15 Coursework Example | Topics and Well Written Essays - 500 words

15 - Coursework Example Heating and cooling service technicians face a difficult task installing a machine in a major city such as Phoenix because of poor air quality due to humidity. This seems to be a huge problem for the citizens residing in these metropolitan areas, who complain of having symptoms caused by bacteria(http://www.phoenixenvironmentallawyer.com). What  Causes  Indoor Air  Problems? Without a doubt, indoor air problems source from inadequate ventilation, pollutants, amount ventilation. Inadequate ventilation is detriment to air since it increases air pollution by not diluting emissions from indoor sources. Poor air ventiliation accounts for 50% percent of air pollution problems. In addition, the cause of indoor air pollution can be displayed by incineration of certain materials such as oil, gas, kerosene and tobacco products. In this case, the age of the particular substance is a critical factor that determines how dangerous the emissions are. The third source for indoor air problems is Amount ventilation. Amount ventilation is harmful because they serve as barriers against outdoor air. High levels of pollutants present in outdoor air entering indoors can be a huge health risks for the residents. All of these factors accumulate to cause an indoor air problem, which continues to pose a threat for the environment. Ask any service technician about identifying a problem, and troubleshooting will be the answer. Troubleshooting is essential because it is standardized set of steps in order to identify the problem. The three phases of basic troubleshooting consist of checking the thermostat settings, inspecting the circuit breaker box, the natural gas line, and finally examining airflow(). Since ventilation remains as a top concern for homeowners, it is vital to understand the main causes that negatively affect ventilation systems. These problems consists of systems design, proportion of

Literacy essay Example | Topics and Well Written Essays - 500 words

Literacy - Essay Example clearly put the whole justice system into a question; whether the evidence of ‘crime’ is the sole criteria of declaring guilty of the prime suspect and whether the crime should be seen from a wider perspectives? The story revolves around the place of crime where ‘Minnie Foster or Mrs. Wright as she is now called’ is accused of murdering her husband. Peter Hale, along with Sheriff and County Attorney visit the house to get the ‘feel’ of the murder and gather clue that might have led to it. Sheriff’s wife and Mrs. Hale also accompany them as some personal items were needed by the Mrs. Wright, who was in custody. While the men folk wander around the scene of the crime, the women remain in the kitchen and try to interpret the events by observing small things that was out of sync with the general way, women work in the house and kitchen. When they notice a block of the quilt that was very different from the rest and looked ‘as if the distracted thoughts of the woman who had perhaps turned to it to try and quiet herself were communicating themselves to her’ (Glaspell, 1993). Both the women perceive the signs that would have been emotionally disturbing for Mrs. Wright, the accused. Finally, when they find the dead canary in the sewing box, they hide the evidence that would have conclusively implicated Mrs. Wright and in their own way, try to give justice to the woman who might have been forced to commit the crime and knew that she would be denied justice if the men found the ‘evidence’! In the literary analysis of the short story by Elaine Hedges that was published in a leading international journal of Women’s studies in 1986, Hedge’s interpretation of the story became highly relevant because they brought into focus the weakness of the legal system that relies heavily on the machinations of ‘evidences’. It also highlights a very pertinent observation in the investigative techniques that are adopted by the two genders. While men like to

Library System Essay Example for Free

Library System Essay Bulua National High School is a leader high school in legislative District 1, located at Barangay Bulua, Cagayan de Oro City which was governed and funded with the Barangay Officials spearheaded by Pedro P. Legaspi. It was in 1970 when the secondary education, Bulua Barrio High School came to an open with two sections in the First year level and the Second year level was opened on the following year until the 4-year high school level was completed. The school was temporarily located at the compound of Bulua Elementary School campus in which they called as squatters. They did not have their permanent classrooms to be used. Sometimes classes were being held under the shades of the Mango and Butterfly trees. They also conduct night classes just to accommodate working students from the neighboring Barangays. Each enrollee was still entitled to pay 10.00 pesos for the freshmen, 15.00 pesos for the sophomores, 20.00 pesos for the juniors and 25.00 pesos for the seniors every month. The fees were received by the hands of the Barangay treasurer. The school was facilitated with 10 teachers and 1 school in-charge only. It was then in 1985 that BBHS became the PILOT SCHOOL of the 1989 Secondary Education Curriculum headed by its school principal Mrs. Enriqueta C. Pabelic. Year after, BBHS became Bulua National High School (BNHS) which was funded already direct from the National Level under the late President Cory Aquino’s administration. Presently, BNHS is located in its owned 1.4 hectare approximately lot donated by the late Congressman Pedro Oloy Roa through the joint effort of Barangay Chairman Pedro P. Legaspi and the late DECS – Division P.E Supervisor, Mr. Bernabe Pabellic for its lot acquisition. Introduction The Library Hub is a program by the Department of Education aiming to address the lack of public libraries across the countries by setting up the library hubs. Library Hub is a novel and unique structure in the Philippines educational system, whereby an infrastructure and new reading materials made possible through collaborative partnerships with stakeholders are provided to public school students for free. To date, DepEd has set up about 50 Library Hubs in a very short span of time throughout the country. These Hubs will be servicing thousands of public schools. Books were placed in plastics. The Library Hubs are housed in existing buildings with an area of at least 250 to 300 square meters. A Library Hub is run by a librarian, library clerk, and utility staff and functions as a book warehouse for public schools in a given district. Each Hub lends books to its designated schools, which in turn lend the books to their students. The provision of reading books for free in the hub is not only for public schools but ALS, SPED, barangay centers, etc. It also serves as a â€Å"wholesale† library exclusively servicing elementary/secondary schools within a division. The hubs operate warehouse style, compared to the traditional public library setupinstead of books being individually placed on shelves; they are stored in plastic bins for storage. These bins would then be checked out and brought by teachers and administrators of public schools to their respective public schools, to be returned after twenty-five days. While at the school, these books can be borrowedor even brought homeby the students