In-Licensing in Pharma Essay Example for Free

In-Licensing in Pharma Essay INTRODUCTION The process of bringing a new drug to market is an extremely expensive one, often costing above $200 million. This enormous cost can be explained by the fact that a very small fraction of molecules in research and development ultimately become pharmaceutical products. However, the rewards of a successful new product can be tremendous generating, depending on the therapeutic areas in which the product will be used and the disease it will directed to, from millions to billions of dollars of sales annually worldwide. Many pharmaceutical companies are facing a pipeline gap because of the increasing economic burden and uncertainty associated with internal research and development programs designed to develop new pharmaceutical products. The need for large pharmaceutical companies to constantly replenish the supply of potential blockbusters requires a consistent and dedicated approach to drug RD. However no longer is inhouse research expertise sufficient. To fill this pipeline gap, pharmaceutical companies are increasingly relying on in-licensing opportunities. Business development and licensing department identifies new pharmaceuticals that satisfy unmet needs and are a good strategic fit for the company, completes valuation models and forecasts, evaluates the ability of the company to develop and launch products, and pursues in-licensing agreements for pharmaceuticals that cannot be developed internally on a timely basis. The in-licensing process provides a source of new drugs to a given company to supplement internal laboratory research, to reach the company’s goal in term of present and future portfolio. As competition in the pharmaceutical market continues to grow, effective business development strategies become critical to maintain momentum and improve global market share for the leading pharma companies. An increasing proportion of revenues are expected to be generated from licensed products and as a result licensing will become an ever more important component of the overall business development mix (source: Wood Mackenzie’s Licensing insight Multi-Client study, April 2003) The in-licensing process might imply enormous effort by the company. It can be compared to the proverbial search for a needle in the haystack. First, the haystacks are large and require a massive amount of searching. Second, no one knows how many needs are in the haystack. There might be none, or multiple. Third, the search is conducted in public and multiple companies compete for innovative therapies, and resource allocation and financial aspect play a role in such competition. The key to pursing in-licensing opportunities is rapidly to identify individuals and companies with the intellectual property sought by the company. New business development teams maintain a business development customer relationship management information system. The information stored in this system has been gathered from personal networking contacts, industry available organization directories, membership directories, commercially PubMed, and online databases. The system contains the contact information, therapeutic interest areas, development stage information for products in development, and other relevant information needed to identify potential in-licensing partners, such as key clinical researchers, biotechnology companies, and small specialty pharmaceutical companies. A search of this system provides a list of potential inlicensing partners. To supplement this list, the new business development team begins a systematic marketing campaign in select industry trade publications and Web sites to promote the company’s desire for an in-licensing partner. The campaign highlights the company’s strengths in clinical development, manufacturing, and sales and marketing. Information regarding the type of product desired (therapeutic class, clinical development stage, and so forth) and the type of licensing agreement being sought is specified. From the list of potential in-licensing partners, the new business development team selects the most appropriate candidates and begins to evaluate the feasibility of in-licensing each potential partner’s product. Despite there is no standard formal process in in-licensing of pharmaceutical products, it is quite standard to utilize a stepwise approach, composed of go/no go gates, that can be summarised in the following stages: 1. evaluation of potential in-licensing opportunities 2. first pass review 3. product evaluation 4. due diligence 5. in-licensing contractual negotiation and deal closing. This stages are ordered following a timeline perspective, so to have a subsequent flow of actions. The approach includes examining opportunities from other pharmaceutical companies and from academic centers involved in research. Once the opportunity has been identified, the first pass review consist generally in the evaluation of information provided by the potential licenser, the medical and scientific literature, and specialised consultant if there is a in-house gap in specific knowledge. This initial step has often been based on a ‘’gut feeling’’ and the company overall strategy in term of therapeutic area focus. For those opportunities not rejected in the first pass review, a more detailed evaluation of the scientific, commercial and financial issues, are undertaken. Additional people with various area of expertise participate in this secondary evaluation. Only if the entire evaluation is positive the opportunity is taken to senior management, that finally approves the in-licensing after due diligence and a full negotiation on terms of the agreement. One aspect that is often underestimated in in-licensing opportunity is the in depth commercial assessment of the putative candidate, leaving the go/no-go decision mainly at strategic fit in terms of therapeutic area focus or financial aspect taken from capital budgeting calculations. In this regards, sales forecast plays a critical role in assessing the net present value of the in-licensing opportunity, but they need to be supported by a complete, although preliminary, full product evaluation. This evaluation has to include external analysis in the context of the future scenario, internal analysis of the given putative candidate, and a preliminary but clear product strategy. The scope of the development of a qualitative model for a full product evaluation in the context of an putative in-licensing opportunity is to define the key relevant steps within the full product evaluation related to commercial aspect that are critical for the precise and coherent definition of the sales potential of the product, that will used in the Capital Budgeting (e.g. Net Present Value) models to assess the financial aspect of the opportunity and set the basis for the full negotiation. Common financial analysis measures for valuation of an in-licensing opportunity Pay Back Period (PBP) Length of time required to recover the cost of an investment Discounted Cash Flow (DCF) Analyzes future free cash flow projections and discounts them using the after tax weighted average cost of capital to arrive at a present value (value in local currency at the time of analysis); DCF analysis estimates the money a company would receive from an investment and adjusts for the time value of money.

