The art of dirty deeds

English Coursework Robert Hoarsely Another cupboard smashed onto the heavy oak table as the maelstrom of debris continued to swirl, fuelled by the vicious wind from the broken windows. There was a resounding crack as a chair was hurled at the table. â€Å"You left me to rot, you are no son of mine,† wailed the lady of the house. He couldn't see her, she was invisible, but he knew all too well she was there as he cowered under the table. The rain continued to pound down, its staccato beat all too loud through the broken windows.Lightning flashed as he made a break for the door that was banging against the wall in the mind. An Inhuman shriek came from behind him. He raced through the door as the table he had been taking refuge hurtled after him into the doorway in a shower of plaster and splinters. The main hallway he was now in was dominated by a huge glittering chandelier. He paused for a moment to catch his breath as he heard his mother howling in rage. With a groan the chand elier above him ripped away from the ceiling.It fell onto him with a crash, landing In an explosion of glittering glass like a frenzied rave of fireflies. He had barely enough time to think as It knocked him cold. As he flitted in and out of consciousness he remembered how he came to be in that current predicament. Don't go daddy,† said his daughter. â€Å"We want you to be here for Christmas daddy,† whined his son. â€Å"Of course I'll be back for Christmas; I'm Just off for a week to get granny's old stuff from her house in the Yorkshire Dales. It'll only be a week you know that and Ill tell you what, Ill bring extra Christmas presents. â€Å"Do be careful Mr. Jerome,† said the nursemaid as she ushered the children onto the pavement. â€Å"l will,† Mr. Jerome said as the children chorused goodbyes , he climbed into the carriage and with a flick of the driver's reins the arraign picked up speed down the misty London street. He vaguely remembered the trai n Journey as the inky blackness swept past, punctuated by lights of villages. He Intended to collect family heirlooms and other valuables to distribute to his family back In London. The dark looming mass of the house had dwarfed him as he had stepped off the carriage.Its Imposing bulk seemed to swallow all living things through its gloomy shaded windows and solid looking front door. It was big enough to take a week to go through all the rooms to get what he needed, then sort them. Lang resounded throughout his head as the huge chandelier was savagely picked up and hurled Into the solid wooden front doors. Then there was a deafening silence In the house. The rain continued to beat down outside and the wind ripped at the garden but the house was silent once more.Rubbing his head, he climbed the grand staircase, still wary of the ghost of his mother. He made his way to the study where there were three traveling trunks, two of which were full of the valuables and the other was to be fil led with Important documents. There was the distinctive tang of smoke but his thoughts were on other things. The door handle felt unusually warm as he opened leaping flames that had already consumed his traveling trunks and was taking hold of the rest of the room in a fiery, swirling inferno.Coughing from the swirling smoke he stumbled into the hallway. It was spreading rapidly, too fast to be any normal fire. His mother, he thought, she was burning down the house, the house he had been brought up in, the house she had lived in for over 60 years. As he watched, smoke streamed out of other rooms in tendrils and the smell of smoke was overpowering. He was trapped; he was going to be burned alive, scorched and screaming in this twisted, sick house.

Fear and Loathing in Las Vegas Essay

Literature is considered a mirror of the society. The pool of content in literary writing stems from the environment in which the writer is placed. A writer will use this environment to advance his/her views of the society and at the same time drive into the audience/readers important information that he/she wishes to pass. Hunter S. Thompson has used his creativity in the novel Fear and Loathing in Las Vegas written in the 1960s to reflect on American society with Las Vegas as the point of reference. Fear and Loathing in Las Vegas describes the American society as hypocritical. The Duke and Gonzo attend a conference on narcotics and dangerous drugs. The theme of the conference is slated as an appeal for knowledge sharing on drugs between those with knowledge on drugs and those that do not. Their attendance is hypocritical in that they have already decided that they were not going to offer their services at the conference. Thompson on page 143 notes that Duke and Gonzo had made it clear that they would be crazy to try any teaching at the conference and they would rather sit and enjoy their drugs. Furthermore, the police who are tasked with law enforcement are also hypocritical, instead of enforcing laws on drugs and alcoholism they engage with criminals in committing crimes. This is illustrated by the police officer from Georgia. Secondly, the American society is as a blacked out society. Drugs, alcoholism and black market enterprises characterize a blacked out society. A black market society is a consumer based society characterized by both legal and illegal business the duke and the attorney are not drug dealers but heavy consumers. As soon as they get to Mint hotel the Attorney orders four shrimp cocktails, four club sandwiches, quart rum and fresh grape fruits. He says they will need to have all they can get. There stay in Las Vegas is characterized by heavy drug abuse and alcoholism. The sorry state of this vices forces the administration to organizes conference to tackle issues of drugs and alcohol dubbed In addition, Fear and Loathing Las Vegas reveals racist nature of the American military and the decay of moral values. This is portrayed in a copy of the Las Vegas Sun newspaper. â€Å"†¦she was just a slope anyway.† This is in reference to killing of Asiatic origin person. His killing is considered right for simple reason that he from the race of the enemy camp. A ‘slope’ referred to Asiatic community. The massive killings during the Vietnam War were ironically regarded as success by the American government. As the Duke continues to read the newspaper, a small article talks about how Mohammed Ali has a final appeal of a case in court which he had been sentenced to five years in prison for refusing to kill â€Å"slopes.† This illustrates the moral decay of the society. A criminal was likely to get a shorter jail term than a person who had refused to join the military and aid in killings. What is right is considered a serious offence. Consumerism and capitalist culture has been embraced in Fear and Loathing in Las Vegas. This is well brought out by the two protagonists in the novel. The lifestyle of the Duke and his attorney on the journey to Las Vegas is characterized by heavy spending on drugs, accommodation, transportation and gambling. Duke says their car trunk looked like a police narcotics lab (Thompson 4). This shows they had bought so many expensive drugs which the writer goes ahead to acknowledge that they did not actually need but for the fun of it. Moreover, the two protagonists are searching for American dream using a fascinating car â€Å"†¦we are looking for the American dream†¦that is why they gave us this white Cadillac† (Thompson 164). This demonstrates the capitalist nature. The car has to be a Cadillac which was a status car of the might in the society. Lastly, the novel’s central theme revolves around the American dream. The American dream is an idea stating that success comes through hard work. However, the dream is a dying one which has not materialized because of the society’s greed, selfishness and corruption as depicted in Fear and Loathing in Vegas by Thomson. Drug business, prostitution and gambling have replaced legal businesses in Las Vegas. Law forces have been tangled up in this game as they watch this acts being committed for a few pennies from the dealers. The picture of a crowd of Las Vegas residence in a casino at early hours of the morning gives more dimensions to the American dream. Emerging from a casino having won seems to epitomize what the society feels about the American dream. Patriotism among American citizens in the pursuit of this dream cannot be disputed despite being portrayed negatively. The Duke says â€Å"†¦I will have a natural American car or nothing at all† (Thompson 104). This illustrates pride in American products as opposed to products from other countries. Fear and Loathing in Las Vegas by Thompson Hunter S. arguments have negatively portrayed the American society in the 1960s and 1970s. Drugs and alcohol abuse, racism, hypocrisy, failed institutions and the dying American dream continue to daunt the image of the Las Vegas society. However all is not lost as the issues addressed have continued to be a point of reference not only to the Americas past but the future ambitions. Thompson plays his role as an author in bringing into public what is ethically wrong or right. Reference Thompson, Hunter S. Fear and Loathing in Las Vegas: A Savage Journey to the Heart of the American Dream. London: Flamingo, 1972 Source document

