Case Study Essay Example for Free

Case Study EssayWhy is it important to get the patients assessment of wellness c ar fictional character? Does the patient shit the expertise to judge the health c be he or she receives? The patient is the customer. If the patient perceives that the health care received is inadequate, then he or she may go elsewhere the next sentence these services are needed. Although patients may not have the expertise to judge some aspects of 2 health care, they can judge appearances of competence, betterments in the way they feel, how they are treated, the cleanliness and comfort of the environment, and timely responses to service requests. . How might a hospital measure quality? Measuring quality in a service setting much(prenominal) as a hospital can sometimes be dif? cult. One obvious way is to keep track of the number of patient complaintsor even lawsuits. Some new(prenominal) measures that could be used include, exactly are not limited to, the following Average time for nurses t o respond to a patients call Average time spent by patients in intensive care Average recovery time after surgery Average condition of patients upon discharge Change in patient condition between penetration and discharge Number patients per staff member 3.Using the steps in the table in the case discuss how from each one might apply to FCGH. To coiffure this question, one must remember that the product provided by FCGH is health care. However, it must also be remembered that the hospitals staff (nurses, physicians, lab technicians, etc. ) are the suppliers of that service. Thus, quality of service will depend a great deal on the stafftheir motivation, attention to details, morale, level of caring, etc. Quality to the Customer Is conformism of the service provided compared to established quality standards? Is quality of the hospitals health are service compared with that of competitors? Quality Costs Have the salutes of quality been metric and have possible areas for cos t savings been identi? ed? Design Review Do procedures exist to review patient treatment for quality? Are these procedures organism carried out? Product Quali? cation Have procedures been established and followed to qualify new treatments before they are used on patients? Product Liability Has each treatment been scrutinized regarding asylum and are provide records kept? Does a written plan exist for dealing with major problems regarding patient?Process Capability Has the effectiveness and risk of each treatment been measured, and is that information used in selecting treatments? Incoming Inspection Is incoming material inspected? Are staff members evaluated before being hired? Are records of these evaluations kept? Supplier Quality Are suppliers and staff members made aware of their quality responsibilities? Are records kept on nonconformance? Process Control Has the hospital real policies for controlling treatments and lab tests? Have employees been trained to follow th ese policies? Inspection and Test Planning Do inspection and test plans exist for all services provided and are records maintained on the pass ons? Are all test procedures and equipment regularly checked for accuracy? Quality Performance Indicators Are quality performance indicators regularly create throughout the hospital and made available to employees? Employee Involvement Program Are employees involved in quality improvement through some process such as quality circles? Multifunctional Quality Improvement Team Has a quality improvement team covering all functional areas been established to monitor quality work and to work o improve it? Quality Business Plan Has quality been integrated into the hospitals business planand from there into the general strategic plan? 4. How can the value of a human life be included in the cost of quality control? Placing a cost on a human life is, of course, dif? cult. However, even companies that manufacture goods must deal with this if ther e is the possibility that a defective product could result in death. In a hospital setting death is always a possibility due to unforeseen complications or adverse drug reactions. The best betterment for FCGH may be to follow whatever policies and rocedures will produce the least chance of patient death. 5. There are certain parallels between the evaluation of health care quality and educational quality. How are customer surveys used to evaluate the quality of teaching at your institutions? How are the results used? Are any other measures available to assess educational quality? What improvements would you suggest to the current system? Teaching evaluations are the customer surveys of education. They are used by faculty and administrators to improve curriculum and teaching methods, to evaluate faculty performance, and to bestow teaching awards.There is general agreement, however, that student evaluations of teaching are insuf? cient assessments of education quality in and of thems elves. Students may give high marks to teachers based on personality, lax administration of the class, or the level of dif? culty of the course (easy grades). Further, how can students (who are just learning) judge whether the appropriate material is being taught? On the other hand, the student perceptions should not be ignored. A professor who is very knowledgeable about a subject, but who cannot carry that knowledge is of little use to the educational process.Therefore, in assessing educational quality, multiple measures of performance should be used, including Teaching evaluations completed by students Peer evaluations by faculty Surveys of employers Surveys of alumni Ranking of departmental performance by other deans or industry Placement data Overall student evaluations based on assessments of total curriculum, rather than individual courses or teachers. QUALITY CLEANERS This case can be used to address several issues and objectives All employees throughout the proce ss must be involved. Employees must be accountable for the quality of their work. In service organizations, determining the attributes that de- ?ne quality service, and the corresponding question of how to measure quality can be dif? cult, but must be done, The student should have suf? cient understanding of SPC to determine when, where, and how it should be applied. Small increases in prevention and appraisal cost will result in large decreases in total cost of quality. Records are kept to maintain accountability of the employee to determine bonuses, additional training required, or possible dismissal.another(prenominal) problem area identi? ed would include quipment (cleaning machine, presses) not functioning properly. These records would also indicate areas where future improvements should be directed. Given below are some points that should be included in the case analysis. 1. Inspections should occur throughout the process with each worker checking his or her work and previ ous activities also. The astute students will also grapple the capability of using the customer as an inspector. When the garment(s) is brought into the store, the customer should be asked if there are any spots or stains that may require exceptional attention, repairs eeded, special requests, etc. Getting this information from the customer will greatly increase the probability that the service provided meets the customers expectations. The counter person and the marker should be checking the garments closely for foreign objects, rather than leaving this for the cleaner, because this has the greatest potential damage in terms of dollars and dissatis? ed customers. A load ruined by an sign pen would impact 1020 customers and cost several thousand dollars in claims. 2. Allow for some student creativity. Possibilities would include he counter person, marker, and assembler initialing the ticket at a designated point. The dry cleaners and pressers could use special shaped (circle, squ are, triangle, etc. ) punches to punch the identi? cation tag pinned in the garment. Another option would be for the cleaners and pressers to use small plastic tags (as sometimes seen on bakery items) placed on the hanger. Whatever the solution, it should achieve the objective of accountability and require limited time and supplies cost. 3. The additional workload must be tracked over time. Time consumed must be matched with the number of complaints.