Acute Care Nurse Practitioner Interview Nursing Essay Example for Free

Acute Care Nurse Practitioner Interview Nursing Essay The Advanced Practice Nurse (APN) I interviewed is FS; she is an Acute Care Nurse Practitioner (ACNP) with the department of Urology at Saint Louis University Hospital (SLUH) and has been licensed and board certified since 2010. FS graduated in 2005 from Goldfarb School of nursing in Saint Louis earning her bachelor of science (BSN) and then took an intensive care staff position with Missouri Baptist hospital for two years. With two years of experience she felt she needed to continue her education in nursing and enrolled in a Saint Louis University (SLU) ACNP program. She realized after the first year that trying to work full time and take classes was too much for her, so she decided to quit her job to focus full time on her studies. Her first position as an ACNP was with the trauma department step down floor at SLUH in 2011. This position was advertised in newsprint and after sending in her resume she was contacted to for an interview in person. My first interaction with FS was last fall when I was teaching Advance Trauma Care for Nurses as she was one of the students that I recognized from the trauma department. We struck up a conversation and I basically did a mini interview then and she since has given me contacts for preceptors this summer. Last week I notified her regarding this interview and she informed me to meet her at noon in her office where we discussed questions listed according to the description of assignment for a total of 30 minutes. Personal history including education FS received a Bachelor of Science degree from Georgetown University in Economics and International Business. When working out a problem or learning a new skill she likes to get the general picture and start gradually focusing in on specifics similar to deductive theory. She knew she wanted to work in a hospital setting, from there to a surgical floor, and now she has focused in on Urology. She learned the Urology department at SLUH wanted to bring in two or three APN’s on service to round and be first assistants in the operating room through networking with other APN’s in the hospital. When she interviewed for the position she had a great working relationship with that service already. They knew she was punctual along with having familiarity with documentation system. She basically had been marketing herself before she even knew it by having a proactive relationship with consults. Description of current practice FS does not currently have a formal job description since her position is new and she is the first APN to fill this newly developed role with this service. Other than being told she would round on patients in the hospital, write orders, discharge patients, and first assist in the operating room she has no formal written description. When she applied for her position she was informed it would be a lateral move with no increase in pay or benefits. FS arrives to the hospital at 0600 similar to an intern or second year resident. Every morning she receives report from night float of any new patients or issues to existing patients who have been admitted. Information is gathered on labs and radiology films that have been completed and she uses this information when her first patient assessment is completed early that morning. The fellow or senior resident will round on each patient to discuss labs, radiology, and patient assessments. From this a plan is developed what needs to be done that day to move forward before the attending rounds with the team to discuss the same items. From this point she may go to the operating room to first assist if it is her patient or write new orders on the other patients assigned to their service. If she happens to be first assistant she will follow the patient back to their room and write post operation orders. Her role is very similar to a second year surgery resident duties. Description of APN functions using the APN core competencies. Working in an inner metropolitan city hospital that has many ethnicities has been challenging. She has had to learn certain customs, body posture, and position can have either a positive or negative impact in perception from the patient with regard to attitude of care they are receiving. She has learned from staff of the same ethnicity or watched family and friends interact with one another on proper cultural customs. The first of two main core competencies FS uses is clinical and professional leadership with fellow APN’s and physicians discussing assessments and plan of care. The second of two core competencies is consultation with other services and the nursing staff in consideration to patient care and goals (Cooke, Gemmill, Grant, 2008). APN’s have additional competencies but these are the two main descriptions FS uses daily. FS has worked through many challenges as an APN the last few years. Some of the minor issues have been the acceptance from other services that do not have APN’s. Over time other services have become accustomed to consults from APN’s by her demonstrating knowledge, professionalism, and kindness. The biggest challenge she has faced is an overabundance additional patient work load since the department will no longer have residents this year. She has the attending’s blessing to hire more APN’s and they will take on more direct patient care. Issues confronting the APN in current practice FS reports there are no real issues she faces at present other than just continue to work on suturing skills in the operating room. She stays current in Urology by attending grand rounds along with reading and presenting journal articles. She also has the luxury of having a fellow who has been a great source of knowledge. Perceived impact on APN role pursuant to current healthcare developments, changes, and national recommendations. It is my personal belief APN’s will be one of the fastest growing professions in the coming years when the Affordable Health Care Act takes place. It appears that many physicians will probably be in specialized services along with the APN. In addition, APN’s will be the majority of primary care in the future as more individuals will seek wellness physicals and the baby boom generation is nearing 70 years of age.

Using gentamicin in the management of sepsis