Cardiovascular Diseases

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

Ask week 7 Essay Example | Topics and Well Written Essays - 250 words - 1

Ask week 7 - Essay Example In what ways is this assertion true? Explain. It is apparent that according to Kash and Rycroft (2002), application of effective management and policy can break bad habits if the organization is not aligned to support the trajectory change. Do you find this to be true? If yes, explain how your organization can be changed through the use of this concept. It can be argued that your organization learned from tacit knowledge due to the fact that exploration and development departments have adopted transfer of knowledge from employee to the employee and from management to employees and vice versa. In what ways have this transfer of knowledge helped your organization? Explain. It can be argued that the first step towards your organization success through learning is by identifying gaps that exists in the organization and adopting tacit knowledge. However, there is also a need to have extended knowledge in order for your organization effectively to learn. Explain how your organization would utilize tacit knowledge and extended knowledge in order to help it solve the work-based

Hand and Wrist Positioning Essay Example | Topics and Well Written Essays - 250 words

Hand and Wrist Positioning - Essay Example The four-view wrist series includes semipronated and semisupinated (reverse) oblique views, Posteroanterior (PA) and PA in ulnar deviation and the three-view hand series includes the semipronated oblique views, PA and Lateral view (Kurtz, 1997). These are the three common positions of X-ray for both the wrist and hand (Kurtz, 1997). The techniques of (PA), Oblique and lateral projections are used to perform the radiography for routine examination of hand and wrist (Dr.Ahmad, 2008; Joseph, 2007) and the best view conventionally according to Dr.Ahmad (2008) is PA projection. The main difference between hand and wrist positioning for the three views are how the fingers are held. In the semipronated oblique view the fingers in hand X-ray are held â€Å"as flat as possible and slightly fanned out† but for wrist, the fingers â€Å"curled under into a loose fit to help press the wrist closer to the film if possible† (Kartz, 1997:1). In the lateral view for hand the positioning of fingers is like an okay sign so that on x-ray each finger is visible and for wrist finger’s position does not matter. In case of Scaphoid the positioning of fingers is similar to that of hand x-ray however â€Å"only one finger is extended so that the finger in question is the only one seen on all three pictures† (Kartz, 1997:1). Bhat, A.K, Kumar, B. and Acharya A. (2011), Radiographic imaging of the wrist, Indian Journal of Plastic Surgery, May-Aug, 44(2):186-196, retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193630/. Dr.Ahmad, N. (2008). The twists and turns of hand and wrist x-ray positioning. Auntminnie, X-Ray Patient Positioning Manual. Retrieved from http://cdn.auntminnie.com/user/documents/content_documents/X-Ray_Patient_Positioning_Manual_080402.pdf. Joseph, N. (2004). Film Critique of the Upper Extremity – Part 3: Hand, Wrist. Online Radiography Continuing Education for Radiologic X-ray Technologist. Retrieved

An operation management (ASDA -UK company) Essay

An operation management (ASDA -UK company) - Essay Example The intention of this study is ASDA as one of the biggest retailing companies in the UK and it is the major subsidiary corporation of Wal-Mart. It deals with several merchandise products comprising food, grocery, housing, and entertainment goods in their retail stores. In the year 2004, ASDA had almost 259 retail outlets and 19 storehouses throughout the UK. It captures significant amount of share of the market of the UK. As a major supermarket, ASDA confronts with numerous supply chain issues which need to be rectified in order to gain competitive advantage. Few problems were identified in the process of operations management of the company ASDA. One of the problems increasingly witnessed by the company was regarding the procedure of reverse logistics. The company has been stated to deal in a varied range of products, most of which entails consumable products. With regard to the kind of business that is conducted by the company, it can be understood that the concept and the process of reverse logistics form an integral part. The company was encountering certain problems in the management of the procedure with regard to the return of goods and products that are received from the customers to the suppliers as well as the manufacturers. ASDA was learnt to witness increased volumes related to returns of electrical products owing to the moderate returns guidelines. Thus, with the intention to deal with such returns in an effective, suitable and cost efficient method, the company requires to concentrate on a competent strategy related to reverse logistics. ... Understand the solutions to deal with the issues identified in ASDA Company Background ASDA is one of the biggest retailing companies in the UK and it is the major subsidiary corporation of Wal-Mart. It deals with several merchandise products comprising food, grocery, housing, and entertainment goods in their retail stores. In the year 2004, ASDA had almost 259 retail outlets and 19 storehouses throughout the UK. It captures significant amount of share of the market of the UK. As a major supermarket, ASDA confronts with numerous supply chain issues which need to be rectified in order to gain competitive advantage (Corporate Watch UK, 2004). Problem Number 1 Reverse Logistics Few problems were identified in the process of operations management of the company ASDA. One of the problems increasingly witnessed by the company was regarding the procedure of reverse logistics. The company has been stated to deal in a varied range of products, most of which entails consumable products. With r egard to the kind of business that is conducted by the company, it can be understood that the concept and the process of reverse logistics form an integral part. The company was encountering certain problems in the management of the procedure with regard to the return of goods and products that are received from the customers to the suppliers as well as the manufacturers. ASDA was learnt to witness increased volumes related to returns of electrical products owing to the moderate returns guidelines. Thus, with the intention to deal with such returns in an effective, suitable and cost efficient method, the company requires to concentrate on a competent strategy related to reverse logistics. The reverse logistics plan of the company would require controlling the flow related to the products

