Case Study On A Patient With Pulmonary Tuberculosis

Case Study On A Patient With Pulmonary Tuberculosis The case that is about to be discussed here revolves around a patient diagnosed with pulmonary tuberculosis. The patient that was clerked, Mrs A, was a 61 year old woman. She was a Malay housewife. Her Body Mass Index value of 26.0 kg/m2 based on her height of 1.58 m and weight of 65 kg indicated that she fell into the overweight range. The patient was admitted to the Accident Emergency mode transferred in from another hospital via an ambulance. She presented symptoms such as shortness of breath(SOB) and her respiratory rate was 20 breaths per minute. She appeared pale and weak and her blood glucose levels were low (2.1 mmol/l) and her blood pressure values indicated she was hypertensive with a value of 152/93 mmHg. Upon physical examination, mild leg swelling was observed. Based on her past medical history, patient was diagnosed with pulmonary tuberculosis for the past 3 months, hypertension for the past 5 years, diabetes for the past 5 years and advanced renal failure for the past 6 months. Upon enquiry, she was seen to be a non-smoker and a non alcoholic. Patient lived with her daughter. Several investigations were performed to evaluate the patients condition. A positive sputum smear test indicated that the patients tuberculosis was still active. Upon renal function assessment, creatinine clearance was calculated and a value of 5.5 ml/min indicated Stage 5 renal failure. Her potassium and urea levels were also above range based on Table 1. Upon haematology assessment, her low blood sugar levels indicated hypoglycaemia and patients haemoglobin count was also low signifying anemia. Chest X ray was conducted on this patient and minor lesions at the apical segments of the upper lobe were seen. This is a typical radiographic representation of patients with tuberculosis. Table 1: Results of the investigations performed Laboratory Test Readings Normal range Sputum Smear Test Positive Renal Function Creatinine, Cr Urea Potassium, K+ 912 ÃŽÂ ¼mol/l 37.8 mmol/l 5.5 mmol/l 44-80 ÃŽÂ ¼mol/l 1.7 8.5 mmol/l 3.5 5.0 mmol/l Haematology Assessment Blood Sugar Level Haemoglobin 2.1 mmol/l 9.8 g/dl 4.5 6.0 mmol/l 13.5 18 g/dl Table 2 provides details about patients drug history giving information about patients drugs and their respective doses. Upon interview, patient informed that she had not been purchasing any over the counter medications. She also has no known drug allergy. Table 2 : Drug History and their respective doses and their indication Drug Dose Duration Indication Rifampicin 300 mg OD 2 months Anti TB Isoniazid 200 mg OD 2 months Anti TB Pyrazinamide 750 mg OD 2 months Anti TB Ethambutol 600 mg OD 2 months Anti TB Pyridoxine 20 mg OD 2 months Treatment of neuropathy Gliclazide 40 mg OD 5 years Anti diabetic Prazosin 2 mg TDS 5 years Anti Hypertensive Furosemide 80 mg OD 5 years Anti Hypertensive Nifedipine 20 mg TDS 5 years Anti Hypertensive Based on the investigations performed, the patient was diagnosed to be suffering from pulmonary tuberculosis and diabetes mellitus. Patients daily condition was monitored and appropriate management was undertaken to control the patients condition. Patients overall progress is tabulated in the table 3 and the observation is recorded. Table 3 : Patients clinical progress and management Day Clinical Progress Management 1 Hypoglycemia = 2.1 mmol/L AFB test positive Chest X ray performed SOB Hyperkalaemia ( 5.5 mol/L) Anemic ( 9.8 g/dL) BP : 152/93 mmHg Strict fluid intake IV Dextrose 10%/24 hours Refer to chest physician Lesions at upper lobes NPO2 to resolve SOB Start on Calcium polystyrene Start Ferrous (IV) sulphate Start antihypertensives Monitor input output 2 AFB test +ve Blood Sugar Level = 3.0 mmol/L BP : 140/90 mmHg Start TB regimen (EHRZ) Continue IV Dextrose 10% Monitor Blood Glucose Continue antihypertensives 3 Blood Sugar level = 3.2 mmol/L Severe renal impairment ( CrCl =5.6 ml/min ) Chest X ray done time to time BP : 130/70 mmHg Continue dextrose infusion Send patient for dialysis Lesions still present Continue antihypertensives 4 No SOB Hypoglycaemia resolved = 5.5 mmol/L AFB +ve BP : 130/75 mmHg Remove nasal prongs Stop Dextrose. Monitor blood glucose Continue TB regimen 6 K+ level in normal range ( 4.5 mmol/L) Blood Sugar level = 6.0 mmol/L CrCl = 7.7 ml/min BP : 130/65 mmHg Stop Calcium polystyrene. Monitor blood glucose Send patient for dialysis 8 Hyperglycemia = 11.1 mmol/L BP : 125/75 mmHg Start on Insulin DM counselling 13 AFB -ve DXT = 10.2 mmol/L BP : 120/70 mmHg Transfer out of isolation Continue insulin. Monitor blood glucose Based on patients presentation and results from investigations performed on day 1, patient was started on dextrose and her blood glucose levels were regularly monitored. Based on patients previous history, a sputum smear test was ordered and two consecutive positive results resulted in the patient being referred to the chest physician. A chest X ray was performed and lesions in the apical segment were present. To resolve patients SOB, patient was started on Nasal Prongs at 3L/min. To control her hyperkalemia, patient was given calcium polystyrene sulphonate powder. Patient was also started on ferrous sulphate infusion to help her cope with her anaemia. A strict fluid intake was imposed on patient to resolve her leg swelling and this was monitored through an input output chart. Her blood pressure (BP) levels were also elevated and patient was given antihypertensives such as nifedipine, prazosin and furosemide to control her BP. On day 2, her sputum smear remained positive and patient was commenced on the intial phase therapy for tuberculosis which consists of isoniazid, rifampicin, pyrazinamide and ethambutol. There was not much improvement in her blood glucose levels and patient was remained on the dextrose infusion. Moving on to day 3, not much improvement was observed and due to patients deteriorating renal function, patient was sent for peritoneal dialysis. By day 4, patient could breath normally and no shortness of breath was seen. Nasal prongs were removed. When her blood glucose levels were monitored, the results indicated patient was within the normal range and dextrose was withheld. Blood