Was Hamlet Mad Essays - Characters In Hamlet, Prince Hamlet, Hamlet

Was Hamlet Mad? Hamlet is a complex character in the play. His character is always changing in some way, and he never seems to be the same person. In some scenes, he appears to be mad, while in others he is perfectly sane. Therefore, a question that has become a major argument for those who analyze the Shakespearean text is : was Hamlet mad or sane in the play? There are several arguments as to why Hamlet was mad. The first occurrence of his madness is found after his encounter with the ghost, his father. Hamlet appears to be act insanely when he speaks to his friends about what he saw. He speaks "wild and whirling words,"(Act 1, Scene V, lines 127-134). Horatio and the others are mystified when Hamlet talks like they have never heard him before. Another argument for his madness can be supported in his treatment towards Ophelia. When he first encounters her after speaking to the ghost, he is courteous at first, but then suddenly turns against her. He completely denies ever having loved her, attacks the womankind, and orders her to go to a nunnery. If this is not mad behavior, what is? Another point where Hamlet acts madly is when he had Rosencrantz and Guildenstern killed even though they had nothing to do with the plan to murder his father. Granted they were carrying letters to England with orders to kill him, but they were not aware of wh at was written in them. The argument can be further supported when Hamlet is in his mother's chamber. Hamlet alone sees his father's ghost. Every other time the ghost appeared someone else could see it. During this scene, the argument for Hamlet's madness can be strongly supported because his mother could not see it. Gertrude even says, "Alas, how is't with you-That you do bend your eye on vacancy,"(Act 3, Scene 4, lines 133-134). IN that same scene, Hamlet acts violently to his mother. He tells her that she is a whore and to abandon his uncles' bed. Finally, Hamlet's madness can be seen in his actions after killing Polonius. Hamlet even tells Laertes that he killed Polonius in "a fit of madness." When Hamlet is confronted about the murder, he will not tell anyone where the body is and seems very happy about it. These are all strong arguments for Hamlet being mad. However, one must look at the other side of the argument before making the decision about whether Hamlet was sane or not throughout the play. For example, Hamlet, after meeting the ghost, tells Horatio that he is going to "feign madness" and that if Horatio notices any strange behavior from Hamlet, it is because he is putting on an act. A pattern also emerges on when Hamlet is "mad" and when he is not. Hamlet's "madness" only manifests itself when he is in the presence of certain characters. When Hamlet is around Polonius, Claudius, Gertrude, Ophelia, Rosencrantz and Guildenstern, he behaves irrationally. However, when Hamlet is around Horatio, Bernardo, Francisco, the Players, and the Gravediggers, he behaves rationally. Several characters also admit to believing that Hamlet is not mad. Even Claudius confesses that Hamlet's "actions, although strange, do not appear to stem from madness,"(Act III, Scene 1, lines 177-180). Polonius admits that Hamlet's actions and words have a "method " to them, and there appears to be a reason behind them, and they are logical in nature. A powerful example that supports this argument is Ophelia's true madness. Ophelia's insanity and Hamlet's are entirely different from one another. In fact, Hamlet's actions contrast them. Ophelia acts mad no matter who is around, and she acts different than Hamlet. Finally, Hamlet believes in his sanity at all times. He never doubts his control over his psyche. He even tells his mother that he is not mad, "but mad in craft," (Act III.Scene IV. Line 210). Therefore, one can see that this argument is also strong. It is up to the audience to decide whether or not Hamlet was truly mad or not. However, it seems that the argument for Hamlet being sane is stronger. Hamlet tells his best friend that he is going to pretend to be mad.

THE USE OF STEROIDS BY ATHLETES essays

THE USE OF STEROIDS BY ATHLETES essays Steroids are drugs that many athletes use to enhance their abilities in sports. The use of steroids can be dangerous to both your body and mind. The drug also can give athletes unfair advantages which could propel them to victory. The use of steroids should not be permitted What is a steroid? Steroids are a synthetic version of the human hormone testosterone. Testosterone stimulates and maintains the male sexual organs. It also stimulates the development of bones and muscle, promotes skin and hair growth, and can influence emotions. In males, testosterone is produced by the testes and the adrenal gland. In the 1930's, researchers first developed steroids to rebuild and prevent the breakdown of body tissues from disease. The first use of steroids in sports was recorded in 1954 at the world championships in Vienna, Austria (Snyder 72). Russian weight lifters were using steroids and were merely invincible in their competition against other countries (Snyder 72). The U.S. coach asked the Russians how they were accomplishing this, and they told him they were given steroids (Snyder 72). This started the craze for steroids around the world especially in the United States (Snyder 72). Many scientists believe it can increase strength and body size, but others believe that using the drug makes you hostile and aggressive which makes you train harder therefore resulting in gained body size and strength (Snyder 74). Many people that take them are athletes and people with body image issues (Steroids). Others such as police officers and bouncers use them because they work in physical fighting environments (Steroids). The use of steroids may cause many serious mental side effects. The drug produces a change in the electroencephalogram, an image of the brain activity (Macmillan 94) . Mood swings are common which are caused by increased hostility and aggressiveness (Steroidsinfo). Som...

