The Cardiovascular System

Intrinsic Conduction System1. The intrinsic conduction system consists of __autorhythmic cardiac______ cells that initiate and distribute __impulses___ throughout the heart. 2. The intrinsic conduction system coordinates heart activity by determining the direction and speed of _heart depolarization___. This leads to a coordinated heart contraction. 3. List the functions for the following parts of the intrinsic conduction system: a. SA Node __initiates the depolarizing impulse and sets the pace for the entire beat___ b. Internodal Pathway __link between the SA node and the AV node__ c. AV Node __delay occurs allowing atria to contract___ d. AV Bundle (Bundle of His) _link between atria and ventricles__ e. Bundle Branches __convey impulses down the interventricular septum___ f. Purkinje Fibers ___convey the depolarization throughout the ventricular walls_____4. The action potentials spread from the autorhythmic cells of the intrinsic conduction system (electrical event) to the _contractile__ cells. The resulting mechanical events cause a heartbeat.5. A tracing of the electrical activity of the heart is called a/an __electrocardiogram__.6. What do the following wave forms reflect? . P wave ___atrial depolarization___ b. QRS complex ___ventricular depolarization____ c. T wave __ventricular repolarization___7. In a normal ECG wave t racing, atrial repolarization is hidden by __QRS Complez__.8. Note: Electrical events lead to mechanical events. For example, the P wave represents __atrial_ depolarization, which leads to atrial _contraction___.9. A left bundle branch block would have a wider than normal wave for the __QRS complex_. (Quiz section) 10. An abnormally fast heart rate (over 100 beats per minute) is called: __tachycardia___. (Quiz section)

Gardner’s Theory on Seven Intelligences

Gardner’s intelligence theory comes from a book he wrote and published titled Frames of Mind (1983). Gardner’s theory on the seven intelligences was quickly adapted by the educational and training fields to help educators and trainers to understand personalities, intelligence, and learning styles. This has enabled educators and trainers to narrow in on how to teach and grasp the attention of all their students and trainees. Whereas encouraging and motivating them by understanding how they learn and the best way to teach them. Gardner’s theories and concepts are aids to understanding overall personalities and strengths. These theories and concepts are all easily understood and can be incorporated into almost any educational or training situation, to better assist in the education and training process. Sometimes combining more than one intelligence helps in finding the best way to educate and train individuals all over the world. Linguistic Intelligence is the intelligence of language or words, when you learn by writing the information down, or when you absorb information my hearing words this is all a form of Linguistic Intelligence. When you form images in your mind when learning or you have to picture what is being taught in your head this is part of the Spatial Intelligence. When you learn by listening to music or if you absorb information better when music is playing this is the Musical Intelligence. Now when learning comes when you actually do what is being taught, hands on so to speak this is called the Bodily-Kinesthetic Intelligence. Interpersonal Intelligence is happening when a person can learn about a person or situation by the vibe they get from another person in the situation. Also when you learn better through interactions with others like group projects or having a study buddy this can be considered Interpersonal Intelligence. When you rely on self to learn, by understanding your own feelings and interest this is the Intrapersonal Intelligence. People that use Intrapersonal Intelligence are usually independent learners. Now with Logical Mathematical Intelligence you learn by patterns and reasoning, often needing facts to solve problems, also with learning things need to make sense or be logical. Out of the Seven Intelligence Theories produced by Howard Gardner I believe that Linguistic and Bodily- Kinesthetic are the two that are most dominate in my life. When I learn or am trying to absorb information. I have to hear the words and follow along with the written words when possible. So I download audio files of my text books and take good notes, and when I go over my notes I always read them out loud. As with the Bodily- Kinesthetic Intelligence, I see this come through when I write information that I am trying to learn this ties into my Linguistic Intelligence, because I not only need to see and hear my work, I have to physically write it down. The motion of the writing and picturing the words in my mind, I always find it easier to retain information. In studying Gardner’s theories on intelligences I have so much about helping myself to learn more effectively and efficiently.

Is Gambling a Social Problem Essay

Gambling is an act of playing for stakes in the hope of winning. It also involves a significant risk as the material good (usually money) wagered in the game may be lost if the player does not win. Common forms of gambling include cockfighting (which usually results in the death of one or both roosters), casinos (which has become a profitable business), slot machines (convenient for those who want to play individually), bookmaking (often used for predicting the winners of sports competitions), and caracruz (simplest form of gambling which has existed since ancient history). There is an ongoing debate among social scientists, psychologists, business lobby groups, and others on the benefits and dangers of gambling. Some anti-gambling social activists argue that gambling is a serious social problem, while others argue that gambling problem is a problem of certain individuals who suffer from psychological ills and that in certain circumstances gambling on the contrary is a significant source of income (for example, for Native American tribes). Gambling Is a Social Problem ?Gambling is associated with a range of social issues and thus needs to be designated as a social problem. According to research on the topic, there is a correlation between various social problems and gambling. For example, Hardoon et al. , point out in their study that gambling problem among adolescents they studied stemmed from the lack of healthy familial and peer support, drug use problems, behavioral problems, problems related to family issues, and the parental gambling problems as well as their substance abuse. According to Hardoon et al. , there is a significant familial contribution to gambling problems. Read more:  Ã‚  Essays on Social Issues Many of their respondents said that their elder siblings had a strong influence in their decisions to experience gambling. Many of the respondents who suffered from gambling problems said that their parents themselves were problem gamblers. The study by Hardoon et al. , also points out that children of problem gamblers suffered from insecurity and a sense of â€Å"pervasive loss† (170). They also argue that gambling problem among parents leads to various kinds of familial dysfunctioning, including drug addiction, conduct problems, and delinquency. Hardoon et al. , also point out that there is a connection between gambling and substance use. â€Å"Compared to nongamblers,† they write, â€Å"adolescent gamblers are more likely to drink alcohol, smoke tobacco, and use drugs† (171). Gamblers are three times more likely to use drugs than non-gamblers. Gambling and substance use problems among adolescents often leads to delinquency and illegal behavior. Adolescents suffering from serious gambling problems are also likely to experience difficulty in school such as decreased academic performance and poor grades. More than half of the problem gamblers Hardoon et al. , studied suffered from conduct problems as well. They were more likely to break rules, get into troubles with individuals in authority, frequently display oppositional behavior, and join anti-social activities (171). This study in general demonstrates that the gambling problem is part of larger social issues and there is a clear correlation between gambling and various social problems. Another study on the impact of gambling on college students suggests that about 1. 6% of the U. S. dult population meets the diagnostic criteria for pathological gambling (Level 1), and 3,85% reportedly suffer from subclinical (Level 2) gambling problems. Among college students, the rate of gambling problem on both levels is twice as high as it is among the general adult population. There are significant social and health-related problems associated with adolescent gambling problems. Adolescents and young adults addicted to gambling suffer from serious stress-related problems. Many of them attempt and even complete suicides. Among these adolescents and young adults, the rate of disorderly familial relationships is much higher. There is a higher rate of comorbidity with other addictive disorders, and there are more frequent instances among these adolescents and young adults of arrests and convictions. The study concludes that â€Å"social norms–based social marketing campaigns (emphasizing accurate descriptive norms for alcohol) to successfully reduce alcohol use on campus† needs to be reworked and applied for combating gambling problems among college students (Larimer & Neighbors 241-242). This is another testament to the fact that gambling is a social problem and that the way to reduce it is to employ tools which are used for combating other social problems. Illuminating in this case is the experience of Native American tribes in the United States. With the passing of the Indian Gaming Regulatory Act (IGRA) in 1988, which mandated legislative basis for managing and regulating Indian gaming, the number of casinos has sharply risen in Native American communities. As a result of this, one study of this phenomenon points out, Native Americans â€Å"are four to six times more likely to be pathological gamblers and two to five times more likely to be problem gamblers than non-Indians† (Momper 139). The study also cites poverty, unemployment, and historical injustice as factors that contribute to the development of gambling problems among indigenous groups. According to this study, there is a similar correlation between the practice of excessive gambling and predisposition to other social and behavioral problems such as alcoholism, drug use, and disruptive behavior among Native American groups—but in significantly higher numbers than it is among non-Indians in the United States. Gambling is Not a Social Problem ?While it is true that gambling addiction, just like any other addictive behaviors such as alcohol addiction or drug addiction, is a social problem, gambling itself is not a social problem. Participants of gambling make conscious decisions and they have the freedom to stop the practice whenever they think it is detrimental to their financial, psychological, and social conditions. For example, in the year 1999 the National Gambling Impact Study Commission surveyed the U. S. opulation and found out that 86% of Americans had gambled some time in their lives, and that 68% gambled in 1999 alone (Seligman 86). Out of this large segment of the population who regularly gamble, only a tiny percentage of the population suffers from serious gambling problems. ?Discussions over the use of gambling are sometimes controversial because it is one of the businesses in America which has a bad reputation, on the one hand, and is so popular that more and more Americans are demanding gambling opportunities, on the other. Due to its popularity, gambling has been legalized in all states except Hawaii, Tennessee, and Utah. Residents of these states also gamble, by traveling to other states or by taking advantage of online gambling opportunities. Total wagering in the Unites States is around $900 billion a year (constituting 10% of personal income), and the lion’s share of wagering takes place in casinos ($600 billion). And casinos now exist in twenty nine states. But these are official figures and unofficially the extent of gambling among Americans is likely to be much higher (Seligman 87). Gambling in the United States is a legitimate form of business, and designating it a social problem would necessitate that we label other legitimate forms of business as social problems as well. As Seligman points out, â€Å"Wall Street offers plenty of bets with risk/reward opportunities that mirror those of slot machines—a long shot with occasional huge payout. Buying out-of-the-money puts on an airline stock just before a union vote would fall in that category. If the members unexpectedly vote against wage concessions, you could make a killing on the bankruptcy† (Seligman 89). Some critics of gambling who criticize it from an economic perspective, say that, while gambling consumes time, energy, and resources, it does not produce any real output. But that argument can be used against most kinds of financial transactions and speculating, both of which are acceptable, and in today’s world, necessary components of international financing. As for the charge that problem gambling leads to comorbidity with other social problems such as alcohol abuse and drug use, more research is required to determine the nuances of this connection. Does excessive gambling lead to alcohol abuse or is it the way around? If it is the former, then it is the problem of gambling addiction which needs to be labeled a social problem and remedied. If it is the latter, then it is the problem of alcoholism rather than gambling because alcohol abusers have more than one way of ruing their lives (gambling is not their only option), and even here the issue is the abusive consumption of alcohol, not alcohol consumption in general. Those who see gambling as a social problem ignore the fact that gambling may—and in many cases it does—lead to positive social outcomes. This is generally the case in the Indian reservations in the U. S. As Momper points out, an IGRA passage which aimed at encouraging gambling on reservations for the purpose of raising the standards of living on the poorest reservations â€Å"was the only federal policy that produced lasting effects for tribes, inasmuch as the unemployment rate (38 percent) on 214 reservations with casinos decreased by 13 percent from 1989 to 1995. Even if one takes into account the increase in the number of problem gamblers, other social and economic gains from casinos on reservations greatly outweighed the negative consequences of this business. In addition to creating jobs, casinos on reservations provided the American Indian community with various social services and strengthened their social bonds (Momper 142; Cornell et al. , 1998). While it is true that gambling addiction as increased among American Indian residents as a result of building casinos, in many instances improvements in standards of living took many of them out of poverty, decreasing the rate of behavioral problems and anti-social activities. ?In summary, both proponents of gambling-is-a-social-problem thesis and their opponents have strong arguments at hand. The debate is likely to continue without being resolved as it is a controversial topic and gambling among the U. S. population leads to mixed results: both positive and negative.