Draftsmans Duty Of Care In The Preparation Of A Will Essay

Draftsmans Duty Of Care In The Preparation Of A Will - Essay Example In this context the common law development of rules which gives the draftsman's duty of care in preparation of a will has been discussed within the context of cases. The analysis is focused on identifying the solicitor's duties and responsibilities in preparing a will for the clients. Various aspects of preparation of a legal document highlight the significant role of the solicitor who has the duty to adequately represent the testator's intentions and wishes through the legal document. The various types of the draftsman's duties in preparation of a will are discussed in the changing contextual situations of family businesses, mutual or joint will, and breach of duty such as errors or delays. Identifying grammatical and omission errors, providing legal advice to clients, severing joint tenancy and adequately representing a testator's wish in preparing a will are some of the broad issues of draftsman's duties in preparing a will. This discussion is focused on identification of the various types of errors, issues concerning negligence of duty on the part of the solicitor and the possible contextual factors that can lead to these errors or failure t o perform the duties. The methodology adopted for this purpose include sear... Databases such as lexisnexis, bailli, zetoc and westlaw were searched with terms as 'draftsman' 'common law' 'preparation of will' 'solicitor duties' and several cases were located and have been included in this study. The studies obtained were then selected to adequately represent the research focus on identifying the draftsman's duties and responsibilities in preparing a will. The studies were analysed using a qualitative analytical approach from the Kerridge and Brierley (2003) framework of draftsman's errors and legal provisions of family law (1992). The aim of the study is to delineate the general rules of draftsman's duty of care in preparation of a will and the various legal aspects that defines a solicitor's responsibilities and the way he carries out these responsibilities. Draftsman's Duties in Preparation of a Will In preparation of a will, in addition to a general common law framework, trust law, succession law and tax law may have to be considered. A critical appraisal of the client's needs and the words that would meet the client's demands are considered in legal construction and consequences. A new trust deed may begin by choosing a precedent which appears to be the closest to what is required2. If a will or a trust does not meet client's needs, then new words will be required. In case of divorce, the divorcing spouse is a beneficiary and also the children in case of deceased. There has been in recent years an increased emphasis on understanding of law relating to revocation or cancellation of wills. Wills can be lost or misplaced, and this may be a problem if the testator has died in any way. It should also be evident that the will has not been destroyed as given in the case Hacquoil v Imperial Cancer Research (2003 JRC 163).

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Psychology - Essay Example English bolstered my comprehension regarding the European Business Model – for the sake of knowing how the business strategies would shape up within the future. Within my BBA course, I gained a much needed exposure in the subjects of administration, communication, management and marketing. As for my personality, I have proactively remained a very ambitious and highly motivated individual. I adapt to different things easily and my command over four different languages makes me unique in my own righteous way. I love spending time playing golf and tennis. I seek to know more and more about cultural understandings and issues. In the same vein, traveling has remained as one of my most revered pastimes. I want to learn psychology due to the fact that it asks for interaction with people on a constant basis. I plan to complete my Masters in Psychology and thus I believe the foundation course would help me to firm up my basics within the subject. As for the future, I look forward to getting a respectable job within the International Relations departments of some esteemed governmental organization. I would request the management at the helm of affairs to support my candidature at Regents College so that I could enliven my dream of learning the science of

Contingency Planning in Action Term Paper Example | Topics and Well Written Essays - 2500 words

Contingency Planning in Action - Term Paper Example In case the initial plan does not work out, the organization should have already identified an alternative to curb the risk (Doughty, K. 2001). The risks should first be identified and prioritized in order of the impacts they could have to the organization. Plan development should be the next step where certain guidelines such as definition of time periods should be done. The next step should be maintenance of the plan; it should be kept practical and relevant. Rephox is an organization based in India. It has its headquarters in Mumbai and a branch in Delhi. The organization has fifty employees in total, thirty of which work at the headquarters and the rest work in Delhi. It is an organization that provides auditing and accounting services. It helps its clients with cost accounting systems, preparation of financial statements, financial reporting, internal audits and services that provide assurance. The organization depends on technology for the provision of their services to clients. It has systems that protect information systems which comply with regulatory requirements. The organization provides information controls for the reduction of costs and gaining of competitive advantage. It uses professional accreditations where personnel handling the information systems must qualify. The business faces certain threats which include internet insecurity. Internet and firewall threats also exist where viruses may infect the audit systems through online services. There is also network and data insecurity threat when transferring information from the branch to the headquarters and vice versa. The organization’s systems might be hacked into and security details such as passwords and biometric controls interfered with. The wide area network for the organization may be interfered with affecting the clients’ servers. The mission of the organization is to serve public interest. This is done by contribution to development of standards and guidance of

Innocent Drinks Case Study Example | Topics and Well Written Essays - 750 words

Innocent Drinks - Case Study Example They had a never give up attitude which helped them to not feel low as soon as they hit an unwanted hindrance during the course of the setting up of their company, right from getting manufacturers to thinking of innovation in the field of providing fresh juices to their customers. Thus, these aspects helped the company to grow, develop and reach success. Expansion and diversification is always the key aspects of helping any enterprise to grow and develop and reach new heights in terms of revenue and sales. Thus, expansion of Innocent Drinks into Europe and U.S seems to be an excellent idea for the company. However, according to the facts presented, except for France, Netherlands and Belgium, the rest of Europe was not helping the company meet a wider range of success. In other countries like Italy, Germany, Sweden and Denmark, the company was not really doing well because of a number of reasons with respect to the beverage. The main reason was that these juices had a longer shelf lif e in these countries; however, these countries already had an established smoothie base, which meant that Innocent Drinks had to beat out a lot of competition in order to set itself or stabilise itself in the region. This was proving to be very difficult for the company, and was leading to marginal or no profit at all, and thus, it is a step that could have been avoided. Instead of France, Netherlands and Belgium, the company should stop selling to the rest of Europe because of negligible returns. The U.S on the other hand, was a much safer and stronger option to expand into, for the company. This was because smoothies as a product were already quite well known and received in the market by the people; thus there was no problem in the demand. For the supply as well, the founders went ahead and established contacts with some leading manufacturers and suppliers in order to set up shop. However, the only problem was beating the tough competition that already persisted in the smoothie m arket. In keeping with the introduction of new combinations of products under the Innocent brand, into different countries and continents, a very bold move was made by the company. Despite the bottlenecks in the business, in my opinion, the company should go ahead with producing and selling ice creams and other such dairy related products in the US and Europe, because both these areas have a high acceptance of such products, and the company can begin by banking on its already established brand name for help. At the time of the case, the company could be valued for a sum of 3 million lira pounds according to a personal opinion, in keeping with the figures that have been presented in the facts. However, despite this, the company should not consider a purchase offer at such a crucial time because this is the main span of its phase of growth and development. This is the time when the company can acquire more and more of the market share and set up a better consumer base. This is also th e time of proper growth and expansion, not to forget penetration into the market. Thus, if the company lost that value of having to grow and develop on their own, and considered a purchase offer at such an early stage, then it would lose its momentum eventually and finally, its value as well. One of the main complications faced by the founders was of whether or not to alter the management structure within the business. According to a pers

