Patient with Congestive Heart Failure

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

Cyrus Hall McCormick :: Biography Biographies

Cyrus Hall McCormick The mechanical reaper. A time-saving invention which allowed farmers to more than double their crop size while at the same time spurring other innovations in farm machinery. This reaper, which combined all the steps that earlier harvesting machines had performed separately, was the brilliant innovation of a man, a man named Cyrus Hall McCormick. Born in Rockbridge County, Virginia, Cyrus was son to a man who's imagination also boggled with new inventions. As a child, Cyrus experimented with different tools in hopes of inventing something which would simplify his father's job. Finally, in 1831, he built his first reaper. Succeeding where his father had failed, Cyrus made some adjustments to his machine before patenting his invention in 1834. At around the same time (1833), a man by the name of Obed Hussey announced a the construction of a reaper of his own. The year was 1840, and by this time, McCormick had started to manufacture his creation and sold it for the first time in Virginia. The reaper's marketing did very well, and it's sales had expanded to other parts of the United States by 1844. Because of it's efficiency, the horse-drawn reaper allowed farmers to harvest five times the regular 2 acre per day amount that skilled workers used to harvest. In 1847, the McCormick Harvesting Machine Company was moved to Chicago. Location, ease of distribution, and reputation were all factors which convinced McCormick that Chicago was the place for him. "Centrally located in the Midwest, he used the Great Lakes to transport reapers to the East, and the Mississippi River to transport to the South."* What more, as industries grew in the Windy City, Chicago soon turned into a major railroad central in the 1850's. This added to the distribution potential which McCormick needed to ship his reapers out to other parts of the US. The company's success thrived under the name McCormick Harvesting Machine Company until McCormick's death in 1884. By this time, McCormick's company had grown to become one of greatest industrial establishments in the United States. Chicago newspapers were bragging about his success and other companies awed at the pace of development. Shortly after his death, the company had a "face-lift." It's name changed to the International Harvester, and sales slowed down from it's initial boom. In 1907, the company produced the Auto Buggy. With this machine, farmers were able to haul their goods to the markets.

The Word Police by Michiko Kakutani Essay -- The Word Police Michiko K

The Word Police by Michiko Kakutani Michiko Kakutani's essay â€Å"The Word Police† is a refreshing look at a literary world policed by the Politically Correct (P.C.). She pokes fun at the efforts of P.C. policepersons such as Rosalie Maggio, author of The Bias-Free Word Finder, a Dictionary of Nondiscriminatory Language . But in mocking authors like Maggio, Kakutani emphasizes that efforts of the P.C. police are often exaggerated to the point of silliness and can even become a linguistic distraction from the real issues. In fact, such filtering or censorship of words can lead to larger problems within the English language: â€Å"getting upset by phrases like ‘bullish on America' or ‘the City of Brotherly Love' tends to distract attention from the real problems of prejudice and injustice that exist in society at large† (686). According to Kakutani, over-exaggerated political correctness just serves in complicating our words and diluting the messages. But really, the problem in P.C. advice on word-choice is the exaggeration of inclusive ness. Kakutani addresses the P.C. police's righteous motive: â€Å"a vision of a more just, inclusive society in which racism, sexism, and prejudice of all sorts have been erased† (684). But where does one draw the line between writing inclusively and walking on eggshells? What is politically correct? Must writers assume the worst of their audiences when debating whether to mutate the spelling of â€Å"women† to â€Å"womyn† in order to avoid sexist language? The truth is, writing purely inclusively is an arduous task; it requires consistent and careful consideration of many exterior elements such as audience, literary content, and societal context. An examination of these elements reveals just how difficult ... ...eading community. This goes to show that sometimes it takes extreme action to produce meaningful results. Kakutani writes, â€Å"In the case of the politically correct, the prohibition of certain words, phrases and ideas is advanced in the cause of building a brave new world free of racism and hate† (687). In this way, the P.C. motive is honorable. And we learn that accountability can be a worthwhile tool for those who strive to better themselves. Therefore, the efforts of the P.C. police are to be equally criticized and applauded: criticized for over-punishing many of the language-abiding citizens, and applauded for their attentiveness to detail and determination to better our language for the sake of inclusiveness. Works Cited Kakutani, Michiko. â€Å"The Word Police.† The Writer's Presence . Eds. Donald McQuade and Robert Atwan. Boston: Bedford/St. Martin's, 2003.