What do the photos we take say about us Research Paper

What do the photos we take say about us - Research Paper Example Publication of Prince Harry’s nude photos irrefutably constitutes privacy violation, as can be discerned from the definition of private facts under privacy law. Private facts are information snippets about an individual’s personal life, which have not been previously disclosed to mainstream public and do not bear any justifiable public concern. Publication or disclosure of these private facts is also deemed offensive to reasonable persons in society (Nordhaus, 1999). Clearly, the Prince’s naked photos meet all these criteria. First, intimate photographs of Prince Harry are not ordinarily available to the public. Secondly, the photos are not of any legitimate concern to the public, since the information does not bear any relevance to critical societal matters. Most importantly, any reasonable person would consider the naked photographs offensive. This is because nudity often typifies indecency, which goes against the conventional principles of morality, especially in conservative environments. In addition to the high level of offensiveness and lack of newsworthiness in Prince Harry’s personal photos, diverse media outlets that published the photos did not acquire consent from the subject. This is a vital element when publishing private photographs. The act of publication, therefore, constituted unlawful use of private photographs and was decidedly unfair (Berkman Center for Internet and Society, 2008). Failure to obtain consent also points to the fact that, the respective media outlets solely focused on sensationalizing the photographs and gaining popularity ratings (Jobson, 2012), as opposed to portraying the Prince as a dignified public figure. The publication was, in consequence, morally wrong and disregarded journalistic ethics of responsible and unprejudiced reporting. The unreasonable nature of the act is aggravated even further, by the fact that the subject was photographed in a private

Frida Kahlo Essay Example | Topics and Well Written Essays - 1000 words

Frida Kahlo - Essay Example The paper "Frida Kahlo" analyzes the life and art of Frida Kahlo. Her father was German, however, his true nationality was Jewish. While his life he was a photographer. Her mother used to be an America originated Spaniard. At the age of six years old, the artist used to suffer from polio. This determined the reason why since then the right leg became shorter and thinner than the left one. At the age of eighteen, Kahlo survived in a car accident: a broken iron rod collector tram stuck in the stomach and left groin, shattering the hipbone. The still painful months of inactivity began. It was that time when Kahlo asked her father for a brush and paint. There was a special frame made for Frida in order to allow her to paint lying. 1929 was an important year for the artist. She enters the National Institute of Mexico. For the year, held in almost total immobility, Kahlo obtained a serious passion for painting. Again, start walking, she attended art school and in 1928 joined the Communist Party. Her work has been praised by the time by the famous artist Diego Rivera of Communist era. When Frida was twenty-two years old, she married him. Their family life is seething passions. They could not always be together, but never – apart. They tied relationship which could be characterized as passionate, obsessive, and sometimes painful. In 1953, Mexico City is hosting the first solo exhibition of Frida Kahlo. None of self-portrait of Frida Kahlo smiles: serious, even mournful face, bushy eyebrows grown together.

Negation in Arabic Essay Example | Topics and Well Written Essays - 1000 words

Negation in Arabic - Essay Example A comparison and contrasts of Arabic with the English language provides for several interesting as well as challenging issues. The Arabic calendar, although based on the lunar year, has the same number of months as the English calendar and there is also similarity in the names of the months (Online Arabic Tutorial). But the similarity ends here. Then the language becomes complex with its own set of rules and applications (Edwards, Malcolm). The Arabic grammar reflects the rule of its alphabets and vowels on the correct arrangement of words in a sentence. It makes good use of prefixes and suffixes for various purposes such as negation and also for indicating the future. The use of the alphabet depends on where it is placed in the word (Online Arabic Tutorial). For instance, the letter t (pronounced ta in Arabic) has five variations on the way it is used, depending on its position in the word. The same rule applies for all the other alphabets. The Arabic language is written right to left. However, its numbers are written left to right, just as is done in English and most other languages. The Arabic numerals are based on the Indian numeral system (Online Arabic Tutorial). The ways texts are written influence various other aspects in written and oral expressions. For instance, if an Arabic student were to make graphs indicating statistics of increasing data, the student will show the data increase from right to left. On the other hand, if the same graph were to be made by an English student, the data will show the increase from left to right (Tversky, Barbara). There is the use of a suffix to address adjectives, masculine and feminine genders. The possessive pronoun 'its' does not exist in Arabic. Depending on whether the noun is masculine or feminine, the possessive pronoun is spoken of as male or female. The verb 'to be' is understood but not expressed in Arabic. The comparative degree is indicated through the use of adjectives. It does not agree in gender with its noun, but remains fixed in form. Negation in the past tense is done by using a prefix at the beginning of the sentence. Also, future is formed through the use of a prefix in a sentence. The Arabic language does not have neutral gender. Every noun is either masculine or feminine gender (Online Arabic Tutorial). Semantics The Arabic language has its own repertoire of folk tales and idioms to buttress the language. The language is dimensionally set with its own culture and intonations. Direct expressions, proverbs, idioms, graphics, etc enrich the language. There is no neutral gender and the gender of every noun must be learned. It is important to pay attention to the gender of the nouns because the gender of adjectives, pronouns and verbs that refers to them must agree. Even cities have gender (Online Arabic Tutorial). The language is set with rules that require the crossing of dotting of every t's and i's. Names are replete with use of the name of the Prophet and his relations. Muhammad, Abdullah, Fatima, Jamila are some of the common names bearing divine attributes. The names and expressions

Problems and Risks with Information Security in the modern world Research Paper

Problems and Risks with Information Security in the modern world - Research Paper Example This essay discusses that increasing and tougher market competition, globalisation, rapid developments in technology, higher demands from customers and other similar factors are some of the changes that companies are confronted with as they try to create their niche in the global market. In response, companies have redefined and re-shaped their strategies in order to equip them with the necessary tools and mechanisms that will enable the organisation to address the challenges brought by change. One of the most important challenges that organisations have to deal with is the rapid evolution and changes in information technology. Information is one of the primary assets organisations. It is being exchanged among organisations, employees, customers, management, partners and other stakeholders of the company. Meanwhile, developments in communication and computer technologies have paved for faster exchanges of information through the use cellular phones, internet, and other technological devices that allow people to be connected anytime, anywhere. In this regard, information technology has become an integral part and tool of organisations as firms respond to the challenges of the market and cope with the increasing demands of the customers. However, as information becomes more valuable to firms and organisational processes become more dependent on information systems (IS), IS security has become one of the major issues that modern enterprises have to tackle. (Belsis, Kokolakis & Kiountouzis 2005). Threats, identity theft, fraud, viruses, data integrity, data protection and other similar concerns have been part of the many issues that IS security have to deal with as the proliferation of the use of computers continue in the Information age. In this regard, this research will focus on the problems and risks in information security in general and in the banking sector in particular. Objectives of the Study The study intends to examine the nature of information security . It also seeks to determine the various problems and risks that information security is dealing with. Likewise, the study aims to identify some of the theories that are proposed in order to address the concerns and issues pertinent to information security. In addition, it aims to understand information security from the viewpoint of the banking sector. Finally, the study seeks to test information that will identify further concerns in information security in the banking sector. Research Questions In view of the integral role that information security in organisations, the research will be addressing two main questions and these are, first,

The Key Differences Between De Beers Old And New Business Model Essay - 24

The Key Differences Between De Beers Old And New Business Model - Essay Example Kodak’s main strategy in this period was to avail to their customer’s high-margin film referred to as the razor blade strategy. This strategy involved Kodak’s development of inexpensive cameras as a way to an end: the company had the objective of facilitating lucrative film sales. In a heart shell, the invention of the digital camera was held back due to management’s worries about the negative effects on film sales. Nonetheless, the developmental dependencies on many other industries were extremely high as microprocessors, advances in electronic storage, and various communication soft wares for the camera and digital data transfer, soft wares for image processing, etc. Microelectronics was a problem for the company during the implementation of its strategy. However, the strategies that the company employed failed. Normally in a perfect market whenever disruptive technology exists, companies always fail to capitalize on the invention of the day for fearing cannibalizing current product sales. For instance, in 1981 when Sony introduced a filmless digital camera into the market, panic permeated Kodak company‘s executive suite. Explicitly, over the next years, the company invested about $5 billion in digital imaging. Through estimation, this was approximately 45% of the company’s R&D budget. Sadly, with disruptive technologies like digital cameras, whenever a company becomes the first-mover it has a lot of advantages and others who follow suit find it very difficult to overcome the competition. The strategy failed since by the time the company realized that their razor-blade strategy was not workable; the lions were by now out of the barn. Kodak was not able to match the competition.

Bottled water is safer than tap water Essay Example | Topics and Well Written Essays - 750 words

Bottled water is safer than tap water - Essay Example Mineral water accumulates various minerals as it flows over rocks before it is collected while spring water emanates from the ground, having no chance to collect minerals. Tap water is treated with chemicals before distribution to consumers. The major chemicals used for tap water treatment are Chlorine and fluorine. It is normally treated to eradicate any pathogens that might be present in the water, and which may cause diseases. This is water that is packaged directly from the source. It is significant due to the fact that it is taken in its natural state, without chemicals. Mineral water contains important elements such as calcium and magnesium that are needed in the body. They are acquired from water that flows along a course composed of rocks that are rich in minerals. Bottled water has established a market in the word population due to the standards that have been set by many governments in order to protect the consumers. It is advantageous because once packed, the water has a long shelf life. Bottled water can also be used for emergency supplies in cases of water shortage. Travelers can conveniently carry bottled water with them when they travel over long journeys. However, there has been a rise in the level of pollution in the environment, causing pollution in the natural water sources. Land fills and incinerators are a major source of pollutants. It is progressively becoming un-advisable for people t o drink bottled water because of the associated levels of pollution. According to Feldman (2003, p.27), â€Å"The quantity of plastic waste generate every year are predictable at half a million tons.† These are mainly disposed in land fills and incinerators. They end up polluting surface water bodies During the rainy seasons, soil erosion causes fertilizers and other pollutants emanating from land to be transported to the rivers, springs and wells, which are the major source of bottled water. Nutrients from the soil are leached in to the ground

Political Instability in Egypt Essay Example | Topics and Well Written Essays - 1000 words