Eight Sign Miracles Essay Example for Free

Eight Sign Miracles Essay The Gospel of John reveals eight sign miracles that Jesus preformed as He started His ministry. The miracles are as follows: turning of water into wine, healing of a nobleman’s son, healing of a lame man, feeding of five thousand, Jesus walking on the water, healing of a blind man, raising Lazarus from the dead, and the miracle catch of fish. As we look into each of these miracles each one has a purpose and a message to the audience, so let’s dive right in. Within the first miracle Jesus and His disciple went to a wedding celebration. While attending this wedding a problem arose, they ran out of wine. Then Mary approached Jesus with this problem â€Å"They have no more wine† (John 2:3). At this point we can only image what went through the mind of Jesus, but as Dr. Towns stated in our lecture time Mary knew that Jesus could do something. Jesus did not say that he could or could not do something he just stated â€Å"my time has not come† (John 2:4). â€Å"Mary is presuming on her relationship with him as her son, yet Jesus is redefining this: He cannot act under her authority but must instead follow the course that has been determined for him by God.† (1) So Mary being a woman of faith knew that Jesus would be willing, but she would not understand it all until it took place. As Jesus took the opportunity to take the six water pots, the servants, and the water to make wine, He wanted them to see that He had power over creation. He performs His miracles at His appointed time and for the purpose that people might believe that He is the Son of God, and might have life through His name.† (2) This points to the fact that through Christ we have a new beginning if we would only believe. 1. Gary M. Burge, John: from Biblical Text to Contemporary Life (Chattanooga, TN: Zondervan, 2000), page 91. 2. Elmer Towns, The Gospel of John: Believe and Live, [Rev. ed. (Chattanooga, TN: AMG Publishers, 2002), page 20. Now we move to the healing of the Nobleman’s son, and he was a high ranking official that served Herod Antipas. The nobleman desired for his son to be healed, because he had exhausted himself trying to find the means to get his son to the right person. â€Å"All he could plead was for mercy, for his child was at the point of death.† (3) He went to Jesus to begging him that he might come and heal his son, but â€Å"Jesus chose to heal this nobleman’s son without making the journey to Capernaum.† (4) The thing that stuck out to me is that Jesus told him, you will never believe† (John 4:48), if you don’t see. Then Jesus tells him to go home and your child will live. I believe Jesus wanted to test the man’s faith, if he might believe without seeing first hand. â€Å" This is the case also when the royal officer â€Å"Believed the word that Jesus spoke to him; he accepted it as true and acted on it, (5) and I believe that exactly what Christ wants us to do with the word of God! As the nobleman was on his way he met some of his servants, and they told him that the boy was living. They informed him what time the fever actual left him, which was the exact time Jesus said that â€Å"Your son will live† (John 4:53). So one could conclude that the nobleman’s faith in Jesus became real when he found out that his son was alive and his family found faith through believing. Next we come to the healing of the lame man, the man had been lame for 38 years and he had been waiting by the pool of Bethesda for healing. This was a place where â€Å"the waters of the pool were popularly believed to posses curative powers.† (6) 3. John F. Walvoord and Roy B. Zuck, eds., The Bible Knowledge Commentary: an Exposition of the Scriptures (Chattanooga, TN: David C. Cook, 1983), page 288. 4. Elmer Towns, The Gospel of John: Believe and Live, [Rev. ed. (Chattanooga, TN: AMG Publishers, 2002), page 44. 5. Leon Morris, Jesus Is the Christ: Studies in the Theology of John (Chattanooga, TN: Wm. B. Eerdmans Publishing Co., 2012), page172. 6. Charles W. Draper, Chad Brand, and Archie England, eds., Holman Illustrated Bible Dictionary, Revised ed. (Chattanooga, TN: Holman Reference, 2003), page 192. Another interesting point is that the pool was used to clean animal before sacrifice. The pool of Bethesda means â€Å"house of mercy, which is exactly what the lame man was looking for, but he could not get himself into the pool. As Jesus meet this man he knew that he wants to be healed, because Jesus asked him â€Å"Do you want to get well† (John 5:6) and his reply was that he has no one to help him. So Jesus gives him clear instructions â€Å"To get up and pick up your mat and walk† (John 5:8) which is a clear indication that when people obey Jesus and believe, then they start to see Him work through his word. We see that Jesus healed him through the power of His spoken word and gave him the desire of his heart.†The Sabbath was made for man so that he could have rest and a time for worship and joy. The Jew’s rigid tradition taught that if anyone carried anything from a public place to a private place on the Sabbath intentionally, he deserved death by stoning.†(7) As the man meet Jesus in the temple Jesus wants him to realize the most things was to stop sinning or something worse might happen to you. Jesus wants him to realize that it was his sin that keeps him from heaven. As we move to the fourth sign miracle Jesus preformed, we see Jesus feeding the five thousand. Jesus saw the crowd coming to them and wondered how we are going to feed these people. When he mentioned this to Philip, he was testing him because He knew what was going to take place. As Jesus evaluated the situation we see a response from Andrew, â€Å"true to his character, brought someone to Jesus. Andrew brought a boy with a lunch, recognized it was not much, but at the same time knowing it was all he had.† (8) 7. John F. Walvoord and Roy B. Zuck, eds., The Bible Knowledge Commentary: an Exposition of the Scriptures (Chattanooga, TN: David C. Cook, 1983), page 289. 8. Elmer Towns, The Gospel of John: Believe and Live, [Rev. ed. (Chattanooga, TN: AMG Publishers, 2002), page 59. So we can see that God cares about the people before him, the crowds were hungry and we see Jesus respond. Jesus took the little and made it enough food to feed the crowd. â€Å"The practical lesson is clear, whenever there is a need, give all that you have to Jesus and let Him do the rest.