until the books are to be returned to the hub. Launched in 2003 by then undersecretary Juan Miguel Luz, the project has now set up library hubs in 32 school divisions all over the country, for a total of around 145 hubs built since 2004. The hubs are financed by both the public and private sector, with major donors having the option to name the hubs whichever way they like. 1. Background of the study The use of computers and various programs are being developed for that certain desire to be done in a short period of time. Manual System for a Library Hub is quite a difficult task to perform. It takes a long period of time in locating and monitoring the availability of the books and can have the tendencies of missing files. That’s why we created this Computerized Library Hub System in order to solve that problem. Our Computerized Library Hub System is a program that is use to update the information about a certain record of books. It allows adding book information immediately and it only takes minutes to search a specific book. It lessens the possibility of missing files unlike the manual system. This system can be able to monitor automatically where, when or who borrowed a book. It also gives more accuracy in processing any transactions. Besides of that, it can help a librarian to work much easier and faster than a manual system. 2. Statement of the Research Problem * A licensed librarian is one of the major concerned problem of Bulua National High School Library Hub. Since they have a what they called â€Å"Acting Librarian† who was also a full time teacher in the school. It takes a long period of time for her to organized the books especially in putting accession number in it and log it in her module. Another concerned is that the books in the library hub has not been arranged in dewey decimal classification which is the main reason why the personnel in-charge and the students has the difficulty in locating the book and to check its availability. * There’s a possibility that the library hub may encounter following problems such loss of records, repetition of data entry and other important details about the books and the one who borrow the book. * How do they record the books? The students will fill a borrower’s card before they can get the book they want to borrow. Then afterwards the in-charge will log the list of the book that has been used or borrowed in the end of the day in the manual notebook. Unfortunately there are times that the in-charge can’t be able to log or record the borrowed books in the manual notebook. * How do the students know if the books are still available? Knowing that the school don’t have a Dewey Decimal Classification in their books, students have difficulties in searching the specific book and it takes too long for them to wait for the librarian to check unto the logbook whether the book is still available or being borrowed. 3. Statement of Objectives 3.1General Objectives This project aims to propose and develop a well-structured and computerized library hub system to help the library hub’s transactions easier, more effective and efficient. 3.2Specific Objectives * To lessen the burden of the user in handling the day by day transactions. * To lessen the possibility of missing files. * To make the process of updating the books efficient and can be done in a short period of time.

Long Bone Fractures in Children: IN Fentanyl Treatment

Long Bone Fractures in Children: IN Fentanyl Treatment Introduction The clichà © that states children are just small adults is certainly not true in the case of long bone fractures. A childs experience of long bone fractures is dramatically different from that of an adult on account of their rapidly developing physiology (Wood et al 2003). This rapid development results in biochemical and physiological differences between a childs and an adults skeleton, the mechanisms of fracture and healing, are an important component of their treatment needs and consequently crucial part of emergency care management (Bonadio et al 2001). In addition, children, from infancy through to adolescence, have common fracture patterns related to their stage of development. The structural differences between the bones of a child and an adult enable childrens bones to endure greater forces and to heal quicker a childs remodeling potential supports full recovery with limited or no long term side effects from long bone fractures (Lane et al 1998). Injuries of all types are the second leading cause of hospitalization among children younger than 15 years (Landin 1997). Musculoskeletal trauma, although rarely fatal, accounts for 10% to 25% of all childhood injuries (McDonnell 1997, Landin 1997, Lane et al 1998). Boys have a 40% risk and girls a 25% risk of incurring a fracture before the age of 16 years (Landin 1997, Ritsema et al 2007). The most common site of fracture is the distal forearm which accounts for 50% of paediatric fractures. The rates of fracture increases with age as children grow; peaking in early adolescence. Fortunately, most fractures in children are minor greenstick and torus fractures constitute approximately 50% of all fractures in children (Landin 1997, Lane et al 1998, Gasc Depalokos1999, Richards et al 2006) and only 20% require reduction. Thus, the management of paediatric fractures is often straightforward. Without exception children will experience pain at the time of injury, attending the accident and emergency department and during recovery. The most common pain management strategies involve a multi-modal approach that includes both pharmacological and non-pharmacological components delivered via the least invasive technique (Worlock et al 2000). In practice this includes oral medication, such as oramorph, paracetamol, and NSAIDs, inhaled entonox, intranasal diamorphine (IND) or intravenous opioid where necessary and distraction with age appropriate devices, such as interactive books, bubbles, music and computer games in older children. Notably, IND is currently embraced as the key route of opioid delivery for children attending AED with fracture pain in the UK British Association for Accident and Emergency Medicine (BAAM E 2002). Parents and guardians of children frequently seek care in AED for the relief of pain from traumatic injuries and as a result the field of emergency medicine has assumed a leadership role in paediatric pain management. However, despite this the literature suggests the provision of pain relief for children attending AED remains suboptimal when compared to adults with the same injuries. Further discrepancies are reported between paediatric accident and emergency departments (PAED) and district general accident and emergency departments (DGAED) (Emergency Triage 2004). One reason suggested for these differences is the geographic distribution of specialised services, which are predominantly located in large cities where they are affiliated with universities. However, a recent audit by the British Association for Emergency Medicine (BAAEM 2005) of their guideline for the management of pain in children shows inconsistencies in provision of analgesia particularly for fracture pain throughout the country with no measurable difference between PAED and DGAED. A key feature of this guideline is the algorithm which advocates the use of IN diamorphine for acute moderate to severe pain in children over the age of one year (see appendix 1). The whole topic of