Cardiovascular Diseases

Thanks to the rising health awareness and government programmes this number significantly reduce during last 30 years. Coronary heart disease and cardiovascular disease Cardiovascular diseases are diseases of the heart (cardiac muscle ) or blood vessels (vasculature). Cardiovascular disease (CVD) means all the diseases of the heart and circulation (blood vessels disease) including coronary heart disease (angina and heart attack) and stroke, as well as coronary and periphery blood vessels disease (problems with circulation). Diseases from this group are the biggest killer in Europe and USA, but developing and non-develop countries too. The final and most tragic consequence of different types of heart disease is heart attack with tragic consequences. Heart diseases are caused by atherosclerosis, a disease of arterial blood vessels resulted from atheroma i. . plaques accumulated (forming; sticking) on artery walls which makes the blood vessels nonelastic and narrowed and leads to decreased blood flow. For the atherosclerosis doctors very often use alternative name chronic cardiovascular disease. The opposite group acute heart disease made group of diseases which are dangerous for patients lives. Acute heart diseases include conditions or illnesses wh ich usually have a rapid onset of symptoms and may resolve within days with or without treatment. A condition or illness that is sudden or severe. On the other hand a condition or illness that arises slowly over days or weeks and may or may not resolve with treatment made a group of chronic heart disease. Both of them are caused by atheroma and the most known are next: a) Acute heart disease Heart attack is caused by lack of O2 in heart muscle cells. Very often it is caused by rupture of â€Å"hard plaques† patches which result in blood clots and partially or completely block blood flow and cause a heart attack. When a fiber cap becomes thin, these â€Å"hard plaques† can suddenly rupture, spilling their contents, resulting in blood clots that partially or completely block blood flow and cause a heart attack http://www. authorstream. com/Presentation/nitin-35423-heart-diseases-science-technology-ppt-powerpoint/ Cholesterol glossary. http://www. mybwmc. org/library/28/000225 Stroke Stroke is death of brain cells caused by obstructed blood flow to parts of the brain. Since the level of LDL cholesterol is main cause of narrowed of blood vessels, it is necessary control it. If not treated properly, high LDL cholesterol can cause a stroke. Cholesterol glossary. http://www. mybwmc. org/library/28/000225 b) Coronary heart disease Heart disease (coronary heart disease), When the plaque build up in th conorary arteries heart does not get sufficient blood, the condition is called coronary artery disease or coronary heart disease. Atherosclerosis is a disease of arterial blood vessels in which plaques form on artery walls. This is a consequence of different substances circulating in the bloodstream (inflammatory cells, proteins, cholesterol and calcium) sticking inside the vessel walls. Plaque patches influence on narrowing blood flow in the artery. ttp://www. bodybuilding. com/fun/gastelu5. htm Peripheral artery disease (reduced blood flow in the limbs, usually the legs Coronary plaque Coronary plaque is a term which use in practice as a synonym for atheroma or atherosclerosis. Patches of atheroma are formed from substances that circulate in the bloodstream. They consist of lipid, or fat, cores covered by collagen fiber cap s which are sticking to the inside of the vessel walls. Over time plaque or patch of atheroma increases making an artery narrower and the blood flow through the artery is reducing. We can see the changes in blood vessels caused by plaque in the Figure 1. Figure 1 Artery with the patches of atheroma – plaque Preventing Cardiovascular Diseases. Patient. co. uk. emis www. patient. co. uk/health/Preventing-Cardiovascular-Diseases. htm (March 13, 2013) http://medicineworld. org/blogs/heart/blog/permalinks/Jan-2006/coronary-plaque-detection-by-molecular-imaging. html (March 13, 2013) Mature plaques typically consist of two main components: soft, lipid-rich atheromatous â€Å"gruel† and hard, collagen-rich sclerotic tissue. Lipid-rich and soft plaques are more dangerous than collagen-rich and hard plaques because they are more unstable and rupture-prone and highly thrombogenic after disruption. Researchers have found that many people who have heart attacks do not have arteries narrowed by plaque. Many heart attacks are now known to be caused by soft or vulnerable plaques, located on an inflamed part of an artery. This plaque can burst, leading to the formation of a blood clot that can cause a heart attack. The 2009 issue of â€Å"The American Journal Pathology† edited explanation of those relations discovered by Olga Ovchinnikova and er colleagues. They found that inflammation results in the formation of soft (vulnerable) plaque which is filled with different cell types that promote blood clotting. This leads to a reduction of mature collagen, resulting in thinner caps that are more likely to rupture, even in the cases when total level of plaque isn’t extremely high. The authors advocate d ifferent viewpoints about relations between the plaque level and structure, i. e. its influence on heart attack. The first group claims that described types of blockages cause only about 30 percent of heart attacks. On the other hand, some sources state that more than two-thirds of acute coronary events result from rupture of coronary plaques. However problems that plaque creates are extremely dangerous for people’s life and it is very important to prevent and monitor its appearance and changes. Graphs of vulnerable plaque and rupture of plaque which causes a heart attack is presented below. Figure 2 Vulnerable atherosclerotic plaques. Vulnerable atherosclerotic plaques. A. Atherosclerosis in a chronic disease that leads to plaque rupture and vascular occlusion. B. Cross-section of a lethal coronary plaque rupture. Adapted from Heistad D. Unstable coronary-artery plaques. N Engl J Med. 2003. Atherosclerosis Modeling In-vitro. http://www. remedi. uzh. ch/research/disease. html Figure 3 Plaque Rupture and Heart attack http://hon. nucleusinc. com/generateexhibit. php? ID=30468A=1027 Factors influencing plaque growth and stability Based on everything mentioned above and medical experience the conclusion about relations between heart attack and other cardiovascular disease and the level of plaque increasing are found. The higher the level of plaque the higher risk of heart disease will be. The level of plaque will increase as the result of high level of cholesterol, type LDL, so called â€Å"bad cholesterol† in blood. When the level of LDL is normal, blood can pass in and out of the blood vessels without problems, but if it significantly increase particles of the blood will accumulate and sooner or later provoke trigger (cause) heart attack. Other very important factors influencing plaque level increasing are high blood pressure and cigarette smoking. Both factors accelerate the plaque formation changing (damaging) artery walls and even more, helping cholesterol forming. Medical experience proved that plaque composition and vulnerability (hard or soft plaque) is more responsible for the conversion of a stable disease to a life-threatening condition than the plaque size. Except the plaque vulnerability the risk of plaque disruption is are consequence of rupture triggers (extrinsic forces). Soft plaque – lipid-rich one is more dangerous because of its instability and higher probability for rupture. Even (IAKO) Although â€Å"hard plaque† that one having higher level of calcium influence on the blood vessels walls and their â€Å"hardness† experience show that heart attacks are mostly caused by soft plaque disruption. Figure 4 Plaque rupture and its consequences in the form of heart diseases http://www. nature. com/nrg/journal/v7/n3/fig_tab/nrg1805_F2. html Risk factors of coronary heart disease Risk factors influencing cardiovascular disease we can group based on their stability into the three groups: a) Modifiable risk factors In this group hypertension is the most dangerous risk factor for heart attacks, but even more for stroke. It is forming as the result of abnormal blood lipid levels which means high total cholesterol, high levels of triglycerides and high levels of low-density lipoprotein or low levels of high-density lipoprotein (HDL). Smoking, physical inactivity, Type 2 diabetes, and a diet full with saturated fats are risk factors strongly influencing the heart disease. All of them are treatable and patients (individuals) belonging into the different types of risk customers’ groups should avoid practice them. b) Non-modifiable risk factors The factors from this group mostly are constant, like the case in gender or family history. Others are changing when time is passing, like age and lifestyle and personal habits. Older people have more chance to get heart attack and the man, especially those having â€Å"bad medical history†. Ration between man and woman are changing when women past the menopause. After that the level of risk is similar as the men’s one. As I’ve presented there is direct correlation between cardiovascular disease and condition and health of blood vessels, more precisely of developing atheroma, means level and structure of plaque in vessels. On the other development of plaque and its level is directly influenced by level of cholesterol and some other elements which are connected with individual person and his/her life and genetic predispositions. As with the other diseases everybody has some risk of developing atheroma, but some risk factors increase the risk level for several categories. Those risk factors include: fn 12 †¢Fixed risk factors – factors that person cannot change: oA strong family history which means close relatives who developed heart disease or a stroke before they were 55 (for males) or 65 (for female). Severe baldness in men at the top of the head. oAn early menopause in women. oAge. Older people have more risk to develop atheroma. oEthnic group. Medical data show that people from different ethnic group have different risk for heart diseases. †¢Treatable or partly treatable risk factors include different health problems caused basically by the same causes as the: oHypertension (high bl ood pressure). oHigh cholesterol blood level. oHigh triglyceride (fat) blood level. oDiabetes. oKidney diseases causing diminished kidney function. All factors from this group have to be controlled and monitor. Any kind of their complication probably will trigger more serious problems such as heart attack or stroke. †¢Lifestyle risk factors that can be prevented or changed. Actually these factors PRETHODE precede to those belonging to the second group. Except the genetic factors way of life and daily habits are the more responsible for different kind of heart diseases. Those factors are: oSmoking (Smoking cigarette increase blood pressure, decrease HDL; damages arteries and blood cells and increases heart attacks. Passive smoking is also a risk factor for cardiovascular disease ) oLack of physical activity. Obesity (People who are overweight (10-30% more than their normal body weight) have 2 to 6 times the risk of developing heart disease. ) oAn unhealthy diet and eating too much salt. oExcess alcohol. Looking on those three groups one can easily conclude that people with â€Å"bad predisposition† having high fixed risk factors have to think about their lifestyle risk factors ev en more, in order to try to decrease the second group of factors (treatable or partly treatable risk factors). On the other hand some of risks are more dangerous than the others; for example smoking increases risk for heart disease more than obesity. And of course combination of two or more risk factors increases significantly the level of risks; older man (or woman) who smokes, without physical activity and with bad eating habits has more chance to get some of previously explained disease than the one who have â€Å"just one of bad habits†. The more risk factors someone has the greater is the likelihood that he/she will develop cardiovascular disease, unless taking action to modify his/her risk factors and working to prevent them compromising his/her heart health. That doesn’t mean that people with â€Å"good genes† can be irresponsible and ZANEMARITI risk factors from other groups. With or without genetic predisposition modern life significantly increases a risk of heart disease for everybody. Hormones impact on lipids and other risk factors Different numbers of man and women died from heart attack initiated a lot of research about hormones’ influence on the risk factor and heart disease development. Number of men died from the heart attack outnumbered the number of women in pre-menopause period, but in the post-menopause data show completely opposite situation. A percentage of women in post-menopause having heart disease and dying from heart attack increase dramatically and now outnumbered the men. The main reasons for those changes are connected to the level of hormones and their influence on level and structure of cholesterol and consequently on risk factors and heart disease. As mentioned before total cholesterol actually is made of two different types of cholesterol: LDL – low density lipoprotein (LDL), so called bad cholesterol and high density lipoprotein (HDL). High levels of LDL cholesterol lead to atherosclerosis increasing the risk of heart attack and ischemic stroke. HDL cholesterol reduces the risk of cardiovascular disease as it carries cholesterol away from the blood stream. http://www. walgreens. com/marketing/library/careguides/careguide. jsp? docid=000225=28=High%20Cholesterol Estrogen, a female hormone, raises HDL cholesterol levels, partially explaining the lower risk of cardiovascular disease seen in premenopausal women. But after menopause (natural or surgical) when a level of estrogen significantly decreases total cholesterol rises, low density lipoprotein (LDL) cholesterol rises, and high density lipoprotein (HDL) cholesterol does not change or decreases slightly. This is the reason why negative hormones’ effect after menopause increasing more than proportionally. Some authors argue that even influence of estrogen on LDL and HDL level is proved it is yet unclear whether increase in risk is caused, at least partially, by increased level of androgen (the other of hormones belong to steroid as estrogen too), which is characteristics of menopause too. This sexual dimorphism means a lower incidence in atherosclerotic diseases in premenopausal women, which subsequently rises in postmenopausal women to eventually equal that of men. These observations point towards estrogen and progesterone playing a lifetime protective role against CAD in women. As exogenous estrogen and estrogen plus progesterone preparations produce significant reductions in low-density lipoprotein (LDL) cholesterol levels and significant increases in high-density lipoprotein (HDL) cholesterol, this should in theory lower the risk of CAD. UKLOPITI U ONO GORE Among estrogen’s positive effects on the heart are: †¢Reducing the LDL (â€Å"bad†) cholesterol in the blood. †¢Increasing the HDL (â€Å"good†) cholesterol in the blood. †¢Helping to keep blood vessels open. †¢Lowering blood pressure at night. †¢Reducing blood viscosity (how sticky the blood is), a property that may cause blood clots which could result in a heart attack or stroke. Estrogen’s effects on clotting are complicated, however, since there also is an increased risk for thromboembolism (a blood clot that blocks a vessel) in women taking estrogen. Possibly enhancing fibrinolysis, which is the body’s natural process for breaking down blood clots. Read more: http://ehealthmd. com/content/what-are-benefits-hrt#ixzz2NbWR3MxY http://ehealthmd. com/content/what-are-benefits-hrt#axzz2NbW1GJJN Nutrition guidelines As presented before three different groups of risk factor exist. Some of them people can cha nge but the other are fixed, non-changeable because they caused by genetic heritage ( ) influences. Controllable factors are connected to the lifestyle of person. Lifestyle changes can prevent or slow the development of coronary plaque and heart disease. In order to prevent a disease development one have to keep track of his/her blood pressure and cholesterol levels. Choosing a heart-healthy diet is vital in controlling weight, which helps keep blood pressure and cholesterol levels down. Foods high in cholesterol and saturated fat should be avoided, and quitting smoking is imperative. Regular exercise and