† (9) Jesus gave thanks and fed the crowd, when they finished there was still some left over to feed the disciples. This shows that Jesus was more than adequate to supply their needs according to His plan for their lives. The fifth sign miracle is that of Jesus walking on water. As Jesus leaves for the mountain of Galilee to pray, His disciples set out for the Lake’s northeast shore. As they sail about three and a half miles a storm catches them by surprise. The disciples are in fear of the storm when Jesus appears to them walking on the water. This causes their fear to increase because they saw Jesus walking on the water, â€Å"but he said to them; it is I don’t be afraid.† (John 6:20) This may be no more than a way of self identification, but the style is the style of deity and it accords with this that Jesus comes walking on the water.† (10) Jesus wants to show them that through Him and His power over nature that they need not to be afraid. As they were willing to take Him into the boat they immediately reached the shore, Jesus wants us to believe in Him and trust him to lead us to our destination. The next miracle introduces Jesus healing a blind man, that from the day of his birth he could not see. The picture behind this miracle was that if one believes in Christ then you will have the opportunity to see and understand what God’s good, pleasing, and perfect will is. 9. Wiersbe, Warren W. The Bible Exposition Commentary. 2 vols. Chattanooga, TN: Victor Books, 1989. Page 309. 10. Leon Morris, Jesus Is the Christ: Studies in the Theology of John (Chattanooga, TN: Wm. B. Eerdmans Publishing Co., 2012), page123. The disciple asks a very important question about sin â€Å"Rabbi who sinned, this man or his parents that he was born blind† (John 9:2) He points back and stated that neither of them did, but this happened so that Gods power might be displayed in his healing. Then Jesus goes on to say that He is the light of the world, but He has given us that light when He is not here. â€Å"When Christ is not physically present in the world, He indwells believers, makes His disciples the light of the world.† (11) The light comes to those who can see, the illumination brought about the question how was he healed. They could only wonder about how and what was the reason that Jesus used clay and saliva to heal this man sight. The question should not have been how, but the question should have been who did this. Then we see â€Å"the blind man to whom Jesus had given sight affirms his identity. (12) That’s exactly what Christ wants us to do when we have experienced His presence a nd that is to tell of the one who has done the work. Now we come to the next recorded miracle and that is the raising of Lazarus from the dead. When Jesus performs this miracle it reveals that He has power over death. This also points to the future for believers that we will be resurrection with Christ. The sisters sent word to Jesus knowing that He could do something, and He implied that Lazarus sickness will not end in death. Then Jesus reveals that the father will be gloried and it will be through Him. Another interesting point here is the time period in which Jesus waits to go to Lazarus to heal him. Jesus waited four days total to go to Bethany, He want them just to believe Him at his word no matter the situation and how difficult it might be for them. When Jesus arrives he sees the mourning and points out to the sister that He has the power over death and the power to give life. For me this miracle gives us great hope that Jesus is our way, truth and life to the Father. 11. Elmer Towns, The Gospel of John: Believe and Live, [Rev. ed. (Chattanooga, TN: AMG Publishers, 2002), pg 91. 12. Leon Morris, Jesus Is the Christ: Studies in the Theology of John (Chattanooga, TN: Wm. B. Eerdmans Publishing Co., 2012), page125. â€Å"If Jesus is life, then those who believe in Him will enjoy the confidence and power over death known by Him. Moreover, they will have a life now and do not have to await the end of human time and history in order to enjoy the benefits of Jesus power.† (13) As Jesus gave thanks to the father so that the people might understand that it was from the father to the son that he accomplishes his purpose. Then Jesus spoke and said â€Å"Lazarus come out† (John 11:42) as Jesus commands Lazarus to come out He tells him to take of the grave clothes, which shows us that Jesus does have the power to defeat death. This confirms the deity of Jesus Christ and His relationship with the Father. Lastly we come to the miraculous catch of fish; Jesus appeared to them while they were fishing on the Sea of Galilee. There is a great connection with the Sea of Galilee with ministry of our Lord Jesus Christ. This is the third time Jesus had appeared to his disciples after He had been resurrected from the dead. The fishing experience leads them out to sea with no results for their efforts, and I believe it was because they were depending on themselves. Then we see Jesus show up, â€Å"it was time for Jesus to take over the situation just as He did when He called Peter into discipleship. He told them where to cast the net; they obeyed and they caught 153 fish! The difference between success and failure was the width of the ship.† (14) A lot of time we are so close but so far away because we depend on our own strength. Jesus wants us to let go of the steering wheel and allow Him to have full control. â€Å"We are molded fishers of men, and there are fish all around us. If we obey His direction, we will catch the fish†. (15) The world tells us that seeing is believing, but Jesus tells us to believe in Him and then we will see the promises of God. 13. Gary M. Burge, John: from Biblical Text to Contemporary Life (Chattanooga, TN: Zondervan, 2000), page317. 14. Wiersbe, Warren W. The Bible Exposition Commentary. 2 vols. Chattanooga, TN: Victor Books, 1989. Pg 397. 15. ibid 397. Bibliography Burge, Gary M. John: from Biblical Text to Contemporary Life. Chattanooga, TN: Zondervan, 2000. Draper, Charles W., Chad Brand, and Archie England, eds. Holman Illustrated Bible Dictionary. Revised ed. Chattanooga, TN: Holman Reference, 2003. Morris, Leon. Jesus Is the Christ: Studies in the Theology of John. Chattanooga, TN: Wm. B. Eerdmans Publishing Co., 2012. Towns, Elmer. The Gospel of John: Believe and Live. [Rev. ed. Chattanooga, TN: AMG Publishers, 2002. Walvoord, John F., and Roy B. Zuck, eds. The Bible Knowledge Commentary: an Exposition of the Scriptures. Chattanooga, TN: David C. Cook, 1983. Wiersbe, Warren W. The Bible Exposition Commentary. 2 vols. Chattanooga, TN: Victor Books, 1989.