analgesia in the paediatric population is complex and still imperfect especially in acute moderate to severe pain requiring urgent treatment in the emergency department (Schechter et al 2002). The road to pain free suffering is still paved with impediments such as failure of pain recognition and methods of delivery of analgesia (Murat et al 2003). Oral administration can be inadequate in an emergency situation with particular limitations in potential choice of drug and delay in gastric absorption and gastric emptying. Intramuscular (IM) and intravenous (IV) administration can be distressing to children and have been shown to influence future response to painful procedures (Gidron et al 1995, McGrath et al 2000, Fitzgerald et al 2005, Walker et al 2007). Rectal administration has limited acceptability given unpredictability of onset together with occasional problems of consent (Mitchell et al. 1995). By contrast, the efficacy and safety of the IN route has been well documented for desmopression acetate (DDAVP), insulin, antihistamines, midazolam and calcitonin (Jewkes et al 2004, Loryman et al 2006). In contrast, intranasal administration has a number of advantages. It is technically straightforward, socially acceptable and demonstrably effective. The nasal mucosa is richly vascular and administration by this route avoids the first-pass metabolism phenomenon Summary Studies in the 1990s such as Yearly Ellis (1992) have also demonstrated the efficacy of administration of intranasal medication via a nasal spray rather than drops in adults, although the efficacy of this application in the paediatric population remains to be proven. Intranasal administration is possibly the ideal route of analgesic administration in children. Currently, within the accident and emergency department (AED) of Bristol Royal Hospital for Children (BRHC) intranasal diamorphine is used as the first rescue analgesia in the paediatric population presenting with acute moderate to severe pain, most frequently in patients with long bone fractures who do not require intravenous access for resuscitation. Diamorphine is a semi synthetic derivative of morphine with a number of properties that render it a desirable analgesic agent for administration via the nasal route. It is a weak base with a pKa of 7.83 and is water soluble allowing high concentration to be administered in small volume (Rook et al 2006). Unfortunately the legal use of diamorphine is limited to two European countries i.e. United Kingdom (UK) and Sweden. Furthermore periodic problems with its availability during the past few years (with further shortfalls in availability predicted by the NHS purchasing and supply agency) have resulted in an alternative efficacious analgesia being sought for this population. Fentanyl, however, is a short rapidly acting opiate has several qualities that render it useful as an IN analgesia and a potential candidate to replace IN diamorphine in the AED for acute facture pain management in children. It has a very high lipid solubility, potency and diffusion fraction, and unlike diamorphine it is not a prodrug and does not cause histamine release (Reynolds et al 1999). Assessment of a patients pain experience is not directly accessible to others, collecting and analyzing information about the processes of pain relief and pain prevention is not straightforward and presents significant challenges to health care professionals. In children, this task is further complicated by their varied stages of physical and cognitive development. Recent research by Bruce Frank (2004) however, has shown that the ability to measure pain in the paediatric population has improved dramatically and that today there now exists a plethora of age appropriate pain assessment tools for acute pain in children ranging from pre-term infants to adolescents, the majority claiming validity (strength and robustness) and reliability (consistency). However, most clinical research into pain management strategies continue to rely on the gold standard self report and visual analogy score tools (mostly 0-10) (Chalkiadis 2001, Walker et al 2007). Although these tools are reliable they are not always adapted appropriately for a childs stage of development. Childrens understanding of pain and their ability to describe pain change with increasing age in a developmental pattern consistent with the characteristics of Piagets preoperational, concrete operational and formal operational stages in cognitive development (Smith et al 2003). The quality or int ensity of the pain can be difficult to determine in children, as most tools rely upon a patients relative judgment between the intensity of present pain versus a patients worst pain experience (Murray et al 1996). These tools can therefore be unreliable where a childs age of development means they have limited or no memory of pain experience. Stevens et al (2002) recently described a conflict of understanding that resulted in a study bias and an insignificant reported power of (p=0.6). In the study an 8 year old boy had chosen the VAS (0-10) but frequently reported his score as 10, although he understood the increasing value of the scoring system further questioning identified he perceived 10 of 10 to be a good score and 0 of 10 to be poor. The boy was at a stage of development that limited his understanding of less is more. This case highlights the importance of utilizing a pain assessment technique that reliably accounts for a childs age of development. A preliminary search of literature suggests there is currently exists limited research to support for the use of intranasal diamorphine or intranasal fentanyl for the management of acute pain in long bone fracture in children as evidenced based medicine. Despite this lack of evidence it remains a key strategy within paediatric AED for the pain management of long bone fractures and is anecdotally reported as a gold standard for paediatric pain management. Therefore; its lack of availability could profoundly compromise pain management for this population. Thus, this extended literature review will examine the efficacy of intranasal fentanyl as an alternative to intranasal diamorphine for traumatic fracture pain in children attending accident and emergency departments. However, in these days of evidence based medicine, it clearly needs to be established beyond all reasonable doubt. In view of that only research into paediatrics will be included increasing the credibility of its applicat ion to practice. SEARCH STRATEGY A range of complimentary search techniques were used to capture key research including a systematic electronic literature search of the Cochrane library, Embase, CINAHL, Proquest, Medline, PubMed since 1990 up to 2009 (this has to be to year of submission). The scope of the search was extended beyond the recognised five years of current research so as to include the empirical work into the development of IN analgesia in children. Key words used included the following: pain, acute pain management, intranasal diamorphine, intranasal fentanyl, procedural, accident and emergency, emergency department, child, pediatric, paediatric, child and fracture pain, as well as various combinations. In addition, in order to ensure the completeness of the search, an internet search was completed using the Google search engine, IASP, Pain Journal, Paediatric Nursing, BAAEM, NICE, Medline, EBM; the RCN was also utilised. Backward