The opening scene Essay Example for Free

The opening scene EssayRomeo Juliet was a play written by William Shakespeare when plays were the main source of entertainment, which if disliked by consultations would end up in actors creation hit by rotten fruit and vegetables. With that in mind Shakespeare devised openings to his plays, which gripped the audience immediately with drama, action or humour. For Romeo Juliet he chose to capture his audiences with humour, which is set during a conversation between devil Capulet servants Sampson Gregory. They discuss the hatred they share for their rival family the Montagues.The Montagues Capulets are two equal families with a history of blood and violence, destroying the cultivatedisation of Verona. precisely the teenagers of both families fall in love in a relationship, which could never be beca uptake of the rivalry. Thus beginning the story of Rome Juliet. The prologue of the play is just a basic introduction to the play, which gives an outline of the familys histor y and sets the scene for the play. In the prologue the families are describe as two households both a like in hauteur showing that still much dislike there is between them they get out always be the same. It also mentions an ancient grudge and that civil blood makes civil hands unclean. Telling us for years the blood and violence shared between them has destroyed the civilisation of Verona. It also introduces the love, of Romeo Juliet, that could never be. Their love in the prologue is described as a pair of star crossed lovers take their lives thus giving away the ending of the story and completing the full title THE TRADGEDY OF ROMEO JULIET At the start of Act 1 Scene 1 Samson Gregory the servants of the Capulets grip the attention of the audience with a conversation consisting of a string of sexual innuendoes.In the conversation they refer to acts of a sexual nature, which they would bestow upon the maids of Montague given the opportunity and refer to taking the maids v irginity as taking their maidenheads. This is intended to grip the audience as such humour would have been regarded highly back then. This kind of opening seen would keep the audiences attention as they would want to stay to see if the play would go on in the manner in which it has began. During the conversation two servants of the Capulet house, Benvolio Tybalt two very opposite men, meet them.Benvolio is a peacekeeping man who fears the oddment of himself or someone close to him, in these regular battles. On the other hand Tybalt is a violence crazed, Montague hater who says I hate the word as I hate hell refereeing to the Montague family name and showing how strong his hatred is for the family. However his love of violence is his downfall as Romeo seeks revenge for the death of his close booster dose Mercutio. The Capulet servants are then joined by two other serving men, one being Abram.The two families then descend into an argument over an repellent thumb biting gesture ma de by Samson. After a brief argument Samson orders the Capulets to draw there swords, saying draw if you be men enticing them to draw by insulting their status should they refuse battle. Shakespeare uses short sentences here to build up the tension between the families also do it a fast paced scene. However the brawl is interrupted by Prince Escalus who is furious that yet another brawl has broken out in the streets of Verona between the two families over an airy word meaning that the two families have been brawling for meaningless reasons. He describes their rage in a metaphorical term fire of your mortal(a) rage and goes on to describe the men as beasts. Which is followed by a threat to the Heads of the houses, Lord Montague Lord Capulet, If ever you disturb the our streets again, your lives shall pay the forfeit precedent the Lords that if every of their servants disturb Veronas streets they shall be sentenced to the Death Penalty.Romeo is a very unhappy man at the start of the play as he is sulking over being rejected by Rosaline and grieves by locking himself in his room in total darkness. He describes the way in which he the rejection has affected him with confusing images, and use of oxymorons reflecting his state of mind of being confused feather of lead, bright smoke this shows who heart break is affecting him mentally.Romeos mother and Benvolio discuss Romeos behaviour as he has been avoiding his family and friends and his mother becomes increasingly concerned about his behaviour O where is Romeo? Saw you him today? not even his mother knows what is going on with him. This tells us Romeo is a very secretive man who keeps his problems to himself. Benvolio then has a plan to relieve Romeo from his sulking and tells him to Examine other beau shackles so that he can lure him away from sulking in his room to admire the beauty of other fine women and not sulk for the rest of his life over one girl.Romeo manages to release all his rage however in a vendetta to seek revenge on Tybalt for the death of Mercutio and falls in love with another beauty the teenager daughter of the Capulets but is so madly in love that when a plan for Juliets heart to stop and Romeo to meet up with her but the message never reached Romeo in tie and took himself to the place of Juliets rest and takes poison at which point Juliet recovers only to take the rest of the poison to be with her lover.The two families then decide to settle their differences because of the death of their star crossed lovers Throughout the play Shakespeare illustrates his impressive writing skills by leaving the audience on edge from time to time and leaving them ask questions what will happen next in the storyline. From Act 1 Scene 1 alone the audience are left asking themselves many questions will there be more fighting? , Will the Lords pay the forfeit of life? , Will Romeo find love? , Will there be any more humour? This is a particularly good introduction to the play as within minutes of the start there is plenty to keep the audience enticed.

