures are only to be taken when there is clinical need to do so and not as routine (DOH 2007). Indepth search for the source of sepsis with rapid institution of appropriate antibiotic therapy. Delayed or initially ineffective antibiotic therapy has been shown to be associated with worse prognosis and if it is important that all likely microbial culprits are covered by the empiric antibiotic which can be altered when culture result s are available (Ronco, C et al 2004). Monitoring is not dependent on expensive equipment, but it requires the continuous presence of trained nursing staff. Clear documentation aids the assessment of subtle changes in the patients clinical state. Patients with severe SIRS / sepsis should have observations recorded hourly. Record body temperature, pulse, blood pressure, urine output, CVP, respiratory rate and SpO2 (if available). Accurate fluid balance is essential. An accurate Early Warning Score is essential as per LTHTR trust protocol along with every set of observations taken. EWS used widely throughout the trust it acts as an assessment of recognising deterioration in patients an identifies at risk patients. It requires the charting of observations such as systolic BP, HR, RR on a regular basis each is given a score from 0-3 and then added together to give an EWS. This is then used to trigger further assessment of the patient by senior nursing or medical staff and referral to critical care outreach who support nurses at ward level to tackle early detection and treatment to prevent intensive care admissions. Early detection and recognition of a patient that is deteriorating is vital (DOH 2007). The initial antibiotic prescription is a best guess, and will depend on the clinical picture of the patient, local patterns of antibiotic resistance and the local availability of antibiotics. It should be broad enough to cover the most likely pathogens, but not so broad as to encourage antibiotic resistance. The advice of a local microbiologist or infectious diseases specialist is valuable. Surviving Sepsis Campaign (2008) states the choice of antibiotics should be guided by the susceptibility of likely pathogens in the community and the hospital, as well as any specific knowledge about the patient, including drug intolerance, underlying disease, the clinical syndrome.ÂÂ   The regimen should cover all likely pathogens since there is little margin for error in critically ill patients. There is ample evidence that failure to initiate appropriate therapy promptly (i.e., therapy that is active against the causative pathogen) has adverse consequences on outcome. Although restricting the use of antibiotics, and particularly broad-spectrum antibiotics, is important for limiting super infection and for decreasing the development of antibiotic resistantÂÂ  pathogens, patients with severe sepsis or septic shock warrant broad-spectrum therapy until the causative organism and its antibiotic susceptibilities are defined. Shermon et al (2007) states that early use has been clearly demonstrated to reduce the mortality in sepsis an if no known source of infection is present then give broad spectrum antibiotic therapy to cover aerobic and anaerobic infections. LTHTR Sepsis Care Pathway (2009) states antibiotics to be given in first hour and all antibiotics to be reviewed after 48hours. Medical staff have been implicated in the spread of infectious agents between patients. All staff must wash their hands before and after attending to a patient. Equipment should not be shared between patients if possible, but where this is necessary the equipment should be thoroughly cleaned between patients. Staff should protect themselves and their clothes from becoming contaminated with biological material by wearing disposable aprons and gloves. Visitors should be discouraged from moving between patients. Wounds, including drain sites and intravenous cannulae sites, should be inspected, cleaned and dressed at regular intervals. Intravenous cannulae and central lines should be removed as soon as practical. Ensure correct documentation is filled in i.e. Vascular access device tool, wound charts and care plans as per trust protocol. In conclusion sepsis remains a major cause of morbidity and mortality in hospitals today. Many authors have looked at best practice in the early recognition and treatment of sepsis. It is vital that nurses and clinicians recognise and treat critically ill patients for the best outcome to reduce the risk of deterioration and potential cardiac arrests. NPSA (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients. Within LTHTR trust and other trusts there are many policies in ensuring this with the early recognition policy, early warning scores to help assist the staff on recognising the deteriorating patient and sepsis care pathway to assist with the treatment of the deteriorating patient. With the use of these policys and the help of critical care outreach teams within the trust early recognition and treatment within the golden hour reduces the morbidity and mortality thus educing admissions into the intensive care unit. It appears that there remains much discussion into which fluid works best during fluid resuscitation. Trust protocols should be followed. Recognition of at risk patients can only be achieved by appropriate and timely assessment and monitoring. Nice made key recommendations in patients at risk policy, assessment and monitoring, response, critical care and staff competencies the LTHTR policy Procedure for the timely recognition and response for patients at risk of deterioration encompasses these key recommendations. There is no predictive scoring system which gives accurate predictions of outcome for individual patients. Survival from an episode of severe sepsis is dependent the patients age, previous health and the time delay before the onset of medical intervention, as well as the appropriateness and quality of medical care. Few countries have limitless resources, and so difficult decisions face all intensive care doctors when deciding between the potential benefits for one critically ill patient and need for provision of healthcare to several less critically ill patients (I, Mackenzie 2001). Word Count 2008