Using gentamicin in the management of sepsis Sepsis is defined as the inflammatory response toward an infection (1). It is either simple or severe sepsis depending on the organ dysfunction involved as a result of the infection and other factors (2). In terms of the pathophysiology of severe sepsis, a cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis causes changes in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death (3). In terms of definitions of other sepsis-associated symptoms, it was generally agreed at the International Sepsis Definitions Conference which was convened in 2001 and the following definitions of sepsis syndromes were published in order to clarify the terminology used to describe the spectrum of disease that results from severe infection. Sepsis is the presence of infection in association with meeting the Systemic inflammatory response syndrome (SIRS) criteria (Box 1 (2)). The clinical significance of meeting SIRS criteria in the absence of organ dysfunction or shock is still unclear. Severe sepsis is defined as evidence of end-organ dysfunction such as altered mental status, episode of hypotension, elevated creatinine, or evidence of disseminated intravascular coagulopathy. Septic shock is defined as persistent hypotension despite adequate fluid resuscitation or tissue hypoperfusion manifested by a lactate greater than 4 mg/dL. Bacteremia is defined as the presence of viable bacteri a within the liquid component of blood (1). Acute pyelonephritis is defined as an acute infection of one or both kidneys; usually, the lower urinary tract is also involved (4). Antibiotic regimen of choice for Sepsis that is associated with urinary tract infection is Co-amoxiclav 1.2g 8 hourly intravenously together with Gentamicin IV dose of 5mg/kg once daily (5). Although that is controversial whether to use the ideal body weight (IBW) or to obtain blood samples indicating Gentamicin level to get the optimal dosing regimen for Gentamicin in obese patient due to risk of accumulation with Aminoglycoside and the fear of oto- and nephrotoxicity (6). Other supportive measures depend on the patients status; table 1 (1) contains helpful measures that indicate markers of organ dysfunction. Case Summary Our patient, C.M., is a 56 years old female who was admitted to the Accident and Emergency department (AE) due to an increased urinary frequency and a high temperature of 40.5 °C. Other complaints were back pain and shortness of breath (SOB). Also, the patient had reported a fall the night before admission. Moreover, the patient had vomited the night before and in the morning of admission. C.M. is a previous smoker who had stopped smoking several years ago and she lives with a partner. She is clinically obese weighing 100kg and her height is 152.4cm. Giving this, her ideal body weight (IBW) comes to 49kg. The only known allergy for this patient is microspores tapes. The patients past medical history (PMH) included asthma, non-insulin dependent diabetes mellitus (NIDDM) and fibromyalgia. She was on one puff daily of each Symbicort Turbohaler 200/6  µg and Ventolin Accuhaler for the management of her stage 3 asthma. Metformin 1g daily was prescribed for her diabetes control; however, its formulation was not mentioned (whether it is a sustained release tablet or a normal release one!). For her fibromyalgia, she was taking 300mg of Quinine sulphate daily together with 150mg of Amitriptyline daily (which is a very high dose; low dose of tricyclic antidepressant (T CA) is recommended i.e. 20-30mg of Amitriptyline). For her pain, the patient was on Co-codamol tablet as required (strength, dose and frequency were not mentioned). Having that she is a diabetic patient over 40 years old, a dose of Simvastatin 40mg daily was prescribed as a primary cardiovascular disease (CVD) protection measure. In addition, Omeprazole 20mg daily was one of her regular m edications with unclear indication. Investigations On admission, an Electrocardiography (ECG) was performed and indicated sinus tachycardia; which could be related to the high temperature, pain or sepsis. The patients vital signs were abnormal having a respiratory rate (RR) of 22 breaths per minute (normal is ~ 12bpm), a heart rate (HR) of 117 beat per minute (normal is ~ 70bpm) and a blood pressure (BP) of 142/65 mmHg (target for diabetic patients is Her laboratory investigations were almost normal except for some parameters. The Sodium level was a bit low which could be a result of the frequent urination or an Amitriptyline hyponatremic effect. Glucose and C-reactive protein (CRP) levels were high which might indicate the presence of infection. Thrombocytopenia may be caused by Quinine or Simvastatin administration! Impression and related Management Plan The patient was diagnosed as a pyelonephritis and sepsis case; so empirical antibiotic regimen was initiated with 1g Amoxicillin intravenously six hourly and 500mg ciprofloxacin orally once daily. Also, 1g Paracetamol intravenously six hourly and one liter Normal Saline intravenously over 24hours was started. Urinalysis on the first day indicated the presence of leucocytes, nitrites, glucose, ketones and blood which means a presence of infection. On the second day, blood culture showed a growth of E. coli which is sensitive to Gentamicin, therefore, 400mg Gentamicin intravenously every 24 hour was prescribed and ciprofloxacin was discontinued. Gentamicin plasma level was requested 6-14 hours after administration of the first dose. In addition to the patients regular medications, 50 mg of Cyclizine eight hourly and 20mg of Citalopram once daily were added, paracetamol IV was switched to orally in the second day and 30mg of oral codeine as required was prescribed ; but the patients Salbutamol Inhaler had been stopped for unclear reason. Discussion Revising the management plan for this patient and in comparison to the local guidelines for the management of pyelonephritis and sepsis patients, we would notice that 1.2g intravenous Co-Amoxiclav is the first-line choice of Penicillins, not Amoxicillin, together with Gentamicin. However, if the ideal body weight is required to obtain the appropriate dosing of Gentamicin for obese patients, so in this case, 245mg of Gentamicin supposed to be prescribed instead of 400mg which is the maximum daily dose (Although that some infectious diseases specialist would recommend going to the maximum dose to make sure that we get the maximum benefit; but we must consider patient status and severity of infection!). Also, it is essential to check the optimal timing for monitoring each drug plasma level, in our case, Gentamicin therapeutic drug monitoring (TDM) has not deviated from the local guidelines recommendation for the once daily dosing of Gentamicin i.e 6-14 hours after giving first dose. Having a patient with increased urination and vomiting, we must consider fluid replacement. Replacing with one liter Normal Saline (NS) might have not met the patients requirement! So it is recommended to check patients need to ensure appropriate replacement i.e. at least 2.5-3 liter daily. We could have recommended giving 2 liter NS each over 8 hours plus the addition of 500ml 5% Dextrose to ensure calories intake if the patient cannot tolerate oral intake. Considering the patients asthma control, we must confirm that Salbutamol inhaler was not mistakenly missed after admission. Since that SOB was one of the patients complaints, we must ensure that it was relieved, if not, consider 5mg of Salbutamol nebulizer four times daily to be added to the regimen and if nebulizer is not necessary, ask for Salbutamol inhaler to be charted as if required basis (6). Also, blood gases were not mentioned so it is probably safer to ask for the oxygen and carbon dioxide saturations to consider if oxygen therapy is needed! Confirm that the patient and nursing staff are aware of inhalers techniques. The patient is on Amitriptyline 150mg orally daily which is considered an old practice for the treatment of fibromyalgia (high dose TCA) and the current recommendation states 20-30mg of Amitriptyline daily for 8 weeks (6) so it is better to re-consider dosing or to change regimen. Low dose Sertraline or high dose Venlafaxine therapy may be effective (6) so consider changing if no further benefit of the use of Amitriptyline. For the associated pain, Paracetamol with Tramadol has better efficacy than Co-codamol. Pregabalin (150-300mg every 12 hours) may improve pain especially if combined with Tramadol; it also improves sleep and morning stiffness (6). So, knowing the patients control with the current medication would be helpful to consider treatment change or modeling to get the most of pharmacologic treatment. Suggesting alternative ways to manage symptoms is also recommended, e.g. spa therapy, physiotherapy, stress management, acupuncture or diet (6). NICE guidelines for the management of type II diabetes mellitus state that Metformin is the first line choice for obese patients. Choosing appropriate formulation that suits the patients lifestyle is essential to ensure patients compliance. Once daily dosing of sustained release formula could provide 24 hour control over glucose, but in this case the present of infection interfered with having accurate reading so it is logical to check the HbA1c to check the glycemic control over the last 8 weeks to consider any therapy modification. Also, pre- and post-prandial glucose level monitoring is required to avoid both hyper- and hypoglycemia using the current regimen. Statins must be prescribed for all diabetic patients who are over 40 years old (6) and having any risk factor of Coronary Vascular Diseases (CVD). The patient was on Simvastatin 40mg daily but no Cholesterol level obtained (consider Ezetimibe if high Cholesterol). Monitoring liver function tests (LFTs) and any muscular side effect is important. Also, having a high BP on admission, checking that BP is normal after sepsis reveals is vital. If persistent high BP, consider adding ACE inhibitors, having the benefit of BP control and protecting the heart in patients susceptible to Vascular Diseases. Weight loss in this patient is advisable so consider dietitian and physiotherapist review to consider going on diet and exercise. Also, annual eye check is recommended to control retinopathy due to DM. Cyclizine was prescribed on regular basis, so we better check if the patient is really on need of a regular anti-emetic, otherwise, consider changing it to as required basis. Regarding Paracetamol, it was prescribed on as needed basis but it was not put clear not to exceed the maximum daily dose, so it is recommended to clarify that to not give the patient more than 4g per day. It is safer to contact the patients GP to confirm the indication of Omeprazole and to consider discontinuation if no clear indication was obtained. Additionally, the patient was thrombocytopenic, which could be a side effect of administration either Quinine or Simvastatin, so monitoring the platelets count is highly recommended to prevent any complication, although DVT prophylaxis is not needed as long as the patient is mobile. Conclusion In conclusion, the overall patient management had no much deviation from the current guidelines recommendation except for some practice that need to be reviewed considering the current patients status. Therapeutic monitoring should be carried on because the patient is under risk of many complications or side effects. Lastly, patients awareness of her clinical condition and treatment requirement for each problem is helpful to prevent or reduce future health problems. Appendix 1: PATIENT MEDICATION PROFILE Patient details Name C.M. Consultant General Practitioner Address Gender Female Weight 100 kg Height 152.4 cm Community Pharmacist Date of Birth (Age) 56 y.o. Known Sensitivities Micropores tapes Social History Previous smoker, lives with partner Patient hospital stay Presenting complaint in primary care / reason for admission Admission date 2008 Increased urinary frequency Back pain Shortness of breath Vomiting Fall (the night before) Fever (40.5 °C) Discharge Date Discharged to Relevant medical history Relevant drug history Date Problem Description Date Medication Comments Asthma Symbicort 200/6 Turbohaler 1 puff daily Ventolin Accuhaler 1 puff daily Non-insulin dependent diabetes mellitus Metformin 1g daily Formulation? Fibromyalgia Co-codamol PRN Strength? Amitriptyline 150mg daily Too high! Quinine sulphate 300mg daily Duration? Simvastatin 40mg daily 1ry CVD prevention Omeprazole 20mg daily Indication? Relevant non drug treatment Prescribed Medication Start Stop Clinical/Laboratory Tests Result 1 Paracetamol 1g IV 6 hourly Day 1 Day 2 ECG Sinus tachycardia 2 0.9% sodium chloride 1000ml IV over 24 hours Day 1 HR 117 bpm 3 Amoxicillin 1g IV 6 hourly Day 1 BP 142/65 4 Ciprofloxacin 500mg PO OD Day 1 Day 2 RR 22 bpm 5 Metformin 1g PO OD Day 1 Urine analysis Leucocytes, nitrites. Glucose, ketones, blood +ve 6 Omeprazole 20mg PO OD Day 1 Blood culture E. coli 7 Quinine sulphate 300mg PO OD Day 1 Na 134 (135-145) 8 Simvastatin 40mg PO OD Day 1 CrCl 145.3 (78-120) 9 Amitriptyline 150mg PO OD Day 1 Glucose 8.9 (3.9-5) 10 Symbicort 200/6 inhaler 1 puff daily Day 1 CRP 180 ( 11 Codeine phosphate 30mg PO PRN Day 1 Bilirubin 35 (3-16) 12 Citalopram 20mg PO OD Day 1 PT 17 (12-15) 13 Cyclizine 50mg PO 8 hourly Day 1 APTT 39 (20-30) 14 Gentamicin 400mg IV 24 hourly Day 2 Platelets 70 (150-400) 15 Paracetamol 1g PO PRN Day 2 Clinical management Diagnosis Pharmaceutical Need Pyelonephritis Evidence-based treatment Sepsis Treatment according to guidelines Care Issue/Desired Output Action Output Confirm drug history + reconcile drug history Ask patient how and when she takes her medication and the indication for each medicine. Compare with GPs DHx + Phone GP for indications for amitrip., omep. and quinine, and when they were initiated. All regular meds have been charted except prn salbutamol. Patient is SOB; advise Dr to chart it prn. Confirm antibiotic regimen for pyelonephritis/sepsis in addition to TDM Check the local guidelines that amoxicillin is first-line for the indication (culture sens. to gent.).Calc. her ideal body weight and CrCl.Calc. gent. dose based on ideal body weight and compare to 400mg iv od (max dose).Check local guidelines whether 6-14 post dose gent. level is correct procedure. Chase level. Monitor BP, Temp, Pulse, RR for signs of resolving sepsis whilst on current regimen. Co-amox 1.2g iv tds is first-line with gent 5mg/kg (max 400mg, ideal body wt 49kg, CrCl 71ml/min). Recommend switch to co-amox because she needs 7/7 iv + oral. Recommend 245mg gent iv od Obtain level before 2nd dose is given+TDM for gent is correct. Review need for gent in 48h Fluid requirements possibly not being met by 1L N. saline in 24hours Request a running fluid balance chart due to vomiting + increased urinary frequency. Ask patient if she can tolerate oral liq. or if feels thirsty. Assess if iv is necessary (2.5L daily + replace losses) Advise doctor to amend first bag to 8 hours and chart 1L N.saline over 8hours + 500ml glucose 5% over 8 hours if patient cant tolerate oral liq. Is her current SOB being treated