chaining of references found was also performed to ensure all relevant papers were identified. Although this review identified twenty seven citations it should be noted that historically there are fewer Randomised Controlled Trials (RCT) in children compared to adults possibly due to problems gaining ethical approval and consent. Additionally even experienced researchers will be unable to find all relevant papers and much research is not submitted for publication. The studies identified were divided into the three modalities of IN route, IN diamorphine and IN fentanyl with the majority presenting evidence for the IN route. All papers were critiqued using a tool published by the Learning and Development Department within the Public Health Resource Unit of the NHS (www.phru.nhs.uk/casp). The tool facilitated critiquing different forms of quantitative research and is based on work by Sackett (1986), Sackett et al (1996) and Phillips et al (2008) (see appendix 2). The results of the critique process for each paper and level of evidence applied in line with the modalities they address informed understanding of current practice and development of a research proposal. STRUCTURE OF THE LITERATURE REVIEW This literature review will focus on determining whether IN fentanyl is an effective alternative to IN diamorphine for the management of long bone fracture pain in children attending an AED. The scope of the literature review considers literature from 1990 onwards although occasionally earlier research has been referenced. Given the limited available evidence on the topic the following review structure has been selected. Chapters 1, 2 3 will present the evidence sourced on each theme intranasal route, intranasal diamorphine and intranasal fentanyl with a short summary to conclude each chapter. Chapter 4 will present an in-depth discussion and conclusion on the utility of the evidence, its application to practice and the requirement for a multi-centred comparative randomised control trial to improve the credibility of the evidence base for this field of treatment. Finally chapter 5 will present a research proposal for a comparative study of these modalities. Intranasal (IN) route of medication delivery in children. Nasal administration of drugs has been reported as having several significant advantages over current practice which are predominately oral, IM, IV and rectal (Williams Rowbotham 1998). It is emerging as a low-tech, inexpensive and non-invasive first line method for managing either pain or other medical problems (Wolf et al 2006). Nasal medication delivery takes a middle path between slow onset oral medications and invasive, highly skilled delivery of intravenous medications. The nose has a very rich vascular supply, IN facilitates direct absorption to the systemic blood supply due to increased bio-availability of the drug by missing first pass metabolism, It avoids the potentially technically difficult of sterile intravenous access, is essentially painless and is considered acceptable to children when compared to other routes of administration (Shelly Paech 2006) (see table 1). a theory which will be considered when reviewing the studies within this chapter Therefore suggesting th e IN route will result in therapeutic drug levels, effective treatment of seizures and pain without the need to give an injection or a pill, furthermore; it is quite inexpensive, an advantage in this era of increasingly expensive medical technology (Shelly Paech 2006). Additionally given the complexity of the developing child and the known consequence of poorly managed pain on the future responses to pain the IN route does, if it is as efficacious and as safe as suggested offer one of the most acceptable, definitive forms of analgesia delivery in children. The degree of accuracy of the previous statements will be established within this chapter by critically reviewing the 16 studies identified on IN medications other than intranasal diamorphine or intranasal fentanyl in the paediatric population (see table 2) as these agents are considered individually in later chapters. The rigour of the studies will be addressed within this chapter and reflect the level of evidence applied according to Sackett (1986) criteria (see appendix 3). Most studies reviewed were randomised clinical trials and in some cases compared against a placebo Conversely, this does not concur with the trials discussed earlier (Lahat et al 1998, Al-rakaf et al 2001, Fisgin et al 2002, Mahmoudian and Zadeh 2004 and Holsti et al 2007) where significant dosing was applied or in Wilson et al (2004) who retrospectively studied 30 children age 2-16 years receiving 0.3mg/kg at 5mg/1ml INM and 13 patients receiving rectal 0.2mg/kg diazepam for seizures. The authors report equal efficacy for both routes. Success of these agents was considered on cessation of seizures, no reported complication and not needing to attend A+E. A total of 27/30 families who had used INM found it effective and easy to use. Although 20/24 (83%) who had previously used rectal diazepam still preferred it mostly due to the coughing and the volume of liquid administered via the IN route. Given it is generally considered that the optimum IN dose as stated above is 0.1- 0.2 ml per nostril, all but the studies discussed so far were using drug concentration and dosing regimes whic h resulted in large volumes of liquid being dripped in to the nasal cavity. This is particularly poignant in Wilson et al (2003) who compared buccal to IN midazolam in 53 children aged 3-12 years experiencing seizures lasting > 5 minutes attending AED. A key feature of this study is the mean age of the children (age 9 years), mean weight (24kg) the study drug concentration as with previous studies was of 5mg /ml. IN dosing was at a dose of 0.3mg/kg. Given these figure the average dose would have been 7.2mg = a volume of 1.4ml being administered. Since the comparative route of administration for this study was buccal there is a possibility that part of the IN dose was buccally absorbed therefore creating a flaw in this study methodology, raising questions over why this comparative route was chosen and suggesting the only real conclusion to be taken from this particular study is buccal midazolam is effective and safe in children. Furthermore although this is described as a blind RCT and the authors claim the time to cessation of seizure was quicker for the INM group 2.43 (SD 1.67) to 3.52 (SD 2.14) for buccal route there is little detail on the blinding process or data collection procedure suggesting the rigour of the study maybe flawed therefore the efficacy and safety claimed for the IN route should not be embraced without further study. On the other hand Fisgin et al (2002) and Hardord et al (2004) compared the INM with rectal diazepam. In Fisgin et al (2002) in an unblinded RCT equivalence study the authors compared INM with rectal Diazepam to ascertain the safety and efficacy of INM for the development of a clinical protocol in the management of prolonged seizure in children attending the AED. Forty five infants and children age 1 month -13years experiencing prolonged seizures > 10 minutes were either given INM 0.2mg/kg or rectal diazepam 0.3mg/kg. The authors report proven efficacy (p Intranasal Diamorphine (IND) The delivery of opioids via the IN route is perhaps one of the most valuable indications for IN medication delivery. Acute