glucose levels were still monitored to prevent sudden drops and increase in blood glucose. Her potassium levels were within range by day 6 and calcium polystyrene sulphonate was stopped and potassium levels were monitored as well. Patient suffered from a hyperglycemia episode on day 8 and the patient was given biphasic insulin to treat this condition. By this day, her BP was also in the normal range but the antihypertensives were still continued. On day 13, patient was transferred out of the isolation ward as her sputum smear test produced negative results. Patients condition for tuberculosis was still being monitored. Her blood glucose levels were still in the high range and patient was to be continued on insulin. To summarize this case, patients active tuberculosis state should be managed well to ensure patient does not suffer from further complications that might arise in the future. Patients history was well noted and this helped in treating the patient in early stages. Adequate investigations were performed to assist the healthcare professional team to diagnose the patient and also to manage the patient. Patient was admitted for a long period but the appropriate management that was undertaken resulted in improvement in patients condition. Further care for the patient would improve the patients quality of life in the future Pathophysiology and Incidence Tuberculosis (TB) is an infectious disease that has plagued many nations across the world. Based on the report by World Health Organization (WHO), almost 9.4 million cases of TB were reported 3. It is highly common of those with TB to contract the Human Immunodeficiency Virus (HIV) and a prevalence of almost 1.7 million deaths from TB among HIV-negative people was recorded around the globe 3. In the United Kingdom, an increasing trend in TB incidence has been reported and this is shown in Figure 1. In 2008, a rate of 14 per 100 000 population in the UK were reported to be suffering from TB 4. Malaysia on the other hand has a higher record of TB cases with 103 per 100 000 population being reported in 2007. Table 1 summarizes some of the data obtained from World Health Organization 3. Figure 1: Number of TB cases reported in the UK from 2000 to 2008 4 Table 1: Statistics displaying number of TB cases in Malaysia in 2007 3 All In HIV + people Incidence All forms of TB (per 100 000 population) 103 17 Mortality All forms of TB (per 100 000 population) 121 8.3 Multi-drug Resistant TB (MDR-TB) MDR-TB among new cases (%) 0.1 Notified relapse cases (per 100 000 pop/yr) 61 The bacteria that is responsible for this disease is the acid fast bacilli aerobic bacterium Mycobacterium tuberculosis 1. A key feature that enables this bacterium to survive would be its unique cell wall. Mycolic acids are linked covalently to arabinogalactan that provides a barrier to host defense mechanism. Antigens such as lipoarabinomannan present on the exterior of the cell wall facilitate the survival of the organism within macrophages 1. Tuberculosis is spread usually spread within droplets containing the microorganism that are produced when an infected person coughs, sneezes or even talks 1,2. Figure 1 gives a schematic impression of the progression of the disease. The inhaled droplets are initially trapped by dendritic cells that act to expel any foreign particles out. Most mycobacteria are able to surpass this defense mechanism and travels further to the alveoli where it gets ingested by macrophages 1. It then undergoes intracellular replication that might take duration o f 4 to 6 weeks. Cytokines are further released during this period and this attracts T lymphocytes that are involved in mediating a cell immune response. The next natural defense system step would be the formation of granuloma that contains the activated T lymphocytes and macrophages. These nodular lesions disable further spread of the disease as the environment within restricts the growth of the bacilli and a latent period occurs 1. For less immunocompetent individuals, the granuloma will not be able to contain the bacilli and the active disease takes form 1. Figure 1: Image depicting the progress of tuberculosis 2 The diagnostic tests available are summarized in Table 2. TB can be divided to latent and active and to diagnose each different test has been recommended. For latent TB, Mantoux test can be carried out and those with positive results can be considered for QuantiFERON TB test 5. To diagnose active pulmonary TB, a chest X-ray would be taken followed by multiple sputum samples that are sent for smear test 5. Table 2: Diagnostic tests available for tuberculosis 1 Variable Purpose Time required for results Sputum smear Detect acid fast bacilli Sputum culture Identify M tuberculosis 3-6 weeks with solid media, 4-14 days with high-pressure liquid chromatography Tuberculin skin test/ Mantoux Detect exposure to mycobacteria 48 72 hours QuantiFERON TB-test Measure immune reactivity to M tuberculosis 12 24 hours Chest radiography Visualize lobar infiltrates with cavitation Minutes The drugs that are commonly used in tuberculosis are isoniazid, rifampicin, pyrazinamide and ethambutol. Rifampicin is a bactericidal agent that inhibits RNA synthesis by binding to the ß subunit of RNA polymerase. It can be given via oral administration and can even be distributed to the central nervous system due to its lipophilicity. Metabolism of this drug occurs in the liver and it is usually excreted in the urine. Isoniazid is a bactericidal pro-drug that inhibits ketoenoylreductase enzyme, InhA, that is responsible in synthesizing mycolic acids. Isoniazid can be administered orally, intramuscularly or intravenously and is acetylated in the liver and subsequently excreted in the urine. Pyridoxine 10 mg is given concurrently to minimize this risk. Pyrazinamide is another prodrug that is activated by nicotinamidase to pyrazinoic acid. This component at low pH carries proton into the cell and collapses the proton motive force present in the mycobacterium which results in cell d eath. It is only bactericidal against non growing bacilli forms.. Ethambutol works by binding to arabinosyl transferase enzyme and inhibits the polymerization of the cell wall arabinan component. Table 3 gives the details