Historical Background Of Foster Care In Ireland Social Work Essay

Historical Background Of Foster Care In Ireland Social Work Essay In order to fully appreciate the present situation of foster care in Ireland, an insight into the past history of foster care will be told. There has been a long tradition of fostering in Ireland. Foster care was present in the past, it was known as fosterage. It can be seen during the Brehon laws. Children from families of all classes were put into care of other families. This form of care was to lighten somewhat of the pressure for space in the home. This may have been as families were quiet large in the past and also financial difficulties. It also included children who were abandoned and needed the support and protection (Robins). The Brehon laws acted as the legal laws in Ireland and created two types of fosterage on where no remuneration was given and the other where a few is given (Shannon, 2005). Foster parents in both cases were to maintain their foster child to there rank. It was under a legal contract to keep and for the child until the period of was fosterage was not being cared for sufficiently, the chid was to be returned to there family home (O Higgins, 1996). Foundations of the present law around foster care were developed with the introduction of the Poor Law Amendment Act 1862. This provided children being boarding out to families who were not in work houses (O Higgins, 1996). The Infant Life Protection Act of 1897 presents where our recent system has originated from. This involved the appointment of females to inspect the conditions in which the children lived in, it also gave power that if not up to standards the child could be removed and placed in with families. Under the Health Act of 1953, health boards were empowered which provided for a major shift towards foster care. The arrangements that were introduced in boarding of childrens regulations in 1954, included provisions around the issue of being boarded out, placement in an approved school or if over 14 placed in employment (Task Force, 1980). Providing to be an important piece of legislation was the childrens act of 1908. It stated that a child who was neglected or abuse could be placed in the care of a fit person (O Higgins, 1996) Foster Care Foster care as previously discussed was a main expression towards the need for recognition of the rights of the child. Development in this area for acceptance that the child has needs of their own has led to the system of foster care that provides personalised family care that the workhouses and institutions could not provide. (Kelly and Gilligan, 2000, pg 7-8) Offers care in family setting Offers care in communication Offers opportunity to make attachment relationship to committed foster parents It can permit children to be attached and identify with family of origin It can include the childs family in care of child It can provide care and support into adulthood It can channel extra support from the agency for the child and carers (Kelly and Gilligan, 2000, pg 8) Modern child protection procedures are not sufficient as to make up a childs placement plan alone. It is more complex, as child care professionals now see the importance of individualisation and providing not only the physical care but the attachment and emotional needs ought to be provided for also (Kelly Gilligan, 2000). Children need to be placed in an environment where there needs are met, wishes can be supported and they can make individual choices for the future (Coakley, Cuddleback, Cox, 2007) Foster care is not a simple method of caring for a child; most children have experienced some form of trauma, may have been hurt or may have health or behaviour problems (Task Force, 1980). This calls for foster carers to be understanding and accept their emotions through being sensitive and caring. This can be a basis for the start of developing a relationship with the child (Fahlberg, 2004). The emergence of relative care in Ireland has proved beneficial to families. Keeping in with familys tradition and connection helps the development of childs identity, the surfacing of partnership as a key principle in child care (Broad, 2001). Legislation in Foster Care Firstly the researcher will examine the legislation in relation to relative foster care in Ireland. Child Care A ct 1991 There is a clear promotion for the welfare of children in the Child Care Act 1991. The health board has a statutory duty to identify children who are not receiving adequate care and protection (RWGFC). The welfare of the child is paramount and where appropriate the board is to give consideration to the wishes of the child based on their age and maturity (RWGFC). If social services are to meet the needs of children going into foster care then they must, among other things, listen to the child and include the children where possible in the decision making process (Kelly Gilligan, 2000). A plan is made which outlines aims and objectives for the placement and detailed guidelines for support to be given to the child, foster parents and natural parents (Shannon, 2005). UN Convention on the Rights of the Child The UN Convention was ratified in Ireland in 1992. It includes articles providing rights that relate to the childs life. It involves protection of the child from any form of discrimination and states the best interest of the child shall be held where possible when action is being considered which involves the child. It recognises the childs right to be protected and provided for. Foster care is mentioned in Article 20, stating that it is a substitute care provider when the parent or guardian fails to do so. This shows that foster care is a recognised as a suitable and appropriate form of care. Children Act 2001 The health board as stated in Section 23P requires at least 30 days notice for a private foster care placement to be arranged ad for an emergency foster care arrangement the health board requires notice within 14 days according to Section 23P2 (Shannon, 2005). At the time of notification, the health board has to be provided with the sufficient information around the foster placement (Shannon, 2005). It is said that the welfare of the child should be a primary concern to the foster parent. Section 23U allows for three interventions which the health board are obliged to use if the following occur. If it comes to the health boards attention that a private foster care arrangement has been arranged without notification to them or that the carers are not providing for the safety and welfare of the child then the interventions which can be implemented include a supervision order, an order to take the child and put into care or an instruction to terminate the order (Shannon, 2005). National Standards of Foster Care The national standards for foster care were devised following concerns around the quality of foster care services. These concerns were highlighted by the Report of the Working Group on Foster care, Foster Care: A child Centred Partnership (NSFC). The standards were developed by a committee who gathered information from experiences from individuals and organisations who work in the area of foster care and from a representative group of young people currently in foster care (NSFC). The National Standards for Foster Care 2003 provide guidelines on the provisions of quality foster care within the existing legislative framework (Shannon, 2005) There are 25 standards in all; the first 13 standards take into consideration the standard of care of the child including quality of response to factors around the childs needs and services required, whilst sticking to the relevant legislation (NSFC). The 2nd section involving the standards 14 to 17 are in relation to the assessment process of possible suitable foster carers and the training and support they require to provide for successful foster placements (NSFC). The final 8 standards are aimed at the duties and responsibilities of the health board. These standards provide guidelines which aim to promote the quality of services provided by the foster care professionals and Health Board (NSFC). The Child Care (Placement of Children with Relatives) Regulations The Regulations where put in place in 1995 as section 39 of the Child Care Act 1991 requiring the Minister for Health and Children to make regulations in relation to foster care. These regulations are directed at children who have been placed with a relative. The health board must pay attention to the rights and duties of the parents but the board must consider and consult with the child on his or her preferences (Shannon, 2005). Certain procedures must be implemented and fulfilled prior to the placement of a child in a foster care setting (Shannon, 2005). In relation to the welfare of the child needing to be considered, being placed in a family members home can cause conflict between