Accountability for Reasonableness for Priority Setting

Accountability for Reasonableness for Priority Setting Essay Accountability for Reasonableness, for priority setting and resource allocation. INTRODUCTION Pakistan as a developing country has very limited health care resources when  considering a huge population of over 170 million. We have very few tertiary care  hospitals and they are providing services to the whole country. Majority of people in  our country are poor and they are unable to afford the expenses of private hospitals,  though private hospitals are also very few. Thousands of doctors are unemployed  and still we have shortage of doctors. Majority of BHU (Basic Health Units) are  closed as majority of doctors belong to urban areas and they don’t want to work in  remote village areas. In all these situations, it is very difficult to maintain health  care throughout country. In this essay, I will take into account four conditions of  accountability for reasonableness for priority setting and resource allocation. I will  take into account these four conditions by Norman Daniels and I will consider a  tertiary care hospital scenario where I did my house job in medicine ward last year. There were majority of patients suffering from chronic liver diseases (CLD). I will  further continue this essay in discussion. DISCUSSION Before discussing the four conditions of accountability for reasonableness, I will  briefly discuss the case scenario. In my medicine ward as I earlier said majority of  patients were of chronic liver diseases (CLD) and it includes Hepatitis B, Hepatitis C  and cirrhosis of liver. Cirrhosis is the end result of hepatocellular injury that leads  to both fibrosis and nodular regeneration throughout the liver. The clinical features  result from hepatic cell dysfunction, portosystemic shunting, and portal  hypertension. Cirrhosis may cause no symptoms for long periods. One of the major  complications is uppergastrointestinal tract bleeding which may occur from varices,  portal hypertensive gastropathy, or gastroduodenal ulcer. Hemorrhage may be  massive, resulting in fatal exsanguinations or enencephalopathy. Esophageal varices  are found in 50 % of patients with cirrhosis. There are several treatment and  management options available for esophageal varices includin g acute resuscitation  as initial management, pharmacologic therapy, balloon tube tamponade, portal  decompressive procedures and emergent endoscopy. Endoscopic techniques are also  used for prevention of Rebleeding. 1. Now, I will discuss my case scenario. In our  hospital there is one associate professor who is trained in doing endoscopy and  Wednesday is fixed for performing endoscopies. Emergent endoscopy is performed  after the patient’s hemodynamic status has been appropriately stabilized (usually  within 2-12 hours). Majority of poor patients come to hospital in end stage liver  diseases. I have taken this case series as it is a perfect example of scarce resources. Many patients faced problems as their endoscopies were not performed on time as  there was only one day fixed in a week. Now I will apply the four conditions of  accountability for reasonableness for priority setting and resource allocation. These  four conditions are publicity condition, relevance condition, revisions and appeals  condition and regulative condition. Accountability for reasonableness makes it  possible to educate all stakeholders about the substance of deliberation about fair  decisions under resource constraints. It facilitates social learning about limits. It  connects decision making in healthcare institutions to broader, more fundamental  democratic deliberative processes. 2. In my case scenario I will apply the four  conditions as follows. The first one is publicity condition. It states that decisions  regarding limits to care and their rationales must be publicly accessible to clinicians,  patients, and citizens in a publicly administered system. When the patients suffer  the complication of esophageal varices, they are informed about the limited capacity  of the ward to arrange endoscopy as it is done on only Wednesdays and surgical  ward have their own burden of patients to be done endoscopies, due to this reason  we were unable to send patients to surgical wards and the patients and their  relatives mostly agrees on this setup and if their was any emergency only then we  take help from surgical ward or send the patients to any other hospital, so the first  condition is fulfilled. In above scenario second condition is also fulfilled which isrelevance condition. It states that the reasons for limit-setting decisions will be  reasonable if it appeals to evidence, reason, and principles that are accepted as  relevant by fair-minded people who are disposed to finding mutually justifiable  terms of cooperation. In my case scenario the decision making is according to the  framework. The rationales w ere reasonable as it is evident that we had limited  facility of endoscopy and it was fairly accepted by patients and their relatives and  also by doctors and other hospital staff. In our setup priority was given to those  patients who needed emergency endoscopy rather than those who requires  endoscopy for diagnostic procedures. The third condition is revisions and appeals  condition. This condition is a very common problem in government hospitals and in  our scenario we request consultants from surgical ward to do emergency endoscopy  if we think patient is serious and he or she may die if the endoscopy is not  performed on time or in other case the other hospital is very far so that it will be late  if we send the patient to other setup and here comes the function of oncall  consultants also, the oncall consultants plays huge role in these emergency  situations. This third condition is a mechanism for challenge and dispute resolution regarding limit setting decisions, including the opportunity for revising decisions in  light of further evidence or arguments. 3. Thus we fulfill the third condition also by  revising our decisions as I explained above. The fourth and last condition is  regulative condition or enforcement. There is either voluntary or public regulation  of the process to ensure that conditions 1-3 are met. This condition is also fulfilled in  our setup as we communicate with the patient and their relatives about our limited  resources. We are able to convince patients in our case scenario. The hospital  leadership is constantly making efforts to meet the conditions of ‘accountability for  reasonableness’. 4. CONCLUSION In this essay I have discussed all four conditions of accountability for  reasonableness, for priority setting and resource allocation. ‘Accountability for  reasonableness’ is a framework that can be used to guide legitimate and fair priority  setting in health care organizations, such as hospitals. In our beloved country  Pakistan we have few government civil hospitals bearing the burden of millions of  population. We try our best to server the humanity. Iam not claiming this system a  perfect one, it needs a lot of improvement and the example is my case scenario in  which we have very limited resources. Government should establish civil hospitals in  small cities also and should increase their budget; they should recruit more doctors  and nurses as we have shortage. They should train doctors with latest equipments  and provide hospitals appropriate medicines. In addition to this all the hospitals  should be provided with computers and also be made online so that a data system  can be established and it can help the patients and also hospitals for future  reference. I will conclude by saying that in such scarce resources, government sector  hospitals are doing excellent job. REFERENCES Current Medical Diagnosis and Treatment 2004. 43rd edition. Norman Daniels. (2000). Accountability for reasonableness. BMJ; 321; 1300-  1301. D K Martin, P A Singer and M Bernstein. (2003). Access to intensive care  unit beds for neurosurgery patients: a qualitative case study. J. Neurol.  Neurosurg. Psychiatry; 74; 1299-1303. Jennifer AH Bell, Sylvia Hyland, Tania DePellegrin, Ross EG Upshur, Mark  Bernstein and Douglas K Martin. (2004). SARS and hospital priority setting:  a qualitative case study and evaluation. BMC Health Services Research, 4:36