of the dose and side effects reported with the administration of the tuberculosis drugs. Table 3: Tuberculosis drugs with their respective doses and side effects 6,7 Drug Dose Side effects Isoniazid 5 -8 mg/kg (max 300 mg) Peripheral neuropathy, hepatotoxicty Rifampicin 10 15 mg/kg (max 600 mg) Nausea, vomiting, thrombocytopenia, orange discolouration of urine Pyrazinamide 20 40 mg/kg ( max 1.5 g 50 kg) Nausea , vomitting, hyperuricemia Ethambutol 15 25 mg/kg Neuropathy, red green color blindness Evidence based medication review Treatment for Tuberculosis In the past three decades, no new drugs have been discovered in fighting TB. The 4 drugs have been the gold standard in treating TB The chemotherapy regimen available for tuberculosis therapy can be divided to the initial phase and the continuation phase. In the initial phase, drugs such as rifampicin, isoniazid, pyrazinamide and ethambutol are used 6. These drugs act to decrease the amount of bacteria present and also prevent resistance from emerging from the strains. This regimen is usually for 2 months. The continuation phase would consist of drugs such as isoniazid and rifampicin. Isoniazid was the first drug to be introduced into combating tuberculosis back in the 1950s. Rifampicin , an antibiotic, was later added to the market and was added to the isoniazid regimen in 1967. This resulted in shortening the duration of treatment from 12 months to a 6 to 9 month treatment 9. Addition of pyrazinamide to the regimen decreased the chemotherapy duration further. Clinical studies have indicated that a pyrazinamide containing short course regimen had a sputum negative conversion rate of 70-95% in the first two months compared to the treatment without pyrazinamide 11. The relapse rates recorded from these studies also were only 4%. A clinical study conducted in East Africa compared the four 6-month daily regimens that comprised of Streptomycin, Isoniazid and Rifampicin (SHR), Streptomycin, Isoniazid and Pyrazinamide (SHZ); Streptomycin, Isoniazid and thiacetazone (SHZ) and Streptomycin and Isoniazid (SH) 10. The SHZ regimen that was the most effective amongst all the regimens and the SHR regimen had the lowest relapse rate of 2% 30 months post treatment 10. No significant difference results were obtained from the treatment regimen that was carried out for 18 months 10. This study gives an impression of the efficacy of the isoniazid, rifampicin and pyrazinamide regimen when used together In a Poland study, the efficacy of the 4 different drug regimens containing rifampicin, isoniazid and ethambutol were assessed. During the initial phase, patients were given isoniazid 300 mg, rifampicin 600 mg and ethambutol 25 mg/kg 8. In the continuation phase the regimens given to patients comprised of rifampicin 600 mg, isoniazid 15mg/kg(Regimen A), isoniazid 15 mg/kg rifampicin 600 mg twice a week (Regimen B), Isoniazid 15kg/mg, rifampicin 600 mg ethambutol 50mg/kg once a week (Regimen C) and Isoniazid 15mg/kg, rifampicin 600 mg, ethambutol 50mg/kg twice a week (Regimen D) 8. The result of this study demonstrated that Regimen D had 47% of its patients displaying a significant change in their sputum result to a negative result compared to the other regimens. There were no significant differences in rates between all regimens by the end of the fifth month as all patients had their sputum converted to negative. This study had the limitation of not including pyrazinamide in its regi men but it can be seen that to achieve a quicker rate of sputum negative cultures a regimen containing ethambutol could be used in the continuation phase. A trial conducted by Jindani et al. assessed the effectiveness of daily dosing of the intial phase drugs compared to the intermittent thrice weekly dosing. The drugs that were assessed were isoniazid, rifampicin, pyrazinamide and ethambutol. The doses that were given to the patients were based on WHO recommendations. The outcome measured after 2 months had 77% of the patients with negative sputum cultures after their 2 month stint (p=0.001) 13. A similar study was conducted in Hong Kong with the difference being a 12 month follow up period. By the end of the second month, 94% of patient receiving the daily regimen had improved. 90% of those under the intermittent regimen also had improved by the second month. Over the long term follow up, more relapse cases were recorded but the values were not significant 14. Hypoglycemia Treatment Patient was hypoglycemic upon arrival and dextrose infusion was provided to restore the patients normal blood glucose range. Two forms of treatment are usually available for hypoglycemic attacks namely glucagon and dextrose infusion. A study compared the efficacy between both the options and it was observed that both were capable of treating hypoglycemia effectively. The only disparity observed was the recovery. Patients on dextrose infusion are capable of regaining consciousness by 4 minutes compared to 6 minutes for patients that were on glucagon ( p Table 4 : Results of 51 hypoglycemic patients treated with dextrose 10% and dextrose 50% 27 Dextrose 10% Dextrose 50% Median time needed to attain recovery (minutes) 8 8 Median total dose administered 10g ( p 25g (p Median post treatment blood sugar levels 6.2 mmol/l (p=0.003) 9.4 mmol/l (p=0.003) Diabetes Treatment Oral antidiabetic agents such as gliclazide in the patients drug history would not be sufficient for her to have proper control over her glycemic levels. It was reported that tuberculosis affects the hormonal secretion by interfering with endocrinal organs such as pancreas 15. Rifampicin reduces the concentration of gliclazide by inducing liver microsomal enzymes CYP 2C9 that rapidly eliminates gliclazide from circulating in the system 15,16,17. In a study by Park et al., patients given with 80 mg gliclazide had the concentration of the drug present in the body reduced by 70% on day 7. The elimination half life of the drug also increased 3 fold 17. All these contribute to the inability of the sulfonyluea to reduce the glucose levels in this patient. According to the stepwise approach in NICE guidelines, the next step to manage this patient would be to start the insulin regimen18. The type of insulin that was given was