relative carers and the birth family, so if this conflict cannot be settled then other placement should be considered (Shannon, 2005). Once the relative carers have lawful custody of the child, Article 16 of the regulations directs that the relatives take all reasonable steps to ensure the promotion of the childs health, development and welfare. In addition to the above many other factors contribute to the regulations. A relative intending to care for the child, must in according to Article 5 give in certain information regarding their health, two referees, examine into the relatives background such as criminal charges and any other relative information to the Health Board (Shannon, 2005). According to Article 12, the Health Board has to keep records of the children in foster care, including personal details of the child, an up to date case record containing certain documents (Shannon, 2005). In addition to this, the health board may visit the child as stated in the care plan. Whatever the arrangements made, Article 17 calls that the foster placement has visitation from an authorised member of the health board at least once every three months for the first two years (Shannon, 2005). To ensure the above aims of the childs placement, it is recommended that the case should be reviewed in terms of the successive of the placement and the possibility of the childs return to their natural familys home (Shannon, 2005). A foster care arrangement will end when the child reaches 18 years. Other possible reasons are that the child returns to their family home or at the request of the relative carers (Shannon, 2005). Assessment Process in Relation to Relative Foster Carers There are certain issues around the assessment process that are a cause for concern. Certain developments and amendments need to be applied to provide the best opportunity for foster care placements to be successful. In traditional foster care the assessment process lasts for a length of nine months usually, this process has to occur before the child is placed in the foster home. In comparison relative care, this process of assessment usually occurs after the child is placed with relatives due to the rapid movement of the child (Kelly Gilligan, 2000). A decision for the child to be placed with relatives is usually in the midst of a crisis. The family can be approached by the agency or the family themselves may contact the agency. As there are different regulations for traditional foster care and relative foster care, and the placement of the children occurs at different times, then it is questionable that there should be different assessment criteria (Kelly Gilligan, 2000). In recent studies, it shows that birth families themselves had preference to relatives caring for their children rather than with a home outside the family. Depending on the route to which the child entered relative care, either by agency approaching the relatives or the relatives approaching the agency, this can cause conflicting tensions between families (OBrien in Broad, 2001). The decision to take on the care of a grandchild is not an easy one. If the birth parents are not happy with the Health Service Executives decision to place their child in care, it can become a dilemma (Climo et al, 2002). The model of assessment of relative care is the same used for traditional foster parents. This is not right for relative carers as they have a connection with the child and family, the process is different to which they become known to the agency and the fact the placement is already made (OBrien in Broad, 2001). The assessment process of placement of a child with a relative usually occurs in two stages. The first is a preliminary assessment of the relatives; if the agency is content with the outcome then they proceed with the placement of the child. When the child is residing in the relatives family home the formal assessment process occurs (Kelly Gilligan, 2000). The following issues were found in a study done by David Pitcher assessing grandparents. The grandparents felt confused when being assessed and feared giving aware giving certain answers would result in their grandchildren not being placed with them. The process needs to be explained and the grandparents informed on the reason behind it to allow the process to be carried out in an honest manner (Pitcher in Broad, 2001). As grandparents have not planned to take on the full time care of a child, the can feel unprepared. Placement of the child usually occur mid crisis so it can cause the grandparents to feel stressed as they face meeting the criteria that is expected of them (Coakley et al, 2007). Social workers need to work with the grandparents in preparing them to cope with the challenges to promote successful placement and to alleviate these pending placements (Coakley et al, 2007). If the process is not explained properly this can lead to difficulty between the social worker and the grandparents. The grandparents can feel overwhelmed by the depth their private lives are being looked into. They can find this process negative and very intrusive and also it can be a frightening experience for them (Kelly Gilligan, 2000) As the process begins the grandparent should be given a written copy of the format of the interview. The social worker needs to give an honest explanatory description to the grandparents to prepare them for the process ahead. The aim of the social worker is to get an idea of the carers personality, to look at practical issues i.e. housing schools and to discuss together the perceived length that the placement will be (Broad, 2001) It can be of some reassurance for the birth parents that the child is going to live with people they know and may trust. The child can have different feelings of moving homes as in a study by Terling, 2003; found that trauma can be reduced when the child knows the person that will care for them rather than a stranger. Although the grandparent must acknowledge that while the child does know the grandparent, it does not reduce all of the stress and trauma that the child may experience when moving into another form of care (Broad, 2001). Also, the relationship between the grandparent and child must be looked at, questions need to be asked by the social workers such as does the grandparent actually like their grandchild and is there a sense of belonging for the child (Broad, 2001). Training should be specific to the carers needs. Parenting the Family Cycle The individual life cycle takes place within the family life cycle which is the primary context of human development (Carter Goldrick, 1988, pg 4). In early adult hood it can be expected that a couple will become parents of the younger generation, this can be an exciting period in a persons life. This new role that they adopt can involve responsibility in the childs developmental process and having authority in acting out parental roles to their children (Carter Goldrick, 1988). Perspectives of the role in later life are viewed as having less responsibilities and more time to reflect and relax. An older person is thought to experience retirement, dependency of others preferably their children or younger relatives, a sense of financial insecurity, possible loss of friends through death and the difficult time when a spouse dies (Carter Goldrick, 1988). Although this is a much generalised view, these experiences do occur. Grandparenthood can offer a person a sense of being and bring joy to their life. Becoming a grandparent can create new motivation and add fulfilment to an elderly person life. It creates opportunities for them to experience a new role and to develop a special close relationship (Carter Goldrick, 1988). Grandparents have a good position in their family network because they are not the parents of the children but they have a caring and considerate interest in their grandchilds development (Brubaker, 1985, citied in Bernades, 1997). A grandparents role has no clear guidelines, they can adopt rules but in remembering that they do not have the same authority that they had with their own children. Instead, grandparents can spoil and indulge in their grandchildren (Bernades, 1997). There are different styles of grand parenting involving different characteristics. The types of relationships they hold with their grandchild can vary from being distant to authoritarian and being involved in their life with assuming responsibility but having love and care (Hammer Turner, 1990). This can have an effect when a grandparent becomes a full time carer for their grandchild. If the grandparent was distant then it can be harder to develop a bond that has been absent. In comparison if a grandparent has been involved and caring, then to gain authority and create rules it can take some time and adjustments (Hammer Turner, 1990). It involves a lot more responsibilities than previously needed. They will have to