pain is a frequent experience for children whether attending an AED, hospital and hospice setting (Hamer et al 1997). Furthermore it is not unusual for them to experience frequent episodes of breakthrough pain which requires additional support from fast acting analgesic agents. Owing to the developmental and physiological difference in the paediatric population there is a need for a variety of effective treatment option from which to select and individualise the patients therapy to meet their needs. IN opioid is simply one such option available which may be useful in children. It has been suggested that the delivery of medications via the IN route results in rapid absorption with medication levels within the cerebral spinal fluid (CSF) being comparable with (IV) administration (Chien and Chang 1997). Diamorphine hydrochloride is a semi-synthetic derivative of morphine. It is extremely hydrophilic, which makes it ideal to use when preparing in high concentrations in solution, thus allowing high doses to be administered in smaller volumes via the intranasal route (Kendall Latter 2003). However, this route of administration can be a painful process as reported by adults (Henry et al 1998). Despite this the intranasal route is considered more acceptable to children and their parents and is thought to lessen the opioid side effect profile seen in IV administration (Stoker et al 2008). This concept has been well recognised throughout the UK and many centres already use intranasal diamorphine for acute pain in children, following the guidelines by the British Association for Accident and Emergency Medicine Clinical Effectiveness Committee (2002) (BAAEM). Although the administration of intranasal diamorphine is now a first line choice for moderate to severe acute pain for children atten ding AED, as is the case within our institution, there is very limited research to substantiate this practice although as noted above it has been readily accepted by the BAAEM for acute pain management in children and very successfully used within our institution A recent shortage of diamorphine evoked the search for an equally effective and acceptable alternative. Early research in animals and adults reported pharmacokinetics of nebulised inhalation and intranasal administration of diamorphine as detected morphine in plasma at six minutes (Masters et al 1988, Kendall 2001). Despite the age of this research and the fact that the later study was in adults, it is still quoted as creditable evidence to support this practice in paediatrics. However the legitimacy of this should be questioned, due to children not being just small adults but have physiological differences intrinsic to their age and stage of development which may affect the bodys absorption and level of toxicity in different ways to adults. The extensive literature search highlighted four randomized controlled trials (RCT) that demonstrate IND to be clinically superior to intramuscular morphine and inferior to IV morphine particularly in the management of acute pain in children, a case study of an 8 year old boy and clinical audit of IND for pain relief in children attending AED (see table 3). The key methodology in the RCTs by Wilson et al (1997), Kendall et al (2001), Brennan et al (2004) and Brennan et al (2005) suggest these are superiority studies where the authors hypothesised improved pain management with the IND when compared to a variety of routes. The rigour of the studies will be discussed later in the chapter. Although while the critiquing process takes place it is fundamentally accepted that RCT are considered level 1 or 2 evidence as opposed to case study or audits at Level 3b and therefore generally sourced to Latest published clinical evidence to support the use IND in the paediatric population is presented in an audit by Gahir Ranson (2006) of 54 children whose care was managed by the use of an integrated care pathway for acute pain management while attending the local AED. This integrated care pathway focused strongly on the use of IND. Data collection was on a one page performa and included consent, date, patient demographic, pain score and side effect profile. Data collection was retrospective and data analysis illustrated limited recording of side effect profile but improved pain scores. However only 60% of patients have this information documented so data collection was difficult. Despite this lack of hard evidence no clinical incident, including the side effect profiles, were reported. Thus suggesting the practice of IND for acute fracture pain management in children could be safe, effective and more acceptable to children than the more painful alternative of IM or IV administration. However there is limited strength in an audit, other than a review of practice (Bowling Ebrahim 2005) and in this case a key feature for review should be the documentation process in the department as there were facets in the care pathway administration documentation missing. Therefore this audit suggests that IND is safe and effective pain management for children, but this conclusion can not be categorically drawn from the limited data available. The potential outcome of this audit could be education on documentation, to do a more rigours prospective audit of practice. Unfortunately at this point it only offers an insight to their clinical practice which is favourable for this agent and route. Albeit as noted before IND has improved childrens pain management and over all experience of acute care in our PAED additionally as with the results of the audit we have experienced no side effects or complications, further highlighting the importance of seeking an alternative to IND which offers equally efficacy. Intranasal Fentanyl (INF) Monitoring of the usual observations and pain scoring in the child was recorded prior to the administration of fentanyl (20 micrograms for 3-7 year olds and 40 micrograms for 8-16 yrs) and continued at 5 minute intervals for the 30 minute period. Additional doses of fentanyl (20  µg) were available if required at 5 minute intervals. Pain assessment was achieved with two validated pain assessment tools, the visual analogue scale (VAS) in older children and the Wong-Baker Faces (WBF) for younger children. Both are reliable and known to support consistency in pain assessment. Though there was no mention of training for those assessing this primary end point using these tools in the paper therefore this should be considered in the overview of the standard of evidence produced by this study. Additionally although forty five patients were randomized following consent unfortunately no details on the randomization process was disclosed in the paper either. This may not be significant, but when reviewing the credibility of the authors claims these obvious omissions could be responsible for a flaw in this study and remains to be established. On the other hand, the methodology that has been disclosed in the paper appears sound as it addresses key areas of sample calculation (power of the study) as a superiority study with the sub groups size adequate to detect a significant difference (Greenhalgh 2004); demographics, blinding of the drugs, assessors and appropriate statistical analysis of the data therefore supporting the validity of the results claimed and the application of the results to the age of patient targeted that this literature review is aiming to find an analgesic