biphasic Mixtard insulin analogue that consists of a short acting analogue and also a long acting analogue. P.V. Rao reported that, due to the insulin resistance present in patients started on anti Tb therapy, the doses of insulin needed to manage these patients increase 15. It is well proven that insulin can achieve better HbA1c levels as a clinical trial by United Kingdom Prospective Diabetes Study (UKPDS) revealed that after 9 years monotherapy with insulin, 28% of patients achieved HbA1c levels below 7% and 42% patients achieved fasting plasma glucose levels below 7.8 mmol/l 19. Hypertension Treatment Patient was suffering from Stage 5 renal disease and the target for blood pressure in this patient would be 125/75 mm Hg 20. First line treatment for this patient would be loop diuretic, furosemide 20. They act by inhibiting the Na+/K+/2Cl- transporter on the ascending limb of loop of Henle which results in natriuresis and hence a fall in blood volume 21. This loop diuretic also performs its vasodilator actions via prostaglandin (PGE2 and prostacyclin) formation. This results in an increased blood flow in the medulla 21. In accordance to SIGN guidelines as well, long acting dihyrdopyridines such as nifedipine and ÃŽÂ ± blockers can be added as supplementary therapy 20. Nifedipine, a calcium antagonist acts by causing vasodilatation due to reduction in peripheral resistance. ÃŽÂ ± blockers such as prazosin block ÃŽÂ ±1 receptors and this results in vasodilation. A study by Vadasz displayed that Furosemide doses at 40 mg did not display any significant changes in systolic blood pressure. However, when the dose was increased to 60 mg, there was a significant reduction in blood pressure 21,22. A combined dose of 40 mg and 60 mg were effective in reducing the diastolic blood pressure. Based on this evidence, it is clear that furosemide on its own is not capable of decreasing blood pressure. When nifedipine was combined with diuretics it was observed that a statistically significant lower risk of cardiovascular events was observed compared to the non-statistically significant difference that was noted with nifedipine monotherapy 22. In another study by Psaty et al, nifedipine did not demonstrate an increase of risk in myocardial infarction compared to the other calcium channel blockers 25. Prazosins efficacy in lowering blood pressure was studied and the lowest effective dose that is capable of reducing blood pressure was noted to be 10mg 26. Doses below 10 mg per day did not significantly reduce the blood pressure compared to the placebo arm. Treatment of Anaemia Patient had very low haemoglobin levels and this was indicative of anaemia. NICE guidelines have recommended that in order to manage anemia, patients are usually given eryhtropoetin stimulating agents and also iron supplements to help produce haemoglobin 23. There has been no evidence in the use of iron supplements in patients with chronic kidney disease prior to treatment with erythropoietin. But it is recommended that the erythropoietin therapy should not be commenced in conditions of complete iron absence 23. In some conditions, where patients were in Stage 5 renal failure also diagnosed with other co-morbidities, treatment with erythropoietin stimulating agents is decided based on clinical judgment by the professional team if the patient were to benefit from the treatment 23. Treatment of Hyperkalaemia Patient was suffering from mild hyperkalemia and it was necessary that this was be treated before it progresses to severe hyperkalemia that might lead to adverse events such as cardiac arrest. A study compared the effectiveness between sodium polystyrene sulfonate and calcium polysterene sulfonate and it is noted that treatement with sodium increases sodium concentration in the body and this escalates the risk of hypertension 24. Treatment with calcium polystyrene sulfonate resulted in 50% decrease in potassium content and an additional advantage of increase in calcium concentration was observed as well 24. Conclusion Based on all the evidence provided for the patients condition, it is clear that the guidelines were adhered in treating the patients individual disease with some minor differences. Tuberculosis treatment for the initial phase was extended for more than 2 months due to the positive result obtained from sputum smear. Patient eventually achieved negative sputum smear and the patient was to be monitored before the patient was commenced on the continuous phase drugs. Effective treatment was undertaken to treat patients hypoglycemia condition, and based on the evidence gathered, dextrose 10% is the suitable treatment option for the patient. The antihypertensive regimen that was chosen was due to the patients renal failure. Nifedipine, prazosin and furosemide collectively controlled the blood pressure of the patient. Ferrous sulphate was chosen as her treatment compared to erythropoietin and this was based on the doctors clinical judgement. Her hyperkalemia which was treated with calcium su lfonate did benefit the patient as her potassium levels were within the normal range at the end of the treatment. PATIENT MEDICATION PROFILE PATIENT DETAILS Name Mrs A Consultant General Practitioner Address Kuala Lumpur Gender Female Weight 65 Height 158 Community Pharmacist Date of Birth (Age) 61 Known Sensitivities None Social History Non smoker Non Alcoholic PATIENT HOSPITAL STAY Presenting complaint in primary care / reason for admission Admission date April Low Sugar Level : 2.1 mmol/L Discharge Date Discharged to Not Known Shortness of breath RELEVANT MEDICAL HISTORY RELEVANT DRUG HISTORY Date Problem Description Date Medication Comments Feb Pulmonary Tuberculosis Feb Rifampicin 6 months Advanced Renal Failure Feb Isoniazid 5 years Hypertension Feb Pyrazinamide 5 years Diabetes Mellitus Feb Ethambutol Feb Pyridoxine 6 months Prazosin 6 months Nifedipine 6 months Furosemide Gliclazide RELEVANT NON DRUG TREATMENT Peritoneal Dialysis Prescribed Medication Start Stop Clinical/Laboratory Tests Date Result 1 Rifampicin Day 1 Sputum Smear Test Day 1 Positive 2 Isoniazid Day 1 Creatinine Day 1 912 Â µmol 3 Pyrazinamide Day 1 Urea Day 1 37.8 mmol/l 4 Ethambutol Day 1 Potassium Day 1 5.5 mmol/l 5 Pyridoxine Day 1 Blood Glucose