Nursing A Patient Receiving Ostomy Surgery Nursing Essay

Nursing A Patient Receiving Ostomy Surgery Nursing EssayVarious gastrointestinal and genitourinary etiologies may need the creation of urinary or fecal diversion. These may accept inflammatory bowel disease, diverticular disease, intestinal obstruction, colon-rectal evokecer, gynecological cancers and gastrointestinal impairment (Beitz, 2004). Indications for coming up with the urinary stoma include neurogenic bladder, bladder cancer, refractory radiation cystitis and interstitial cystitis. The cause of the disease impart determine if the stop will be a temporary or permanent whizz (Thomas and McGinnis 2004).Among various types of surgically created ostomies, colostomy involves the opening made on the large intestine to forget for the passage of faeces. The fix of colostomy can be in sigmoid, transverse or ascending position. In this case, surgical resection will ultimately determine the stool proceeds consistency. Ileostomy is a surgical construction from the small intesti ne and it is located full(prenominal) in the gastrointestinal route hence the stool railroad siding is comparatively of high quantity and liquid consistency (Gordon and Vasilevsky, 2004). Ileal conduit or urostomy is made exploitation a short portion of the ileum to supporter in pissing elimination. Ureters are connected to conduit to lay off weewee to give ear out of the body into ostomy pouch through the stoma (McGinnis and Tomaselli, 2004). Whether the ostomy is temporary or permanent, nurses must(prenominal) posses the knowledge to give the forbearing of and the family the necessary culture to improve recovery and enable a positive receive when obtaining information about ostomy care.Patient education.Any patient who is scheduled for an ostomy surgery can experience a number of feelings like fear, anxiety, depression and loss of body image especially if the cause of the surgery is a diagnosis related to cancer. Pre operative teaching methods assist the patient by r eceiving these feelings and contribute to quick recovery of the patient (Oshea, 2001). A very important ingredient in the teaching procedure before the subroutine is the Wound Ostomy and Continence Nurse (WOCN). Counseling before the operation allows for the assessment of the patients knowledge about the disease, support bodys, level of education, employment, physical activity involvement, financial concerns and hobbies. judging of any physical shortcomings is also necessary because poor manual dexterity, poor vision and loss of hearing may presume the patients ability to undertake ostomy self care. Patients spiritual and cultural beliefs should be also assessed because certain particular rituals concerning ostomy care may need to be taken in. Employing all these factors can assist the patient to recover successfully and feel confident in managing the condition (Oshea, 2001).WOCN reviews the cause of the disease, stoma characteristics, surgical procedure, peristomal spit out care, dietary considerations and a variety of ostomy appliances. If appropriate teaching proceedings may enable the patient to have an insight of the ostomy pouching system. Use of teaching booklets and illustrations helps to improve the education.A nonher component of preoperative teaching is the stoma range marking. This is recommended for all who are set to undergo a permanent or temporary stoma (Goldberg and Carmel, 2004). A poorly located stoma on the patients tum can lead to peristomal contend complications, stool and urine leakage, stoma, emotional and physical stress for the patient. During stoma office marking, there is abdomen assessment with the patient in sitting standing and lying positions. Also the abdomen can be assessed for the disrobe folds, bony, creases, scars and prominences. Patients belt and line should be avoided from the stoma site and not affect any prosthetic devices. The stoma site should also be put in an area that the patient can visualize and acce ss. Ideal stoma site is situated in the anal muscle that extends to symphysis from the xyphoid process (Goldberg and Carmel, 2004).Nursing education.In stoma assessment the patient must enter the operating room with the pouching system on stoma. Immediately after the operation the, a transparent pouch is recommended to enable the nurse to have a view of stoma characteristics and stool and urine presence (Goldberg and Carmel, 2004). Initially after the operation period, the stoma can appear edematous, red, shiny and moist. In general terms, the stoma is red to pink in coloring material according to tissue that was used in construction. Brown to dark color may show stoma ischemia and the consultations must be made with the physician.The act of the stoma ranges from round to oval. It wobbles its shape and size in a period of six to eight weeks after the surgery. Since the stoma decreases in size with time, the nurse must use a skin barrier that has been cut to rival to the stoma ( Goldberg and Carmel, 2004). For the first six to eight weeks after the surgery, measurements of the stoma should be taken each time the barrier of the skin is changed. Measuring guides are provided to measure round stomas, oval stomas will need the length and width measurements of the stoma (Colwell, 2004). Lack of sphincter by the stoma to regulate the passage of urine or stool, then the opening should be placed near the center of the stoma to aid the flow of urine and stool (McCann, 2002).The stoma may not or may protrude out of the skin find. Stomal protrusion vary from a flush stoma at the skin level to a moderate one which is about 1-3 cm in length (Erwin-Toth and Doughty, 2002). Actually, stoma protrusion should be at least 0.8 inches above the skin level (Colwell, 2004). Protruding stoma helps urine and stool to flow into the pouch directly. A flush stoma is not suitable because it can cause difficulties when skin barrier attaches to it and leakage of stool below the skin b arrier leading to peristomal skin irritations.The stoma output is determined by the location of ostomy. The output resulting form the ascending colon produces a semi liquid consistency whereas the one from the transverse colon produces a semi-liquid to pasty consistency and the one located in a sigmoid or descending colon will be more of a solid stool (McCann, 2002).An Ileostomy stool output is constant and peeingy with a lot of digestive salt and digestive enzymes. At the initial postoperative stages, the stool may be greenish and thick. The stool output from Ileostomy range from 800-1,700 cc in one day (Colwell 2004). When the patient comes back to the regular diet, there is development of the stool consistency from the ileum and a cut down out put in a daily basis ranging from 500-800cc/day. With time the small intestines recovers and with a decrease in stool output (McCann, 2002). Urine is flat produced after the surgery by the Ileal conduit stomas. It is usually normal for t he urine to be blood-tinged after the operation. Also the small intestines produce mucous which may be seen in urine (Colwell, 2003).Peristomal skin care involves the protection of the peristomal from coming into contact with the urine and stool to stop the occurrence of peristomal skin complications. Skin barrier needs to be properly measured to suit the stoma. If the skin barrier opening is too large, urine or stool will cause irritation on the peristomal skin area. The opening should not be more than 2cm larger than the size of the stoma. Cleanliness of the peristomal skin can be done by gently using warm water then dry it. Moisturizing soaps must be avoided because they affect negatively the skin barrier