an increased overall activity level contribute to heart health and help reduce stress. The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All people, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. e. 150 mins/week minimum). Currently practiced measures to prevent cardiovascular disease include: †¢A low-fat, high-fiber diet including whole grains and plenty of fresh fruit and vegetables (at least five portions a day)[29][30] †¢Tobacco cessation and avoidance of second-hand smoke;[29] †¢Limit alcohol consumption to the recommended daily limits;[29] consumption of 1-2 standard alcoholic drinks per day may reduce risk by 30%[31][32] However excessive alcohol intake increases the risk of cardiovascular disease. [33] †¢Lower blood pressures, if elevated, through the use of antihypertensive medications[citation needed]; †¢Decrease body fat (BMI) if overweight or obese;[34] Increase daily activity to 30 minutes of vigorous exercise per day at least five times per week;[29] †¢Decrease psychosocial stress. [35] Stress however plays a relatively minor role in hypertension. [36] Specific relaxation therapies are not supported by the evidence. [37] Routine counselling of adults to advis e them to improve their diet and increase their physical activity has not been found to significantly alter behaviour, and thus is not recommended. [38] http://www. news-medical. net/health/What-is-Cardiovascular-Disease. aspx http://www. barnesandnoble. om/w/prevent-halt-and-reverse-heart-disease-joseph-piscatella/1100260037 Primary and secondary prevention of heart disease It is necessary start with prevention from heart disease as early as possible. Changes in the number of people killed by heart attack in developed countries show that prevention and awareness about this group of disease help to http://circ. ahajournals. org/content/123/20/2274/F2. expansion. html health plans must continue to drive cardiovascular care further along the continuum toward primary prevention of cardiovascular disease (CVD). CVD risk factors should be managed not only after a coronary event has occurred, but also before the onset of such and event. Ideally, health lifestyles should be promoted with all patients so that risk factors for CVD never develop. In this way, CVD care can be moved from the inpatient setting to the outpatient setting. Sidney C. Smith Jr, MD. Focus on Cardiovascular Disease; A Word About the Quality of Care in Cardiovascular Disease. Director, Center for Cardiovascular Science and Medicine University of North Carolina at Chapel Hill. http://www. qualityprofiles. rg/leadership_series/cardiovascular_disease/cardiovascular_introduction. asp Key priorities for implementation Primary prevention of CVD †¢For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40–74 who are likely to be at high risk †¢People should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Thei r CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records †¢Risk equations should be used to assess CVD risk People should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that: opresents individualised risk and benefit scenarios opresents the absolute risk of events numerically ouses appropriate diagrams and text (See www. npci. org. uk) †¢Before offering lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible. Baseline blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) thyroid-stimulating hormone (TSH) if dyslipidaemia is present †¢Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or approp riate (for example, older people, people with diabetes or people in high-risk ethnic groups) †¢Treatment for the primary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen. Secondary prevention of CVD †¢For secondary prevention, lipid modification therapy should be offered and should not be delayed by management of modifiable risk factors. Blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) othyroid-stimulating hormone (TSH) if dyslipidaemia is present. Statin therapy is recommended for adults with clinical evidence of CVD †¢People with acute coronary syndrome should be treated with a higher intensity statin. Any decision to offer a higher intensity statin should take into account the patient’s informed preference, comorbidities, multiple drug therapy, and the benefits and risks of treatment †¢Treatment for the secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions , or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin ay be chosen †¢In people taking statins for secondary prevention, consider increasing to simvastatin 80 mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained. Any decision to offer a higher intensity statin should take into account informed preference, comorbidities, multiple drug therapy, and the benefit and risks of treatment http://www. eguidelines. co. uk/eguidelinesmain/guidelines/summaries/cardiovascular/nice_lipid_modification. php How to lower the risk of cardiovascular disease The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All people, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. . 150 mins/week minimum). Cessation of smoking The aim of this measure is complete cessation of smoking and avoidance of second-hand smoke. Patient and their families need to stop smoking. Those who are unable to quit may need professional help in form of counselling, behavioral therapy and even pharmacological therapy. Nicotine replacement therapy (NRT) is the first line choice of medication. Nutrition The aim of thi s measure is to ensure a healthy diet. Total diet should have no more than 8% (of total energy intake) of saturated + trans fatty acids. All patients are advised to take approximately 1g Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA) and more than 2g Alpha Linolenic Acid (ALA) daily. Diet should have vegetables, fruits and legumes, grain-based foods, moderate amounts of lean meats, poultry, fish and reduced fat dairy products. EPA and DHA can be obtained from oily fish and marine n-3 (fish oil) capsule supplements. Alcohol consumption All patients should be advised to lower alcohol consumption. Men should drink no more than 2 standard drinks per day and women no more than 1 standard drink per day. Physical activity The aim of this measure is to raise physical activity and exercise to the recommended goal of at least 30 minutes of moderate intensity physical activity on most, if not all, days of the week (i. e. 150 mins/week minimum). Maintaining a healthy body weight The aim should be to achieve a waist measure of less than or equal to 94 cm in men and less than or equal to 80 cm in women. The body mass index (BMI) should be maintained at 18. 5–24. 9 kg/m2 Lowering blood cholesterol The aim of therapy should be to maintain blood cholesterol at: †¢Low density lipoprotein (LDL) at – less than 2. mmol/L †¢HDL – more than 1. 0 mmol/L †¢Triglyceride (TG) less than 1. 5 mmol/L The blood cholesterol can be maintained with the use of pharmacotherapy. Statins are commonly used lipid lowering drugs. Those with diabetes and atherosclerosis need stringent blood cholesterol control as well. Other lipid lowering drugs include fibrates like gemfibrosil, clofibrates etc, Eze timiber and niacin. Lowering blood pressure High blood pressure is one of the important risk factors for cardiovascular disease. Those with coronary heart disease, diabetes, kidney disease or stroke need tight blood pressure control. The aim should be a blood pressure of less than 130/80 mm of Hg. Diabetes and blood sugar control Those diagnosed with diabetes need stringent blood sugar control to prevent cardiovascular damage. HbA1c levels should be maintained at less than 7%. Other drugs to lower risk of cardiovascular disease Other drugs used to lower risk of cardiovascular diseases include: †¢Antiplatelet agents – this includes Aspirin and Clopidogrel. These drugs when given to patients with risk of heart attacks may prevent such attacks and events. †¢ACE inhibitors like Enalapril, Captopril, Lsinopril and Cardiovascular Diseases Thanks to the rising health awareness and government programmes this number significantly reduce during last 30 years. Coronary heart disease and cardiovascular disease Cardiovascular diseases are diseases of the heart (cardiac muscle ) or blood vessels (vasculature). Cardiovascular disease (CVD) means all the diseases of the heart and circulation (blood vessels disease) including coronary heart disease (angina and heart attack) and stroke, as well as coronary and periphery blood vessels disease (problems with circulation). Diseases from this group are the biggest killer in Europe and USA, but developing and non-develop countries too. The final and most tragic consequence of different types of heart disease is heart attack with tragic consequences. Heart diseases are caused by atherosclerosis, a disease of arterial blood vessels resulted from atheroma i. . plaques accumulated (forming; sticking) on artery walls which makes the blood vessels nonelastic and narrowed and leads to decreased blood flow. For the atherosclerosis doctors very often use alternative name chronic cardiovascular disease. The opposite group acute heart disease made group of diseases which are dangerous for patients lives. Acute heart diseases include conditions or illnesses wh ich usually have a rapid onset of symptoms and may resolve within days with or without treatment. A condition or illness that is sudden or severe. On the other hand a condition or illness that arises slowly over days or weeks and may or may not resolve with treatment made a group of chronic heart disease. Both of them are caused by atheroma and the most known are next: a) Acute heart disease Heart attack is caused by lack of O2 in heart muscle cells. Very often it is caused by rupture of â€Å"hard plaques† patches which result in blood clots and partially or completely block blood flow and cause a heart attack. When a fiber cap becomes thin, these â€Å"hard plaques† can suddenly rupture, spilling their contents, resulting in blood clots that partially or completely block blood flow and cause a heart attack http://www. authorstream. com/Presentation/nitin-35423-heart-diseases-science-technology-ppt-powerpoint/ Cholesterol glossary. http://www. mybwmc. org/library/28/000225 Stroke Stroke is death of brain cells caused by obstructed blood flow to parts of the brain. Since the level of LDL cholesterol is main cause of narrowed of blood vessels, it is necessary control it. If not treated properly, high LDL cholesterol can cause a stroke. Cholesterol glossary. http://www. mybwmc. org/library/28/000225 b) Coronary heart disease Heart disease (coronary heart disease), When the plaque build up in th conorary arteries heart does not get sufficient blood, the condition is called coronary artery disease or coronary heart disease. Atherosclerosis is a disease of arterial blood vessels in which plaques form on artery walls. This is a consequence of different substances circulating in the bloodstream (inflammatory cells, proteins, cholesterol and calcium) sticking inside the vessel walls. Plaque patches influence on narrowing blood flow in the artery. ttp://www. bodybuilding. com/fun/gastelu5. htm Peripheral artery disease (reduced blood flow in the limbs, usually the legs Coronary plaque Coronary plaque is a term which use in practice as a synonym for atheroma or atherosclerosis. Patches of atheroma are formed from substances that circulate in the bloodstream. They consist of lipid, or fat, cores covered by collagen fiber cap s which are sticking to the inside of the vessel walls. Over time plaque or patch of atheroma increases making an artery narrower and the blood flow through the artery is reducing. We can see the changes in blood vessels caused by plaque in the Figure 1. Figure 1 Artery with the patches of atheroma – plaque Preventing Cardiovascular Diseases. Patient. co. uk. emis www. patient. co. uk/health/Preventing-Cardiovascular-Diseases. htm (March 13, 2013) http://medicineworld. org/blogs/heart/blog/permalinks/Jan-2006/coronary-plaque-detection-by-molecular-imaging. html (March 13, 2013) Mature plaques typically consist of two main components: soft, lipid-rich atheromatous â€Å"gruel† and hard, collagen-rich sclerotic tissue. Lipid-rich and soft plaques are more dangerous than collagen-rich and hard plaques because they are more unstable and rupture-prone and highly thrombogenic after disruption. Researchers have found that many people who have heart attacks do not have arteries narrowed by plaque. Many heart attacks are now known to be caused by soft or vulnerable plaques, located on an inflamed part of an artery. This plaque can burst, leading to the formation of a blood clot that can cause a heart attack. The 2009 issue of â€Å"The American Journal Pathology† edited explanation of those relations discovered by Olga Ovchinnikova and er colleagues. They found that inflammation results in the formation of soft (vulnerable) plaque which is filled with different cell types that promote blood clotting. This leads to a reduction of mature collagen, resulting in thinner caps that are more likely to rupture, even in the cases when total level of plaque isn’t extremely high. The authors advocate d ifferent viewpoints about relations between the plaque level and structure, i. e. its influence on heart attack. The first group claims that described types of blockages cause only about 30 percent of heart attacks. On the other hand, some sources state that more than two-thirds of acute coronary events result from rupture of coronary plaques. However problems that plaque creates are extremely dangerous for people’s life and it is very important to prevent and monitor its appearance and changes. Graphs of vulnerable plaque and rupture of plaque which causes a heart attack is presented below. Figure 2 Vulnerable atherosclerotic plaques. Vulnerable atherosclerotic plaques. A. Atherosclerosis in a chronic disease that leads to plaque rupture and vascular occlusion. B. Cross-section of a lethal coronary plaque rupture. Adapted from Heistad D. Unstable coronary-artery plaques. N Engl J Med. 2003. Atherosclerosis Modeling In-vitro. http://www. remedi. uzh. ch/research/disease. html Figure 3 Plaque Rupture and Heart attack http://hon. nucleusinc. com/generateexhibit. php? ID=30468A=1027 Factors influencing plaque growth and stability Based on everything mentioned above and medical experience the conclusion about relations between heart attack and other cardiovascular disease and the level of plaque increasing are found. The higher the level of plaque the higher risk of heart disease will be. The level of plaque will increase as the result of high level of cholesterol, type LDL, so called â€Å"bad cholesterol† in blood. When the level of LDL is normal, blood can pass in and out of the blood vessels without problems, but if it significantly increase particles of the blood will accumulate and sooner or later provoke trigger (cause) heart attack. Other very important factors influencing plaque level increasing are high blood pressure and cigarette smoking. Both factors accelerate the plaque formation changing (damaging) artery walls and even more, helping cholesterol forming. Medical experience proved that plaque composition and vulnerability (hard or soft plaque) is more responsible for the conversion of a stable disease to a life-threatening condition than the plaque size. Except the plaque vulnerability the risk of plaque disruption is are consequence of rupture triggers (extrinsic forces). Soft plaque – lipid-rich one is more dangerous because of its instability and higher probability for rupture. Even (IAKO) Although â€Å"hard plaque† that one having higher level of calcium influence on the blood vessels walls and their â€Å"hardness† experience show that heart attacks are mostly caused by soft plaque disruption. Figure 4 Plaque rupture and its consequences in the form of heart diseases http://www. nature. com/nrg/journal/v7/n3/fig_tab/nrg1805_F2. html Risk factors of coronary heart disease Risk factors influencing cardiovascular disease we can group based on their stability into the three groups: a) Modifiable risk factors In this group hypertension is the most dangerous risk factor for heart attacks, but even more for stroke. It is forming as the result of abnormal blood lipid levels which means high total cholesterol, high levels of triglycerides and high levels of low-density lipoprotein or low levels of high-density lipoprotein (HDL). Smoking, physical inactivity, Type 2 diabetes, and a diet full with saturated fats are risk factors strongly influencing the heart disease. All of them are treatable and patients (individuals) belonging into the different