Day 1 2.1 mmol/l 6 Prazosin Day 1 Blood Pressure Day 1 152/93 7 Nifedipine Day 1 Haemoglobin Day 1 9.8 g/dl 8 Furosemide Day 1 Chest Xray Day 1 Lesions in the apical segment 9 Dextrose Solution Day 1 Day 4 Blood Glucose Day 8 11.1 mmol/l 10 Ferrous sulphate Day 1 Sputum Smear Day 13 Negative 11 Calcium polystyrene sulphate powder Day 1 Day 6 12 Insulin Mixtard Day 8 CLINCIAL MANAGEMENT Diagnosis Pharmaceutical Need Pulmonary Tuberculosis Continue patient on intial phase drugs Hypoglycemia Start patient on dextrose Hypertension Continue antihypertensive treatment Hyperkalaemia Start calcium polystyrene sulphonate powder Anaemia Start ferrous sulphate Advanced Renal Failure Send patient for peritoneal dialysis PHARMACEUTICAL CARE PLAN Date Care Issue/Desired Output Action Output Sub therapeutic doses For Anti TB drugs Discussed with the pharmacist and patients diabetic condition was the reason for the dose regimen Doses were not changed Drug sensitivity testing was not performed Patient is diabetic and is more susceptible for MDR-TB No test was performed Management of patients compliance towards anti tuberculosis drugs -Patient might be hospitalised for a long period of time due to renal failure -DOTS scheme to be implemented upon discharge -Adequate patient education on the importance of completing the regimen is important Hospitalisation or DOTS scheme Renal failure Ethambutol excreted by kidney. Suggest change of medication to 2 Isoniazid + Rifampicin + Pyrazinamide -If treatment continued, monitoring essential Continue treatment as before and patient being monitored AFB test Another 2 samples should be taken for AFB tests before switching to the continuous phase Action yet to be taken Monitor drug toxicity Lab investigations on full blood count, liver function, serum uric acid, serum bilirubin, should be done to ensure no toxicity Eye examination for ethambutol side effects Scheduled appointments for patient Education on side effects of drugs To inform patient about anti Tb drugs side effect and advise patient not to stop the drug and side effects can be controlled ( PZA and arthralgia ) Counseling by pharm

Global Warming - A Problem Blown Out of Proportion Essay -- Greenhouse

Global Warming - A Problem Blown Out of Proportion It is ironic that fifty two years before hosting the 1997 United Nations Conference on Climate Change, the city of Kyoto had barely missed being destroyed. It was one of four cities considered as primary targets by President Harry Truman’s secretary of war, Henry L. Stimson. The others were Kokura, Hiroshima, and Niigata. Gale E. Christianson describes Kyoto in her book Greenhouse as a magnificent city surpassed only by Tokyo in the number of its institutions of higher learning. Kyoto served as the seat of the emperor for more than 1000 years until the Imperial Household moved to Tokyo in 1868. All Japanese try to visit the city at least once in their lives. The city remains the heart of Japanese culture. Buddhist temples and Shinto shrines dominate the landscape. Japanese theater was founded in Kyoto. It was in this setting that the Nations of the world gathered to discuss the issue of global warming in late November of 1997 (Christianson 254).   Ã‚  Ã‚  Ã‚  Ã‚  From the beginning the United States was viewed as the villain. Undersecretary of State, Stuart Eizenstat, and head of the U.S. delegation, let it be known that no amount of pressure could force the administration to flinch. â€Å"We want an agreement, but we are not going to Kyoto at any cost† (qtd. in Christianson 255). Vice President Al Gore added: â€Å"We are perfectly prepared to walk away from an agreement that we don’t think will work† (qtd. in Christianson 255). It was quite obvious that the United States did not want to be there – and for good reason.   Ã‚  Ã‚  Ã‚  Ã‚  The reason had everything to do with cost and benefit. The Protocols would require that the United States reduce its 2008 – 2012 overall greenhouse emissions by about a third of the current levels. The economic costs are quite significant and the benefits are not. Tom Wigley, a senior scientist at the U.S. National Center for Atmospheric Research, calculated â€Å"saved† warming under the assumption that every nation met its obligation under the Kyoto Protocol. According to his calculations, the earth’s temperature in 2050 would be 0.07 ËšC lower as a result (Wigley). According to Patrick J. Michaels, a professor of environmental science at the University of Virginia, a warming of such an infinitesimal amount cannot accurately be measure on a thermometer. â€Å"The benefits of Kyoto are so miniscule as to ... ...crosoft Corporation. All Rights Reserved. Robinson, Arthur B. and Jane M. Orient. â€Å"Science, Politics and Death.† The New American 20.12 (June 2004): 37 par. 24 November 2004 http://www.thenewamerican.com/tna/2004/06-14-2004/science.htm Taylor, Jerry. â€Å"Global Warming: The Anatomy of a Debate.† Diss. John Hopkins University, January 16, 1998 http://www.cato.org/speeches/sp-jt011698.html Boyachek, Karen. â€Å"Argument Against the Global Warming Theory† U of Saskatchewan Newsletter 26 Jan. 20 http://www.cs.usak.ca/undergrads/kmbl129/49/assignment Mendelsohn, Robert. Global Warming and the American Economy. Northampton: Edward Elgar, 2001. Moran, Edward, ed. The Global Ecology. New York: Wilson, 1999. Christianson, Gale E. Greenhouse. United States: Walker, 1999 James Hansen et al. , â€Å" A Common-Sense Climate Index: Is Climate Changing Noticeably?† Proceeding of the National Academy of Science 95 (1998): 4113-20 Thomas Wigley, â€Å"The Kyoto Protocol: CO2, CH4, and Climate Implication,† Geophysical Research Letter 25 (1998): 2285-88 Michaels, Patrick J. â€Å"Long Hot Year Latest Science Debunks Global Warming Hysteria.† Policy Analysis 329 (1998): 1-12

New Research Indicates That Drug Therapy Is More :: essays research papers