attachment. Male patients need to be taught trimmed peristomal using electric razor, scissor hold and other safety devices in an outward manner from the stoma (McCann, 2002).When choosing the pouching system of the patient, the information that was gathered before the operation is heavily relied upon. Other factors to be considered include location of the stoma, its size and shape plus the anatomical location. Pouching system should give anticipated wear time and protect the underlying skin from stool and urine (Colwell, 2003). Most of the pouching systems are designed in a way that the weight is light, easy to maintain and odor-proof (Colwell, Carmel and Goldberg, 2001).One of the most important components of the pouching systems is the skin barrier because it protects the peristomal skin from stool and urine (Colwell, 2004). Skin barriers can be found in either cut-to fit or pre-cut product. The pre-cut models are meant for the round stomas. Barrier opening should fit stoma size to limit the probability of the urine and stool coming into contact with the peristomal skin. The cut-to fit models can be used in oval stomas or the ones which are irregular in shape. The cut-to fit barriers are the commonly recommended in initial postoperative stage because th e size of the stoma will reduce for not less than six to eight weeks from the day the surgery was performed. A large skin barrier may cause peristomal skin problems resulting from the exposure to stool or urine (Colwell, 2004).Skin barrier wear time is necessary the barriers are either classified as extended or standard. The difference between the both lies in their interaction with the moisture and the degree of affinity to the skin. The two barriers absorb the moisture. However, the extended model absorbs moisture slowly as compared to the standard model. This delays the erosion of the skin barrier (Colwell, 2003).Skin barriers have flat or convex shapes. At the back of a f lat barrier is one level surface while the convex one has an outward protrusion. Skin barriers are made with in-built convex shape which is created by putting the ring into the barrier. The intention of the curve is to place blackmail in a downward position to the peristomal skin to enable the stoma to protr ude in an outward position (Colwell, 2003). Different convexity depths are referred to as deep, moderate and shallow. Generally convexity is used in stomas which are flat and retracted to minimize urine and stool leakage below the pouch. Also the convexity can be used in abdomens with skin folds or soft abdomens in peristomal skin (Colwell, 2004).Various ostomy pouching systems are available. It is therefore necessary to elaborate to the patient that the systems used in hospital after surgery may not be necessarily the system he or she will continue using after recovering from the operation. The following must be considered while selecting the ostomy pouching system the ostoma size and shape, effluent type, presence or absence of abdominal folds and contours and the type of the ostomy. The patients manual and visual dexterity must be considered as well including day to day activities (Colwell, 2004).Pouches sealed to the barrier are categorized as a hotshot piece, and systems that are connected to the skin barrier are seen as a double piece. A two piece pouch gives the patient the capacity to change or remove it without altering the skin barriers. Again it is easier to position the skin barrier at the middle of the stoma. One mechanism for making sure that a two piece pouch is closed is will ultimately depend on the ability of the patient to snap the pouch and the wafer together. Application of the pouch to the wafer will require the patient to be instructed so that he or she can listen to an audible click to make sure that the pouch is safe to the skin barrier.

Rheumatoid Arthritis Treatment Methods

Rheumatoid Arthritis Treatment MethodsINTRODUCTIONAutoimmunity is the inability of an organism in recognizing its own parts asself, which triggers an abnormal immune response against its own carrells or tissues. Due to much(prenominal) a response, autoimmune distempers occur.Autoimmune distempers are in general divided into the followingSystemic autoimmune diseases The symptoms and damold age occurs throughout the body, i.e the antigen is not tissue-specific.Localized autoimmune diseases The damage is localized, i.e., the antigen is tissue specific.Rheumatoid arthritis (RA) is a chronicinflammatory, systemic autoimmune disorderthat whitethorn affect m either tissues and organs, but mainly attacks the flexible (synovial) joints. 75% of the reported cases of RA occur in women, especially at age 30 and 40 years and between 50 and 60 years (Bach, 1982). It can be a disabling andpainfulcondition, which can lead to of import neediness of mobility and function if not treated adequa tely. But it is still unclear whether T-cells primarily respond to a microbial antigen, or a self-constituent antigen (Chiniet al., 2002).Lesions developed in RA appear to be involved in both cell-mediated and humoral responses. Prior research work focused on identifying the cells present in the stirred synovium, and has been concluded that CD4+ T lymphocytes, active B lymphocytes, and plasma cells, have with well- tropeed lymphoid follicles having germinal centers (in more serious cases), are present in the synovium of the patients (Abbas et al., 1994). Major cells present in the synovial filtrate of patients are T-cells, and a partial therapeutic effect was observed due to depletion of T-cells in these patients (Berneret al., 2000). Present ground of RA conveys that TH1 cells which are specific for a particular antigen (which hasnt been identified yet) are present in the joints of the patients.Pathogenesis and symptomsFig1.1 Release of cytokines due to T-cell activation causin g an inflame synovium and pannus.Cytokines released in the synovium are Interleukin(IL)-1, IL-8, Interferon-gamma (INF-gamma), and Tumour Necrosis Factor-alpha(TNF-alpha). But the clinically essential unmatcheds are IL-1 and TNF-alpha. These cytokines stimulate increase in collaginases, IL-6, chemokines, nitric oxide and Cyclo-oxigenase-2(COX-2) production. The combined action of these and a few others like IL-2 and IL-4 lead to the pathogenesis of the disease. Other than antigens, RA to a fault involves antibodies- this is most likely due to formation of immune complexes. The auto-antibodies produced are called derelict factors and are specific to the Fc region of IgG. This rheumatoid factor is an IgM antibody and hence the immune complex consists of IgG-IgM which cause the damage (Janeway et al., 2001).Symptoms include stiffness, pain, swelling, and erythema, joints become tender, swollen, and warm. As it progresses, sextuple joints would be affected (polyarthritis). The clin ical manifestations are collection of polymorphonuclear leukocytes and macrophages at the inflamed region, cartilage damage, and, destruction of the joint Synovitis (inflammation of the synovium) can lead totetheringof tissue, lack of movement and wearing of the surface leading to deformity and loss of function. Systemic complexities are damage to various other organs like lungs, myocardia, pericardia pleura, eyes, and Central Nervous System as a result of inflammatory reactions (fig-1.1).Many agents are now available to treat RA, and many of them are monoclonal antibody antibodies. Several new monoclonal antibodies are currently under development and hope amply will be available as other alternativesThe focus of this paper is to state the latest therapeutic monoclonal antibodies being used for RA give-and-take, to state their merits and demerits and whether they are mitigate than normal drugs/ medication. monoclonal antibodies with different mechanisms of action and route of ad ministration are discussed and whether they pose as good therapeutic agents with an acceptable safety profile.2. REVIEW OF LITERATURE2.1Treatment of Rhematoid ArthritisSome of the handlings for RA areAnti-TNF-alphaTreatmentsMedicationsTherapeutic monoclonal antibody treatmentEarlier it was believed that if nonpareil cytokine signal cascade was blocked then another cytokine would takeover. It was hypothesized that IL-1 caused the cartilage and bone damage.Through a study(at Kennedy Institute of Rheumatology), it was found that IL-1 bioactivity had stopped due to TNF-alpha blocking. This led to the development of anti-TNF-alpha treatments like- cyotokine antibodies and soluble-receptor antagonists (Feldmann et al., 1999). at that place are mainly four types of medications being used- Disease-modifying anti-rheumatic drugs (DMARDs), Non-steroidal anti-inflammatory drugs (NSAIDs), immuno-suppressants, and corticosteroids (glucocorticoids).