Quality of Work Life Essay

Employees at any level many time experience a sense of frustration because low level of wages, poor working conditions, unfavourable terms of employment, inhuman treatement by their superiors & the like whereas managerial personnel feel frustrated because of alienation over their condition of employment , interpersonal conflicts, role conflicts, Job pressure , lack of freedom , absence of challenging work, etc. QWL means different things to different people, J. Richard & J. Loy define QWL as † the degree to which members of a work organization are able to satisfy mportant personnel needs through their experience in the organization. † In the search for improved productivity, manager & executives alike are discovering the important contribution of QWL. Hackman & suttle describe QWL from varied viewpoints. From a professional view point , it refers to industrial democracy, increase workewrs participation in corporate decision making , or culmination of the goals of human realations. In terms of management perspective, it relates to a variety of efforts to improve productivity through improvements in the human , rather than he capital or technological inputs of production. From standpoint of the characteristics of individual workers , it refers to the degree to which members of a work organization are able to satisfy important personal needs through their experience in the organization. From the unions, perspective , it is a more equitable sharing of the income and resources of the work of organization, and more human & healthier working conditions. DIMENSIONS OF STUDY : Quality of work life improvement are defined as any activity which takes place at very level of organization which seeks greater organizational effectiveness through enhancement of human dignity and growth a process through which the stockholders in the organization management, union and employees- learn how to work together to better to determine for themselves what actions, changes & improvements are desirable and workable in order to achive twin & simultaneous goals of an improve quality of life at work for all members of organization & greater effectiveness for the company and unions. Trade union claim that they are responsible for the improvements in various facilities to workers hereas management takes credit for improved salaries, benefits & facilities. However, HR manager has identified specific issues in QWL. Klott Mundick& Schuster suggested major QWL issues. They are: (1) Pay & Employment on permanent basis: Good pay still dominates most of the other factors in employee satisfaction. Various alternative means for providing wages should be developed in view of increase in cost of living index , increase in levels & rates of income tax & profession tax. QWL must be build around an equitable pay programs . in uture more workers may want to participate in the profits of the firm. Employment of workers on casual, temporary, probationary basis gives them sense of insecurity. On the other hand , employment on the other basis gives them security & leads to higher order QWL. (2) Occupational Stress : Stress is a condition of strain on one’s emotions, thought process ; physical condition . stress is determined by the worker’s abilities & nature and match with the Job requirements. Stress is cause due irritability, offering prestigious designation to the Jobs, providing well furnish amp; decent work places, offering membership in clubs or association , providing vehicles, offering vacation trips, or means to recognize the employees hyper- excitation or depression unstable behaviour, fatigue, stuttering, trembling psychometric pains, heavy smoking & drug abuse. Stress adversely effects on employee’s productivity. The HR manager, in order to minimize the stress has to identifiy, prevent ; tackle the problem. He may arrange the treatment of problem with the health unit or provide some stress buster activities during the hectic work schedule. 3) Organizational Health programs : Organizational health programs aim at educating employees about health problems means of maintaining ; improving health etc. These programme covers drinking and smoking cessation ( if it is affecting the productivity of employee ) , hypertension control , other forms of cardiovascular risk reduction, family planning etc. Effective implementation of these progrme results in reduction in absenteeism, hospitalization ,disability, excessive Job turnover ; premature death. It should also covers relaxation, physical exercise , diet control etc. 4) Alternative work schedule : Alternative work schedule including work at home , flexible working hours, staggered hours , and reduced work week, part time employment which may be introduced for the convenience ; comfort of the workers as the work schedule which offers the individual the leisure time , flexible hours of work is preferred. 5) Participative Management ; control of work : Trade unions and workers participation in management and decision making improves QWL . workers also feel that they have control their work, use their skills ; make a real contribution to the Job if they re allowed to participate in creative and decision making process. (6) Recognition : recognizing the employee as a human being rather than as a labourer increases the QWL . Participative management , awarding the rewarding systems , congratulating the employees for their achievement , Job enrichment, offering prestigious designation to the Jobs, providing well furnish and decent work places,offering membership in club or associations , providing vehicles , offering vacation trips, or some means to recognize the employees . (7) Congenial Worker- supervisor Relation : Harmonious supervisor- worker relations give the worker essence of social association , belongingness, achievement of worker results etc. This in turn led to better QWL. 8) Grievance procedure : workers have a sence of fair treatement when the company gives them opportunity to ventilate their grievances and represent their case succinctly rather than settling the problems arbitrarily. (9) Adequacy of resources : Resources should match with stated objective ; otherwise , employee will not be able to attain them . This results in the employee dissatisfaction and lower QWL. 10) Seniority ; meri t in promotions : seniority is generally taken as the basis of promotion in case of operating employees . Merit is considered as the basis for advancement for managerial people whereas seniority cum- merit is preferred for promotion of ministerial employees. The promotional policies ; activities should be fair 7 Just in order to ensure higher QWL. (11) Welfare Benefits : Since workers are now better organized , educated ; vociferous, they demand social security ; welfare benefits as a matter of right which were once considered a part of bargaining process.