types of risk customers’ groups should avoid practice them. b) Non-modifiable risk factors The factors from this group mostly are constant, like the case in gender or family history. Others are changing when time is passing, like age and lifestyle and personal habits. Older people have more chance to get heart attack and the man, especially those having â€Å"bad medical history†. Ration between man and woman are changing when women past the menopause. After that the level of risk is similar as the men’s one. As I’ve presented there is direct correlation between cardiovascular disease and condition and health of blood vessels, more precisely of developing atheroma, means level and structure of plaque in vessels. On the other development of plaque and its level is directly influenced by level of cholesterol and some other elements which are connected with individual person and his/her life and genetic predispositions. As with the other diseases everybody has some risk of developing atheroma, but some risk factors increase the risk level for several categories. Those risk factors include: fn 12 †¢Fixed risk factors – factors that person cannot change: oA strong family history which means close relatives who developed heart disease or a stroke before they were 55 (for males) or 65 (for female). Severe baldness in men at the top of the head. oAn early menopause in women. oAge. Older people have more risk to develop atheroma. oEthnic group. Medical data show that people from different ethnic group have different risk for heart diseases. †¢Treatable or partly treatable risk factors include different health problems caused basically by the same causes as the: oHypertension (high bl ood pressure). oHigh cholesterol blood level. oHigh triglyceride (fat) blood level. oDiabetes. oKidney diseases causing diminished kidney function. All factors from this group have to be controlled and monitor. Any kind of their complication probably will trigger more serious problems such as heart attack or stroke. †¢Lifestyle risk factors that can be prevented or changed. Actually these factors PRETHODE precede to those belonging to the second group. Except the genetic factors way of life and daily habits are the more responsible for different kind of heart diseases. Those factors are: oSmoking (Smoking cigarette increase blood pressure, decrease HDL; damages arteries and blood cells and increases heart attacks. Passive smoking is also a risk factor for cardiovascular disease ) oLack of physical activity. Obesity (People who are overweight (10-30% more than their normal body weight) have 2 to 6 times the risk of developing heart disease. ) oAn unhealthy diet and eating too much salt. oExcess alcohol. Looking on those three groups one can easily conclude that people with â€Å"bad predisposition† having high fixed risk factors have to think about their lifestyle risk factors ev en more, in order to try to decrease the second group of factors (treatable or partly treatable risk factors). On the other hand some of risks are more dangerous than the others; for example smoking increases risk for heart disease more than obesity. And of course combination of two or more risk factors increases significantly the level of risks; older man (or woman) who smokes, without physical activity and with bad eating habits has more chance to get some of previously explained disease than the one who have â€Å"just one of bad habits†. The more risk factors someone has the greater is the likelihood that he/she will develop cardiovascular disease, unless taking action to modify his/her risk factors and working to prevent them compromising his/her heart health. That doesn’t mean that people with â€Å"good genes† can be irresponsible and ZANEMARITI risk factors from other groups. With or without genetic predisposition modern life significantly increases a risk of heart disease for everybody. Hormones impact on lipids and other risk factors Different numbers of man and women died from heart attack initiated a lot of research about hormones’ influence on the risk factor and heart disease development. Number of men died from the heart attack outnumbered the number of women in pre-menopause period, but in the post-menopause data show completely opposite situation. A percentage of women in post-menopause having heart disease and dying from heart attack increase dramatically and now outnumbered the men. The main reasons for those changes are connected to the level of hormones and their influence on level and structure of cholesterol and consequently on risk factors and heart disease. As mentioned before total cholesterol actually is made of two different types of cholesterol: LDL – low density lipoprotein (LDL), so called bad cholesterol and high density lipoprotein (HDL). High levels of LDL cholesterol lead to atherosclerosis increasing the risk of heart attack and ischemic stroke. HDL cholesterol reduces the risk of cardiovascular disease as it carries cholesterol away from the blood stream. http://www. walgreens. com/marketing/library/careguides/careguide. jsp? docid=000225=28=High%20Cholesterol Estrogen, a female hormone, raises HDL cholesterol levels, partially explaining the lower risk of cardiovascular disease seen in premenopausal women. But after menopause (natural or surgical) when a level of estrogen significantly decreases total cholesterol rises, low density lipoprotein (LDL) cholesterol rises, and high density lipoprotein (HDL) cholesterol does not change or decreases slightly. This is the reason why negative hormones’ effect after menopause increasing more than proportionally. Some authors argue that even influence of estrogen on LDL and HDL level is proved it is yet unclear whether increase in risk is caused, at least partially, by increased level of androgen (the other of hormones belong to steroid as estrogen too), which is characteristics of menopause too. This sexual dimorphism means a lower incidence in atherosclerotic diseases in premenopausal women, which subsequently rises in postmenopausal women to eventually equal that of men. These observations point towards estrogen and progesterone playing a lifetime protective role against CAD in women. As exogenous estrogen and estrogen plus progesterone preparations produce significant reductions in low-density lipoprotein (LDL) cholesterol levels and significant increases in high-density lipoprotein (HDL) cholesterol, this should in theory lower the risk of CAD. UKLOPITI U ONO GORE Among estrogen’s positive effects on the heart are: †¢Reducing the LDL (â€Å"bad†) cholesterol in the blood. †¢Increasing the HDL (â€Å"good†) cholesterol in the blood. †¢Helping to keep blood vessels open. †¢Lowering blood pressure at night. †¢Reducing blood viscosity (how sticky the blood is), a property that may cause blood clots which could result in a heart attack or stroke. Estrogen’s effects on clotting are complicated, however, since there also is an increased risk for thromboembolism (a blood clot that blocks a vessel) in women taking estrogen. Possibly enhancing fibrinolysis, which is the body’s natural process for breaking down blood clots. Read more: http://ehealthmd. com/content/what-are-benefits-hrt#ixzz2NbWR3MxY http://ehealthmd. com/content/what-are-benefits-hrt#axzz2NbW1GJJN Nutrition guidelines As presented before three different groups of risk factor exist. Some of them people can cha nge but the other are fixed, non-changeable because they caused by genetic heritage ( ) influences. Controllable factors are connected to the lifestyle of person. Lifestyle changes can prevent or slow the development of coronary plaque and heart disease. In order to prevent a disease development one have to keep track of his/her blood pressure and cholesterol levels. Choosing a heart-healthy diet is vital in controlling weight, which helps keep blood pressure and cholesterol levels down. Foods high in cholesterol and saturated fat should be avoided, and quitting smoking is imperative. Regular exercise and an increased overall activity level contribute to heart health and help reduce stress. The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All people, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. e. 150 mins/week minimum). Currently practiced measures to prevent cardiovascular disease include: †¢A low-fat, high-fiber diet including whole grains and plenty of fresh fruit and vegetables (at least five portions a day)[29][30] †¢Tobacco cessation and avoidance of second-hand smoke;[29] †¢Limit alcohol consumption to the recommended daily limits;[29] consumption of 1-2 standard alcoholic drinks per day may reduce risk by 30%[31][32] However excessive alcohol intake increases the risk of cardiovascular disease. [33] †¢Lower blood pressures, if elevated, through the use of antihypertensive medications[citation needed]; †¢Decrease body fat (BMI) if overweight or obese;[34] Increase daily activity to 30 minutes of vigorous exercise per day at least five times per week;[29] †¢Decrease psychosocial stress. [35] Stress however plays a relatively minor role in hypertension. [36] Specific relaxation therapies are not supported by the evidence. [37] Routine counselling of adults to advis e them to improve their diet and increase their physical activity has not been found to significantly alter behaviour, and thus is not recommended. [38] http://www. news-medical. net/health/What-is-Cardiovascular-Disease. aspx http://www. barnesandnoble. om/w/prevent-halt-and-reverse-heart-disease-joseph-piscatella/1100260037 Primary and secondary prevention of heart disease It is necessary start with prevention from heart disease as early as possible. Changes in the number of people killed by heart attack in developed countries show that prevention and awareness about this group of disease help to http://circ. ahajournals. org/content/123/20/2274/F2. expansion. html health plans must continue to drive cardiovascular care further along the continuum toward primary prevention of cardiovascular disease (CVD). CVD risk factors should be managed not only after a coronary event has occurred, but also before the onset of such and event. Ideally, health lifestyles should be promoted with all patients so that risk factors for CVD never develop. In this way, CVD care can be moved from the inpatient setting to the outpatient setting. Sidney C. Smith Jr, MD. Focus on Cardiovascular Disease; A Word About the Quality of Care in Cardiovascular Disease. Director, Center for Cardiovascular Science and Medicine University of North Carolina at Chapel Hill. http://www. qualityprofiles. rg/leadership_series/cardiovascular_disease/cardiovascular_introduction. asp Key priorities for implementation Primary prevention of CVD †¢For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40–74 who are likely to be at high risk †¢People should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Thei r CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records †¢Risk equations should be used to assess CVD risk People should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that: opresents individualised risk and benefit scenarios opresents the absolute risk of events numerically ouses appropriate diagrams and text (See www. npci. org. uk) †¢Before offering lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible. Baseline blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) thyroid-stimulating hormone (TSH) if dyslipidaemia is present †¢Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or approp riate (for example, older people, people with diabetes or people in high-risk ethnic groups) †¢Treatment for the primary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen. Secondary prevention of CVD †¢For secondary prevention, lipid modification therapy should be offered and should not be delayed by management of modifiable risk factors. Blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include: osmoking status oalcohol consumption oblood pressure (see ‘Hypertension’, NICE clinical guideline 34) obody mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43) ofasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) ofasting blood glucose orenal function oliver function (transaminases) othyroid-stimulating hormone (TSH) if dyslipidaemia is present. Statin therapy is recommended for adults with clinical evidence of CVD †¢People with acute coronary syndrome should be treated with a higher intensity statin. Any decision to offer a higher intensity statin should take into account the patient’s informed preference, comorbidities, multiple drug therapy, and the benefits and risks of treatment †¢Treatment for the secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions , or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin ay be chosen †¢In people taking statins for secondary prevention, consider increasing to simvastatin 80 mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained. Any decision to offer a higher intensity statin should take into account informed preference, comorbidities, multiple drug therapy, and the benefit and risks of treatment http://www. eguidelines. co. uk/eguidelinesmain/guidelines/summaries/cardiovascular/nice_lipid_modification. php How to lower the risk of cardiovascular disease The risk of cardiovascular disease is possible to reduce following recommendation for lifestyle changing: Cessation of smoking and avoidance of second-hand smoke. Nutrition should ensure a healthy diet wiht total diet no more than 8% of saturated + trans fatty acids of total energy intake. All people, especially ones with high risk factors should lower alcohol consumption As the prevention physical activities are recommended – at least 30 minutes of moderate intensity physical activity per day or three days week (i. . 150 mins/week minimum). Cessation of smoking The aim of this measure is complete cessation of smoking and avoidance of second-hand smoke. Patient and their families need to stop smoking. Those who are unable to quit may need professional help in form of counselling, behavioral therapy and even pharmacological therapy. Nicotine replacement therapy (NRT) is the first line choice of medication. Nutrition The aim of thi s measure is to ensure a healthy diet. Total diet should have no more than 8% (of total energy intake) of saturated + trans fatty acids. All patients are advised to take approximately 1g Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA) and more than 2g Alpha Linolenic Acid (ALA) daily. Diet should have vegetables, fruits and legumes, grain-based foods, moderate amounts of lean meats, poultry, fish and reduced fat dairy products. EPA and DHA can be obtained from oily fish and marine n-3 (fish oil) capsule supplements. Alcohol consumption All patients should be advised to lower alcohol consumption. Men should drink no more than 2 standard drinks per day and women no more than 1 standard drink per day. Physical activity The aim of this measure is to raise physical activity and exercise to the recommended goal of at least 30 minutes of moderate intensity physical activity on most, if not all, days of the week (i. e. 150 mins/week minimum). Maintaining a healthy body weight The aim should be to achieve a waist measure of less than or equal to 94 cm in men and less than or equal to 80 cm in women. The body mass index (BMI) should be maintained at 18. 5–24. 9 kg/m2 Lowering blood cholesterol The aim of therapy should be to maintain blood cholesterol at: †¢Low density lipoprotein (LDL) at – less than 2. mmol/L †¢HDL – more than 1. 0 mmol/L †¢Triglyceride (TG) less than 1. 5 mmol/L The blood cholesterol can be maintained with the use of pharmacotherapy. Statins are commonly used lipid lowering drugs. Those with diabetes and atherosclerosis need stringent blood cholesterol control as well. Other lipid lowering drugs include fibrates like gemfibrosil, clofibrates etc, Eze timiber and niacin. Lowering blood pressure High blood pressure is one of the important risk factors for cardiovascular disease. Those with coronary heart disease, diabetes, kidney disease or stroke need tight blood pressure control. The aim should be a blood pressure of less than 130/80 mm of Hg. Diabetes and blood sugar control Those diagnosed with diabetes need stringent blood sugar control to prevent cardiovascular damage. HbA1c levels should be maintained at less than 7%. Other drugs to lower risk of cardiovascular disease Other drugs used to lower risk of cardiovascular diseases include: †¢Antiplatelet agents – this includes Aspirin and Clopidogrel. These drugs when given to patients with risk of heart attacks may prevent such attacks and events. †¢ACE inhibitors like Enalapril, Captopril, Lsinopril and Cardiovascular Diseases