set routines, assume responsibility in daily tasks and educate the child with essential skills and attend to the needs of the child (Hammer Turner, 1990). Grandparent hood can be seen as a second chance at parenting. This can be seen for grandparents when their own child has failed at their duty of parenting, the grandparent can become the main carer due to the fact that they feel part to blame. They may feel that in helping, they can fix the problem that they may have blame in (Hammer Turner). Another possible reason presented by Climo, 2002, seen that grandparents felt a commitment to the value of family continuity, they agreed to take care of the family. Their commitment to both generations their child and grandchild meant they felt it was their responsibility to step in (Climo, 2002). Also grandparents may not want their grandchild to be placed with strangers and fear that they may lose contact with their grandchildren (Climo, 2002). Factors Attributing to Relative Care It may be hard for the grand parent to deal with conflicting issues between themselves and the birth family so by introducing skills this can assist in managing family dynamics. This can essentially result in ensuring the best outcome for the childs welfare (Coakley et al, 2007). These include boundaries with birth parents, adopting care plan and following guidelines around maintaining a good relationship with the birth family (Coakley et al, 2007). If the grandparents allow continuous contact with the birth family, it can have a negative effect. This can be said when the reason for placement was abuse, if constant communication is occurring then the child may be put in danger. Also, the grandparents will never be able to gain responsibility, authority or develop a routine if the parents are interfering and not sticking to access plans that have been drawn up (Terling, 2001). Some argue that relative carers are not capable of meeting the childs needs (Sparr, 1993, Dubovitz, 1994 citied in Terling, 2001). There are assumptions that a child experience of parenting from their parents can be transmitted from one generation to another (Pugh De Ath, 1985). The grandparents capability needs to be questioned, looking also at their suitability of caring for their grandchildren, as they are the ones who raised the troubled parent (Gladstone Brown, 2007). Parental failure can be seen as a result of learnt behaviour from previous generations poor parenting (Davidson, 1997, citied in Climo, 2002). As characteristics run through the family, it can prove that the relative carers might have similarities in parenting to that of the birth parents. Especially in this case considering that the grandparents raised the birth parents. It can be said that if the reason for placing the child in care is due to abuse or neglect this can be a worry and should be considered (Terlin g, 2001). Implications can occur when a grandparent takes their grandchild into care. They can find it hard dealing with the childs emotional, behavioural, physical problems, issues of attachment or loss, perceived agency inadequacy, dealing with authority of the child welfare system and dealing with birth parents (Coakley et al, 2007, pg 93). A custodial role can affect the grandparents health as they need to alter their routine and plans, they can feel physical tired, have less time for themselves and have extra duties to do around the house with the addition of a new person (Gladstone Brown, 2007). As they are then busier, relationships can be affected. They have less time to interact and enjoy doing things with their friends, this can cause them to become socially isolated (Broad, 2001). Other relationships include the grandparents other grandchildren who can become jealous at the thought of their grandparent being closer to one grandchild and providing them with more attention (Jendrick, 1993, citied in Climo, 2002). Depending on the grandparents employment status, they may have to quit their job as they will be responsible for the child, this can have an affect on their financial income. They will have more to payout as an extra person, with less money to do this with (Gladstone Brown, 2007). It was found that grandparents can become to resent the situation they are in and it showed they felt they were incapable of keeping up with the child (Climo et al, 2002). Role of the Social Care Worker Relatives who foster care tend not to receive as much support, can ask for less help and it is believed that social workers feel they need less help than traditional foster care workers. The worker and grandparent need to draw up a support plan that will ensure the above do not occur (Broad, 2001). The social worker needs to assess what it was like for the grandparent when they were parenting their own children. They need to reflect on what worked for them when raising their children, try to identify possible mistakes they made and acknowledge how it will be different raising their grandchild (Broad, 2001). They need to understand it may be difficult in altering their role towards their grandchild, possibly identifying their idea of discipline as it may not be appropriate in terms of child welfare, for example corporal punishment was norm years ago but times have now changed. Also as the hope is that the child can one day return to their birth family, the parents own beliefs in raisi ng a child has to be made aware to the grandparent so they do not confuse the child (Broad, 2001). The grandparent may find parenting hard if they have to deal with social services monitoring them. It can be difficult for the grandparents as now there are many factors to be considered which put increases in the demand of them (Pugh De Ath, 1985). In comparison to parenting in the elderly persons time, the knowledge around the needs of the child in terms of physical, intellectual, social and emotional development has become more recognised. All of these will be monitored by officials in the case of relative foster care. As before a parent would not receive this type of pressure to ensure that their child is constantly receiving care and having there needs met (Pugh De Ath, 1985). Grandparents can feel inadequate under the high expectations of their role in the childs development. It can be quite a comparison as when the grandmother was parenting there was little demand to satisfy social demands. The importance was to run the household and the saying mother knows best was the pare ntal ethnic (Pugh De Ath, 1985). In comparison to traditional foster care, relative carers are said to not receive as much support as needed. Possible reasons for this are because the social care workers may have the idea that the relatives do not require the same level services (Dubowitz, Feigelman Zuravin, 1993, citied in Mc Coakley, 2007). According Schlonsky Berrick citied in Mc Coakley, social workers may be influenced by the relationship that is already present within the family. As the child is under the care of their family, the social worker may feel it is the families right to raise the child without the intrusion of them (Coakley et al, 2007). Another possibility is that the grandparents themselves either refuse or do not request support from services (Coakley et al, 2007). Grandparents may feel that asking for help or showing a need for help may be perceived as a weakness in their ability to cope. In the findings conducted by Mc Coakley 2006, it can be seen that mutual goals should be drawn up in the a ssessment process so that the best possible care for the child can be achieved. In addition to this, if the agency can show how committed they are in tailor making the families intervention and meeting the needs specific to the child and family then the family may welcome support more openly (Coakley 2007). Gladstone Brown (2007) identified the following factors which contributed to a positive relationship between the social worker and grandparent. It was found that firstly if a social worker presented as a friendly, considerate personality and the grandparents felt that they could connect and talk to them then they were more likely to open up to them. Social workers need to show an understanding to the situation, and allow the grandparents to feel appreciated for the contribution they are making (Gladstone Brown, 2007). Grandparents appreciate when a social worker responds to their needs and offers them informative advice and support on child management issues and referrals of other services that could offer support (Gladstone Brown, 2007). For a grandparent being informed can help them with their new role of parenting. As they are monitored and assessed, receiving feedback can allow them to know where they stand and how they can improve and also know what they are doing right. Also as their situation changes they need to know about entitlements that they can receive (Gladstone Brown, 2007).