Certificate Essay

Whilst the layout of reports is often a personal or corporate matter, it is wise to follow a few simple rules. )The report should have a beginning, middle and end. b)It should be laid out in a manner that makes it easy to read (e. g. a title, sub headings, references to observation sheet where necessary). c)Any recommendations are usually left until the end. This allows the busy manager to skip all the wordy report and look at the ‘bottom line’. 2. Relevant topics. It is important to remember the purpose of this report. The majority of faults found during the inspection will be of a minor nature, which would be rectified by the workforce supervisor. The secret of a good report is identifying those matters, which will need management action. Typically, these would include: a)Anything that has a cost implication, e. g. the need to budget for rebuild, the need to provide lockers etc. b)Possible breaches of legislation, e. g. All portable electrical equipment should be regularly tested, a requirement of the Electricity at Work Regulations 1989. c)A breakdown of procedures, e. g. PPE not being booked in and out of stores, a requirement of the workshop. )Poor supervision, e. g. Personnel working without PPE. e)Underlying problems, e. g. Attitude of workers regarding tidiness. There is a need for further training to highlight the need for good housekeeping 3. Cost implications. One of the most important factors associated with convincing management about taking action is the cost implication. If you can assure the reader that the action necessary will cost little or nothing, then the chances of agreement to the action is almost certain . The above, notwithstanding, if there is a substantial cost implication then it is necessary to highlight the fact to enable plans for future budgeting to be made. 4. Relevant legislation. As with the cost implications above, highlighting Possible breaches of legislation will often lead to management action. It is necessary to ensure that the legislation quoted is relevant, however. 5. Strength of argument. By producing a well balanced, logical report encompassing all of the above points, it should be enough to convince most managers that action needs to e taken. (it should be noted that in real life situations there are certain managers who will never be convinced, short of an accident happening, of the need for good health and safety practice.

Organizational Change & Leadership from a Systems Perspective Essay

There are many aspects to running a successful organization. The dream of running a business initially starts off as a vision in the mind of the founder. That vision materializes into the mission statement, and progresses on to becoming an organization worthy of being put into a business plan. After completion of the many administrative and legal steps required, one must make sure to hire good people. A successful business will start with positive human interaction. The people of the organization must have the skillset to progressively advocate, not only for the clients, but also for that of the organization. The members of our organization must have the ability to see the vision and the willingness to work hard to make the organization successful. I will discuss the leadership that will best benefit our dream organization based on our staff input. I will also discuss from a systems perspective what organizational force will energize human services to our staff and clients. I will ad dress the six functions that are salient which work together and contribute to the efficiency of the dream organization, and last, but not least, I will discuss the leadership role in the conceptual framework for human service management. I believe our dream organization to be diverse in all aspects. A diverse model would suit the needs of the community, but I would have to say both the diverse and visionary model would best accommodate the needs of all staff involved with the growth of the organization. As stated in an article I read, people often associate qualities to the leaders that are inherent in the personality of the leader. Credible leadership reflects concerns about image, professional appearances are key to success (Chin, 2011). Leaders need to acknowledge the challenges in making decisions in diverse organizations; â€Å"become more comfortable with tension and complexity†; one must be more strategic in their thinking, considering diversity issues in the context of mission, vision, and strategy (Lewis, Packard, & Lewis,  2012). The founder will set the example of behavior by encouraging respect for all staff members. Management will promote understanding of values and traditions from the diverse population the organization will provide service to. Strong leadership has a trickle-down effect. If our management team is strong, the staff will follow. A diverse leadership that has a vision to lead will show our clients that anything they put their mind to is attainable. Goals were set by each staff member and as a team we all brainstormed those goals to make sure they were attainable and met the needs of the organization. Our organization provides a service to the females of our community and it is important that we impact their lives by the examples we set as management. We will employ a diverse population of females from all aspects of life to support our organizational desire to provide needed services to our community. We will have interns from the college on site with hopes of being financially able to hire those showing to be outstanding with their volunteer ability. Staff will have input in how the operation is run. We will also give the client a chance to provide input as they work through our program. The life skill classes we will be providing will enhance the client’s desires and expectations in life. Leadership traits ideal to our agency are the task oriented Behaviors According to Lewis, Packard, and Lewis (2012). In order to run a successful organization a leader must have these traits and they are Intelligence: be able to run the organization, Self-confidence: must be confident in the work that is being done, Determination: the desire to get the job done persistence dominance and drive, Integrity, High energy level, tolerance for stress, social intelligence, emotional stability, sociability agreeableness and lastly conscientiousness material A leader must possess knowledge and understanding of the organization (Lewis, Packard, & Lewis, 2012) . The Contingency Theory of leadership theory basically suggest that there is no one way to lead and every situation is differently and the different behaviors are appropriate for different situations (Lewis, Packard, & Lewis, 2012). The systems perspective is full of subsystems according to Lewis, Packard, and Lewis (2012), all subsystems work together first with planning, budgeting, designing, staffing, supervising, evaluating which are all important to the systems. Without one you cannot proceed to the other (Lewis, Packard, & Lewis, 2012). Leadership must look at the  subsystems, and make sure the organization is on track. Management must make sure to have the proper skillset of employee in each department. All six sub-systems must work together to assure the success of the organization. One of the images in the reading showed leadership to be the center of the organization. Leadership is surrounded by designing, budgeting, staffing, supervising, planning, monitoring and evaluating. I would hold to that order and consider it a key to success. In conclusion, our dream organization will make sure we hold to the vision of the founder while keep the mission statement in mind as we provide service to the community. After reading the many different leadership styles available to various organizations, I have come to the conclusion that is to the advantage of the organization to input a little of all the various means of leadership into the organization in order to successfully run the organization. There is no right or wrong way and you must tweak the various leaderships in order to create the one that will best suit your organization. When we look at the system and the systems perspective and evaluated how they work, it is key that the leader manage them and understand how each system operates. Management must give positive direction and clear instruction as to what the outcome should be at any given stage. When each step of the system are completed accurately, and in order, you are setting the organization up to succeed References Chin, J. L. (2011). Women and Leadership; Transforming Visions and Current Contexts. Forum On Public Policy Online, 2. Retrieved from http://www.forumonpublicpolicy.com Lewis, J. A., Packard, T. R., & Lewis, M. D. (2012). Management of Human Service Programs (5th ed.). Mason, OH: Cengage Learning.