(Rang et al.,1995). DMARDs include pencillamine s (Cuprimine, Depen), gold compounds (Myochrysine, Ridaura) and chloroquine (Plaquenil). Although their mechanism of action is not properly understood, they have a very operative effect on RA patients. NSAIDs like asprin, ibuprofen (Advil ), ketoprofen (Orudis), naproxen (Naprosyn), etc.. have a variety of effects like anti-inflammatory, anti-pyretic, and analgesic effects.Immuno-suppressants like cyclosporine and cytotoxic agents like azathioprine suppress both humoral and cell-mediated immunity. Corticosteroids like prednisone, hydrocortisone, etc., have immunosuppressive and anti-inflammatory effects (Rang et al.,1995).2.1.1 Therapeutic monoclonal antibodiesEach B-cell synthesizes only one attractive of antibody and every organism has various populations of B-cells which secrete various antibodies specific to various antigens being recognized. But in order to turn this function into a helpful tool, we need huge amounts of a same antibody. So we need to culture a B-cell populati on originating from the same ancestral B-cell and hence obtaining the same kind of antibodies.Such a population of cells are called monoclonal and the antibodies aremonoclonal antibodies(mAbs).Such monoclonal antibodies used for various therapeutic purposes are referred to as therapeutic monoclonal antibodies.If a specific antibody of a B-lymphocyte is needed, that B-cell should be secreted in an organism. So the antigen for which the antibody is needed is injected into a mouse and it secretes the B-cell antibodies against the antigen. Such B-cells are isolated from the spleen and fused with myeloma cells (using Poly Ethylene glycol, or electroporation), forming hybridomas. To selectively isolate the hybridoma cells, they are grown in HAT(Hypoxanthine AminopterinThyamidine) medium. (Fig 2.1.1) The cancer cells are HGPRT- and the B-cells are HGPRT+(HGPRT is an enzyme Hypoxanthine-guanine phosphoribosyltransferase which helps in the synthesis of nucleotides from hypoxanthine). Theref ore, all the unfused myeloma cells die in the HAT medium and all the unfused B-cells cant divide for long and only the hybridoma cells survive indefinitely. It is from these cells that the antigen-specific antibodies are labelled and isolated using radioactivity or immunofluorescence.Fig 2.1.1- A summary of the process of monoclonal antibody production.TypesTill date there are four types of therapeutic mAbs-MurineChimericHumanizedHumanMurine antibodies (suffix omab)refer tomAbs made from any mammal of the family muridae (like mouse, rat). These mAbs were produced using hybridoma technology and were analogous to murine antibodies. But these were not a success because immune complexes formed due to which they only had a short half-life in vivo and caused cytotoxicity resulting in allergies and anaphylactic shocks .Hence these were replaced by chimerical and mercifulizedmAbs.Chimeric mAbs (suffix ximab) has variable regions of murine and constant region of humans fused together (they are 65% human). This decreases immunogenicity. Humanized antibodies (suffix zumab) are made by grafting murine hyper-variable region onto the amino acid region of the human Abs (they are 85% human). However, these antibodies lacked the specificity of their parent murine mAbsso, affinity was increased by introducing mutations in the CDR (complementarity determining region). Phage display libraries or transgenic mice are use to produce human mAbs (suffix umab). In this the murine genome is injected with the human immunoglobulin genes due to which it becomes transgenic. This mouse is injected with the desired antigen to yield the subsequent mAbs(Hudson PJ, Souriau C., 2003).2.1.1.1 Monoclonal Antibodies Directed Against TNF-TNF- is a key mediator of the inflammation-induced joint damage that is a assay-mark of this disease. Monoclonal antibodies to TNF bind soluble and transmembrane TNF, thereby down-regulating TNF-induced immune responses including adhesion molecule expression, cytoki ne production, matrix metalloproteinase production, neutrophil activities, dendritic cell function and osteoclast differentiaion. (Blumi S, Jet al.,2012) Monoclonal antibodies to TNF, except for certolizumab have the ability to lyse TNF-expressing cells in the presence of complement. (Kukar M, et al.,2009). Currently there are four mAbs canonical for the treatment of RAInfliximabThis is a chimeric IgG1 mAb and has human constant region with murine variable regions.(Perdriger A., 2009). This is best used with methotextrate(MTX) and is available only in the intravenus form. In 2001, it was approved by the FDA in combination with MTX to treat moderate to severe RA. Effectiveness and improvement in the disease compared to placebo was shown in multiple, randomized trials(Elliott MJ, et al., 1993) ,( Lipsky PE, et al., 2000), (MainiRN, et al., 2004). It was proven to be strong in early stages of the disease (et al., 2004).Given that influximab is comprised of a significant proportion o f murine protein it was anticipated that patients would develop antichimeric antibodies that could impair the might and increase the risk of infusion reactions. The combination of infliximab and MTX results in a substantial reduction in antichimeric antibody and increased serum infliximab levels..AdalimumabAdalimumab is a human recombinant IgG1 mAb that has no murine component and is produced by phage display technology. It was FDA/EMA approved in, or soon after, 2002 for the treatment of moderate-to-severe RA as monotherapy or in combination with disease-modifying antirheumatic drugs (DMARDs). It is available in the subcutaneous form at a venereal infection of 40 mg every 2 weeks. Despite adalimumab being a fully human antibody, anti-adalimumab antibodies have been detected in a significant shape of patients(Vincent FB, Morland EF, Murphy Ket al.2013). Adalimumab responses and long-term sustainability may be reduced by anti-adalimumab antibodies, but adalimumab generally has goo d sustainability similar to that of etanercept and generally better than infliximab.GolimumabGolimumab is a fully human IgG1 anti-TNF- antibody that was generated and affinity matured in an in vivo system. It is very similar in structure to infliximab without the mouse protein. It was approved by the FDA/EMA in or soon after 2009 for the treatment of moderate-to-severe RA in combination with MTX(Kremer J, et al,2010).CertolizumabCertolizumabpegol is a humanized Fab fragment (Fc free) fused to a 40-kd polyethylene glycol (PEG) moiety. It was FDA/EMA approved in 2009 for the treatment of moderate-to-severe RA as monotherapy or in combination with MTX. It is available in the subcutaneous form at a dose of 400 mg at 0, 2 and 4 weeks, then every 2 weeks or 400 mg every 4 weeks.2.1.1.2 Antibodies against B CellsB cells are unfavorable to the pathogenesis of RA. Mature B cells may evolve into antibody producing plasma cells. Although the precise role of B-cell-producing autoantibodies in RA remains unclear, B cell and plasma cell infiltration into synovium has consistently been found.In addition to their role as precursors to antibody producing plasma cells, B cells may function as antigen-presenting cells and may also produce inflammatory cytokines and co-stimulatory molecules important for T-cell function.