Contractual Agreement for an Architect in Canada Research Paper

Contractual Agreement for an Architect in Canada - Research Paper Example The general architect is entirely responsible for the construction in accordance with this kind of agreement and for every compensation made for the expenses and performance connected to the subcontractors. The advantages associated with kind of contractual arrangement include: A single prime deal is regularly simpler to manage since it has a centralized task for the architect and client. The transactions made by the client are transferred to one architect, reducing the possibility of confusion, unlike multiple prime contractors. Design plans for the construction are originally arranged by a planning expert. The client then selects one architect to perform the work, following a bidding procedure grounded on the design plans. This is the most widespread of architectural deal used in Canada. This is because another major advantage lays in the plans and requirements being prepared by design experts turning out to be part of the bidding credentials. This way, the client is bound to recei ve high quality outcomes of the construction from the contractors (Quatman and Dhar 342). ... 2. Design-build contractual agreement The Design-build agreement is an accord between a client and an architectural firm that offers design and building services (Hopper 134). An expansion of this kind of contract is a â€Å"turnkey† project where the contractor gets project funding, acquires land, offers blueprint and construction services, and delivers the final product to the client, available for occupancy. The advantages of using this kind of contractual agreement include: Saving time, an aspect of the sort of  contract an architect might go into when offering archetypal Design-Bid-Build services. Nevertheless, time is not considered a major factor in architecture in comparison with the expenses, construction and quality of the project. The association with a quick track program, able to eliminate the possibility of incorporated designs. The programs frequently imply that each period of the building phase is spent with the occupants to determine their requirements in th e new building (OAA 2011). When the designer operates for the builder, instead of working directly for the client, checks and balances existing in other techniques’ are mislaid. The architect and contractor’s engineer, otherwise known as the ‘clerk of the works’ in Canada, are normally depended upon to maintain the trend made by the construction. This approach of the contract assures that the builder sticks to the plans and regulations of the contract. Under such an observation, the client is guaranteed adherence and honor to the contract made with the construction organization (Quatman and Dhar 342). Certain disadvantages may arise from this kind of contractual agreement depending on the organization and builders the client has awarded. The demerits