appropriately? If patient is still wheezy, ask for PaCO2 + PaO2. Request salbutamol nebs 5mg qds + O2 60% to be charted. If not currently SOB, ask for accuhaler to be charted prn. Assess inhaler technique for both inhalers when breathing ok Is her fibromyalgia regimen in-line with current evidence? Check Brit. Soc. Rheum for current guidance on fibromyalgia. Check that citalopram is the SSRI of choice in fibromyalgia since it has been started on admin. Review quinine; if has been in use for 3 months with no benefit consider stopping it High dose TCA is an old practice; current evidence states 25mg/day for 8 weeks. Advise a review of Amitrip. Low dose sertraline has better evidence for use in Fibro. Advise switch + show evidence to prescriber. Tramadol with paracetamol has better efficacy than co-codamol. Suggest trial switch and monitor for dizziness due to recent unexplained fall. Consider pregabalin. Lifestyle advice: stress management, diet, physiotherapy/massage, etc. Is her type II diabetes under control? Check SIGN guidelines on diabetes for current management. Request HbA1c test to determine control over last 2-3/12 Monitor glucose pre/post-prandial and random. Ask patient how she takes the metformin and how regularly Metformin is first-line in obese type II. From lab results, assist endocrinologist in determining whether metformin dose should be increased + which preparation suits patients lifestyle. Is her CVD primary prevention needs being met? Check SIGN guidelines on CVD primary prevention. Check BP + Cholesterol. Next UEs ask for urine albumin + protein levels. Ask patient about current diet and exercise plan (obese) + last eye test. Simvastatin 40mg charted. Check cholesterol. If it is high, may need ezetimibe 10mg od. LFTs ok BP 142/65, upon resolving sepsis recheck BP and initiate ACEi if appropriate. Advise dietician review (obese) + physiotherapy review (or GP) for plan (30mins exercise 5/7). Advise eye test once a year Regular cyclizine may be unnecessary Endorse chart for paracetamols maximum daily dose Reassess patients need for a regular anti-emetic and re-chart cyclizine as prn instead of regular if required Max 4g in 24 hours (e.g. 1g QDS) Highlight patients thrombocytopenia No need for DVT prophylaxis if patient is mobile. Mention that quinine or simvastatin could be the cause of low platelets. Suggest trial withdrawal of quinine if not planning on stopping anyway. Monitor Platelets level if continued. Indication for omeprazole Determine indication from GP and patient. Consider trial withdrawal if indication unknown. Appendix 2: Box 1. Consensus Conference of the American College of Chest Physicians and Society of Critical Care Medicine definitions for the various manifestations of infection.   Ãƒ ¢Ã¢â€š ¬Ã‚ ¢ Systemic Inflammatory Response Syndrome (SIRS): Manifest by two or more of the following conditions: 1. A temperature >38oC or 2. A heart rate >90 beats per minute 3. A respiratory rate >20 breaths per minute or a PaCO2 4. A white blood cell count >12,000/mm3 or 10% immature forms. à ¢Ã¢â€š ¬Ã‚ ¢ Infection:Microbial phenomenon characterised by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by these organisms. à ¢Ã¢â€š ¬Ã‚ ¢ Bacteraemia: The presence of viable bacteria in the blood. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis (Simple): The systemic response to infection, manifested by two or more of the SIRS criteria pus an infection. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis (Severe): Sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status. à ¢Ã¢â€š ¬Ã‚ ¢ Septic shock: Sepsis-induced hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that the perfusion abnormalities are measured. This is a subset of severe sepsis. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis-induced hypotension: A systolic blood pressure 40 mmHg from baseline in the absence of other causes for hypotension. Adapted from Bone RC et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992; 101: 1644-1655. Appendix 3: Table 1. Clinical and laboratory markers of organ dysfunction. Organ System Clinical Laboratory Cardiovascular Tachycardia Hypotension Cardiac arrest Arrhythmias Haemodynamic support Altered CVP, PCWP Reduced cardiac output Endocrine Weight loss Hyperglycaemia Hypoalbuminaemia Haematological Bleeding Thrombocytopenia Increased D-dimers Abnormal white cell count Abnormal clotting profile Gastrointestinal Ileus GI bleeding Acute pancreatitis Acalculous cholecystitis Decreased intestinal pH Elevated amylase Hepatic Jaundice Hyperbilirubinaemia Increased PT Elevated LFTs Hypoalbuminaemia Neurological Delirium Confusion Altered consciousness Altered EEG Renal Oliguria Anuria Renal replacement therapy Elevated creatinine Elevated urea Respiratory Tachypnoea Cyanosis Mechanical ventilation PaO2 SaO2 PaO2/FiO2 Immune Pyrexia Nosocomial infection Altered white cell count Impaired white cell function Adapted from Balk RA. Pathogenesis and management of multiple organ dysfunction or failure in severe sepsis and septic shock. Crit Care Clin 2000; 16: 337-352.

The Genuine Nick Carraway of F. Scott Fitzgerald’s The Great Gatsby :: Great Gatsby Essays

The Genuine Nick of The Great Gatsby Nick Carraway is a very genuine character throughout the novel. He gets involved with situations such as Daisy and Gatsby, he helps them rekindle their love and he also becomes a true friend with Jay Gatsby. Throughout the novel Nick Carraway starts off not having to many friends, until he starts getting involved other people. It all starts when Jay Gatsby, Nick's neighbour, invites Nick to his party. Nick decides that it would be a great idea so he attends. While attending the party Nick gets acquainted with many of the guests. Then Gatsby sends for him to come and meet him. At first Nick has no idea where he is headed, then he see's Gatsby and they talk for a few minutes. By meeting Gatsby Nick has changed for the better. His idea's and actions all start to change. He becomes very genuine. Sometime after the party, Nick says "I believe that on the first night I went to Gatsby's house I was one of the few guests who had actually been invited." (Gatsby, p.41) He said this because most of the people at Gatsby's parties just invited themselves. This is the time when Nick's character is showing some development of genuineness. Another time that Nick shows his development into a more genuine person is when he helps rekindle the love between Jay Gatsby and Daisy. He does this by setting up a surprise meeting at his house. Gatsby knew of this because he had asked him to do it. At this time in the novel is when Nick says "I'm going to call Daisy tomorrow and invite her over here to tea." (Gatsby, p.82) This shows that Nick is genuine because he is trying to rekindle the love between Gatsby and Daisy. After this period in the novel Gatsby and Nick became even closer friends. Getting closer to the end of the novel is when the reader see's the true friendship between Jay Gatsby and Nick Carraway. Whenever Gatsby would ask Nick to do something Nick would always have or make the time to do it. The strongest example of the genuineness of Nick is when Jay Gatsby was murdered by Mr.