Political Instability in Egypt - Essay Example Mubarak has been oppressing the rise of rebellion for many months in order to keep the centralized power. This clearly relates to Mill’s On Liberty, as the dictator is trying to maintain harmony and status quo. He clearly uses this to for explaining the necessity of a political sovereign state (Mill). Furthermore, he insists on a sovereign leader with absolute power that would bring security and calmness to people. In addition, he himself insists on this fact, since he witnessed a civil war that tore his country. The evil that lurks in unlimited power is the focal point of Mill’s argument. Undoubtedly, Mill’s argument for absolutism is due to the fact that the state of nature is indeed war (Mill). Mill’s main agenda is to show that, rationally, men will seek peace against the state of nature of conflict behavior. Mill’s bold attempt to convince the fact that men are creatures of peace in a state of nature is, nonetheless, a difficult thing to prove since mankind is struggling in constant warfare (Mill). Thus, Mill’s explanation of conflict is complex and hard to comprehend since, even in perfect conditions, certain man will rise to occasion to challenge authority (Mill). It’s human nature to seek pride, glory and fame; without doubt, humanity will continue to be engrossed in these acts because it can never be satisfied. Clearly, the author’s task is to show that the nature of men is complex. Mill’s theory elaborates that men are instrumentally designed to seek rationality in all instances for their best self-interest (Mill). Thus, this is the reason for the general tendency of mankind to desire power after power until death strikes them. The competition does not rise from the general scarcity of resources but Mill does not imply that. He implies that when distributed equally, even if insufficient for fulfillment of community needs, resources will never be sufficient for the satisfaction of certain p eople’s quest to obtain more power (Mill). People in their state of nature tend to have mistrust and compete for natural competition of power. Thus, the people of Egypt have revolted because of lack of free elections, high unemployment, corruption that plagues the country, and restriction of free speech. Egypt was less than a month away from holding parliamentary elections after Hosni Mubarak was ousted from power earlier this year. The natural competition for men to elect a leader that can protect their interest is crucial for Egypt (Brennan). Mill states that if the leader under power cannot provide his people with sustenance, a rebellion can threaten to change the status quo (Brennan). Clearly, Mubarak failed to give his people the free democratic elections he promised earlier. For many decades, the mass majority of the populous was surprised to see Mubarak’s party known as the National Democratic Party win by huge margins (Jensen, 2010). Many began to question the true cause of these results and accusations of vote rigging, fraud and bribery have been the focal point against Mubarak’s campaign. Hence, according to Mill, a revolution is almost guaranteed when individuals have little or no impact in the politics that govern themselves (Mill). Another key element Mill discusses in his work is brilliantly illustrated in this particular scenario. It is the fact that individuals are likely to rebel if unemployment plagues the region. This scene can be brilliantly depicted

Healthcare Systems Management Essay Example | Topics and Well Written Essays - 500 words

Healthcare Systems Management - Essay Example Another option is 'taking direct action to reduce expenditure on pharmaceuticals, both by encouraging the use of generic drugs and by restricting or prohibiting the use of expensive branded pharmaceuticals' (CEC 2002, p43). Suppliers of medical equipment may be asked to reduce the astronomical prices they charge for their goods in exchange for some Government incentives such as reduced taxes or more tenders or contracts. 'Nanomedicine is a further exciting new field that has the potential to revolutionize healthcare. It involves the monitoring, repair, construction and control of human biological systems at the molecular level, using engineered "nanodevices" PricewaterhouseCoopers 1999, p22).' New medical opportunities could totally revolutionize healthcare systems despite concerns about spiraling costs. These technologies include Genomics, biotechnologies, nanotechnologies, telesurgery and robotics. The Education Authorities should be proactive in redressing the shrinking pools of talent and young recruits. On the other hand the Immigration department could also play a major role by providing healthcare professionals who have fled their countries to play a hand in developing the health care system.

Ready For New Achievements Essay Example for Free

Ready For New Achievements Essay To begin with, through all the writing assignments that I have written so far, I have showed to have the capacity to come out with good ideas. Thinking about possible reasons of the problem, consequences or even solutions to the topic, are all very important as the first step to begin. For instance, while writing assignment number two, I started with questions to make us think how armed guards may not be prepared to work with children, and I listed detailed examples on how its consequences can affect the kids’ welfare. In doing so, it can make the readers think profoundly, and realize that there is more to worry about over its negative consequences. In other words, deeply comprehending the topic helps to increase my and the readers’ critical thinking and develop better viewpoints and conclusions. Having good concepts, motivated me to write well-developed writings. At the same time, profound thoughts lead me to overthink about the topic and make me spend more time on my writings. Having a lot of ideas to write about are sometimes not necessary. An example of this situation is my â€Å"Kids With Better Futures† midterm writing assignment. Since this was an in class paper, I had to come out with strong and good ideas quicker than usual, but I tend to write some run-on sentences. Moreover, I couldn’t show all the ideas I had in that specific moment; because of the time I spent thinking about my main ideas. For example, I could also have written about my own experience as a child and how my parents have been a huge influence in my academic life, or how my environment and life style might affect the way â€Å"The Western† and â€Å"Chinese† parenting styles work. Lacking several ideas made me feel that I did not completely show my thoughts or even feelings about the topic, which I think is one of my biggest weaknesses. Nevertheless, this 263 ESL class has helped me to learn how I can organize my ideas in each paragraph and create good topic sentences. For instance, at the beginning of the course I did not know the correct order in which I had to write out my main ideas. I used to just write what I had in my mind, without taking into account that I was missing the organization of each paragraph, starting from the main idea, the controlling idea, paraphrase, and examples in the conclusion. As a result, my first writing assignment did not turn out that strong. But now, I know how to properly and correctly construct my paragraphs, and how to focus on each paragraph’s structure to make them look precise and clear. I took advantage of this class, learned as much as possible and I am completely prepared for the following levels.

Analysis of The Sykes-Picot Agreement

Analysis of The Sykes-Picot Agreement Christopher Mike White The current actions of the Islamic State (ISIS) in Syria and Iraq are a result of religious and political conditions which exist due to irresponsible foreign diplomacy and the imperialistic tendencies of both Great Britain and France over one hundred years in the past. In a viral video declaring the establishment of their Islamic Caliphate early in the summer of 2014, the Islamic militants of ISIS expressed their goal to reverse the territorial lines established by the Sykes-Picot agreement.1 By the end of 2014, the groups advances in Northern Iraq and at the Turkish-Syrian border had, in fact, destabilized the existing borders drawn in the Sykes-Picot agreement.2 The Sykes-Picot Agreement was a deal negotiated between the Entente Allies, minus America, in anticipation of the fall of the Ottoman Empire at the end of World War One. The agreement split the Middle East, which had been under Ottoman Rule for nearly four hundred years, between the three Western nations. Britain would maintain control over what is modern day Iraq, France the region of what is now Syria and Lebanon, and Russia initially partitioned a small section of land north of Iraq. The Russian zone was removed with the rise of the Bolsheviks in 1917 and subsequent collapse of the Russian Imperial State. The boundaries drawn in the Sykes-Picot agreement would be used post-war as the basis for the formation of the mandate system in the Middle East under the League of Nations, giving Great Britain and France their mandates to develop their respective regions.3 The Sykes-Picot agreement ultimately failed for several reasons. First, they used a negotiator who was centered on imperial interests and refused to listen to those who had experience with the people and history of the region. Second, they sought to use King Hussein as a political tool and negotiated in bad faith to make sure that things went in their favor. These mistakes showed a flawed understanding of the people and culture of the region, an error that haunts the American military today as they too refuse to learn the history of the area and use errors of past Empires to their advantage. The first problem the British encountered in the agreement was made before the deal even being signed. The British used a negotiator who was not objective enough to realize what would be necessary for a lasting peace and control, a negotiator who was focused on imperial interests and expansion. Mark Sykes was the representative of the British Empire in the negotiations. Sykes was an imperialist member of the Tory Party who, to his credit, possessed a broad personal experience in the region. Sykes was atypically tolerant of different religions but still suffered from the typical racial and cultural prejudices of the time. These biases would affect his decision-making process during negotiations.4 Sykes was convinced the Arabs were incapable of self-rule, not being as capable and civilized as the British, a common feeling in the Empire at the time. Due to these arrogant Imperialist ideals, Sykes sought to help them prosper through continuing advancement of the British Empire and its beneficial, benevolent influence in the Middle East. Sykes lack of understanding of the local population and his Britain-centric ideals of Empire made him a poor choice to negotiate the fate of the Middle East due to his lack of proper analysis or to use any of resources available to him. Sykes negotiations ignored the proposals made by a group of scholars known as the British Arabists who were very familiar with the issues of the region. These men and women were members of the British foreign service, a branch of British Government similar to the U.S. State Department, who worked almost exclusively in the Middle East. The unique experiences of this group led them to develop a deeper understanding of the local population than that of most close minded imperialist subjects. Their deeper understanding led them to develop ideologies about the local culture and people based on self-determination of the indigenous peoples vice outside rule and interference. The most famous and easily recognized of the Arabists were T.E. Lawrence and Gertrude Bell. Lawrence and Bell both petitioned the British Empire to move forward with a policy supporting independence in the Middle East to avoid future conflict in the region due to the Governments complete lack of understanding of local c ultures. Despite their considerable knowledge and experience, both Lawrence and Bell were marginalized by the bureaucracy of British political intrigue. The borders drawn by the Sykes-Picot agreement were recognized during the San Remo Conference of 1922 through the League of Nations mandate system.5 Had the British government looked at, analyzed and understood any of the Arabists policies, the post-war borders drawn for the Middle East would have considered the myriad differences in culture and religion, differences that still complicate regional politics. By ignoring the Arabists, the Sykes-Picot Agreement altered the development of Middle Eastern society and politics in the twentieth century from its natural tribal based system into a Western, nation system with definite borders that did not consider religious and cultural differences. This modified system contributed to several unintended consequences. It motivates militant groups such as ISIS. Additionally, perhaps, more importantly, it grants them a level of legitimacy with the local population that makes them a larger threat. The militant groups have developed into an idea to be eliminated not just insurgents to be killed. The second issue in the agreement was the faithless negotiations they conducted with King Hussein. In early 1914 the British initiated discussions with the ruler of Mecca, Emir Hussein, the King of Hejaz, who claimed to be a direct descendant of the Prophet Muhammad. Because they were direct descendants of the Prophet Muhammad, Hussein, and his sons would be a powerful and symbolic tool to unite the various religious sects in a revolt.6 As Britain was drawn into the War with the Ottoman Empire, Husseins son Abdullah reached out to the British to garner support for an Arab revolt in Hejaz.7 Discussions in support of this revolt continued over the next two years with both sides specifying demands.8 These negotiations were primarily carried out through a series of letters between Hussein and Henry McMahon, the British High Commissioner in Egypt. Husseins desired an independent Arab state in the Middle East in return for his cooperation in defeating the Ottoman Empire, conversely, while the British badly needed the local Arab support they would not abandon their imperial ambitions in the region. by October 1915, with negotiations having stalled on this point, Hussein had become increasingly angered by Britains unwillingness to agree to his terms. To move past the negotiations stalemate, Hussein gave the British an ultimatum of thirty days in which to concede to Arab independence following the war in return for his suppo rt. If the British declined, Hussein informed them that he would sign an agreement with the Turks who were willing to consent to his demands in return for his allegiance to the Axis powers at this point of the war.9 Britain now had an important decision to make. They could grant Hussein his wishes, gaining crucial support in what had become a long and costly war, but in doing so give up any hope of acquiring any new post-war provinces in the Middle East. Alternatively, they could decline his offer turning potential allies into yet another enemy to contend with, making gains in the Middle East more costly and endangering vital territories already held such as the Suez Canal. Given these choices, and in the grand fashion of Brittania waving the rules as she sees fit, McMahon combined the choices into a less than optimal choice. McMahon informed Hussein of his consent to Husseins conditions in return for aid in defeating the Turks, consent which of course came with stipulations in favor of the British. The most significant demand by the British was that certain regions of Mesopotamia, those rich in oil, be placed under special administrative arrangements.10 McMahon also specified that such conditions could only be enforced with the approval of Britains ally, France. McMahon and his advisors knew of the French desire to acquire more territory in the Middle East and the potential trouble which would be caused by overtly opposing them following an Allied victory.11 By making these requirements including the stipulations on France, the British had virtually made Hussein a promise which they would not and could not keep. The French ambassadors discussed their determination to take hold of the entire region but the British having special administrative arrangements now had the upper hand. Now British diplomats wer e willing to negotiate in regards to Syria, however, they were absolutely unwilling and had no reason to relinquish any claim to the area that is now modern day Iraq. With this impasse, France and Britain set out to negotiate an agreement which would split the Middle East between them following the collapse of the Ottoman Empire instead of honoring any agreement they had with Hussein. By May 1916 British representative Mark Sykes finished his meetings with Georges-Picot of France, mainly in the pub over a few pints per Professor Kohnen, and had drawn a map which would ultimately determine the boundaries of the modern day Middle East.12 Looking at the map of the modern Middle East and the ongoing conflict involving ISIS in Syria and Iraq today you can see the geographical connections to the negotiations between McMahon and Hussein which centered around Husseins desire for an independent Arab state in the Middle East. At the height of its power the Islamic State had established territories under their control stretching over parts of Syria and Iraq up to the border of Turkey. The Areas that ISIS has reclaimed were the areas originally promised to Hussein for Arab independence by McMahon in his correspondence. This rapid rise and success of ISIS has come about due the direct results and the inadequacies of the Sykes-Picot Agreement and British Imperialism as well as the dispute between Sykes and the Arabists. ISIS seeks to create the promised independent Arab State envisioned by Hussein, though this time based on Islam, promised in the McMahon-Hussein Correspondence and Sykes-Picot agreement one hundred years prior. T he problem now is that they have a desire to expand beyond what was promised and turn it into a worldwide caliphate in revenge for the past.13 The Peshmerga, Kurdish fighters from Turkey and Iraq, are in opposition to ISIS and its policy of ethnic cleansing. The Peshmerga are fighting for an autonomous Kurdish state in competition with the Arab state desire of ISIS. At least these two opposing forces in the Middle East and its current conflict are motivated by ethnic and religious differences exacerbated Sykes-Picot and the arbitrary lines it drew in the sand without considering culture and religion. Because of the imperial ambitions of Sykes and the desire of France to control Syria and the disregard of input by the Arabists and the individual Arab groups affected by the agreement, the borders of the Middle East were artificially created by Sykes and Picot. These artificially created countries have populations who fundamentally oppose each other ethnically and religiously. Had the Arabists and affected Arab ethnic groups been involved in creating the new Middle East map instead of just the Governments of France and Britain focusing on imperial aspirations, many of todays problems could have been avoided. If the British Government had acted in good faith in the negotiations with King Hussein, they would have been regarded more as allies than enemies whose word could not be trusted. The locals of the Middle East have a strict code of ethics and honesty is important. With the British being the visible representative of the West to the local population, McMahon has managed to show t he entirety of the West as untrustworthy to a populace with a very long memory. The United States has now inherited this problem and has a chance to use the history of the region and the agreements made here to help come to a more peaceful and lasting conclusion. Unfortunately, we are not using history and its lessons, instead reverting to mirror imaging the enemy and trying to win a war based on what we consider to be rationality without considering that the enemy gets a vote on the progression of hostilities. The training that we do to learn the culture of the area is a decent start, but it is only an overview and does not help in that it is out of context with the beliefs of the people. We are the same in the eyes of the locals as those who have oppressed and invaded their territories for hundreds of years with the only difference being a slightly different accent. If we are to be effective, we need to incorporate more history into the cultural training of the region so that our troops and Government leaders can begin to understand the root causes of the prob lems seen and then start to find solutions while avoiding further antagonization of the local people. Perhaps it would be a good choice to ensure a space for a historian on the major command staff so that these lessons wont have to be relearned. NOTES 1 The End of Sykes-Picot, (ISIS. 2014. Syria: Youtube, February 26th, 2015). 2 Sykes-Picot Agreement | 1916 | Britannica.com, accessed January 5, 2017, https://www.britannica.com/event/Sykes-Picot-Agreement. 3 Sykes-Picot Agreement | 1916 | Britannica.com, accessed January 5, 2017, https://www.britannica.com/event/Sykes-Picot-Agreement. 4 The Balfour Declaration Key Players and Events by Mary Grey | The Balfour Project, accessed January 9, 2017, http://www.balfourproject.org/the-balfour-declaration-key-players-and-events-by-mary-grey/. 5 The Origins of the Sykes-Picot Agreement | History | Smithsonian, accessed January 5, 2017, http://www.smithsonianmag.com/history/sykes-picot-agreement-180957217/. 6 Lawrence of Arabia. King Hussein | PBS, accessed January 6, 2017, http://www.pbs.org/lawrenceofarabia/players/hussein.html. 7 Lost Islamic History | The Arab Revolt of World War One, accessed January 12, 2017, http://lostislamichistory.com/the-arab-revolt-of-world-war-one/. 8 Husayn-McMahon Correspondence | British-Palestinian History | Britannica.com, accessed January 15, 2017, https://www.britannica.com/topic/Husayn-McMahon-correspondence. 9 Husayn-McMahon Correspondence | British-Palestinian History | Britannica.com, accessed January 15, 2017, https://www.britannica.com/topic/Husayn-McMahon-correspondence. 10 Contradictory Promises, by Peter A Shambrook | The Balfour Project, accessed January 14, 2017, http://www.balfourproject.org/contradictory-promises/. 11 Contradictory Promises, by Peter A Shambrook | The Balfour Project, accessed January 14, 2017, http://www.balfourproject.org/contradictory-promises/. 12 Sykes-Picot Agreement | 1916 | Britannica.com, accessed February 7, 2017, https://www.britannica.com/event/Sykes-Picot-Agreement. 5 Sykes-Picot Agreement | 1916 | Britannica.com, accessed January 4, 2017, https://www.britannica.com/event/Sykes-Picot-Agreement. 13 The Sykes-Picot Agreement and the Making of the Modern Middle East, accessed February 4, 2017, http://theconversation.com/the-sykes-picot-agreement-and-the-making-of-the-modern-middle-east-58780.