Women and the Agricultural Revolution Essay -- essays papers

Women and the Agricultural Revolution Elise Boulding in her article, Women and the Agricultural Revolution, argues that women played a key role in initiating the Agricultural Revolution. She defines the revolution as happening within two stages: horticulture and agriculture proper. Women had a prominent role within the earlier form, horticulture. Horticulture is defined as farming for subsistence only.Women’s roles on the farm were not as dominant as society grew to farming for surplus instead. Boulding begins the article by discussing the shift society made from wandering nomads to settled villagers. She explains that it was women who recognized that plants could be easily domesticated. It was because of the domestication of plants that people decided to eventually settle down. In doing so, the early settlers exchanged the fairly simplistic nomadic life to that of a hard-working farmer. Throughout the essay, Boulding emphasizes the role women played in initiating this revolutionary shift. She describes the main duties women had and the status they held within a horticulture society. However, this changed as the purpose of farming shifted to agriculture proper. According to Boulding, women’s influence on the Agricultural Revolution began very early on. Women had recognized the significance of einkorn, a nutritious plant that was easy to cultivate. It was because of women recognizing that plants could be domesticated that nomads were introduced to farming....

Energy Crisis Interrelated to Global Warming. Photovoltaic Cell †A Pos

Energy Crisis Interrelated to Global Warming. Photovoltaic Cell – A Possible Solution Abstract- The world’s energy crisis has worsened in recent years, as oil prices dramatically increased due to the limited amount of available oil. Global warming is considered as a byproduct of energy crisis, because as oil continues to burn in the refining process, CO2 is constantly emitted to the atmosphere at a fast rate and in heavy concentrations, which in turn, worsens the global warming situation. Photovoltaic cell technology converts sunlight into direct current electricity. This source can be a possible solution to solve the energy crisis as well as the global warming issue. Introduction- Energy crisis has remained a top concern in the world today. Fossil fuels, the most widely used energy source in the U.S. and in the world, is rapidly being depleted due to the fast consumption rate. Since we are highly depended on oil for transportation, cooking, and communication in our daily lives, the oil storage is starting to run out and eventually it will be all gone. Petroleum oil is always considered as a cheap energy source; however, the price of oil per barrel and per gallon has gone up significantly worldwide. The price of oil has already passed $60 per barrel, due to the energy crisis and oil shortages (Crude Oil Futures Prices – NYMEX, 2005). The increased oil prices and the limited energy resources will have a great impact to the global economy where stock prices fall, unemployment rates increase, economic recession and inflation can occur. Burning fossil fuels are not only causing the existing energy crisis in the world but are leading to global warming as well. Due to the excessive burning of fossil fuels, the ... .... Website: http://www.cintelliq.com/res_photo.htm Renewable Energy (2005) The Wikipedia Free Encyclopedia. Retrieved July 23,2005. Website: http://en.wikipedia.org/wiki/Renewable_energy Turner, John A. (1999) A Realizable Renewable Energy Future. Retrieved July 21, 2005, from Energy Viewpoint. Website: http://www.sciencemag.org/cgi/reprint/285/5428/687.pdf 14 The Coming World Energy Crisis. (2005) Retrieved July 21, 2005 from Planet for life. Website: http://planetforlife.com/ William, James L. Alhajji, A. F. PhD. (2003). The Coming Energy Crisis? Retrieved July 21, 2005, from Energy Economics Newsletter. Website: http://www.wtrg.com/EnergyCrisis/ Zittel, Werner. Schindler, JÃ ¶rg (2003) Future world oil supply. Retrieved July 21, 2005, from University Salzburg. Website: http://www.energiekrise.de/e/articles/International-Summer-School-Salzburg- 2002.pdf

Goldeneye and computer