alternative to IND for. The results concluded by Borland et al (2002), are a reduction in pain score at 10 minutes to 44.6 mm (95% confidence interval) 36.2-53.1 mm from 62.3 mm 53.2-69.4 mm (95% confidence interval) at assessment using the VAS and 2.2 (95% confidence interval 1.3-3.1) at 10 minutes from 4.0 (95% confidence interval 3.3-4.7) at assessment in 16 children using WBS. Visual analogue pain scores demonstrated clinically significant reductions in pain scores by 5 minutes that persisted throughout the entire study (up to 30 minutes) for both INF and IV morphine. The second primary end point of this study (side effect profile) showed no significant change in physiological parameter of the childrens pulse or respiratory rate, blood pressure or oxygen saturations, interestingly the side affect profile chosen for monitoring such as pulse and blood pressure are not considered to be one of the primary side affects of morphine, however nausea and vomiting which are was not assessed. Ultimately, there wer e no negative side-effects and the sizeable reduction in pain scores (compared to baseline assessments) was accomplished in children using INF by 10 minutes and maintained throughout the 30 minute period with the mean INF dose at 1.5 µg/kg and ranging from 0.5-3.4  µg/kg. Interestingly 35.5% of children in the INF group only required one dose. Given the clinical equivalency of these two agents and routes the authors conclusion that INF offers the benefits of a simple painless technique for treating acute pain is substantiated. These benefits suggest that the IN route could be a valuable technique not only in an AED but also for breakthrough pain by offering a fast onset of pain control in moderate to severe painful conditions. It could also provide pain relief and allow topical anaesthetics to take effect on the skin prior to IV establishment. Therefore this may be a suitable alternative to IND. A similar and more recent double blinded RCT trial by Saunders et al (2007) claimed efficacy of a larger dosing regimen with a mean dose of 2 µg/kg INF (50 µg/ml) for pain reductions in paediatric orthopaedic trauma compared with IVM at 0.1mg/kg in 60 3-12 year old children. This study reports positive outcome for INF following both patients and carers reporting very effective pain management and satisfaction using this treatment method. However there is little information in the paper of methodology and results are given in percentages rather than a P value or NTT which should be expected in a rigorous creditable RCT of two agents (Bowling Ebrahim 2005) reducing the level of evidence applied to the paper to L3. Even supposing the results are an accurate reflection of the efficacy and safety of INF, particularly the fact that no significant difference in pain score or side effect profile and INF is a way forward, the lack of detail the randomisation process and analysis of data in the study methodology merely implies that these results maybe flawed. Interestingly given the concentration of fentanyl 50 µg/ ml a dosing volume for a 25kg child would have required one ml = 0.5ml per-nostril therefore suggesting some of the administration may have been oral rather than IN and present the issues of bad taste which is put forward as a possible study limitation by the authors. Then again there are no complications or reports on taste presented in the results and the authors conclusion on the efficacy of INF for acute pain management in children may be founded. However, without sourcing more details from the authors it cannot be considered evidence to inform this dissertations aims but merely an ex ample of poor research or appropriate omission by publishers. Further suggesting there remains a requirement for more research on the topic within double blind, equivalence, RCT focused on INF efficacy and dosing with sound methodology that is transparent in publication to answer the dissertation question. Conversely an older and more rigorous study which also looked at dose related analgesic effect between routes of administration is by Manjushree et al (2002). The authors demonstrated the clinical efficacy of INF in a cohort of 32 children (aged 4-8 yrs) in a postoperative situation and with a double blind level 1 RCT. The study design gives the impression of sound methodology as blinding, assessment and analysis of data was appropriate and available for scrutiny in the paper, particularly the analysis of both nonparametric and nominal data. The only weakness is possibly the sample size of 32 patients. Although the authors performed a power calculation which identified 40 patients to show a significant affect, they only recruited 32 patients, furthermore, this appears to be an equivalency study where the authors hypothesised INF would be equal to and not inferior to IVF therefore would have needed a larger sample to de

Reinsurance Business :: GCSE Business Marketing Coursework

Reinsurance Business ARTICLE I – PARTIES TO AGREEMENT This Agreement is solely between the Company and the Reinsurer and the performance of obligations of each party under this Agreement shall be rendered solely to the other party. In no instances shall anyone other than the Company or the Reinsurer have any rights under this Agreement except recognizing the Company has the sole responsibility for the evaluation and appointment of the Underwriting Manager, Managed Care Concepts of Delaware, Inc. (MCCI). Further, it is agreed that Associated Accident and Health Reinsurance Underwriters (AAHRU), a participating Reinsurer, is deemed to be the Lead Reinsurer. In that capacity, any and all actions of the Lead Reinsurer shall be made in the best interest of this Agreement and binding upon the other reinsurers. Should the Company appoint a new Underwriting Manager, the Reinsurer must approve any change in the Underwriting Manager, otherwise the Reinsurer has the right to cancel at the time of change. This Agreement shall be binding upon the parties, their heirs, and successors, if any. ARTICLE II – BASIS OF REINSURANCE On and after the effective date of this Agreement, the Company shall cede and the Reinsurer shall accept as reinsurance, a Quota Share portion, as shown within ARTICLE XXXII – EXECUTION, of the liability on policies, binders, contracts or agreements of insurance, hereinafter referred to as policies, issued or renewed by the Company on or after the effective date of this Agreement and underwritten for and on behalf of the Company by the Underwriting Manager and classified as Basic College Accident and Sickness Medical Expense Insurance, as described below: ï‚ · Basic College Accident and Sickness Medical Expense Insurance: Excess of all other valid and collectible insurance issued to the eligible students (various classes including, domestic undergraduate, domestic graduate and foreign students) and their eligible dependents. If the eligible student does not have primary insurance, this plan will be primary. Some plans may be written on a primary basis for which benefits will then be coordinated with any other plan in which the student is covered as a dependent. Premiums must be paid before insurance is in force and valid. The maximum benefit per individual covered insured is $500,000. ARTICLE III – RETENTION AND LIMIT The Reinsurer agrees to accept a fixed proportion of 85% of the first $500,000 per person per risk for all business subject to this Agreement.