Tourism Crisis Management Techniques Tourism Essay

Tourism Crisis Management Techniques Tourism Essay Today the inescapable media exposes even the most impromptu viewer to our current world of hazard, disaster and crisis; from Northern Africa and the Middle Easts political unrest and upheaval, to earthquakes in New Zealand, Turkey and Haiti, cyclones and floods in Australia and the Global Financial Crisis in 2008. It was once believed that whichever countries controlled the worlds oil reserves would forever prosper however with the realisation that the supply is not ever ending many UAE States such as Dubai and Abu Dhabi have turned to tourism to secure a continued future income into the country. Tourism is facing an ever increasing threat from crises coming in all shapes and forms, causing it to become even more necessary to develop effective disaster prediction and management plans with an instantaneous recovery strategy to mitigate the impact of any crisis. The nature of the tourism environment will be shown highlighting its global importance whilst introducing different causes an d types of crises supported with numerous examples. Alongside this the hardships faced by the industry and the techniques use to minimise the impact will also be seen. The events of the first decade of the 21th century may lead one to believe that it is a bleak time for the tourism industry and a recessive time for the overall tourism environment however even despite the current economic crisis, to which tourism is not immune, the World Tourism Organization forecasts 1.6 billion international tourists by the year 2020. The importance of world tourism is reflected by The World Travel and Tourism council, whose figures show that the contribution of the Travel and Tourism Economy to GDP was 9.3% in 2010 and will rise to 9.7% by 2020. Cabrini (2010) expressed that tourism is not only important economically it also important for human development as it provides income to some of the worlds poorest people. The extraordinary growth of tourism requires increasing attention from all stakeholders on its sustainability and contribution to world development. Over time, an ever increasing number of destinations have opened up and invested in tourism development , turning modern tourism into a key driver for socio-economic progress through the creation of jobs and enterprises, infrastructure development and the export revenues earned. It is believed that the majority of the tourism in the world is international however the large majority of international travel takes place within the travellers own region, with about four out of five world arrivals originating from the same region. As economic development permeates through the Chinese middle class, so does the demand for new destinations with, in 2010, China having the worlds largest domestic tourism market. Their ethos can be summed up by the British journalist, novelist and poet Gilbert Keith Chesterton, the whole object of travel is not to set foot on foreign land; it is at last to set foot on ones own country as a foreign land. The SARS epidemic in 2003 was one of the most serious public health crises of a decade having the potential to seriously damage or even freeze the tourism industry in China. Crisis management techniques which are strategies, processes and measures which are planned an put into force to prevent and cope with crises (Glaesser, 2006) were immediately implemented and after initially stalling and prevaricating causing the tourism industry to suffer for more than three months, the Chinese government managed to control SARS before it became a global catastrophe. This accomplishment required political will, national mobilisation and a series of support policies such as the exemption of administrative, operation and construction taxes, the provision of discount loans and quality assurance deposits to travel agencies (Dombey, 2004). China also developed its own practice of domestic tourism policies such as promotional campaigns like the 2009 China domestic travel fair in April 2009, partnerships like the collaboration between provinces themselves and national and provincial tourism administrators; they also implemented fiscal policies, investing around US$140 million and price cutting where Beijing started to issue two million free tickets of scenic spots to domestic tourists along with longer national holidays (Li, S.N 201 0). Source markets for international tourism are still largely concentrated in the industrialized countries of Europe, the Americas and Asia and the Pacific, however, with rising levels of disposable income, many emerging economies have shown fast growth over recent years. Tourism as a product is itself a function of risk, which is a perceived probability of negativity associated with a tourists behaviour or destination choice. Risk is not a tangible aspect of travel; it is what tourists perceive and experience during the process of purchasing and consuming tourism related services and while being at the destination (Cooper et al, 2008). Travel risk has a great influence on a tourists decision and if the risk perceptions are too high than a destination can suffer greatly as risk averse tourists, who have a diminishing marginal utility, are deterred from the visiting. Tourism is an economic sector whose response to negative events is like no other, it has an above average sensitivity and is more susceptible to shocks and disruptions due to it being a highly perishable sector, requiring consumers to travel to a destination and the environment in which the destination is in. Tourism can be seen as a vulnerable industry for that its particular size and structure means that a large amount of little companies will be needed to provide a tourism experience that are all interdependent on one another. As tourism is a global industry even a country not directly related to a crises can easily be affected, for example even though 9/11 occurred in the US there was a snowball effect which caused not only the worst impact on the worldwide tourism industry since World War II, but also demonstrated how terrorism was able to trigger a slowdown of the whole worlds economy (Ali 2010). A greater number of countries are interlinked and have a degree of inseparability meaning that you cant separate a tourism experience from its place of production with Buhalis (2000) believing a destination is an amalgam of tourism services and experiences; also having to get tourists to the destination increases the level of risk by increasing volumes of people. The places in which tourism is located also increases its vulnerability, such as coastlines, and that the power of one natural disaster such as the 2004 Indian Ocean Tsunami whipped out all tourism amenities and accommodation, with world nations needing to provide over US$14 Billion in aid for damage regions (Jayasuriya 2010). Ski resorts are also another example, as mountains themselves are more hazardous than urban areas, but crisis management techniques, actions taken by firms in an attempt to control the progress and outcome of a crises (Laws 2006) are regularly imposed such as controlled avalanches. This example highlights that fundamentally crisis management should be embraced in a management system rather than as a threat moving away from it being a management reactive response. Tourist places are also affected by climate change, nowhere more so than the Seychelles and Maldives in the Indian Ocean which are both economically dependent on tourism, with the latters very existence being really threatened with rising sea levels. Tourism is also very sector specific relying heavily on transport and any disaster in this industry will have a great effect on tourism with the ash could over Europe in April 2010 grounding flights and closing airports. Crisis management strategies were instigated no more impressively so than KLM who took the chance to adopt social media to manage this crisis by using its Facebook page. It addressed every single wall post promptly providing much timely information to customer service with regards to re-booking, detailed reports and location specific information (Tan 2010). Tourist destinations are also often seen as soft targets for terrorism as tourists are easy to spot and stand out from natives in any area. They are essentially a big target in a small area for example in October 2002 a few bars in the tourist district of Kuta in Bali was targeted killing 202 people. If terrorist have a political motive targeting tourist is a influential way as there will be a mass influence on the media. Tourisms importance can also be seen in its intra and inter linked nature in figure 3, whether its with other tourism organisations and destinations or with governments and other industries. Figure 3 The tourism environment For example a British tour operator may use an Australian flag carrier to fly to Singapore and utilise a local transfer company to get to the Hong Kong based Shangri-La hotel. Leipers (1979) model of tourism takes into account all these stakeholders and includes all the elements intrinsic for a tourist to travel. Its power is inherent as it places tourism in the context of various external environments such as society, politics and economies which are fundamental for crisis management as these must all be assed when one takes place. A typical large scale disruption will force complex movements away from previous relationships which will then usually tend towards stability and equilibrium with Keown-McMullan (1997) noting that organisations and the way in which they interlink will undergo significant changes even when they are successful in managing a crisis situation. During and after a crisis, the destination and its organisations also have to manage their ongoing relations with oth ers in its network of partners. It is often the case that many services will have to be cancelled at very short notice, but, apart from the contractual obligations between partners, there are more fundamental issues of trust and reciprocity. Support organisations are also likely to make considerable efforts beyond their contractual responsibilities to assist in dealing with the problems that result from a crisis. Competitors often come together and provide extra resources to support a fellow member of the tourism industry. There has been an increase in the number of natural catastrophes from 20 in the 1950s to 91 in the 1900s and over 1000 in the 2000s (Glaesser, 2006) such as earthquakes in New Zealand in 2011 and Chile in 2010. Their impact on the world especially on the tourism industry has been heightened due to continued exponential population growth, climate change and human technological achievements. Tourism can also be plunged into crises due to manmade circumstances such as war, the 2000 coup in Fiji, disease and epidemic, the 2001 Foot-and-mouth outbreak in the UK and SARS across Asia 2002-2004, transport, the Air France Concorde crash in 2000, political and economic, the Global Financial Crisis in 2008 and recent events in Northern Africa and the Middle East, acts of terrorism, 9/11 and the bombings in Bali in 2002. It may be thought that the words crisis, disaster, catastrophe and hazard are all synonyms for each other however they all have very different meanings. Catastrophes are negative events which in contrast to a crisis have a clear inevitable outcome thus missing a crisis ambivalence of development and restructuring opportunities ex post. A hazard can be thought of as a lower level problem that would not in itself deter tourists from a destination but could be the swaying factor in a decision which was already uncertain; for example for a risk averse or neutral tourist. Smith (1995, from Ritchie 2004) believed that a disaster would spring from a hazard and that there are no such things as natural disasters only natural hazards with a disaster being the realisation of a hazard and its impact on society. A disaster and crisis can be similar as they both involve an event, natural or manmade, which impacts with such severity that the affected community, organisation or group has to respond by taking exceptional measures. There is often confusion when a crisis results as cause from a disaster with Falkner (2001) making the distinction that a crisis has some degree of being self inflicted through problems such as inept management structures and practices or a failure to adapt to change whilst a disaster has an element of no control as an enterprise is confronted with a sudden unpredictable catastrophic change. Some places may be associated with greater travel risk than others and thus even without an actual crisis taking place travellers may be deterred from that destination. In the context of tourism the World Tourism Organisation (UNWTO) has defined a tourism crisis as any unexpected event that affects traveller confidence in a destination and interferes with its ability to continue operating normally and Sonmez (1998) as any occurrence which can threaten the normal operations and conduct of tourism related businesses, damage a tourist destinations overall reputation for safety, attractiveness and comfort by negatively affecting visitors perceptions of that destination and, interrupt the continuity of business operations for the local travel and tourism industry by the reduction in tourist arrivals and expenditures. These two definitions focus on the direct impact of the event itself however Beriman (2003) expressed a tourism crises as a situation requiring radical management action in response to events beyond the internal control of the destination, necessitating urgent adaptation of marketing and operational practices to restore the confidence of emp loyees, associated enterprises and consumers in the viability of the destination. Glaesser (2006) saw a crisis as an undesired, extraordinary, often unexpected and timely limited process with ambivalent development possibilities. It demands immediate decisions and countermeasures in order to influence the further development again positively for the organisation/destination and to limit the negative consequences as much as possible. A crisis situation is determined by evaluating the seriousness of the occurring negative events, which threaten, weaken or destroy competitive advantages or important goals of the organisation. In order to pursue the effectiveness of crisis management techniques on impact mitigation, we shall focus on the latter two definitions as they not only focus on the direct impact but also the ex post responses. Figure 6 below highlights the impact of any crisis showing that numerous parties would be affect due to tourisms interlinked nature. Figure 6 The various spheres of activity In observing that our environment appears to have become increasingly tumultuous and with the number of crisis increasing, Richardson (1994) suggested that this may not only because we live in a more complex and crowded world but because we have more powerful technology that has a real capacity to generate disasters, which complicates the process of isolating cause and effect relationships. Thus the boundaries between natural and manmade disasters are becoming increasingly blurred which needs to be taken into account in any analysis and critical evaluation. Ali (2010) highlighted that recently crisis management in the tourism industry seems to have received more attention in the generic fields of management and crisis management, whereas Henderson (2003) believed that despite the expanding literature in the field, the interaction between crisis and tourism in its multiples forms still appeared under-researched in comparison to other dimensions with scope for further scrutiny in pursuit of a better understanding. Sonmez (1998) argued that although there has been a large advocation of the necessity of crisis management efforts, few have explored solutions and preventative solutions possibly due to the grandeur of the task. Ritchie (2004) insisted that due to the different paradigmatic positions in crisis management, research must explore the attitudes and opinions of mangers and policy makers in both the private and public sector in order to test different models and concepts in the field. To see how crises are managed and whether the met hods employed are effective we must understand that there are many different stages. One of the most extensive works done was by Faulkner (2001) who developed a disaster management framework in tourism that provided a six-phase process. The first is the pre-event phase in which disaster contingency plans, scenarios and probability assessments play a major role in the disaster management strategy. Although the actual timing, location and severity of natural disasters cannot be accurately predicted it is possible to learn from the past to pre-plan emergency procedures and to mitigate the severity of such events by adopting appropriate building codes, escape routes and alternative measures. A study conducted by Boudreaux (2005) discussed the impact of the September 11, 2001 attacks on participants crisis preparation. It was stated that there has been a new emphasis on the security of their facilities and the use of government sanctioned training or meetings to support crisis preparation and highlight public safety. The second is the prodromal phase where the disaster is imminent and warning systems and command centres are established with contingency plans being initiated. The role of a crisis manager here is not reactive, but instead a proactive approach where information can be found in various places, such as internal and external audits, government legislation and industry publications. The third is the emergency phase in which the disaster effects are felt and actions are necessary to protect people in the tourism destination. A prime example of this was immediately after the 2004 Indian Ocean earthquake and tsunami in which tourists and locals had to flee for their lives seeking safety in any types of buildings with sizable ground clearance and authorities constructing shelters for disaster ridden South East Asians. The fourth is the intermediate phase in which short-term and immediate needs of people have to be addressed by emergency and rescue teams with a clear media communication strategy also being crucial in this phase. An example of t his was post Hurricane Katrina in the 2005 Atlantic hurricane season in which the US government alongside domestic and international aid agencies set up community shelters and organised food, water and sanitation programs. The fifth stage is the long-term (recovery) phase in which the damaged infrastructure has to be rebuilt, and environmentally damaged areas have to be reconstructed. A prime example is the 2010 Haiti earthquake in which Renois (2010) estimated that 250,000 residencies, 30,000 commercial buildings and 16,500 schools had collapsed or were severely damaged which all needed to be rebuilt. The final is the resolution phase corresponding to Finks (1986) where routine is restored or a new, improved state occurs. This stage identifies a clear end to the crisis; although organisations view this as the goal, it is not one to be rushed to. An organisations premature conclusion that Finks (1986) third chronic stage has ended can leave them vulnerable to the resurgence of the c risis. Due diligence in the earlier stages of the model must be practiced to ensure such a regression does not occur. Having explored crises in great detail we shall now move to see how they are handled in order to limit their damage. Crises occur on a scale spectrum that ranges from local through to global and in todays world, crisis and disaster management is a major requirement for all businesses, defence and government organisations. How efficiently any crisis or disaster is handled depends on the decision making capabilities and the resources available. While technical expertise can improve crisis avoidance or minimise the disruption resulting from a crisis good management is also need to deal with both the needs of those affected and the adverse publicity which might result. Policy makers are faced with the challenge of how to respond to such crises sometimes in the absence of any disaster management framework. Good crisis management is partly about the ability of organisations to learn from experience and that of others and partly about the willingness of leading organisations to carry out research and then pass on information which is required for effective pre-planning. Dreyer (2001) believes that it is o f prime urgency to assess the crisis early enough and to adopt existing crisis plans within the affected area and then later in the operational crisis management stage the goal is to manage the ongoing crisis and to limit damage. It is clear that a strategic approach to crisis planning and management is needed to help retain the confidence of travellers and the travel industry and to minimise the negative impact of crises on destinations. The goal is to get tourists back to affected destinations as quickly as possible and with good crisis management techniques this can be speedy. Regardless of crisis type, the techniques for dealing with it are similar. According to the UNWTO, good communications based on the principles of honesty and transparency together with communications, promotion, security and market research are the key to a successful strategy for crisis management. The early reports of a respiratory disease in one part of China didnt alarm the tourism industry in most countries and the first few days reports of the Foot and Mouth outbreak in the UK generated some concern but primarily for agriculture. In both cases measures were taken as a reaction which triggered an impact on tourism. The latter caused all footpaths and bridleways to be closed effectively closing the countryside to tourists and the latter made the travel advice given by governments and the WHO (World Health Organisation) made consumers and airlines change their plans. A large consequence of a crisis will be a substantial drop in sales volumes, for example the drop in turnover for airlines alone as a result of the Gulf War was estimated at 2 billion dollars (Blake and Sinclair 2003). Terrorist attacks in Egypt during the 1990s also caused tourist to stay away which meant that in the space of a year, the revenue from the international tourism industry for this destination droppe d by 1 billion US dollars. This was topped by the events of 9/11 in the USA, which caused not only the worst impact on the worldwide tourism industry since World War II, but also demonstrated how terrorism was able to trigger a slowdown of whole worlds economy. These examples illustrate how the tourism industry as an economic sector is challenged by negative events. It is therefore important to analyse negative events from every angle, to systematically identify critical success factors which are elements that organisations should focus on during a tourism crisis and integrate them to ensure effective strategic corporate orientation between different stakeholders, ensuring a most effective recovery plan. Lynch (2004) provides steps for tourism organisations that should be taken to mitigate the effect of a crisis over a three phase model, the first few weeks, three months and three years later. During phase one resources and media messages must be organised, statistics and scenario planning must be undertaken, mechanisms of communications within the tourism industry and customers must be established as some methods may have been destroyed and a wish list uniting all parties around a few key things articulated consistently. This time is likely to be frantic but is most important for the provision of human life. In phase two certain new realities will have influenced everyones thinking and there will be an urgent need to get customers travelling again. This is about tactical marketing to make sales and rebuild confidence, for example do you price cut or add value. The main things to focus on are making the case for financial support, lobbying for other measures which will help business with cash flows e.g. deferral of tax payments and providing good quality information to policy makers on how the crisis is developing. In the next three years (phase 3) it is necessary to wind down the crisis teams, promote the destination and focus on the return of the customer especially traditional customers. Systems changes will be now be being implemented and as we know new relationships will have formed which need to be nurtured. A recurring theme in crisis management is that of recovery and getting tourists back to the area and this is largely influenced by the medias response and so Beirman (2003) defines four steps in the marketing management of a destination crisis with the emphasis on how the crisis is managed in terms of the appearance projected. The first two steps are identifying the event or problem as a crisis or hazard with the latter just being a lower level problem that would not deter tourists in itself and establishing a crisis management team and defining roles, both which we have seen before. The difference is in the emphasis of the third step which is promoting the destination during and after the crisis, highlighting the importance of the media again in the recovery of a destination as crisis management is as much about dealing with human perceptions about the crisis and the management of a crisis as it is about physically resolving the crisis (Health, 1998 in Miller and Ritchie 2003). The last is monitoring the recovery and analysing the crisis experience in order to learn from the situation and improve their techniques. There are numerous crisis management frameworks or models available for companies and destinations to base their activity on. One suggested was by Heath (1998, from Ritchie 2009) known as the 4 Rs; reduction (risk management), readiness, response and recovery. Another was by Hystad and Keller (2006, from Ritchie 2009) which involved the stages; pre-disaster, disaster, post disaster and resolution. Santana (2003, from Ritchie 2009) nicely brought these similar strategies and others together and put together a two stage model of proactive crisis management consisting of signal detection, preparation and prevention and post crisis management involving damage limitation and recovery. The pre-crisis stages normally involve scanning the environment using a PEST (political, economic, socio-cultural and technological) analysis or consulting the countries foreign office for advice. It can be challenging to specify the danger precisely but even if you know what to look for provisions may not b e implemented. In 2002 post 9/11 there was widespread international recognition that the tourism industry may be a soft target for terrorists which should have prompted tourism industry bureaucrats to consider the possibility of an attack, however believing that Indonesian tourism enhances peace between nations the government were too optimistic that no incident would befall them (Andari, 2008). Even so there was no organisation learning, incapacity to improve or continuity in the institutions responsible for designing and implementing the recovery plans as they believed that it would never happen again, leading to private organisations doing a large bulk of the work, but in 2005 the second bombs struck (Andari 2008). Quite often this first stage does not occurs as we have seen but also was the case in turkey 2001 where the research findings reveal that neither the government nor private organizations had any plans for dealing with the crisis before or after the event (Okumus 2005). A pre-crisis success method is in the form of examining and risk assessments using maps which help identify the most vulnerable parts of a destination for example landslide maps in Brazil and Chile, and flood maps in the UK and Australia. Successful mitigation can also help to reduce the loss of human life and damage through physical measures like dams and cyclone shutters and through diversification if an area relies too heavily on tourism like the Maldives. The importance of plan creation is paramount like emergency plans and warning systems which are now in place throughout South East Asia, building codes in earthquake prone areas; the London 2012 Olympic Games have also had stringent terrorist attack simulations. Responding to the crisis itself requires coordination and control with its handling being essential to mitigate a crisiss impact. The 2001 Foot Mouth Outbreak in the UK and 2005 Hurricane Katrina were poorly managed with the former suffering as tourism was not perceived as a stakeholder leading to the allocation of resources to the agricultural sector. This disaster for the tourism industry was not the disease itself but the actions taken to eradicate the farming crisis and the media images associated with these actions (Miller 2003). The latter became the costliest natural disaster in the history of the USA (Knabb, 2005) due to reasons like a slow response at the federal level given there was some warning and time to prepare and a lack of overall control as discrepancies as to which body were in charge. In this stage of a crisis the media play a huge part to whether the area will recover and prosper in the near future. In regards to the very early stages of a crisis it is often not at all clear what the scale is, what the likely duration will be of solving it will be or exactly who has been affected. There may be many reporters on the ground, tourists who may phone or email contacts often providing video clips of the situation which are inserted into news broadcasts; in this way misinformation may spread. In the longer term, in managing the aftermath of a crisis when the immediate short term problems have been dealt with, the destination will turn to the media with a combination of advertising and public relations to communicate to their client base that the crisis has been resolved. This alongside marketing campaigns will be used to stimulate demand in order to fill some of the lost revenue. Essential is a quick response, consistency in the information given out and openness and honesty. The 1988 Lockerbie disaster and the two examples just discussed were examples of poor media communication however much better handled disasters were the 1989 Kegworth air di saster with the companys reputation actually enhanced ex post even though it was actually their fault and 9/11 with New Yorkers positive spirits documented and the Mayor as the spokesperson for the city. The final stage is that of recovery and resolution which has already been discussed in Faulker and Finks frameworks. The key elements are media and marketing communication getting tourists back to the affected area, physical recovery like infrastructure repair and sharing best practices in the reflection and learning process. As well as negative outcomes, crisis and disasters also have potentially positive results such as stimulus for research and innovation, economic and human development and the emergence of new markets. Some crises are largely restricted to the tourism industry and arose from problematic characteristics in its own operations. The origins of other crises lay completely outside the influence of tourism sector managers, and many of these crises devastated large areas and killed, injured or damaged many sectors of the local population or key infrastructure and industries. Thus we have seen the ever changing nature of the world and its population making tourism organisations and destinations more susceptible to crises and disasters, a more vulnerable industry in general with the potential for major impacts. This creates vast challenges for the industry however by establishing the phases of a crisis, disaster management techniques and strategies can be implemented to mitigate the impact of t hese, more often than not, catastrophic events.