(TngYKO,et al., 2007).RituximabAs rituximab is a B-cell-depleting agent, chimeric/IgG1 monoclonal antibody which binds to the CD20 cell surface marker found on several(prenominal) maturation stages of B lymphocytes. It gained FDA/EMA approval in 2006 for the treatment of moderate-to-severe RA in combination with MTX in patients with inadequate response to anti-TNF. Rituximab is given via the intravenous route at a dose of 1000 mg for cardinal doses 2 weeks apart for each cycle. The first study evaluated rituximab in RA was reported by Edwardset al., 2004.Four treatment groups consisting of MTX monotherapy, rituximab monotherapy, rituximab plus cyclophosphamide and rituximab plus MTX were compared, and all rituximab groups had a better ACR20 response compared with MTX monotherapy, with a comparable safety profile.2.1.1.3 Antibodies That Interfere With IL-6 FunctionIL-6 is a cytokine produced by immunologically important cells that has an important role in T-cell activation and immunoglobulin secretion.It also stimulates synovial fibroblast differentiation and osteoclast activation.Dysregulation of IL-6 is also, in part, responsible for many of the generalized systemic effects of RA, including anemia of chronic disease as well as the acute phase reactants seen in this disease(Tanaka.Tet al. , 2010).TocilizumabPreviously called MRA, tocilizumab is a humanized/IgG1 mAb directed against IL-6 receptor in its soluble and transmembrane form. It was approved by the FDA/EMA in early 2010, or about before, for the treatment of moderate-to-severe RA in patients with an inadequate response to DMARDs and/or anti-TNF. A subcutaneous form of tocilizuma b is currently under study. It is also indicated in patients with anemia of chronic disease since it dramatically increases hemoglobin as a consequence of reduction in hepcidin the protein that inhibits iron utilization in RA.2.1.1.4 Antibodies That Interfere With IL-1 FunctionIL-1 is produced by many cell types in response to myriad inflammatory stimuli and mediates multiple immunologic and inflammatory pathways. In patients with RA, the levels of naturally produced IL-1 receptor antagonist in the synovium is thought to be insufficient to counteract the increased levels of IL-1 produced in this disease (Arend WP., 2002)AnakinraAnakinra is the recombinant form of a human receptor antagonist (IL-1ra), and was approved by the FDA/EMA in, or slightly after, 2002 at a daily dose of 100 mg subcutaneously for moderate-to-severe RA that has been unresponsive to initial disease DMARD therapy. It has been studied in RA in several trials. (Fleischmann RM.et al,2003)2.1.1.5 SafetyInfectionsIn fections are the most common adverse event associated with the use of all biologics. Infection risks with anakinra and tocilizumab are probably similar to the TNF inhibitors, with rituximab perhaps having slightly less risk.Infection risk may be higher with the use of increased doses of infliximab and anakinra.Respiratory tract infections are most commonly reported. The risk of granulomatous infections, such as tuberculosis, is also increased in patients using monoclonal antibody TNF inhibitors.MalignanciesThe use of TNF inhibitors in patients with RA has not been associated with an increased risk of self-colored cancers, with the exception of cutaneous malignancies.. Malignancies have been reported with anakinra, tocilizumab and rituximab, but the risk does not seem higher than predicted in RA patients.(Ding T et al., 2010)Longer-term follow-up is required to more clearly understand the risk of malignancies with these drugs.Demyelinating diseasesSymptoms of demyelinating neurologi cal dysfunction have been associated with TNF inhibitors. Resolution of these symptoms with drug withdrawal is common. TNF inhibitors should be withdrawn immediately if neurologic symptoms occur with use, and probably should be avoided in patients with pre-existing demylelinating symptoms(Ding T, Ledinghamet al., 2010).3. DISCUSSION AND CONCLUSION3.1 Drugs vs mAbsJust as monoclonal antibodies have various side effects the medication used for RA also have various complications There have been many news reports about how pain-killing drugs known as COX-2 blockers increase affection attack and stroke risks. Additional studies suggested that older non- steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen could also elevate heart risks.One of the culprits methotrexate. Its the most commonly confirming disease-modifying anti-rheumatic drug, orDMARD, for rheumatoid arthritis. Its also responsible for hair loss in about 1 to 3 percent of people. The hair loss happens because methotrex ate is doing what its supposed to do stop cells from growing, including cells causing inflammation and, unfortunately, hair follicles. Folic acid, which is commonly prescribed with methotrexate to mitigate some of its side effects, is a synthetic form of folate, a B-complex vitamin. It can help keep hair healthy, but it has not been found to promote hair growth.Generally as a drug-related side effect, the hair loss is not drastic and the hair does not fall out in patches. And it usually grows back once the patients stop taking the drug.So as of now, most of thesuccesful treatments for RA using monoclonal antibodies are in combination with methotrexate.3.2 Conclusion and future prospectsMonoclonal antibodies with different mechanisms of action and route of administration are highly effective therapeutic agents in the treatment of RA with an acceptable safety profile. Choosing the appropriate treatment is a complex decision that is affected by clinical data, medico and patient prefe rence, and payers. Almost undoubtedly, these types of agents will continue to be important agents in the rheumatologists armamentarium. How to use these agents more selectively, particularly regarding which agents are best for which patients, hopefully will be better established in the future with new biomarkers. Prediction as to what agent to use in the right patient at the right condemnation is clearly a research priority. Monoclonal antibodies as new agents are expensive, and the cost/benefit analysis justifying their use is also critical to practitioners. . Many aspects regarding the efficacy and safety of the supposedly cheaper biologics need to be evaluated before they are available for widespread use, but their availability and the emergence of new agents in the future may substantially change the RA treatment landscape.Although current therapies can reduce the signs and symptoms of RA for many patients, the quest for a cure (or a more carry through blockade of the structur al damage) in RA is still ongoing and will need treatment approaches, which are not exclusively confined to blocking a particular cytokine, receptor, or auto-reactive B or T cell involved in disease progression. To this end exciting treatment alternatives and drug targets are on the horizon that may become available to patients in the future.