For decades, psychologists have devised many treatment regimes for schizophrenia patients, with varying degrees of success and effectiveness. There have been great obstacles in their efforts, mainly due to the fact that patients of schizophrenia lack insight into their impaired conditions. Often patients refuse treatment of any kind because they do not perceive any mental illness associated with their behaviour. In particular, individuals suffering from paranoid schizophrenia regard therapy as intrusions from hostile outside forces, which reduces compliance on the part of the patient (Davison & Neale,1998). Other problems with treatment programs for schizophrenic’s is that they suffer from both positive and negative symptoms, each requiring different type of treatments. In order to combat the difficulty of treating schizophrenia, several techniques have been devised; psychoanalytic therapy, behavioural therapy, family therapy and most predominantly, drug therapies. Drug therapy is the primary form of treatment implemented at the onset of schizophrenia. The drug clozapine is very effective for many patients who do not respond to initial drug treatment programs and treats both the positive and negative symptoms of schizophrenia (Advokat et al., 1999; Robinson et al., 1999). Moreover, a reduction in negative symptoms has also been noted to occur as individuals are treated with amisulpride and (Danion et al., 1999). The use of newer drugs to treat schizophrenia has produced fewer side effects in most patients. However, it has been found that although the use of risperidone to treat patients is very effective in treating the symptoms, there may be negative side effects for women using the drugs (Caracci,1999). As well, haloperidol has been one of the most widely used drugs for treating schizophrenia and is very effective, but if it is over-prescribed it could result in severe side effects for the patient (Yasui et al., 1999). Despite the possible side effects for some patients using drug therapy, it is still the treatment regime which produces in the highest success rate (Davison & Neale, 1998). Psychoanalytical Therapy A revised form of Freud’s psychoanalytical therapy was first devised by Harry Stack Sullivan to treat schizophrenic patients in the early 1920’s. Sullivan believed that schizophrenia was a result of individuals regressing to earlier forms of childhood communication due to the fragile ego’s inability to handling the stress of their interpersonal relationships (Davison & Neale, 1998). He believed that by building a trusting relationship with the patients, the patients would become willing to examine their interpersonal relationships, thus resulting in improvement of symptoms.

Culture Competency Essay

In the aspect of interacting with the global community, it is important for an individual to understand the cultural aspect of the subject society and relate to this factor in terms of their interactive business. As the aspect of culture manifest to be a significant part in the characteristics and qualities of each individual and collective society, understanding this identity factor is indeed important in the pursuit of establishing an effective interaction with the different people in the global community. In particular to the healthcare profession, the aspect of culture competency manifests to be an important concern in healthcare education as having the ability for interacting, understanding and relating to different cultures can effectively enhance the services rendered by healthcare professional. Indeed, the general concern of the healthcare profession is to render effective healthcare assistance and services to people of different culture thus, the global community is the main subject in this mission. In part though, cultural background resembles an important part in the personal identity of each person or patient thus, the healthcare profession must incorporate this in his or her pursuit of relating effectively the said matter for the benefit of the patient. In the actual practice of the healthcare profession, the concept of culture competency manifest particularly in the personal interaction between the healthcare professional and the patient. In this scenario, the two parties are often with different cultural background yet, in best effort, the health professional must overcome this difference in the process or realizing his or her responsibilities. For example, some of the common barriers are the language factor, the cultural awareness and acceptability, perception and understanding, and others. At some point, the healthcare professional must incorporate the cultural factor in the profile identity of the subject thus, adjusting his or her pursuit and interaction based on this element. Forwarding the healthcare service and assistance through relating it with the cultural background of the patient can effectively influence the understanding and acceptance of the subject in this pursuit. For example, acknowledging the cultural limitations and the preferences of the subject in his treatment and medication can indeed influence his acceptance towards the process. Through this approach, the healthcare practitioner can effectively motivate active participation and encourage interest from the patient towards the success of the treatment and the healthcare program. Due to the importance of culture competency, healthcare practitioner must assess and realize in themselves their individual strengths and weaknesses in this aspect and develop their flexibility towards the different cultures in the global community. In this aspect, the author of this paper realizes certain weaknesses in terms of cultural awareness due to the social limitations he has experienced in his upbringing. Raising from a rural town with a small community and having only experienced interacting with people from different culture during only college years, culture competency has developed late in this author as such it is important to focus much attention towards developing this skill. However, continuing the effort of developing social relationship with people from other cultures and building up academic information from researches and reading can indeed contribute in developing culture competency. With this effort, one can effectively develop awareness and understanding of various cultures and undermine cultural difference towards the mission of providing quality healthcare service towards the global community from different races and cultural society. Bibliography Zwell, Michael (2000). Creating a Culture of Competence. Wiley Publication. 1st Edition. ISBN-10: 0471350745.