The Foreign Corrupt Practices Act Research Paper

The Foreign Corrupt Practices Act - Research Paper Example INTRODUCTION This paper shall discuss the Foreign Corrupt Practices Act of 1977 (FCPA), which is a United States federal law passed mainly to ensure accounting transparency as mandated by the Securities Exchange Act of 1934. It also includes provisions meant to address the bribery of foreign officials. This paper shall discuss the act, including its pertinent details and essential provisions, as well as its reasons for passage and application. II. BODY The Foreign Corrupt Practices Act is a law which includes specific provisions on accounting and prohibitions on bribery (Cook and Connor, p. 2). The accounting provisions of the law are meant to prohibit illegal accounting practices which are often carried out to conceal corrupt practices. The provisions are also meant to guarantee that company shareholders, including the Securities and Exchange Commission are given an accurate picture of corporate status and finances (Cook and Connor, 2010). This law covers two groups of corporate per sonalities, first are â€Å"those with formal ties to the United States and those who take action in furtherance of a violation while in the United States† (Cook and Connor, 2010, P. 2). The US issuers and domestic concerns are required to heed the provisions of the FCPA, regardless of their actions being within or outside the US territories. Issuers are companies with securities in the US or those which are legally called for to regularly report with the US SEC (Cook and Connor, 2010). On the other hand, those under domestic concerns have a wider coverage, and include individuals or residents of the US. Corporations, partnerships, business trusts, sole proprietorships, and like entities are also covered under domestic concerns, for as long as their main place of business is in the US or their governing provisions are under the US laws (Cook and Connor, 2010). This act holds corporations and other entities legally liable for bribing foreign officials even if such act was carr ied out beyond American shores and throughout the years, various violators have been prosecuted under these provisions. The basic provisions of this law hold the following practices as illegal: â€Å"1) a payment, offer, authorization, or promise to pay money or anything of value; 2) to a foreign government official (including a party official of manager of a state owned concern), or to any other person knowing that the payment of promise will be passed on to a foreign official; 3) with a corrupt motive; 4) for the purpose of (a) influencing any act or decision of that person, (b) inducing such person to do or omit any action in violation of his lawful duty, (c) securing an improper advantage, or (d) inducing such person to use his influence to affect an official act or decision; 5) in order to assist in obtaining or retaining business for or with, or directing any business to, any person† (FCPA, in Cook and Connor, 2010, p. 2). Individuals and corporate entities violating th e provisions of this law can be held criminally liable and may be imprisoned and/or fined for their actions (Biegelman and Biegelman, 2010). The law also provides a generalized definition for what is to be qualified as ‘payment’ punishable under the FCPA. The FCPA defines these payments to cover any benefits (monetary or otherwise) given or gifted to a foreign official in order to curry favorable treatment in business activities with the involved foreign official (Cook and Connor,

Blood clotting enzyme Essay Example for Free

Blood clotting enzyme Essay Serine protease proteins are important enzymes involved in the process of blood coagulation. Blood coagulation is an importance defense mechanism that prevents the host mammal organism from losing excess blood or from forming unwanted blood clot. The process of coagulation can be initiated by both intrinsic factors and extrinsic factors. A cascade of event is followed which activate these enzymes; normally the enzymes are inactive state a condition called zymogens. Zymogens by their virtual condition of being inactive prevent unwanted blood clotting which may have a far reaching consequence such as thrombosis. Blood clotting in a series of processes, in which the zymogens’ need to be activated by reacting with its glycoprotein co-factors. Among the serine protease is the thrombin enzyme factor five (v) responsible for clearing clot in the blood. The enzyme is usually present circulating in plasma which is made up of a single monomer chain, it life span can range from 12 to 36 hours. In human the main regulator in blood coagulation is erythrocytes leukemia cells which activate adenylate cyclase, the process is reversible by the interaction of Aalpa-thrombin with glycoprotein while b alpha enhance the platelets interaction which initiate the proteolytic process. Fibrin-bound thrombin is cleaved by thrombin at a very specific site at the extracellular N-terminal, PAR-1 regulates a number of endothelial cell biology, vascular development but more so is a mediator of thrombin signaling. The human thrombin consist of two gamma chains namely the gamma A and gamma’ the final stage of coagulation of mammalian blood involves the cleavage of the four arginine and glycine bond. Binding studies shows both fibrin 1 and fibrin 2 with low affinity to the E domain and high binding affinity at the extreme end of 408 to 425 on the gamma chain The mode of action involves conversion of fibrinogen to fibrin by breaking the bonds in the fibrinogen at a precise position of arginine and glycine where the fibrin peptides are released. The serine proteases require restructuring itself in order to fit the key and lock model. The glycine at the position five is highly conserved because it is the one which occupy the active site which is determine by the acryl group during the substrate conformation. Asparagines 189 help the enzyme to easily recognize the substrate. The active site is entirely made of histidine 57, asparagines 102, serine 195 and serine 214. The reaction on many a times prefers position 1 to position 4 during remodeling, therefore the type of protein presence to a large extend determine the kind protease and also the kind of cleavage to take place. Thrombin activation is regulated by pentapeptide of the COOH terminus of the factor (v) heavy chains. Thrombin and thrombin receptors is another regulatory point where they both posses strong protective barrier and at the same time cancerous cells were eliminated by apoptosis. A study carried out using mitochondrial membranes which were depolarized using attenuated Catalase lead to controlled cell death. Statistical finding indicate that 30% of the population carried world wide indicated that activated peptide segment at position 4 of factor eight caused a substitution in V34L after binding the structure and analyzing the interaction according to (Brenda 2010). The switching of receptor is PAR-1-dependent signaling specifically to thrombin resulting inhibition of adhesion cell surface which activate thrombin the ligand occupancy position switches the protease receptor by signaling specifically to the thrombin. Human cell in culture indicated low amount of thrombin and receptor PAR-1 agonist induced strong anti-inflammatory activities which was secondary effect of the low concentration of thrombin after activation by P13 kinase and PAR-1. Thrombin like other enzymes is very specific in the binding domain and the insertion loop which is determined by the residues involved in ligand binding as result of interaction glycoprotein and protease receptor on the platelet membrane. This uniqueness makes it very efficient in it task according to (Webert 2006). The enzyme play vital role in homeostasis, cell differentiation, thrombosis and activation of blood cell types, on exposure to phosphatidylserine on the outer surface the platelets were stimulated. A study done using heparin indicated an overlap of the active site, which was attributed to the interaction of thrombin and the gamma peptide chains to the external and the interaction to the active site in close proximity to the Na+ of the substrate. The role of the enzyme can be explained in terms of NA+ binding to thrombin on the basis of prothrombotic and procoagulant. The cascade is a continuous cycle of events that are activated by two factors ,factor (ix) and factor (viii) to form tenase complex which is discontinued by down regulation that occur in the following mechanism which include; serpin (serine protease inhibitors) which function to degrade thrombin and other activation factors, it can also be regulated by protein C where thromodulin bind to it and is inactivate in the presence of protein S, limiting the action of tissue factor by the tissue factor pathway inhibitors by inhibiting excessive TF mediated activation of factor (ix) and factor (x), plasmin help to degrade fibrin hence preventing more fibrin being formed and lastly but not the least regulation through adenylate cyclase pathway by inhibiting platelet activation by decreasing cytosol level of calcium which ultimately result to decreased release of granules which are responsible for the activation of more platelets and coagulation cascade. In conclusion the work play by thrombin enzyme is of paramount importance considering the complexity of the enzyme kinetics involved in the human body. References Brenda Enzyme database retrieved on 13 August 2010 from http://www. brenda-enzymes. org/php/result_flat. php4? ecno=3. 4. 21. 5 Furie B, Furie BC (2005). Thrombus formation in vivo. J. Clin. Invest. 115 (12): retrieved on 12 August 2010 from http://www. jci. org/cgi/content/full/115/12/3355. Webert KE, Cook RJ, Sigouin CS, (2006). The risk of bleeding in thrombocytopenic patients with acute myeloid leukemia. haematologica .

NAFTA and Mexico Essay -- essays research papers fc

Mexico’s economy is undergoing a stunning transformation. Seven years after the launch of the North American Free Trade Agreement, it is fast becoming an industrial power. Free trade with the U.S. and Canada is turning the country from a mere assembler of cheap, low-quality goods into a reliable exporter of sophisticated products from auto breaks to laptops computers. Although Mexico has seen economic growth lately, it still faces tremendous problems in the aftermath of the 1995 recession and the revolution that took place in the Chiapas which still wages on today. The purpose of this paper is to explore the effects that NAFTA has had on the economy and it’s people during the implementation of NAFTA and in what NAFTA will bring in the future. The North American Free Trade Agreement was designed to open borders and promote free trade between three countries: Canada, the United States and Mexico. Signed in 1992, ratified by the U.S. Congress in November 1993 and implemented January 1, 1994, NAFTA reduced some tariffs immediately while others are scheduled to fall to zero over a 15-year period. NAFTA follows the prescription of liberalization- including the deregulation of government restrictions to allow increased trade, direct foreign investment, and foreign ownership of businesses.   Ã‚  Ã‚  Ã‚  Ã‚  On January 1, 1994, a Mexico still sleepy from New Year’s celebrations awoke to discover a passionate new revolution sweeping across the state of Chiapas. The Zapatistas, a small, yet powerfully forceful group of indigenous people, exhausted from centuries of oppression, poverty and corruption, rose up to end this societal injustice, and most specifically, to battle the new tyrant that would be born that very day: The North American Free Trade Agreement. This revolt was viewed by the indigenous population of Chiapas as an essential act to stop the debilitating cycle of injustice and to prevent future harm to the Mexican people by opposing NAFTA. â€Å"The Zapatistas have pulled back the curtain that covered up the other Mexico. It is not the Mexico of eager entrepreneurs lined up to open Pizza Hut franchises or consumers eager to shop at Wal-Mart, but rather the Mexico of malnourished children, illiteracy, landlessness, poor roads, lack of health clinics, and life as a permanent struggle.† (Quoted in Russell, p. 1)   Ã‚  Ã‚  Ã‚  Ã‚  NAFTA was ... ...nmental Issues Under the NAFTA. Canadian – American Committee. Toronto: 1993. Marinez, Elizabeth and Arnoldo Garica. (No Date). What is â€Å"Neo Liberalism†? [Online]. Avaible:   Ã‚  Ã‚  Ã‚  Ã‚  http://www.corpwatch.org/trac/corner/glob/neolib.html (June 27-29, 1997). NAFTA’s Failure to Deliver [Online]. Available:   Ã‚  Ã‚  Ã‚  Ã‚  http://www/coha.org/pressr/naftapr/html Nelan, Bruce W. (April 4, 1994). Days of Trauma and Fear [Online]. Available:   Ã‚  Ã‚  Ã‚  Ã‚  http://www.time.com/time/magazine/archieves/1994/940404/940404.mexico.html Perlo, Vicotr. (March 4, 1995). The Rape of Mexico [Online]. Available:   Ã‚  Ã‚  Ã‚  Ã‚  http://www.hartford-hwp.com/archives/46/031.html â€Å"The President, the peso, the market and those Indians.† The Economist 24 Dec 1994: 43. Russell, Philip. The Chiapas Rebellion. Mexico Resource Center. Austin: 1995 Shadows of Tender Fury: The Letters and Communiques of Subcomandante Marcos and the Zapatista Army of National Liberation. Monthy Review Press. New York: 1995 Wise, Carol. â€Å"The Post-NAFTA Political Economy.† Mexico and the Western Hemisphere. Pennsylvania State University Press: September 1998.