Premarital Sex And Promiscuity

Premarital Sex And promiscuityThis essay will be discussing the topic of promiscuity and premarital shake from both Ellistons and Punzos theories. fit in to Punzo on Premarital sex activity, it is for two people to gestate prosecute in a internal contact/intercourse without having the full inscription alone on the other hand, promiscuity according to Elliston it is to have sex with objet darty different people without having any consignment. When comparing both, Punzo is seen as the conservative while Elliston is seen as sustenance casual sex. Punzos supposition is when two people argon together having sex they both must be engaged in a deep commitment amid the two people. On the other hand, Elliston is arguing that sexual intercourse doesnt require any thoughts or strong consideration with any commitments since it is non that broad of a deal.According to Elliston promiscuity is seen as free love, where you can just meet someone and starting to fall(a) in love with th em. With this definition, it might be easier for some to understand it, as having freedom. It can alike be recognized as having recreational sex, having sex just for fun. When the word fun comes with anything, it will be seen as attractive and easy going. Elliston has created a definition himself that better defined promiscuity. Promiscuity is defined as sex with a series of other adults non directly related through conglutination and with no commitments no promises of warmheartedness, sexual exclusivity in future (Elliston 144).Elliston also stated that for those who just want to get others in bed to have sex by lying, exploiting, and deceiving or something close to it ar wrong. It is seen as wrong because it breaches the ethical principles that we all learned as a child, which is non to lie. When someone is lying about everything just because they are trying to get someone in bed to have sex with them, it is seen as very unethical. Promiscuity is seen as to the advantage of males and to the disadvantage of females because it is unbowed that males do non have anything to lose while females will lose their virginity and at times their love. It has become exploitive woman would get social blame but man would get sexual satisfaction. Promiscuity is not actually wrong but it is the triplex exemplar that is in places where woman is at a disadvantage in comparison to man. Promiscuity can not be defined as wrong all the time the charges that it necessarily violates generally accepted a moral principle is false. (Elliston 146). Elliston is saying that the double standard that should be remove but not the promiscuity, since it is ceaselessly seen as a disadvantage for woman. The female involved might not feel the same as to being cheated or being used for the man to have their sexual satisfaction but it might be the woman who is using the man to satisfy herself.Sex is just a body lyric in the form of body interaction between the two people that are willin g to interact and it leads to pleasure. It also has a deep meaning bottomland it. According o Elliston, sex is more than thrusts and moans, caresses and sighsjust as verbal style has a dimension of meaning beyond phonemes and morphemes, so body talking to has a significance beyond the intertwining of two bodiesPromiscuity has instrumental value in that it can facilitate the mastery of one kind of body languagesexual body language is learned through sexual interactionexperiences enable an individual to develop a repertoire of gestures for communicating desire and affection and of decisive movements that clearly state intentions of love or amusement. People can be moved not provided by the things we say but also by the things we do-with them, for them, or to themdesire and satisfaction can be communicated not only through verbal exchanges, but also through a delaying look and an appreciative caress. To a shattered ego a physical embrace may express far more reassurance than its v erbal counterparts, and a embrace may convey desire more eloquently than pleas or poemsThe observance of this etiquette is an acknowledgement of the selfhood of the other. The acquisition of it is one of the opportunities promiscuity provides(Elliston 149). Based on this quote, Elliston is saying sex is a part of body language and the more you practice it the better you will get. The skills that you get from promiscuity will wider range of people outside of marriage or committed-relationships. Usually a married couple would be seen as only one man is allow to have dinner with one woman, which is referring to only having sex with the partner and that is it, third party is not acceptable (traditionally). Elliston sees having sex with one individual at first before you decide to love that person or not. Pretty much he is saying having sex first will be a pre-stage of trying out whether the persons sexual skill or chemistry from sexual intercourse will help you decide to love this per son or not. Therefore Elliston is arguing that promiscuity should be allow and should not be seen as wrong because it is something for the two to try out and see if the chemistry is there.In Punzos view, sex before marriage or even having sex with no commitment is seen as wrong. Punzo has answered the question of is having pre-martial sex without any commitment wrong, with using Wilsons theory of sexual intercourse to compare it with playing tennis and Chessers theory of two people going to see movies together. Both Wilson and Chesser see it normal and there is nothing morally wrong about having pre-marital sex. At the same time, Punzo has dis jeerd with both of them stating that going to the movies or playing tennis with many people are just some general activities which anyone can encounter, but it does not necessary have to be the one you would have sex with, or have any sexual interest with. In Punzos view, sexual intercourse must be between two committed people, so having sex w ithout any sort of commitment is wrong. Punzo states that commitment is a must before sex, as one must agree to commit to a relationship before they can move on to a new level in their relationship, through having sex, the two gives themselves to each other in the way of trust, expressing ones mind, and feelings through the most intimate activity, sexual intercourse.Punzo see Ellistons blood between sex and dinning is a wrong example because dinning and sex are two different things, it is in an extreme that it has nothing to do with each other, dinning and sex has no connection at all. Dinning can be with any friends, or family members, and it does not involve any sexual contacts. Yes, dining can be with your spouse, partner but it can also be with someone else. Both eating and sex do give people satisfaction, but they are totally different from each other. Food is a need for people to survive but people can live with out sex. Ellistons theory is to have sexual intercourse with as many people as you can before travel in love, but Punzos theory is to be in love or have the necessary commitment before having sexual intercourse. The moral perspectives of both are totally different from each other. This is why Punzo would