American cinema has changed as American culture has changed. This can be observed by focusing on genre movies produced during different time periods. A fantastic example is to analyze different James Bond movies. The James Bond franchise began with Sean Connery starring in the movie Dr. No in 1962 and is currently still very popular with Daniel Craig starring as James Bond, most recently in Casino Royale. There are some things that never change with James Bond, he always drives stylish cars, uses gadgets and gets the girl or girls.But stylistically the movies have changed as American culture has changed. An excellent example of this is by comparing From Russia with Love (1963) and Golden Eye (1995). Both plot lines deal with Russia and Soviet agents and involve travel to exotic locations. Many plot points are actually almost identical, Sean Connery seduces a Soviet defector and Pierce Brosnan has relations with a Soviet government worker. Both movies deal with finding or stopping an important device, the Lektor and the Golden Eye. Both films also contain unknown evil organizations, S.P. E. C. T. R. E. and Janus. (Broccoli, A. , 1963, Broccoli, B. , 1995) One of the largest differences is the roll of women. The females in Goldeneye are very active in the story line not only as love interests. Xenia Onatopp is the main assassin and second in command to Alec Trevelyan. Nataylia is a Russian computer programmer working with Goldeneye who first appears to be passive as she is the only innocent survivor from the massacre at her work. From Russia with love also has females but their actions are not on par with the men.Tatiana is a Soviet spy that eventually defects because she has fallen in love with Bond, but she doesn’t actually save Bond, her image is much more of the perception of woman from the mid 1900s. The woman was just beginning to become independent and self-reliant. During Goldeneye and the future modern Bond films woman can take care of themselves and they even save Bond! During the Bond era of For Russia with Love women were still very much eye-candy and caused trouble, they haven’t gotten to the point of saving Bond. (Broccoli, A. , 1963, Broccoli, B. , 1995)Do to the advancement of cinematography the stunts are bigger and louder and the gadgets are even more complex and cool. In For Russia with Love James Bond is looking for Lektor a cipher machine used by the Soviet’s. In Goldeneye Bond is trying to find the Goldeneye, a satellite system with killer capabilities. Pierce Brosnan manages to take out Russian buildings with a tank and a Russian armored train. This really is an example of how technology has developed and been incorporated into films.Computers play a large part of Goldeneye and computer usage had not become popular yet during the 1960s and is not featured in From Russia with Love. At the time of From Russia with Love a cipher machine would be very important, where as during Goldeneye space technol ogy has advanced and weapons threat has become very advanced. Bond and Tatiana do travel by train but it is a passenger train, no secret armored vehicle. The clothes, cars and music of the times are incorporated into the films.Despite the fact that Golden is supposed to take place in the mid 1980s the clothes, except for the uniforms are very modern from ten years or so in the future. During From Russia with Love the clothes are very mush from the 1960s and traditional of what one thinks of when they picture Russia. Large thick coats with fur collars, very Dr. Zhivago. (Broccoli, A. , 1963, Broccoli, B. , 1995) Even the quality of the picture and influence of new cameras has an effect on the style of film. Both films are good quality but the more modern films are sharper, you can almost see the influence and advances made using digital images.It is a fascinating time to watch the James Bond films in succession as you see how American culture influences almost all parts of the film e ven down to the costumes. The basic plot lines contain some very similar scenarios but the role of women, influence of technology and advancement of weapons make it possible to place the time period in which each movie was produced. References; Broccoli, A. , (producer), Young, T. , (director), From Russia with Love, USA, MGM, 1963 Broccoli, B. , (producer), Campbell, M. , (director), Goldeneye, USA, MGM, 1995