Can Telemedicine Reduce Health Costs Health And Social Care Essay

Telemedicine utilizes assorted information and telecommunication engineerings to supply medical services remotely. Besides specific medical processs, nosologies and electronic records, it besides provides supervising systems between healthcare suppliers and patients to advance home-health direction, instruction, clinical position and wellness result followup ( National Association for Home Care And Hospice, 2008 ) . It is frequently seen as a possible scheme to cut down wellness disparities created by geographic or temporal barriers, homebound position, and cultural stigma. It can buoy up the job of disproportionality in the geographic allotments of healthcare resources and work forces, and increase the entree of health care system among the underserved communities and populations ( Cousineau, 2010b ) . It has besides shown an ability to better wellness communicating by exceeding the temporal boundaries and diminishing the waiting clip in the diagnostic procedure. The expeditious ent ree to telemedicine non merely saves clip but besides reduces cost by using the resources more expeditiously and extinguishing unneeded travelling clip for both doctors and patients, courier services, excess staffing, and excess infirmary stay ( Matusitz & A ; Breen, 2007 ) . Therefore it is really likely to be an alternate and economical option to relieve the load of the limited wellness work force and resources in our health care bringing systems. The Healthy People 2010 includes ends of eliminate wellness disparities among sections of different populations ( U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion, 2005 ) . Surveies have shown that rural countries experience more wellness disparities such as both morbidity, mortality, and with insurance coverage ( Agency for Healthcare Research and Quality, 2009 ) . Age is besides an of import factor that contributes to healthcare barriers such as homebound position and transit affairs. The aged have systematically accounted for about 50 % of all health care expenditures in the United States ( Cousineau, 2010a ) . As the demand for the wellness attention additions, there will be fewer health care workers for attention bringing. If the current tendencies continue, the spread between supply and demand of rural doctor and nurses will be even larger than in urban countries ( Cousineau, 2010b ) . Given the continued growing of chronic unwellne ss in our society and the detonation of new health-related engineerings, surgical techniques and drugs ( Cousineau, 2010c ) , inquiries of how, or if telemedicine can cut down costs or better entree must be address in order to see it as a feasible solution for the drawn-out health care bringing in the United State.IssuesIn malice of the progresss of medical engineering and wellness information sciences that have improved the ability for telemedicine to supply entree to a spectrum of attention, insurance companies and funders continue to eschew the issue of reimbursement for telemedicine services. Indeed, though there has been great promise of telemedicine development really small advancement has really been achieved. The primary challenges continue to be limited reimbursement, licensure, and patient privateness ( Matusitz & A ; Breen, 2007 ) . Since Senate Bill 1665 enacted the â€Å" Telemedicine Delivery Act of 1996 † which imposed legion demand regulating the bringing of h ealth care via telemedicine, several related policies such as HR3030 and HR3200 have besides been introduced to Congress to supply low-cost telemedicine services with ordinances. However, they are all still pending and have been unable to continue. Since there is no direct opposition disputing telemedicine-related policies, this paper will concentrate on discoursing the regulative barriers and legislative actions forestalling them from come oning. With respect to the limited research grounds and expertness in telemedicine, this paper will besides analyse the recent Congressional proposal HR 1601 by sing the quality and wellness results of telemedicine system. Last, it will discourse the impact of Healthcare Reform on telemedicine and my recommendation for future waies.Regulative Barriers and Legislative ActionsLicensurePresently each province regulates its ain pattern of medical specialty. This is a jurisdictional right that is recognized by the Supreme Court. For this ground, most healthcare professionals are licensed on a state-by-state footing. Telemedicine hence is besides geographically regulated by single provinces. Many legal issues originate when a â€Å" pattern † is done via a telecommunication nexus across different province lines. Each province they cross into can enforce a demand on the supplier to keep a full medical licence before seeing their out-of-state patients via telemedicine engineerings. It is hard and dearly-won for healthcare practicians to keep and keeping multiple licences, particularly those in the rural countries where the healthcare demand is non stable ( Cousineau, 2010b ) . For this ground, many merely choose to restrict their pattern to a individual province. In 1996, the Federation of State Medical BoardsA developed theoretical account statute law which allows a province to supply and administrate a limited telemedicine licence. This limited licence permits wellness practicians to pattern in different provinces via telemedicine engineerings, but non physically. Conversely, the American Medical Association decided to follow a policy that requires a full and unrestricted licence in order for a doctor to pattern telemedicine across province lines ( Nickelson, 1998 ) . Beyond licensure issues, while interstate telemedicine patterns could better entree to our current health care systems, it besides raises inquiries about malpractice and struggle of jurisprudence. Presently each province develops its ain malpractice insurance evaluation and most malpractice insurance does non use in instances outside of the province. On the other manus the suppliers of each province are besides concerned about how to exercise legal power over such malpractice claim against other suppliers from out of province who may non be capable to the legal power of the administrative regulative organic structures. Although a national licensure theoretical account for telemedicine seems like a logical solution, it is improbable to get the better of the political and constitutional issues in one measure. A regional geographic attack affecting province medical insurance companies to clear up coverage bounds and develop new policies might be more executable. For illustration, based on telemedicine activities from the Governor ‘s Associations and Councils in the yesteryear, Cwiek et Al found that the Southern Governors ‘ Association and the Western Governors ‘ Association demonstrated a important degree of leading in the country of telemedicine. They have proven to better entree to healthcare and medical specializers and cut down medical costs by traveling information alternatively of people ( Cwiek, Rafiq, Qamar, Tobey, & A ; Merrell, 2007 ) .ReimbursementIn 1997, both the House and the Senate passed HR2015 – Balanced Budget Act. It enabled partial Medicare reimbursement f or Telemedicine services. However, professional audience was the lone service allowed by the measure and the payment had to be shared among assorted parties with really rigorous ordinances. In 2000, Congress passed appropriations measure HR 5661, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act, which significantly revised Medicare ordinances for reimbursement for Telemedicine services ( The American Telemedicine Association, 2010 ) . The Healthcare Financing Administration extended Medicare coverage to medical visits, audiences, mental wellness services, and pharmacologic monitoring of patients populating in the rural country. Further, it extended payment rates to suppliers which were similar to that paid without the usage of telemedicine. Medicare besides pays a installation fee for per telemedicine session. However, obstructions remain because the reimbursement is normally allowed for directed physical communicating merely, such as face-to-face audiences. Besides, the opposition of reimbursement from the private insurance companies continues with non-feasible ordinances ( Matusitz & A ; Breen, 2007 ) .Limited research grounds on Telemedicine and HR1601HR1601 was introduced to the Congress by Jefferson in 2007 and it was referred to Committee for consideration of telemedicine service facilitation ( Thomas Library of Congress, 2007 ) . The end of this measure is to bespeak grants to put up telemedicine services in a spectrum of assorted healthcare systems including nursing place and public clinics. Rather than proposing the solution or overall support mechanism in the long term the purpose of this measure is to bespeak support for telemedicine pilot undertakings and bring forth research grounds. HR1601 would guarantee that the Office for the Advancement of Telemedicine in the Health Resources and Services Administration ( HRSA ) would supervise and organize pilot surveies with related federal bureaus of medical underserved populations in both urban and rural country, with the assistance of grants. HRSA would do recommendation harmonizing to their rating of whether these undertakings consequences in addition of entree and quality of attention, publicity of patient independency, lessening wellness disparities, and betterment of cost effectivity ( Prinz, Cramer, & A ; Englund, 2008 ) .QualityThe quality of telemedicine services has the most direct impact on the likeliness of go throughing policies of support. In order to present the optimum telemedicine service the quality of the telemedicine system needs to be reliable, user friendly and cosmopolitan in order to incorporate into assorted computerized system. Standardized counsel should be implemented so the telemedicine system can efficaciously and accurately pass on with bing computerized system in the infirmary and place wellness bureaus. The challenge lays in the complexness of telemedicine engineering, including hardware and package mutual exclusiveness, syste m integrating complexness, and communicating troubles due to low velocity digital lines ( Prinz, et al. , 2008 ) . Information could be lost while meeting communicating troubles and equipment failures which would earnestly impact the dependability of telemedicine service suppliers, particularly private place wellness bureaus in the rural country.Health resultUse of Telemedicine engineering ( such as picture cameras and supervising devices ) in the Home Care puting additions entree to healthcare bringing by leting direct communicating between patients and wellness practicians beyond geographic and temporal boundaries. There is increasing grounds demoing that that telemedicine is associated with the positive result of self-management and conformity in chronic unwellness such as cardiovascular diseases and diabetes ( Artinian, 2007 ; Chumbler, et al. , 2005 ) . On the other manus, some argue that this grounds is non quantifiable because of the use of assorted telemedicine engineerings in different disease countries. The deficiency of thorough clinical tests might be the ground that holds back reimbursement organisation and promotion of telemedicine uses ( Prinz, et al. , 2008 ) . Some grounds even shows that using telemedicine services contributes no difference in patients ‘ wellness result but a greater cost comparison to other healthcare bringing methods ( Bowles & A ; Baugh, 2007 ) , therefore corrupting the necessity to reimburse a more dearly-won healthcare bringing method.The Impact of American Recovery and Reinvestment Act & A ; Patient Protection and Affordable Care ActBased on the belief that wellness information engineering and electronic medical records are indispensable for the transmutation of telemedicine health care bringing, the federal authorities utilized the commissariats of the American Recovery and Reinvestment Act of 2009 ( ARRA ) to authorise about $ 38 billion in funding for wellness information engineering substructure over the foll owing 6 old ages. The inside informations about how this support will be utilized are written in the Health Information Technology for Economic and Clinical Health ( HITECH ) subdivision in the ARRA. The largest part of this support is targeted at incentive payments by Medicare and Medicaid to eligible suppliers for the execution of wellness information engineerings. Specifically, in order to be qualified for these inducements the health care suppliers must follow a certification for the electronic medical record system and exhibit the practical usage ( Cline, 2010 ) . In March 2009 President Obama signed HR 3590, the Patient Protection and Affordable Care Act ( PPACA ) into jurisprudence. ThisA important wellness attention reform jurisprudence allows advanced payment and service bringing theoretical account to better entree, quality of health care, and cut down plan cost to persons, written specifically in Section 3021 ( Government Relations Staff, 2010 ) . A New Center for Medicare and Medicaid Innovation will back up primary attention practicians on flying telemedicine application in chronic attention direction. It will implement telemedicine plan in infirmaries, accountable attention organisations, and independency at place for distant patient monitoring. This jurisprudence encourages wellness information engineering and electronic medical records acceptance to ease attention coordination. It besides allows each province to utilize the new Medicaid â€Å" Health Home † plan to progress chronic attention.RecommendationsOverall, I believe that the Telemedicine can increase entree and cut down cost in the long tally with the support of American Recovery and Reinvestment Act & A ; Patient Protection and Affordable Care Act. There is no uncertainty that the Telemedicine is capable of transforming our health care bringing system in both positive and negative waies, nevertheless, I believe that the pros outweigh the cons. It is notable that most of the up to day of the month pilot research surveies mentioned supra have made positive impacts on the entree of healthcare bringing. Inadequate and unequal coverage for telemedicine service earnestly delayed the execution of cost-saving and quality-improvement solutions, and constrained the entree and picks in assorted forte services in rural countries. Current expanded Medicare coverage for Telemedicine is in procedure of work outing this issue, but specifically I think Congress should besides widen Medicare coverage to medical services using â€Å" store-and-forward † t elemedicine ( for illustration direction and showing for diabetic related retinopathy ) , and to suppliers whose services are otherwise covered for Medicare. I besides recommend a more aggressive plan for pull offing the demands and costs of chronic patients who are presently homebound or are potentially at hazard to be administered into a infirmary or nursing place. Thousands of veteran patients are profiting from place wellness telemedicine plan to organize their attention. The US Veteran Affairs have found that their patients follow the usage of these devices easy and are really satisfied with their attention coordination service ( US Department of Veterans Affairs, 2009 ) . Therefore, Congress should advance Home Telemedicine and include it in the reimbursement component to cover the costs of related devices and engineering. Most provinces ‘ Medicaid already covered some telemedicine services. It can be optimize by back uping primary attention doctors to suit telemedicine services, maximise the usage of picture and telecommunication to cut down patients ‘ travelling, and increase â€Å" store-and-forward † engineering uses such as sharing medical images for diagnosing. The current rural wellness plan should prolong the operation of high-velocity cyberspace entree and wireless connexion within all eligible wellness installations to accomplish efficiency and cost-effectiveness. Congress should besides set up a licensing board to promote interstate medical licensure cooperation by geographic zone. Finally, I believe that with effectual execution, wellness practicians and patients can get the better of the challenges limited the development and success of telemedicine.