Hospice :: essays research papers

Hospice General Purpose of the Department: As we have learned, the hospice idea is not new. Literally meaning "given to hospitality," hospices provided comfort, kindness, and nourishment to people in need hundreds of years ago. Today, hospices offer comfort to people as they near the end of life's journey. Hospice is a special way of caring for people with terminal illnesses and their families. It is a multidisciplinary health care program that is responsible for palliative and supportive care with consideration of the patient's and families wishes. Hospice focuses on care, not cure. Hospice care is important because it provides many benefits that aren't possible in a traditional acute or long-term health care setting. Within hospice, the family of the patient is directly involved in making decisions and helping their loved one. Hospice also gives the patient to have a great amount of control by deciding where they want to spend the rest of their lives. It can also help make choices about advanced directives which we will discuss shortly. Major Functions of the Department: Hospice is a very unique department because it truly looks at the "big picture" and treats a spectrum of patient needs equally. Special attention is given to: Physical needs - this is the first and foremost function. Within hospice you are dealing with a patient that has been given a diagnosis of having 6 months or less to live. For many patients, relieving pain through medication is an important part of hospice care. I have provided you with a list of ways that patients are made more comfortable. A goal of hospice it to help patients use their physical abilities as fully as possible. Social Needs - Sometimes little things make all the difference to people. Although these patients may not be as active as before their illness, you can see on your handout a list of things that they probably still enjoy. Hospice can help to make these things happen, as well as provide assistance with practical issues like putting finances in order. Emotional Needs: Hospice can help patients cope with loneliness, isolation, and the fear of being abandoned. This is outlined on your handout as to how the hospice staff accomplishes this. Hospice also helps friends and families of the patient express their emotions through group and bereavement counseling. Spiritual Needs - the realization that a person's spirituality is of a daily concern to the patient has led hospice care to this area. Hospice tries to organize the types of care outlined on your handout. Members of the clergy can also help family and friends who are in need of spiritual support.

Tribulations Of The Self (sociology) Essay -- Sociology Essays

What constitutes the 'tribulations of the self' in contemporary society, according to Anthony Giddens? Do you agree? Give reasons for your answer.This essay will seek an explanation of what constitutes the 'tribulations of the self' according to Anthony Giddens (1991). In the first part of this paper, I discuss some central ways language has been viewed focusing the review on social constructivist writings as well as those stemming from the study of human development. In the second part of this paper, I discuss data that leads to the reconsideration of aspects of the language - selfhood interface. I conclude by suggesting some future avenues of research.First the essay will outline the various tribulations that Giddens describes in 'Modernity and Self-identity' (1991).A tribulation of the self is a test or trial for the self, that involves some degree of severity. Many of these tribulations that Giddens outlines are to do with the anxieties brought about by different aspects of life and how the individual deals with them.The first tribulation that Giddens examines is the influence of risk and doubt. Feelings of anxiety arise when the individual doubts or takes risks. Such anxieties may be reduced by adhering to a faith or religion. Often these will dictate a certain lifestyle that either reduces doubt and risk or allows the individual to think about them less (Giddens, 1991). This was certainly the case in pre-modernity. Today more anxiety arises with the awareness that there are several possibilities and choices to do with decisions about life. Anxieties caused by risk may be more often caused by the risk calculations than the risks them selves (Giddens, 1991). Risk taking is an important part of life, people take risks every day and some become so much part of a routine that they appear no longer to be a risk. There are certain risks that are beyond our immediate control. Such as 'ecological disaster, nuclear war or the ravaging of humainity by as yet unanticipated scourges' (Giddens, 1991. p 183). Those who spend all their time worrying about such things are not considered normal yet they are sources of anxiety (Giddens, 1991). Among other things there is awarness of high consequence risks and the notion that 'things go wrong' (Giddens, 1991. P182) are going to cause anxiety in every day life. The next tribulation Giddens examines is 'ontological... ...or town. Through mediation we are informed of day to day events across the other side of the globe. According to Giddens (1991, p 188):'the appropriation of mediated information follows pre-established habits and obeys the principle of the avoidance of cognitive dissonance.' Most of the mediated information is accepted without question. In avoiding this questioning of the information one is remaining protected from the outside world and thus maintaining ontological security (Giddens, 1991). In this world we live in Giddens makes some direct comaprisons which are the root of tensions. The first dilemna is 'unification versus fragmentation'. Modernity fragments as well as unifying. In traditional society fragemntation was not seen as such a problem. Fragmentation of the self is the division of the self into several selves. This may come from different presentations of the self that may be used upon meeting with different people. Part of the problem that causes tension and anxiety is that a person maybe more aware of 'the debate over global warming that with why the tap in the kitchen leaks.' (Giddens, 1991, p189). Tasks at hand may be more obscure than large scale global events.