Bangladesh capital market

It has two full-fledged automated stock exchanges namely Dhaka Stock Exchange (DSE) and Chittagong Stock Exchange (CSE) and an over-the counter exchange operated by SEC. It also consists of a dedicated regulator, the Securltles and Exchange Commission (SEC), since, it implements rules and regulations, monitors their implications to operate and develop the capital market. It consists of Central Depository Bangladesh Limited (CDBL), the only Central Depository In Bangladesh that provides facilities for the settlement of transactions of dematerialized securities In CSE and DSE.Dhaka Stock Exchange was set up on 28th April, 1954 that started formal trading on early 1956. Post-independence government did not promote a capital market during the first five years, and it was activated again in 1976 with 9 issues on board. In 1995, a second bourse, the Chittagong Stock Exchange, was set up with sophisticated loglstlc support and modern management. Two stock exchanges exist in Bangladesh Dhaka stock Exchange (DSE) Chittagong Stock Exchange (CSE) One Investor must know about these markets before he/she goes for an Investment.To make this report more understandable and specific, we will only focus on Dhaka tock market. â€Å"The stock market is an important ingredient of the financial system in Bangladesh. It is an important avenue for channeling funds to investors through mobilizing resources from individuals. In view of the rapidly Increasing role of the stock market, volatility In stock prices can have significant Implications on the performance of the financial sector as well as the entire economy. There exists important link between stock market uncertainty and public confidence in the financial market.The policy makers usually rely on the market estimate of volatility as he barometer of the vulnerablllty of the stock market. Stock return volatility represents the variability of day-to-day stock price changes over a period of time, which is taken as a measure of risk by the relevant agents. High volatility, unaccompanied by any change in the real situation, may lead to a general erosion of Investors' confidence In the market and redirect the flow of capital away from the stock market.Excessive volatility also reduces the usefulness of stock price as a reflector of the real worth of the firm. Volatility, however, is not an evidence of rrational market behavior or inefficient markets. Stock return volatility is usually asymmetric in its response to past negative price shocks compared with the positive shocks, but what factors drive volatlllty over time Is not clear. Moreover, Increase In firm-specific risk appears to adversely affect its stock valuation.This note analyzes 2003-2007 and draws some policy implications. † Dhaka Stock Exchange (DSE) â€Å"Dhaka Stock Exchange (Generally known as DSE) is the main stock exchange of Bangladesh. It is located in MotiJheel at the heart of the Dhaka city. It was incorporated in 1954. Dhaka stock exc hange is the first stock exchange of the country. As of 9 December 2009, the Dhaka Stock Exchange had 671 listed companies with a combined market capitalization of $34. 2 billion. Dhaka Stock Exchange (DSE) is a public limited company.

Fdi Norms, Foreign Participation in an Indian Insurance Company

As per the current (Mar 06) FDI norms, foreign participation in an Indian insurance company is restricted to 26. 0% of its equity / ordinary share capital. The Union Budget for fiscal 2005 had recommended that the ceiling on foreign holding be increased to 49. 0%. The government approved the much-awaited comprehensive Insurance Bill that seeks to raise foreign direct investment (FDI) cap in private sector to 49 per cent from 26 per cent. abc 4JVGh 7596 Insurance Market in India: Past-Present-Future pic2 pyYXW 7596FDI Cap 49% from 26%: Impact on Indian Insurance Industry A higher foreign direct investment (FDI) will unshackle the insurance industry and drive growth and long-term development enrich the business by bringing world-class business practices and processes expand distribution capabilities and deepen market penetration. Over US$ 2 billion of foreign capital could flow into the country if the Government were to pass the Insurance Amendment Bill that raises the FDI limit. Scene 1: Change in waive service tax on micro insurance productsThe growth of the rural insurance industry necessitates a waiver of the service tax, which currently stands at 10. 3 per cent, including education cess. This tax is detrimental to the growth of the rural insurance industry and insensitive to the plight of rural populace which lacks quality healthcare and is vulnerable to numerous perils, including illness, accidental death and disability, loss of property due to theft or fire, agricultural losses, and disasters of both the natural and man-made varieties.Rural insurance has an enormous potential for growth and a service tax waiver will make micro insurance products more affordable for the rural populace, and will drive pan-India penetration of this market. Scene 2: Revision on Service tax on small transactions There is an urgent need to increase the threshold for the levy of service tax on policies. The present notification exempts small transactions involving premium of less than Rs 50 (except motor insurance) from the ambit of service tax.The threshold limit of Rs 50 which was fixed in 1994 needs urgent revision. Small transactions involving premium up to Rs 1,000 should be exempt from service tax which will benefit the under-privileged sections of our society. Insurance premium for covering small and medium enterprise risks should be exempt from service tax. For other insurance products, we would like a reduction in the service tax by at least 3-4 per cent. Scene 3: Exempting personal insurance from service taxThere is an overwhelming demand across all players in the industry that individual health insurance policies should be totally exempt from service tax. Exemption of health insurance from the service tax will make health cover affordable and accessible for the layman. Consequently, cheaper health insurance will increase its pan-India penetration. Additional IT exemption for householders’ policies and concessional IT rates will give a fill ip to home insurance and will also reduce the burden on the government in the event of catastrophes. Scene 4: Exemption for profit on sale of investmentsTo encourage general insurance players to be active participants in capital markets, there is a requirement for specific exemption from income-tax on profit on sale of investments. The issue of admissibility of UPR (unexpired premium reserves) as per IRDA regulations rather than as per Insurance Act only, for IT deductions. The UPR is at present restricted to the extent of limits specified in rule 6E of the Income Tax rules due to which insurance companies need to pay tax beyond their profit disclosed in their audited accounts. Hence, the UPR created as per IRDA regulations should be allowed as per rule 6E.