My Teaching Style Essay -- Education Teaching Teachers Classroom Essay

My Teaching Style Pragmatist teaching style is the best way to describe my style of teaching. I will involve the kids in hands on learning. I want to be an educator because I want to make learning more fun for the children. I also love to work with children. I really like to work with children, and I would like to work with the children to help better them in school. Working with children in helping them learn makes me feel great. I am more of a progressive when it comes to my philosophy of education. I think you should have children based activities in the classroom. Children should have more hand-on activities to help them learn. I think the teacher should deal with the small problems there in the classroom, and not involve the office. Involving the office too much could result in losing control of your classroom. In my classroom I will have the seats arrange in a semi-circle because all the students can see you and the chalk-board easier. It also prevents the children that like to sit in the back of the classroom. It will involve everybody in the learning process. I will have bulletin boards up according to the time of the year it is. In the fall, I will put up leaves on the bulletin board to show the leaves are changing, and they are falling off the trees. For winter, I will put snowflakes on the board to show it is cold outside. For spring time, I will have the leaves coming onto the trees, and showing how the things outside are changing back to green. I will have projects going on throughout the year. I will have children play games to help them study for upcoming test. I will have items on a bulletin board to show how well the children are behaving. I will give ... ...elp me out in a lot of ways. I am planning to continue my education by going onto graduate school. I am hoping that furthering my education will have a positive effect on my teaching style. My mentor teacher will help me further my education in ways of them teaching me the ways of teaching in that school system. I will be willing to take in information from outside the classroom, and use it in my everyday teaching style. My development in the future will be helped out through my mentor teacher, and the efforts of the other teachers. I will bring my own ideas into how I teach in the classroom. I will bring in new stuff to teach the students of how or not how to do things. I will always explain to my students, like the 9/11 tragedy, of the importance of what just happened in the world. I will make everything clear that is happening in the world.

Physics-Bridge Project

Humans have tamed steel, stone, lumber, and even living vegetation, all in effort to reach the people, places, and things that we desire. Although the concept of bridges is as simple as a tree falling across a creek, bridge design and construction requires very serious ingenuity. Artists, engineers, and architects pour vast resources into bridge construction so that they can reshape our daily environment for the better. When building bridges you’ll need help from BATS which are the key structural components of bridge construction such as beams, arches , trusses, and suspensions.Various combinations of these four technologies make it possible for numerous bridge designs, ranging from some bridges as simple as beam bridges, arch bridges, truss bridges, and suspension bridges to more complicated bridges like side-spar cable-stayed bridges. Some of the key differences between these four types of bridges is the lengths that they can cross a single span, which is the total distancve between two of the bridges supports. Bridges supports can take the forms of columns, towers or even the walls of nature around the bridge like canyons.Beam bridges range up to 200 feet , while modern arch bridges can reach up to 800-1000 feet safely. Suspension bridges on the other hand are able to extend from 2000-7000 feet across. Compression and tension are present in all bridges and they are capable of damaging parts of the bridge as varying load weights and other forces act on the structure of the bridge. It is the job of the bridge design to handle these forces without buckling or snapping. Buckling occurs when a compression is able to overcome a objects ability to endure that certain force.Snapping is what happens when tension surpasses an objects ability to handle the lengthening force. The most effective way to deal with these powerful forces is to either dissipate them or transfer them. With the dissipation the design allows the force to be spread out over a greater area so that no one certain spot has to endure to much pressure. In transferring force, a design moves stress from an area of weakness to an area of strength. Beam bridges, bridge building isn’t more simple than this. When building a beam bridge all you need is a rigid horizontal structure and two supports, one at each end, to rest it on.These components directly support the downward weight of the bridge and any traffic traveling over it. Many beam bridges use steel or concrete to handle their certain loads. The size of the beam, and the certain height of the beams, determines how far that the beam can span up to. By increasing to height of the beam, the beam has more material to lower the tension. To create taller beams the designer of the bridge adds supporting latticework, or a truss, to the bridge’s beam. The support from the truss adds rigidity to the existing beam, greatly increasing its ability to dissipate the compression and tension of the bridge.Once the beam begi ns to compress, the force spreads through the truss. Yet even with a truss a beam bridge is only good for a max-limited distance. To make the bridge have a greater distance you need to build a bigger truss, until you have reached the point where even a truss cant support the bridges weight. During the industrial revolution, beam bridges were developing in the United States rapidly. Engineers gave many different truss designs in order to try and perfect it. All the different truss patterns also factored into how bridges were being built. ome designs had the truss under the bridge ,while some designs had the truss above the bridge. A single beam spreading any distance undergoes compression and tension. At the very top of the beam has the most compression and at the very bottom of the beam has the most tension. In the middle of the beam has very little compression or tension. This is why beams are built with bridges, they provide more material on the tops and bottoms of beams to better handle the forces of compression and tension. There is another reason why a truss is more rigid than a single beam; a truss has the ability to dissipate a load through the truss work.The truss design, which is a variant of a triangle, creates both a very rigid structure and one that transfers the load from a single point to a considerably wider area. After being used for 2000 years of architectural use, the arch continues to feature prominently in bridge designs. Its semicircular structure elegantly distributes compression through its entire form and diverts weight onto its two abutments, which are the components of the bridge that directly take on the pressure being exerted onto the bridge. The tensional forces in arch bridges are virtually negligible.That is because the natural curve of the arch and its ability to dissipate the force outward greatly reduces the effects of tension on the underside of the arch. The greater the degree of curvature, the greater the effects of tension on the underside of the bridge. If you build a big enough arch, the tension will eventually overtake the support of the bridges natural structure. While there is a fair amount in variety in arch bridge construction, the basic structure of every arch bridge is the