Muscle Growth Essay -- Muscle Growth Physiology Health Essays

Muscle Growth With the introduction of such modern conveniences such as the automobile, remote control, and even the electric toothbrush people are relying on technology to do everything for them. With a generation growing up in todays society physical tasks have almost become obsolete. Tasks such as even going shopping and going out to visit a friend can be done from the comfort of your own computer. With this sedentary lifestyle, muscular size will almost be unnecessary, except for the athlete who wants to succeed in sports. To the non-athlete, there will be no reason to leave the house because everything that you need will be at your fingertips, you will not have to get up and do anything. Any type of exercise is good for the body and muscles. Muscle growth is essential if you want to look better, feel better, and perform everyday tasks such as walking to the car, and getting out of bed easier. A person who is in shape will also sleep better then an out of shape person, and feel more revitalized in the morning. Muscles account for approximently 35% of the body weight in women, and about 45% of the body weight in men. With over 600 muscles covering the human skeleton muscles give the body bulk and form. Then human body contains millions of muscle fibres whose coordinated contraction cause the whole muscle to contract. Muscles are the foundation on which our bodies are built. Without muscles our bodies could not perform the simplest tasks such as opening our eyes, talking, breathing and even the pumping of our heart or the most difficult tasks, such as running the hurdles in a track and field event.. Muscles are also important to maintain balance and posture. Description of Muscles In the body there are several types of muscles that control different functions in the body, one of these types being skeletal muscle. Skeletal muscle is the most evident in the human body due to it having the most mass the other types of muscles and that it lies directly under the skin attached to the skeleton by tendons and ligaments. Skeletal muscles are divided into three structural units, the entire muscle, the muscle bundle, and the muscle fiber (cell). Each muscle fiber is divided into two types of fiber structure, fusiform and pennate, with the pennate being broken up into three basic structures. These structures being the un... ...ng program you should properly stretch the muscles being worked in order to keep them loose. Stretching should also be done directly after a workout because the muscles are still warm and can be stretched more easily. This will also increase flexibility which can be very advantageous in preventing injuries such as muscle sprains and strains. A Conclusion to Muscle Growth A muscle growth program can be beneficial to everybody, from the young athlete wanting to succeed in sports, to the older man trying to help stay and feel young. The benefits of muscle growth are too high to be passed out by anybody who has any sort of ambition of feeling better about themselves, looking better, and having more energy for everyday tasks. You will find that once you start weight training, and muscle and strength growths are noticed that it will almost become addicting and the desire for bigger and better results will become greater and greater. I would recommend muscle growth to anybody, and anyone who disagrees should give it a try, just for a little while, and after the results of improved strength and muscle size are noticed weight training will become a part of their life.

Poor Time Management of Island Students Essay -- internet usage, video

Introduction & Problem The simplicity of life, and the more relaxed environment, does not permit students who grew up on islands, or Island students, to understand the importance of time. There are more than 30 Island students studying on campus. Coming from a carefree society where time is not a major concern is having a great impact on individual students. Poor time management by Island students is a major problem and concern that needs to be improved in order to enhance the effectiveness of study process and academic performance. The main purpose of this research is to find out and reduce the processes or factors involved in contributing to poor time management. The reduction in the time management factors will help Island students to utilize time in manner that is beneficial for academic performance. Processes that contributes to poor time management There are many processes that contribute to poor time management in students. In this context, a major contributor of poor time management for Island students is the use of Internet. Coming from the Islands, where excess to internet is very difficult, students tend to spend hours surfing through the net. Internet is a helpful tool for students but it also wastes time if not used in the way it should be used. Apart from academic reasons, Facebook, YouTube and watching movies online are the main sites visited by Island students. Research Methods Research methods that has been utilized for this process comprises of data collection, observation of students in the computer labs and student accommodation halls. Students were followed on Facebook to see latest updates and activities and face to face interview was carried out to collect the necessary data needed for this... ...he exact number of hours each student spends. The Pie Chart below clearly shows the percentage of average number of student’s time spent on each activities. 20% of students investing private time to Facebook is certainly a factor that needs to be reduced to help students. 14% of YouTube viewers is also much higher than the percentage of students investing time in reading studying and doing assignments. Recommendation As long there is free internet service on campus, Island students will still have access in visiting the above mention sites. The students must be given more workshops to manage time wisely, teaching students about how internet can be used in an effective way that is beneficial for academic purposes. Though the student service, extra tutorials needs to be provided to keep students busy, instead of wasting time on sites such as Facebook.