Nursing and Reflective Practice Essay

â€Å"Reflection is not just a thoughtful practice, but a learning experience†. (Jarvis 1992) This is a reflection on an incident that occurred during a shift on the labour ward. I have chosen Gibbs model of reflection (1988) to guide my reflective process. (Gibbs 1998) (Appendix I). Gibbs model (1998) goes through six important points to aid the reflective process, including description of incident, feelings, evaluation, analysis, conclusion and finally action plan. The advantage of Gibbs’s six-stage model is that it allows you to learn from experiences and make changes for your future practice. Description The incident involves the administration of a wrong opiate drug to a postnatal patient. The incident occurred whilst checking and administering a controlled drug. The drug error was discovered by the co-ordinator at the end of the day shift. During the daily checking of the controlled drugs, the co-ordinator and another midwife, found a discrepancy with the number of Diamorphine 10mg and Morphine 10mg ampoules, there being one too many Morphine 10mg ampoules and one too few of the Diamorphine 10mg ampoules. Myself, as the midwife checking the drug, along with the midwife who administered the Diamorphine to her patient, were the only midwives to have administered a controlled drug on the shift. The drugs were correct on the previous daily check. Feelings On being informed of the error my initial feelings were of disbelief and horror. I was confused; two midwives had checked the drug and neither of us noted the mistake. I felt very upset and embarrassed that I had made this mistake, since qualifying as a midwife I have never made such an error. When the error was highlighted I instantly remembered checking Diamorphine and mixing the drug with 2mls of water for injections, I remembered talking to the other midwife concerned about personal affairs. I felt ashamed that I had allowed myself be distracted during such an important task. I was very angry that I had allowed myself to become complacent about drug administration. The Code States that midwives shall, â€Å"provide a high standard of practice and care at all times†, (NMC 2008), I felt that I had not only failed the patient but the profession too. I started to worry about the potential effects to the patient concerned. The Standards for Medicine Management, (NMC 2010), states â€Å" as a registrant, if you make an error you must take any action to prevent any potential harm to the patient†. The patient had suffered no real harm as a result of the dug error and she was recovering well post-operatively. Evaluation The main advantage regarding this incident is that the patient concerned came to no serious harm. Personally, I feel that I have learnt from the experience, thus enhancing my clinical practice. Gladstone (1995) agrees that planning problem solving strategies and accepting responsibility is found to lead to positive changes. This incident has highlighted the need for vigilance at all times. I have changed my practice to avoid drug errors occurring in the future, I am aware not to be complacent with drug administration. I will never let this or any other incident occur due to lack of concentration again in my practice. Analysis Drug administration is one of the highest risk areas of nursing practice and a matter of considerable concern for both managers and practitioners (Gladstone 1995). Consequently, detailed and comprehensive procedures and standards exist, thus ensuring safe, legal and effective practice, for example of the Medicines Act (1968) and NMC’s Guidelines for the Administration of Medicines (2007). The Consumer Protection Act 1987 and Medicines Act 1968 require that to administer medication, the practitioner has to ensure that the right medication is given, to the right patient, at the right time, in the right form of the drug, at the right dose and right route. Nursing & Midwifery Council’s Code of Professional Conduct (2004) emphasises the administration of medication is an area of concern for public safety, and generally follow the principles laid down by law. The NMC also publish the appropriate guidelines for nurses on the administration of medicines (NMC 2004). The Standards for Medicine Management (NMC 2010) states that I am â€Å"accountable for your actions and omissions†. This incident has highlighted the need for vigilance at all times. Rule 7 of the Midwives Rules and Standards (NMC2004), states that â€Å"A practising midwife shall only supply and administer those medicines, including analgesics, in respect of which she has received appropriate training as to us, dosage and method of administration†. Although the local policy and procedures were followed, it seems that unintentionally the incorrect drug was administered. As a registered midwife I am up to date with all training, I have never before in my practice made a drug error. Research studies demonstrate that many drug errors within clinical practice occur as a result of distractions on the ward, illegible writing or because nurses failed to check the patient’s name-band (Gladstone 1996). The incident discussed demonstrates how easily practitioners can become distracted when checking and administrating drugs. With regard to reporting drug errors, (Webster and Anderson 2002) found that several areas of concern emerged, including nurses’ confusion regarding the definition of drug errors and the appropriate actions to take when they occurred. Nurses also reported their fear of disciplinary action and the loss of their clinical confidence. The Guidelines for the Administration of Medicine by the Nursing and Midwifery Council advises that an open culture exists in order to encourage the immediate reporting of errors or incidents in the administration of medicines. It also advises that nurses who have been made the subject of local disciplinary action, has discouraged the reporting of incidents which is detrimental to patients. Furthermore, all errors and incidents have a thorough investigation at local level, taking into account the full context of the circumstances, which requires sensitivity (NMC 2004). To learn from our mistakes, Williams (1996) believes we first need to acknowledge that we have made them. As mistakes in a professional capacity do happen, these mistakes need to be used as a learning experience to reflect upon and to therefore avoid them from happening again. Conclusion As discussed previously, the administration of medicines is a vital part of the midwives role. Drug error is costly in terms of increased hospital stay, resources consumed and patient harm (Webster and Anderson 2002). A study by Kapborg (1999) showed that the most common errors among nurses were administration of the wrong drug and levels of drugs administered exceeding the prescribed ones. Action Plan From my experiences of the incident, I have learnt a valuable lesson. I no longer allow myself to be distracted from other members of staff, patients or relatives when I am in the process of administering medication. 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