same. For example there is Roman, Baroque and Renaissance which are all architecturally different they all have the same basic structure.It is the individual arch itself gives its namesake bridge its strength. An arch made of stone doesn’t need a mortar. In fact the ancient Romans built arch bridges and aqueducts that are still standing today and are made of stone. The tricky part , however is building the arch, as two converging parts of the structure have no structural integrity until they meet in the middle, which mean additional scaffolding or support systems are typically needed. The modern materials such as steel, and prestressed concrete allow us to build far larger arches than the ancient Romans ever were ab le.Modern arches typically span between 200 and 800 feet. There is one bridge in West Virgina named the New River George Bridge and it measures an impressive 1700 feet. Suspension bridges, as the name implies its suspend the rail the railway by cables, ropes, or chains from two towers. These towers support most of the bridges weight as compression pushes down on the suspension bridges deck and then travels up the cables, ropes, or chains to transfer compression directly into the earth. The supporting cables receive the bridges tensional forces. The cables of the bridge run horizontally between the two far flung anchorages.Bridge anchorages are essentially solid rock or massive concrete blocks in which the bridge is grounded. The tensional forces pass through anchorages and into the ground. In addition to all the cables almost all the suspension in bridges feature a supporting a truss system beneath the bridge is called a deck truss. This often helps to stiffen the deck and reduce th e tendency of the roadway to sway and ripple. Suspension bridges can easily cross distances such as 2000 to 7000 feet and this enables them to reach distances that other bridge designs cannot.Because of this bridges complexity and of their design they require a lot of materials , they are the most costly bridge to build. But not every suspension bridge is made out of steel andother costly materials. It can be as simple as twisted grass. When the Spanish conquistadors made their way into Peru in 1532, there they discovered an incan empire connected by hundreds of suspension bridges, achieving spans up to 150 feet or more across deep mountain gorges. Europe on the other hand wouldn’t see a suspension bridge for atleast 300 more years. At a first glance the cable-stayed bridge may look like just a variant of the suspension bridge, ut don’t let their similar towers and hanging railways confuse you. Cable stayed bridges are different from suspension bridges because they don ’t require anchorages, nor do they need two towers. Instead the cables run from the railway up to a tower that bears the weight alone. The tower in a cable stayed bridge is responsible for absorbing and dealing with all the compression forces. The cables attached to the bridge run to the tower in a variety of ways. For example, they can run in a radial pattern, cables can extend from several points on the road to a single point at the tower.They can also be in a parallel pattern, the cables attach to both the roadway and the tower at several separate points. The first cable strayed bridges were constructed in Europe after world war 2, but the basic design dates back to the 16th century and Croatian inventor Faust Vrancic. A contemporary of astronomers Tycho Brache and Johannes Kepler, Vrancic produced the first well known sketch of a cable stayed bridge in his book â€Å"machinae Novae. † Today cable stayed bridges are a popular choice as they offer all the advantages of a suspension bridge but at a leser cost for spans, up to 500 to 2800 feet.They require a less steel cable, and are faster to build and incorporate more precast concrete sections. Most of humanities build bridging legacy is a story of artificial structures crafted out of the natural elements. Build a bridge out of woven vines or hewn boards and nature will certainly turn it into compost. Building a living bridge takes patience of course. The war-khasis people for example create root-guided systems from hallowed halves of old betel nut tree trunks to direct strangler fig roots in the desired direction.They simply direct the roots out over a creek or river spanning and only allow the roots to dive into the earth on the opposite bank. The larger living bridges boast lengths of up to 100 feet and care bear the weight of 50 people. There are things that engineers such as torsion which occurs when high wind causes the suspended roadway to rotate and twist like rolling a wave. Also there is shear stress which occurs when two fastened structures are forced in opposite directions. If a bridge has sighs of shear stress and it is unchecked the bridge can literally rip the bridge in half.A simple shear force would be to drive a long stake halfway into the ground and then apply lateral force against the side of the upper portion of the stake. With enough sufficient preasure youd be able to snap the stake in half. Resonance, you can think of this as simply a vibrational equivalence of a snowball rolling down a hill and becoming an avalanche. It starts off relatively small and periodicly stimulus of a mechanical system, such as wind buffeting a bridge. These vibrations however are more or less in harmony with the bridges natural vibrations.If unchecked the vibrations traveling through the bridge can form torsional waves. The best example of this occurred in 1940, when resonant vibrations destroyed the Tacoma Narrows Bridge in Washington. The innocent was especially shockin g at the time as the structure was designed to withstand winds up to 120 miles per hour and collapsed in a mere 40 mile wind. When there was close examination of the innocent it suggested that the bridges deck-stiffing truss was insufficient for the span, nut this alone couldn’t bring such a structure down.As turned out, the wind that day was at just the right speed and hit the bridge at just the right angle to set it off the deadly vibration. Continued winds increased the vibrations until the waves grew so large and violent that they broke the bridge apart. This simple effect is just like a singer breaking glass with their voice. Wind isn’t the only thing that is a threat to bridges. For example when an army marches across a bridge, the soliders often â€Å"break step† so that their rhythmic marching will start resonating throughout the bridge. A sufficient large army marching at the right cadence could set the deadly vibration into motion.In order to mitigrate fully the resonance effect in a bridge, engineer incorporate dampeners into the bridge design to interrupt the resonant waves and prevent them from growing. Another way to halt resonance is to give it less room to run wild. If a bridge boast a solid roadway, then a resonant wave can easily travel the length of the bridge and wreak havoc. But if a bridge roadway is made up of different sections with overlapping plates, then the movement of one section merely transfers to another to another via the plates generating friction. The trick is to create enough friction to change the frequency of the resonant waves.Changes the frequency prevents the waves from building. While wind can certainly induce destructive resonant waves, whether a whole host of destructive assaults on the bridges we build. In fact, the relentless work of rain, ice, wind, and salt will inevitably bring down any bridge that humans can erect. Bridge designers have learned their craft by studying their failures of the pass. Iron has replaced wood and steel has replace iron. Pre-stressed concrete now plays a vital role in the construction of highway bridges. Each new material or design Technique builds off the lesson of the past. Torison, resonance.