Diabetes Mellitus Study Guide

DIABETES MELLITUS * Chronic multisystem dz , abnormal insulin production / impaired utilization * Disorder of glucose metabolism related to absent/ insuff insulin supply or poor utilization of inslin that’s available * 7th leading cause of death * leading cause of blindness, ESRD, lower limb amputation * contributing factor for heart dz/ stroke risk 2-4 x higher than without DM * INSULIN – hormone produced by cells in islets of Langerhans of pancreas.Normal – continously into bloodstream ( basal rate), or increased w/ meals (bolus) * Normal glucose range 70-120 mg/dL, average insulin secreted daily 40-50 U 0. 6 U/kg * Glucagon, epinephrine, GH, cortisol oppose effects of insulin counterregulatory hormones they blood glucose lebels, stimulate glucose production by liver, movement of glucose into cells. Insulin released from cells – as precursor / proinsulin thru liver enzymes form insulin & C-peptide ( C-peptide in serum & urine indicator of cell function) * in plasma insulin after meal storage of glucose as glycogen in liver/ muscle, inhibits gluconeogenesis, fat deposition, protein synthesis * Nl overnight fasting release of stored g;ucose from liver, protein from muscle, fat from adipose tissue * Skeletal muscle & adipose tissue receptors for insulin insulin-dependent tissues Type I Diabetes Juvenile onset, insulin-dependent, s/s abrupt but dz process present for several yrs, 5-10%, absent or minimal insulin production, virus/toxins, under 40, 40% before 20 yr * s/s thirst( polydipsia), polyuria, polyphagia ( hunger), fatigue, wt loss, Kussmaul respirations * immune mediated dz; T-cells attack & destroy cells * genetic predisposition & exposure to virus * Idiopathic diabetes – not atoimmune, strongly inherited, in small # pt w/ type I DM , African/Asian * Predisposition HLAs human leukocyte ntigens when exposed to viral infection cells destroyed * Long preclinical period, s/s develop when pancreas can no longer produce suffi cient insulin to maintain nl glucose levels * Req. insulin from outside source exogenous insulin eg. injection * No insulin diabetic ketoacidosis (DKA) life threatening, results in metabolic acidosis * â€Å"honeymoon period† – newely diagnosed pts, tx initiated pt experience remissions req little insulin because cells produce suff amount of insulin lasts 3-12 mths then req permanent insulin Prediabetes * risk for developing diabetes glucose levels high but not high enough for diabetes diagnosis * impaired fasting glucose IGF 100-125 mg/dL * 2 hr oral glucose tolerance test OGTT 140-199 mg/dL * HgB A1C – 5. 7%-6. 4% risk for diabetes * Increased risk for developing DM type II – if no preventive measures develop DM in 10 yrs * Long term damage to body heart, blood vessels occur in prediabetes * Usually no symptoms * Maintain healthy weight, exercise regularly, healthy diet risk of developing diabetes Type II Diabetes * Adult onset, non-insulin dependent, 9 0% * > 35, overweight, tendency to run n families * African Am, Asian, Hispanics, Amerian Indians Some insulin is produced but either insufficient for body needs / poorly utilized * Gradual onset, many yrs undetected hyperglycemia, 500-1000mg/dL * Early usu. asymptomatic; high risk pt screen annually * Fatigue, recurrent inf, vaginal yeast inf, candida inf, prolonged wound healing, visual changes * Risk factor obesity ( abdominal/ visceral ) * 4 major metabolic abnormalities * insulin resistance > tissue no response to insulin / unresp receptors – receptors are located on skeletal muscles, fat & liver * ability of pancreas to produce insulin – fatigued from compensatory prod of insulin, ell mass lost * inappropriate glucose by liver – too much glucose for body needs – type II * altered prod. of hormones & cytokines by adipose tissue ( adipokines) role in glucose & fat metabolism – type II. Two adipokines ( adiponectin & leptin ) affect insulin sens itivity altered mechanism in type I & I * Metabolic syndrome > risk for type II & cardio dz, cluster of abnormalities, insulin resistance, insulin levels, triglycerides, HDLs, LDLs, HTN * Risk factors for metabolic syndrome central obesity, sedentary lifestyle, urbanization, westernization Gestational Diabetes During pregnancy, 7% of pregnancies * High risk – severe obesity, prior hx of gestational DM, glycosuria, polycystic ovary syndrome, family hx of DM II screened at 1st prenatal visit * Average risk OGTT at 24-28 wks of gestation * Higher risk of cesarean delivery, perinatal death, neonatal complications * Will have nl glucose levels within 6 wks postpartum but risk of DM II in 5-10 yrs * Nutritional therapy – 1st line , if doesn’t work insulin therapy Other specific types of diabetes * Due to other medical condition or treatment causes abn blood glucose levels * Damage , injury, destruction of cell function Cushing’s, hyperthyroidism, pancreatitis, cystic fibrosis, hemochromatosis, TPN * Meds > corticosteroid (prednisone), thiazides, phenytoin(Dilantin), antipsychotics – clozapine * Tx underlying condition, stop meds Diagnostic studies * A1C > 6. 5 % ; greater convenience, no fasting req, less day to day alterations during stress/ illness * FPG >126 – no caloric intake for 8 hrs prior testing ; confirmed by repeated testing another day; if has s/s and FPG>126 further testing OGTT not req * 2 hr OGTT >200, glucose load 75g accuracy depends on pt preparation, and factors that influence results.False negative > impaired GI absorption, falsely elevated> severe restrictions of carbs, acute illness, meds corticosteroids, contraceptives, bed rest * IFG impaired fasting glucose & IGT > prediabetes, 100-125 mg/dL, IGT 2 hr > 140-199 * Glycosylated HgB – HgB A1C > amount of glucose attached to HgB molecules over lifespan ( RBC 90-120 days ) DM pts should check it regularly, done to monitor success of tx / make chang es to tx < 6. % – risk of retinopathy, nephropathy, neuropathy dz affecting RBCs – can affect A1C results Treatment * Goals > s/s, promote well being, prevent acute complications, prevent/ delay onset/ progression; met when pt maintain glucose level as near to nl, daily decisions about food intake, blood glucose testing meds, exercise * Rapid acting insulin – lispro (Humalog), aspart (NovoLog) – onset 0-15 min, peak 60-90 min, dur. -4 hrs , clear, give 15 min before meals ; bolus * Short acting – Regular (Humulin R, Novolin R) onste ? -1 hr, peak 2-3hr, dur 3-6 hrs, injected 30-45 min before meals; bolus * Intermediate acting – NPH, basal insulin, onset 2-4hrs, peak 4-10hrs can result in hypoglycemia, dur. 10-16 hrs, can be mixed w/ short & rapid, cloudy, must be agitated before adm. Long acting – glargine (Lantus), detemir ( Levemir) addition to mealtime insulin, type I, to control glucose between meals & overnight, without it risk of developing DKA, no peak – risk of hypoglycemia , not diluted or mixed, clear; onset 1-2 hrs, dur. 24hrs +, basal * Combination > pt don’t want 2 separate injections, 2 type of insulin mixed together, not same control of glucose levels as with basal-bolus; ahort/rapid mixed w/ ntermediate provide both mealtime & basal coverage * Storage > vials room temperature 4 wks, heat & freezing alter insulin, between 32-86 F; avoid direct exp to sunlight, extra insulin in fridge/ traveling-thermos, Prefilled syringes – sight impaired, manual dexterity; syringes w/ c;udy solution in vertical position needle up to avoid clumping of suspension, rolled gently, warm before injection. * Injection > abdomen fastest absorption arm, thigh, buttock, rotate within 1 particular site; never into site that’s about to be exercised (heat = absorption & onset), vial 1ml=100U, SQ 90 degrees * Needles ? 5/16 inch (short – children, thin adults); gauges 28,29,30,31 – hi gher gauge = smaller diameter = more comfortable injection * Recapping done only by person using syringe, never recap syringe used by pt; alcohol swabs in health care facility before inj to HAI, at home soap & water * Insulin pump – continuous subq insulin infusion 24 hr/d basal rate , loaded w/ rapid acting insulin via plastic tubing to catheter in subq tissue.At meal time – bolus . (+) tight glucose control, similar to nl physiologic pattern, nl lifestyle, more flexibility (-) infection at site, risk of DKA, cost Problems w/ insulin therapy * Hypoglycemia * Allergic rxn – itching, erythema, burning around inj. site, may improve w/ low dose antihistamine ; rxns to Zinc, protamine, latex , rubber stoppers on vials * Lipodystrophy – atrophy of subq tissue if same inj site used Somogyi effect – rebound effect, overdose of insulin induces undetected hypoglycemia in hrs of sleep, produces glucose decline in response to too much insulin s/s headaches, n ight sweats, nightmares ; if in morning glucose – adcised to check glucose levels at 2-4am if hypoglycemia present at that time.If it is insulin dosage in affecting morning blood glucose is reduced TX : less insulin * Dawn phenomenon – hyperglycemia on awakening in the morning due to release counterregulatory hormones in predawn hrs ( possibly GH/cortisol) adolescence/ young; TX: adjustment in timing of insulin adm. or in insulin. Predawn fasting glucose levels insulin production from pancreas , s. ff > wt gain, hypoglycemia * Meglitinides repaglinide(Prandin) insulin prod, less likely cause hypoglycemia because more rapidly absorbed/eliminated, cause wt gain, take 30 min before meal, not if skipped * Biguanides – Metformin > glucose lowering, first choice DM II/prediabetes, obese & â€Å"starch blockers† slow down carbs absorption, taken with â€Å"first bite†, effectiveness> check 2 hr postprandial glucose levels * Thiazolidinediones – Ava ndia > â€Å"insulin sensitizers†, for pts w/ insulin resistance, don’t insulin Production, not cause hypoglycemia; risk of MI, stroke , not for pt w/ HF * DPP4 inhibitor – Januvia > new class, slow inactivation of incretin hormones; DDP4 inh are glucose dependent = risk of hypoglycemia, no wt gain * Incretin mimetics – exenatide (Byetta) > stimulate incretin horm which are in DM II, stim. of insulin, Suppress glucagon, satiety = caloric intake, slows gastric emptying; prefilled pen * Amylin analog > Amylin hormone secreted by cells, co secreted w/ insulin Pramlintide (Symlin) is Synthetic , type I & II when glucose level not achieved w/ insulin at mealtimes , subq thigh or abdomen NOT arm , not mixed w/ insulin – cause severe hypoglycemia ! * blockers — masks s/s of hypoglycemia, prolong hypoglycemic effects of insulin * Thiazide / loop diuretic — hyperglycemia, K Nutrition Type I > meal planning, exercise, developed w/ pt’s e ating habits & activity pattern in mind, day to day consistency in timing & amount of food eaten * Type II > wt loss = improved insulin resistance, total fats & simple sugars = calorie & carbs intake; Spacing meals , wt loss 5-7% = glycemic control, regular exercise * Carbohydrates > sugar, starches, fiber whole grains, fruits, veggies, low fat milk included min 130g/d * Glycemic index GI > describe blood glucose levels 2 hrs after carb meal , GI of 100 = 50g glucose * Fiber intake 14g/1000 kcal * Fats 7% of total calories , < 200mg/d cholesterol & trans fats * Protein same for diabetes / normal renal function / gen. population, high proein diet not recommended * Alcohol > inhibits gluconeogenesis ( breakdown of glycogenglucose) by liver; severe hypoglycemia in pt on insulin / oral hypoglycemic dx.Moderate alcohol consumption < 2 drinks men, track carbs w/ each meal & daily, set limit for max amount ( depends on age, wt, activity level) usu. 45-60g /meal ; also My Pyramid & plate me thod ( ? nonstarchy veggies, ? starch, ? protein, nonfat milk & fruit * Exercise > 150 min/wk moderate intensity aerobic; DM II resistance training 3 x wk, most adults should 30 min moderate intensity activity 5 x most days * Exercise > insulin resistance, blood glucose, wt loss which insulin resistance ( may need less meds), triglycerides, LDL, HDL, BP, circulation * Start slowly w/ progression. Insulin, sulfonylureas, meglitinides >risk of hypoglycemia with increase physical activity esp if exercise at peak of dx or no food intake.Effect may last 48 hrs post exercise Exercise 1 hr after meal, have 10-15g carb snack every 30 min. during exercise (prevent hypoglycemia). Before