not agree with Elliston and vice versa.Ellistons argument has a defect to it, it is having sex with a number of people does not only increase the skills of ones sexual ability, but it also limits the important value of having the most intimate relationship with the other through sexual intercourse. I count we all know that having sex with the one we love is the most loving and special feeling of being complete as a whole. If one is engaged in a sexual activity with many other people and then stated that the one is now in love with their partner is not a rational theory, but it is also very confusing and unreasonable that promiscuity does not damage a committed relationship. Having sex without any commitment, and sequester oneself with uncomm itted sex is a view that may not be true. They can have sex without any commitment but they might do more about themselves. It doesnt mean they are isolating themselves just because they do not involve in a committed relationship. Punzos full commitment does not have a clear definition, does it mean to be in a legal marriage with legal documents, and so if the two are just case law couple then does that mean they are not legal? Punzo should have clear that term and have a better explanation of it. With the mutual arrest and respects towards each other with pre-martial sex, it is not going to affect the two negatively. It would not be harm if pre-martial sex will lead the two into commitment and onto future commitment, it would become a good thing. If pre-martial sex is happening then protection is needed to prevent any unexpected or unwanted pregnancy.In conclusion, both Punzo and Elliston has their pros and cons. Premarital sex should follow Punzos theory of sex, and they must i nvolve commitment, but not with full commitment. Punzo did not clarify what full commitment means, if it meant at the stage of being legally married, then those who are only engaged or soon to be marry couples should not be having any sexual interactions. Also promiscuity must be permitted only if no one is being hurt and lie to as a result of promiscuity. It is true that Ellistons argument of double standard needs to be remove because it is only seen as woman being the one that are at a disadvantage, but sometimes it is not the case, woman would be out to lie to man just to get money or any material that need from the man. Therefore double standard should be remove but not promiscuity. Also promiscuity is a good way to practice ones sexual skills and ability in the bed, it is true to the term practice makes prefect, it would suit this practice of promiscuity closely.

Joan of Arc :: biographies bio biography

Jeanne dArc, commonly known as Joan of Arc , is the national heroine of France. Born in 1412 she was raised as a religious French peasant in Domrmy, in eastern France. Joan of Arc is famed for her input in several victories during the degree Celsius Years War, which secondually lasted 116 years, and the coronation of King Charles VII. At the young age of twelve years old Joan first encountered the heavenly voices sent by backer Michael, Saint Catherine, and Saint Margaret. The voices told her to drive out the side and help the Dauphin, soon to be Charles VII of France, to Reims to his coronation. Joan convinced Robert de Baudricourt that she was sent by god to save France. Baudricourt was skeptical, plainly her persistence gradually made an impression on him. On 17 February she announced a great defeat which had befallen the French arms outside Orlautonomic nervous system (the Battle of the Herrings). As this statement was officially confirmed a few days later, her cau se gained ground. At the battle of Orleans in May 1429, Joan conduct the troops to a miraculous victory over the English. She continued fighting the enemy in other locations along the Loire. Fear of troops under her leaders was so formidable that when she approached Lord Talbots army at Patay, most of the English troops and Commander Sir John Fastolfe fled the battlefield. Fastolfe was later stripped of his Order of the Garter for this act of cowardice. Although Lord Talbot stood his ground, he lost the battle and was captured along with a hundred English noblemen and lost 1800 of his soldiers. Charles VII was crowned king of France on July 17, 1429 in Reims Cathedral. At the coronation, Joan was given a place of honor next to the king. One year later she was captured by the Burgundians while defending Compiegne near Paris and was sold to the English. The English handed her over to the ecclesiastical court at Rouen led by Pierre Cauchon to be tried for witchcraf t and heresy. Much was made of her wearing anthropoid clothing. She was told that for a woman to wear mens clothing was a crime against God. Her determination to continue wearing it (because her voices hadnt yet told

Humorous Wedding Roast for a Sports Player :: Wedding Toasts Roasts Speeches

Humorous Wedding Speech for a Sports PlayerGood afternoon, Ladies and Gentlemen. For those of you that dont know me, my name is Martin and Im here to say a some words about Bradley. But first of all, Bradley thanks for agreeing to be my groom today. And thank you, Marta, for allowing Bradley to agree. Its traditional for the best mankind to let the brides parents know what sort of man has married their daughter - although, its really too late now to do anything about it. Bradley and I have been friends all our lives, so you can trust me to be completely honest, and let you have it straight First, you probably know that Bradley was born in 1975, which happens to be the same year the disposable lighter was invented - an invention that in his teenage years Bradley would find indispensable. But aside from that one small indiscretion, which was brought under control before there was any loss of life - and which he was never actually charged with, Bradley has lived an exemplary, if not a boring life. It wasnt until he joined my football club that he got into any real trouble. Before Bradley arrived we were so starved of success we did a lap of honour every time we got a corner. Although our fortune didnt change, Bradley immediately brought a new dimension to the team. But unfortunately, part he would consider his defensive play competitive, the referees would often interpret his face-high tackling as violent and dangerous. Away from the football field, Ive only known Bradley to lash out once. It was a swift left hook dealt to a local thug who, having no idea that Bradley was left handed, approached him as he sat in the passenger screw of a friends car and made a couple of disparaging remarks. Bradley beckons him over, winds down the window and wham - knocks the guy out cold. So heres a bit of a safety tip for you Marta if youre ever out in Richmond and it looks like theres going to be trouble, stay on his right side Now, as I understand it, Bradley actually propo sed to Marta overseas, whilst they were skiing earlier this year. The holiday spanned Valentines Day and Bradley suddenly realized that after six years of being with Marta, he could combine the amative day, the beautiful mountainside location and the rather favorable exchange rate - and finally propose.