Multi Criteria Analysis of the Local Environmental Impacts of a Factory

The chief constructs of this survey are environmental impact appraisal, environmental impact analysis, impact designation and significance finding. Environmental impact analysis is one of the phases of environmental impact appraisal ( EIA ) to inform determination shapers about the likely effects of their actions ( Sadler and McCabe, 2002 ; Wathern, 2013 ) . It includes impact designation and impact significance finding. Impact designation is the procedure of exemplifying cause and consequence relationship of a undertaking activities and their cardinal environmental facets, and needs a systematic expert cognition and judgement to qualify them ( Sadler and McCabe, 2002 ) . The cardinal environmental facets of this survey are activities that interacting straight with the environing environment and imposed environmental impacts in the two suppression and Pyro treating units of MCF. Significance is the strength of impacts that includes about the impacts’ beneficial or determiner, reversible or irreversible, repairable or irreparable, short-run or long-run, impermanent or uninterrupted, local, regional or planetary, inadvertent or planned, direct or indirect and cumulative or individual ( Canter & A ; Canty, 1993 ) . Significance finding is a procedure of building judgements which is of import, desirable or acceptable of impacts ( Lawrence, 2007a & A ; b ; Sippe, 1999 ) . It is besides a anticipation of impact magnitude ( Thompson, 1990 ) . In add-on, impact significance finding considered impact features such as magnitude, continuance, frequence, spacial distribution, reversibility, likeliness, nature and timing ( Beanlands & A ; Duinker, 1983 ; McCabe, 2002 ) . In another instance, Canter & A ; Canty ( 1993 ) related the impact significance finding with showing and scoping. The showing and scoping are performed before a undertaking execution to look into whether an environmental impact survey is needed or non. However, this survey chiefly focused on bing mill to make up one's mind its farther monitoring and commanding way on the bing important impacts. Therefore, impact significance finding of this survey is the procedure of doing judgement about of import or desirableness of the impacts of the bing production procedure of the mill. It is the procedure of placing the local impacts of the two treating units ( Fig 1.1 ) by associating the causes and effects, and analysing it for farther attending and commanding mechanisms. By and large, environmental impact analysis of this survey is referred to the procedure of placing and analysing the defined impacts and provided indicants for the decisive organic structure to the effects of the existed pr oduction activities of the mill.Model of the surveyThis survey framed on the integrating of Multi Criteria Analysis ( MCA ) and perceptual experience study analysis to roll up and analyse informations about local environmental impacts of the mill ( Figure 2.1 ) . This model comprises the stairss of the multi-criteria analysis of the survey and how this integrates with perceptual experience study analysis.1.1.1.Impact designationThe first measure of the MCA for this survey was local impact designation that comprises designation of activities and environmental facets led to local environmental impacts. To place the local environmental impacts sing the overall cement production procedures of the mill are needed. It helps to find the chief activities performed to bring forth cement and their environmental facets. Face to confront interviews with the higher forces of the mill and literature were the beginning of informations for local impact designation. The higher forces included two pr ocedure directors from crush and raw factory ( CRM ) and coal and kiln ( COK ) treating units and a deputy general director of the mill and they selected purposively. The interviewees had 10 to 16 old ages of work experience in the mill. The survey collected informations utilizing cardinal informant interview ( Annex 10 questionnaire II ) , site visit, structured questionnaire ( Annex 10 questionnaire I ) and literature reappraisal as informations aggregation instruments. The cardinal informant interview was integrated with site visits to understand the cardinal activity of each processing unit and their environmental facets and possible impacts. In add-on, it was supported by structured questionnaire about overall images of the mill. The collected informations about the impact designation was compiled utilizing the checklist. The checklist used to sum up the identified activities, environmental facets and possible impacts. This was taken topographic point by incorporating of the relationship of flow of procedure of activities and environment facets that resulted in impacts.1.1.2.Criteria designationStandards are necessary to find the significance of impacts.Generally, standards features includemagnitude of the impact, continuance, frequence, spacial distribution, reversibility, likeliness, nature and timing ( Beanlands & A ; Duinker, 1983 ; McCabe, 2002 ) . Hence, these features are wide and are used foranytype of impact, to be more specific on local environmental impacts this survey adopted six standards byKumar & amp ; Armani ( 2012 ) listed inTable 2.1.These adopted standards are easy apprehensible by local stakeholders and all fulfills the standard demands listed by Dodgso, et Al. ( 2009 ) . These demands are completeness, avoids similarity and redundancy, selects of import to judge option /impacts in this study/ , gives precedence for impact comparing and rating, options are independent, avoids dual numeration, manageable standards size. The standards had a value ranged from one ( lower limit ) to ten ( Maximum ) on the Likert graduated table that made easier the respondents to set their judgements about the local impacts numerically. Table 2.1: Detail description of the adopted standards and scope of their value.MagnitudeHappeningImpactDetectionControlsLegislation adoptedThe size or the extent of the impactFrequency of the impactThe grade of consequence of the impactFeeling clip of the impacts or the consequenceControling steps to the beginning of the consequence taking in the millThe position of following with the states criterions5 – severe6-continuous6– fatal to life5-more than 24 hours5– absence or no effectual control10– no meeting statute law or control bound3- centrist5-several times a twenty-four hours5-health effects4– within 24 hours4– mechanism but non dependable1– in conformity1- low4– one time a twenty-four hours4– affects vegetations and zoologies3– within 8 hours3-control needs human intercession3– one time a hebdomad3– resource ingestion2– within 1 hours2-has built-in secondary control2-once a month2– uncomfortableness1– instantly1– available and effectual at beginning1-very rare1– negligible ocular impact1.1.3.Burdening standardsFollowing to following the standard was burdening of these standards which is specifying the comparative importance of the standards to judge the local impacts. In this survey weighting was determined through ranking of the standards by experts found in different