exercise glucose immediate info about glucose levels – can make adjustments diet, activity, meds * Recomm. for all insulin-treated pts * Multiple insulin injections – 3 or more x day, done before meals, before & after exercise esp in type I, whenever hypoglycemia suspected, when ill (stress), 2 h rs after start of meal – if effective Pancreas transplantation * For pt w/ ESRD, plan to have kidney transplant * Pancreas transplanted following kidney transplant, pancreas alone –rare * Pancreas alone only if hx of severe metabolic complications, emotional roblems w/ exogenous insulin, failure of insulin-based management * Improve quality of life, no exogenous insulin need, no dietary restrictions * Only partially able to reverse renal & neurologic complications * Need lifelong immunosuppression to prevent rejection * Pancreatic islet cell transplantation in experimental stage, islets from deceased pancreas via catheter into abdomen portal vein Nursing management * Pt active participant in management of diabetes regimen * Few/no episodes of acute hyper/hypoglycemic episodes, maintain glucose level near nl * Prevent/ delay chronic complications * Adjust lifestyle to accommodate DM regimen w/ min. stress Nursing assessment Past hx mumps, rubella, viral inf, recent trau ma, stress, pregnancy, infant>9lbs, Cushing, acromegaly, family hx of DM * Meds > compliance w/ insulin, OA; corticosteroids, phenytoin, diuretics * Eyes > sunken eyeballs, vitreal hemorrhages, cataract * Skin > dry, warm, inelastic, pigmented lesions on legs, ulcers(feet), loss of hair on toes * Respiratory > Kussmaul – rapid, deep * Cardio > hypotension, weak rapid pulse * GI > dry mouth, vomiting, fruity breath * Neuro > altered reflexes, restlessness, confusion, coma * MS > muscle wasting * Also electrolyte abnormalities, fasting glucose level >126, tolerance test> 200, leukocytosis, BUN, creatinine, triglycerides, cholesterol, LDL, HDL, A1C 45yrs without risk factors for diabetes Acute intervention * Hypoglycemia, DKA, HHS – hypersmolar hyperglycemic syndrome * Stress f acute illness/ surgery > counterregulatory hormones > hyperglycemia ( even minor upper resp infection or flu can cause this) * Continue regular diet, noncaloric fluids (broth, water, diet gelatin, decaffeinated), take OA/insulin as prescribed, monitor glucose Q4H * Acutely ill DM I , glucose>240 test urine for ketones Q3-4H , medium/large report to MD * Ill > eat than normal > continue OA meds/ insulin as prescribed + carbohydrate containing fluids (soup, juices, decaffeinated) * Unable to keep fluids/ food down MD * Don’t stop insulin when ill counterregulatory mechanisms will glucose level * Food intake important body needs extra energy to deal w/ stress Extra insulin may be needed to meet this demand, prevent DKA in DM I * Intraoperative > IV fluids & insulin before, during, after sx when there’s no oral intake In DM II w/ OA – explain it’s temporary measure, doesn’t mean worsening of DM * If contrast medium (w/iodine) > Metformin discontinued 1-2 days before sx, resumed 48 hrs after sx risk of acute renal failure.Resume after kidney function nl ( creatinine checked & is nl) * Insulin adm > teach proper administration, adjustments, side e ffects, assess response to insulin tx, if new to insulin assess ability to manage tx safely, cognitive status, ability to recognize/ tx hypoglycemia, if cognitive skill another responsible person must be assigned; diff to self inject/ afraid of needles * Follow ups > inspect injection sites ( lipodystrophy ) * Short term memory deficit > OA or short acting OA cuz doesn’t cause hypoglycemia * OA w/ diet & activity, not take extra pill when overeating * Diligent skin care & dental > aily brushing/ flossing, inform dentist about DM * Foot care !!! scrapes, burns treated promptly & monitored > nonirritating antiseptic ointment > dry sterile pad> not start to heal in 24 hrs or infection > MD * Regular eye exams * Travel – sedentary > walk Q2H to prevent DVT & prevent glucose , carry snacks, extra insulin COMPLICATIONS Diabetic Ketoacidosis DKA * Diabetic coma Profound deficiency of insulin > hyperglycemia, ketosis, acidosis, dehydration * Most likely in DM I pts, but someti mes in DM II ( severe illness/ stress) * Causes > illness, infection, undiagnosed DM I, inadeq insulin dosage, poor self management, neglect * Insulin – glucose cant be properly used for energy fat broken for fuel ketones (by product) serious when excessive in blood alter pH, cause metabolic acidosis ketonuria (in urine) & electrolyes depleted; impaired protein synthesis, nitrogen lost from tissues * Untreated depletion of Na, K, Cl, Mg, phosphate hypovolemiarenal failure/ retention of ketones & glucose shockcoma (result of dehydration, lytes & acidosis)death * s/s > dehydration, poor turgor, dry mm, HR, orthostatic hypotension, Kussmaul , abdominal pain, sunken eyeballs, acetone fruity odor, early s/s > lethargy,weakness * blood glucose >250, arterial blood pH IV access begin fluid/ electrolyte replacement NaCL 0. 45% or 0. 9% to restore urine output 30-60 ml/hr & BP * glucose level approach 250 5% dextrose added * Incorrect fluid repl > sudden Na & cerebral edema * Obtain K level before insulin started – insulin > further K * Insulin withheld until fluid resuscitation & K>3. 5 * Too rapid IV fluids & rapid lowering of glucose cerebral edema Hypersmolar hyperglycemic syndrome HHS * Life threatening, able to produce insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, ECF depletion * Less common than DKA * Often > 60, in DM II Causes > UTI, pneumonia, sepsis, acute illness, new DM II * Asymptomatic in early stages > so glucose can rise very high >600mg/dL * The higher glucose > in serum osm > neurologic manifestations somnolence, coma, seizures, hemiparesis, aphasia * Resemble CVA (stroke) determine glucose level for correct dx * Ketones absent in urine * Tx similar to DKA * First IV 0. 45% or 0. 9% NS, regular insulin given after fluid replacement * Glucose fall to 250 – add glucose 5% dextrose * Hypokalemia not as significant as in DKA * HHs require greater fluid replacement * Assess VS, I&O, turgor, l abs, cardiac / renal monitoring related to hydration & electrolyte levels, mental status, serum osm Hypoglycemia Low blood glucose glucagon & epinephrine > defense against hypoglycemia * s/s of epinephrine > shaking, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor * brain req constant supply of glucose > when > affect mental functioning > LOC, diff speaking, visual disturbances, confusion, coma, death * Hypoglycemis unawareness > no warning signs until glucose reach critical point > incoherent, combative, LOC > often elderly w/ beta blocker meds * When very high glucose level falls too rapidly, too vigorous management of hyperglycemia * Mismatch in timing of food intake & peak of isulin/ OA * Can be quickly reversed Check glucose levels, if contain fat that glucose absorption; check glucose in 15 min * Still 70 eat regular meal/snack low peanut butter, bread, cheese, crackers, check glucose in 45 min * No significant imptovement after 2-3 doses of 15g carb MD * Pt no t alert to swallow 1mg glucagon IM in deltoid muscle ( nausea, vomiting rebound hypoglycemia) * Hospital setting > 20-50ml of 50% dextrose IV push * CHRONIC COMPLICATIONS OF DM Angiopathy * end organ dz from damage to blood vessels (angiopathy) 2nd to chronic hyperglycemia * leading cause of diabetes-related deaths, 68% deaths due to cardio, 16% strokes * causes: accumul.Of glucose metabolism by products (sorbitol) damage to nerve cells, abnormal glucose molecules in basement membrane of small blood vessels (eye,kidney), derangement in RBCs – oxygenation to tissues * DM I > keep blood glucose levels near to normal – retinopathy & nephropathy (complications of microvascular complications) Macrovascular complications * Dz of large, medium size blood vessels , earlier onset in pt w/ diabetes * W > 4-6x risk of cardiovascular dz, M > 2-3 x * risk factors > obesity, smoking, HTN, fat intake & sedentary lifestyle * Smoking injurious to pt w/DM, risk for blood vessel dz, CV d z, stroke, lower extremity amputations * Maintain BP control – prevention of CV / renal dz Microvascular complication * Thickening of vessel membranes in capillaries/ arterioles in response to chronic hyperglycemia * Are specific to diabetes Eyes ( retinopathy ), kidneys ( nephropathy ), skin (dermopathy ) * Some changes present w/DM II at time of dx, but s/s not appear until 10-20 yrs after onset of DM * Diabetic retinopathy – microvascular damage to retina, most common cause of blindness 20-74 yrs old. Nonproliferative> most common, partial occlusion of small blood vesselin retina microaneurysms, Proloferative> most severe, involves retina & vitreous neovasculization ( form new blood vessels to compensate) if macula involved vision is lost * DM II > dilated eye exam at time of diagnosis & annually, DM I within 5 yrs after DM onset * Laser photocoagulation * Virectomy * Glaucoma Nephropathy – microvascular complication, damage to small blood vessels that supply glomeruli / kidney.Leading cause of ESRD in US; same risk for DM I & II > HTN, smoking, genetic predisposition, chronic hyperglycemia * Screen for nephropathy annually w/ measurement albumin / creatinine ratio * If micro/macroalbuminuria > ACE inh ( lisinopril ) or angiotensin II rec antagonist ( Cozaar ) tx HTN & delay progression of nephropathy * Aggressive BP management & tight glucose control Neuropathy Sensory neuropathy (PNS)– loss of protective sensation in lower extremities amputations * Hyperglycemia > sorbitol & fructose accumulate in nerves damage * Distal symmetric polyneuropathy > hand/ feet bilaterally * Loss of sensation – to touch/ temperature * Pain > burning, cramping, crushing, tearing , at night * Paresthesias > tingling , burning, itching * At times skin too sensitive (hyperesthesia) * Foot injury & ulcerations without having pain TX : blood glucose control, topical creams capsaicin ( Zostrix ) 3-4 X/d pain in 2-3 wks, selective serotonin, norepin ephrine reuptake inh ( Cymbalta ), pregabali ( Lyrica ), gabapentin Autonomic neuropathy – can affect all body systems & lead to hypoglycemic unawareness, bowel incontinence, diarrhea, urinary retention Complications : * Delayed gastric emptying ( gastroparesis ) anorexia, n/v, reflux, fullness, can trigger hypoglycemia by delaying food absorption * Cardiovascular abnormalities , postural hypotension assess change from lying, sitting, standing, painless MI, resting tachycardia HR * Risk for falls * Sexual dysfunction > ED in diabetic men > 1st s/s of autonomic failure * Neurogenic bladder > urinary retention, diff. voiding, weak stream empty bladder Q3H in sitting position, Crede maneuver ( massage lower abdomen) * Cholinergic agonists > benthanechol Feet & lower extremities Risk for foot ulcerations & lower extremity amputations * Sensory neuropathy > major rosk for amputations due to loss of protective sensations LOPS * Unaware of foot injury, improper footwear, stepping on objects w/ bare feet * Screening using microfilament > insensitivity to 10g Semmes-Weinstein > risk for ulcers * Proper footwear, avoid injuries, diligent skin care, inspect feet daily * PAD risk for amputations due to blood flow to lower extremities * PAD s/s > intermittent claudication, pain at rest, cold feet, loss of hair, cap refill, dependent rubor ( redness when extr in dependent position ) * DX : ankle brachial index ABI & angiography * Casting to redistribute weight on plantar surface * Wound control > debridement, dressings, vacuum, skin grafting etc. Charcot’s foot > ankle & foot changes joint deformity need fitted footwear * Acanthosis nigricans – dark, coarse, thickened skin in flexures & neck * Necrobiosis lipoidica diabeticorum – DM I, red-yellow lesions w/ atrophic skin , shiny & transparent revealing blood vessels under the surface – young women * Granuloma annulare – DM I, autoimmune, partial rings of papules, dorsal surface of h ands/ feet Infection Candida albicans, boils, furuncles, bladder infections (glycosuria) antibiotics Gerentologic * reduction in cells, insulin sensitivity, altered carbohydrate metabolism * 20 % > 65 YO * # of conditions treated w/ meds that impair insulin action (