Formal and Informal Groups Essay

A formal group is the deliberate and systematic grouping of people in an organization so that organizational goals are better achieved. Now any organization would have a certain formula. They are very essential for the efficient functioning of the organization. What does an organization do? The total no. of people working in an organization is divided into smaller groups (teams or sections or departments) and each group is responsible for fulfilling a task which would ultimately contribute to fulfilling the organization’s goal. This increases the efficiency of the organization. Ex: If we take NITK as an example, we all know that we have a larger goal of training students for the engineering profession. But within this larger goal, we want students to be trained for computer engg, electrical, mech, etc. So this larger goal is divided into departments (example computer department), which is a formal group in this larger organization. So, all the departments together achieve the goal of efficiently training the students for engineering purpose. Informal Group: Informal groups are the natural and spontaneous grouping of people whenever they work together over a period of time. Whenever people interact and work together over a certain period of time, it’s very natural for them and it comes very spontaneously for them, that they form informal groups. For example, we are officially assigned to the computer engineering department. But in the hostel, we live with friends from other branches. So when all of us live together for a 4 year period, it’s very natural for us to interact and build up groups informally with our friends from other branches. So like this, any organization would have informal groups. Let’s compare both Formal and Informal Groups:   FORMAL GROUPS |INFORMAL GROUPS | |Deliberately created. |Spontaneously created. | |Formal groups are knowingly and systematically created. |Informal groups are not really created, they are naturally formed. | |Systematic structure. |Loose structure | |As we discussed earlier, in the computer department, we have HOD, |In informal groups, there is no structure at all. So there is a system in place. |together for some time. There is no junior and senior†¦everybody is | | |equal. | |Importance to position. |Importance to the person. | |In a formal group, importance is always given to the position. Ex: |The beauty of being in an informal group is that the position does | |the group leader, the head of department, etc. The position gets |not exist at all because there is no structure. So importance is | |importance in a formal way because there is a system in place. always given to the person. | |Relationship is official. |Relationship is personal. | |The relationship is very formal and official in a formal group. So |In an informal group, the interaction and the attachment becomes very| |the relationship and behavior is almost prescribed in a formal group. |personal and not official. | |Communication is restricted and slow. |Communication is free and fast. | |By restricted we mean that the â€Å"boss may decide that certain |Everybody wants to tell everyone all the information. With the gossip| |information should not be discussed below a certain level. † |network in an informal group, information is passed very quickly. | |Communication is very slow because a certain procedure has to be | | |followed if we want to pass down the information. | | Importance of formal groups: As human being, we tend to tilt towards informal groups. But   we have to remember that formal groups have certain characteristics that are very essential for the efficiency of the organization. For example: If we remain informal all the time, the organizational goals cannot be met. Importance of informal groups: Informal groups are just as important because they serve some very important human means. Informal groups help in developing good human relations in the organization. When we interact with people in an informal scale, we develop good relationships with them . So this develops better working relationships and therefore creates better efficiency in the organization. So, good organizations today are promoting informal activities and formation of informal groups. Ex: Parties in companies, which promotes informal interaction. Informal groups promote human dignity. Human dignity is something which is very important for every human being. As human beings, we want to be respected and treated in a particular way. So, self respect is very important for a human being. In a formal group setup, very often, our dignity is destroyed. For example: If we have a very bossy boss, everyday he will be de-motivating you by saying things like â€Å"You are useless fellow!! Who made you an engineer†!! So our dignity is destroyed. But what supports us It’s the informal group that supports us and keeps up our dignity. For example: The support from our friends helps us to keep our dignity. Informal groups help in spreading information fast through the GRAPEVINE-the informal network of communication (â€Å"The gossip network†). The grapevine is the plant on which the grape fruit grows. The characteristic of a grapevine is that it grows in all directions. So in an organization, the grapevine is the informal communication network that has grown into every group and corner of the organization. If we want information to be passed on very fast to everybody in the organization, then the grapevine is the best way. Example 1: â€Å"We can put information on a notice board† Example 2: When director makes an announcement for a holiday, information is passed very quickly. So the grapevine is active. And if a formal notice is made, then it takes time for the information to reach everybody because the formal network is very slow.