What Does a Rigorous High School Schedule Look Like?

We at frequently use the term â€Å"rigorous† to describe course loads and course schedules. That’s because rigorous studies in high school are something that admissions committees look for specifically during the application process. They want to know that applicants are capable of difficult, college-level work.    It’s not surprising then that we often hear from students asking, â€Å"How can I make sure my course load is challenging or rigorous enough?† If you’re wondering how to assess if your classes are up to snuff and how to choose a course load that’s challenging without being overwhelming, this post is for you. Rigorous is a vague term, but it can be more helpful to think of your course load as it compares to the course loads of other students at your high school. Admissions committees understand that not all high schools offer a full suite of challenging course options. While some have dozens of AP classes or an IB program to choose from, others have only college placement or honors tracks available. Luckily, you don’t need to worry too much about how many options are available at your high school, since this is out of your control. Instead, you need to focus on choosing the most challenging options available to you. You can think of a rigorous course load as the one that represents the most challenging track available at your high school. To learn more about how your classes will impact your college applications, check out our post Should I Take AP/IB/Honors Classes? . Being the most challenging track available, a rigorous course load can sometimes be a little overwhelming, especially at first. You should start by easing into a challenging course load. During ninth grade, select classes that are rigorous enough to challenge you, but not enough so as to overwhelm you. Think of 9th grade as a time to test the waters and see what you’re capable of. Remember, it is always easier and looks better to add another class or transfer to a more challenging section than it is to drop a class or move down to a less challenging one.    In addition, balance your course selections with reasonable extracurricular commitments. Focusing on two or three extracurriculars is ultimately enough, especially if you stick with them consistently and work your way up to leadership positions or increased responsibility. Dropping an extracurricular after 9th or 10th grade is no big deal if doing so means that you can keep your grades up and take on more challenging classes. Our Early Advising Program helps students in 9th and 10th grade discover their passions and build strong academic and extracurricular profiles to succeed in high school. Admissions committees generally want to see well-rounded students insofar as having completed four years of coursework in each core subject area. This includes English, history, math, science, and usually a foreign language. In fact, many colleges require that applicants have completed four years of coursework in each of these subject areas just to meet application prerequisites. In these core subject areas, you should strive to take the most challenging courses that you’re capable of doing well in, and your primary focus in studying and achieving should be in these core subject areas. Taking any additional classes is not necessary, but it does represent an opportunity.    Beyond the core subject areas, any elective classes that you take should reflect your interests. This is an opportunity to reinforce any potential career choices or college majors. Rather than worrying about taking especially challenging electives, think of them as a chance to explore and demonstrate your interests. Taking electives shows intellectual curiosity and might even allow you to discover a new interest. The balance between better grades and harder classes is always a delicate one. We hear from many students wanting to know if they should take a harder class and get a B, or an easier one and get an A. While there’s no universal answer that will impress every admissions committee, it’s important to know that admissions committees aren’t interested in easy A’s. In fact, a 4.0 GPA in regular college-placement classes may actually be a deterrent to some admissions committees who are looking for students who want to challenge themselves. In general, a good rule of thumb is that if you think you can achieve a B or higher in it, take the more difficult class. Admissions committees will appreciate that you have worked hard for that B, rather than pursuing a less rigorous track. Planning a rigorous track starts in 9th grade. To get off on the right foot, you should make a four-year plan. The simplest way to do this is by using backward design. Start with 12th grade—what classes do you need to be taking in 12th grade in order to get into the types of colleges you hope to attend? These classes are generally the highest level courses available at your school. They might be AP or IB classes if your school offers them, or they could simply be honors level classes if that’s all your school has available. Work backwards from 12th grade to ensure that your prerequisites are met each year. It is much easier to work backwards incrementally from your final 12th grade goal than it is to start with your ninth grade classes and try to imagine where they’ll take you. It’s a good idea to meet with a guidance counselor as you create your four-year plan. You’ll want to ensure that you’re meeting all graduation requirements and that it represents a course schedule that is rigorous as compared to others available at your school. Your guidance counselor will be able to lend some insight into which paths are commonly taken by students with the same goals as you. In addition, remember that the classes you enroll in aren’t the only way to impress admissions committees. You can also highlight your academic chops through options like independent studies, summer college courses, or online coursework. To learn more about these options, check out our post What To Do If Your High School Doesn’t Offer AP Classes . Lastly, if you’re looking for more personalized guidance through high school, consider the benefits of ’s Mentorship Program , which pairs each student 1:1 with a mentor from a top college who can help you develop the skills you’ll need for becoming a successful college student.