sectors of the regional province, such as Tigray Environmental Protection, Land Administration and Use Agency ( TEPLAUA ) , Bureau of Labor and Social Affairs ( BoLSA ) , Bureau of Urban Development, Trade and Industry ( BoUDTI ) and Bureau of Health ( BoH ) . Data was collected in a structured questionnaire ( Annex 11 questionnaire II ) . The experts were selected purposively from the sectors. These sectors are selected, because they have responsible experts to measure and command the mills in the Tigray regional province. Based on the features of the experts, 80 % of the experts were master degree holders in different field specialisation. The experts’ work experience was 60 % 1-5 old ages, 40 % above 5 old ages. The 90 % of the experts were responsible to measure and command mill, in relation to environmental issues. The ranks were converted to burden utilizing the expression specified in equation 1. It was analyzed utilizing Rank Order Centroid ( ROC ) method ( Barron & A ; Barrett, 1996 ; Edwards & A ; Barron, 1994 ) . This is a procedure of change overing the ranks given by the experts into weights [ 1 ] of each single rank for each standard, and so calculated the mean weight ( WI) for each standard among each other. i= 1, 2†¦ , 6.( Equation1) Where WIis the weight for each IThursdaystandards, N is the figure of standards and K is a rank given by experts.1.1.4.Scoring environmental facetsAfter burdening, the following measure was hiting to the identified environmental facets. The beginning of informations for this measure was employees in the mill, and the information was collected in a structured questionnaire ( Annex 11 questionnaire IV and V ) . The employees selected utilizing a bunch sample method by constellating them in three working displacements. Then, ten employees were selected utilizing a simple random method from each displacement which is a sum of 60 employees ( 30 from CRM and 30 from COK ) from the mill. Respondents are characterized: in CRM, 40 % sheepskin and 60 % grade holders, and their working experiences are the 30 % 1-5 old ages, 33 % 6-10years and 37 % above 10 old ages. In COK: 57 % sheepskin and 43 % degree holders. Wholly participants were 48 % sheepskin and 52 degree holder employees participate in hiting. Their on the job experience was 30 % employees had 1-5 old ages, 38 % employees 6-10 old ages and 32 % employees had above 10 old ages. The mark given for each impacts by each employee is calculated its norm by ratio method ( RM ) . The RM was calculated the mean mark utilizing the amount of entire respondents replied to each mark multiplied by the value given in the Likert graduated table and divided by the entire figure of respondents participated in hiting ( equation 2 ) . ( Equation2) Where OmegaIis mean mark of IThursdayidentified impacts, RNis the figure of respondents replied to the mark of IThursdayimpact and VIis the given value in the Likert graduated table of the IThursdaystandard ( Table2.1 ) . RoentgenThymineentire figure of respondents participated in marking.1.1.5.Accumulating end productsThe cumulative grade of impact of each activity calculated from the end products of ROC and RM. They combined utilizing comparative significance ( equation 3 ) ( Deng et al, 2011: Noah & A ; Lee, 2003 ) . ( Equation3) Whereis a comparative significance of impactsis the weight for IThursdaystandards andis the deliberate mean mark of IThursdayidentified impact on the Kithstandards. Note that the scope of standards ‘legislation adoption’ was modified to ‘1’ for the mean mark 1-2, ‘2’ for 3-4, ‘3’ for 5-6, ‘4’ for 7-8 and ‘5’ for 9-10. It keeps the comparison of the standards during taking the combined consequence of the merchandise summing up of the tonss and weights. For impact significance finding, benchmark scene is necessary to place the ‘significant’ and ‘insignificant’ impacts by comparing cumulative consequences of impact significance finding against the stated benchmark ( Table 2.2 ) . This helps to find what and where betterments are needed. Table 2.2: The manner of puting benchmarks of the survey.StandardsTot Respondent50 % MarkStandards WeightCombination 50 % mark & A ; The weight of standardsMagnitude302.50.1760.4Happening3.00.2040.6Impact3.00.3261.0Detection2.50.1270.3Controls2.50.1110.3Legislation adopted3.00.1030.3Decisive value2.9Table 2.2 shows the procedure of benchmarking to find the significance of the impacts. Benchmark decided by presuming the 50 % scope value of the standards in the Likert graduated table given as a mark. Consequently, the survey sets 2.9 as benchmark to make up one's mind the significance of possible impacts. The deliberate weight utilizing ROC is straight used for the benchmarking. When the combined consequence of the impacts equal or less than 2.9 it is undistinguished and if the consequence is greater than 2.9 it is important and needs farther controlling and monitoring steps.1.1.6.Perception study analysisThis survey did perceptual experience study analysis to compare the community perceptual experience on the impacts with the consequences of the employees about the significance of the local environmental impacts of the mill. The survey used local community ‘s families as a beginning of informations to the study analysis. In the study a sum of 120 local communities’ from entire population of 1122 families were participated and selected indiscriminately. These families were 68.3 % male households’ caputs and the remainder were female households’ caputs. Their age was 75 % in the age scope of 31-50 old ages, 17.5 % in more than 51 old ages and 7.5 % in the age of 18-30 old ages. The 65.0 % of the families can read and compose and the staying completed primary and high school instruction. The 99.2 % of the participant family has lived in the topographic point since their birth. The distance of the respondent’s place from the mill, 52.5 % of the respondents are populating at a distance of above 200 metres radius the remainder 33.3 % and 14.2 % respondents are populating within 101-200m and 100 m radius ( Annex 10 Table 9.1 ) . The Data was collected from the families utilizing structured interview ( Annex11 questionnaire VI ) . Descriptive statistic ( means, frequence, per centum and count ) was used to analyse the collected information from the local community in the SPSS statistical bundle. Note that the community perceptual experience on environmental impacts assessed their understanding utilizing ‘disagree’ , ‘not much’ and ‘agree’ . However, the ‘not much’ count is included to ‘disagree’ count on the presented informations, because it was perceived that similar account between ‘not much’ and ‘disagree’ during informations aggregation ( Annex 10 Table 9.3 ) .1.1.7.Examine consequencesThis is the procedure of impact significance finding from the overall gathered and processed informations. It is a measure that determined the cardinal environmental facets and their effect, and is identified the beginnings from bing activities’ of the treating units. In add-on, it is correlated to the consequences of other bookmans and within the consequences of this survey. In add-on, it is the procedure of set uping the decision of this survey.