Alice’s Adventures in Wonderland and Alice Essay

At the beginning of the story Alice starts off being pressured into marring a man she doesn’t even love. Her sister tells her to go get married and live just happily ever after like her but her husband is cheating on her. I think Alice’s call was when she kept spotting the white rabbit in the bushes and began to follow him in the middle of getting purposed to. Also after she fell down the hole the rabbit was trying to explain to her who she is and how she’s supposed to be the champion for wonderland. Stage 2: Refusal of Call Alice starts to refuse when she begins telling them that she is not the right Alice their looking for. I didn’t think she would still be refusing even after they showed her the scroll of what happened. I kind of thought she was just saying no because she was afraid of what was ahead of her if she took on the challenge of becoming the champion. Throughout the beginning and middle of the movie she Lyric Perry 9/22/13 World Literature was trying to convince everyone that this was her dream and everything would be ok when she woke up. Stage 4: Crossing the first Threshold I thought during the whole story I think she crossed more than one threshold. The first one was when she fell down the hole and entered wonderland because the trees by the two holes were both twisted and looked very similar. Her coming out of the hole to Wonderland to me was like the crossing in a new unknown land. Another threshold was when she made it up in her mind that she was the hero and started believing in wonderland and the impossible. Stage 5: Belly of the Whale The belly of the whale is when a character is fully enclosed in the new world or adventure. I think she entered the belly of the whale when she began to accept the fact that it wasn’t a dream and wonderland is a real place. I think that Lyric Perry 9/22/13 World Literature the only way she was going to get out and go back to the real world was to complete her quest and slay the jabberwocky. Stage 6: Road of Trials Alice had lots of trials during her journey such as when the dog/polar bear thing started to chase her and cut her arm. At the tea party when the red queen’s knight, soldiers, and bloodhound came looking for Alice I felt it was a trial because if they were to have caught her she wouldn’t have been able to complete her goal. The road of trials is a very important stage because I think they help the character get ready for what they are about to embark on. Stage 11: The Ultimate Boon The ultimate boon to me was when she cut the head off of the jabberwocky. This was really important because the whole fate of wonderland was in her hands. I think the white queen was depending on her the most because she really wanted the crown and for the red queen to stop torturing Wonderland. Stage 15: Crossing the Return Threshold At the end of the story I saw two returning thresholds the first one when she climbed out of the hole and when she started standing up to everyone at the party back home. When she was climbing out of the hole she was crossing back over to the real world and her normal life. She started telling everyone the truth and saying what she really felt even things that sounded impossible. Stage 17: Freedom to Live I thought this happened for Alice at the very end of the movie because that’s when she really decided to live her own life and do what she wanted. Such as she told the man she wasn’t going to marry him she was going to find someone she loves. Alice starts talking to the man about his business and how he should move it china. Her falling down the hole to me was on purpose to get her to really follow her own bliss not everyone else’s.