A Critique of the Lin Article Essay

Lin, Mack, Enright, and Baskin (2004) state that prior to the writing of this article anger and related emotions have already been associated as triggers within the realm of substance abuse. As way of illustration the authors cite the Project Match 12-step facilitation therapy manual which states that â€Å"Anger and resentment are pivotal emotions for most recovering alcoholics† (Nowinski, Baker, & Carroll, as found in Lin et al, 2004, p. 1114). The traditional therapeutic method of choice within treatment settings has been that of anger management. The focus of this form of treatment is in establishing surface level coping mechanisms by â€Å"attempting to teach patients to more effectively manage or express anger rather than actually decrease their anger† (Dakken et al, 1995 as found in Lin et al, 2004 p. 1114). The authors present that there is insufficient documentation related to the efficacy of this approach. An alternative approach has been developed by a number of researchers titled Forgiveness Therapy (FT). FT states that while anger, resentment and other accompanying related emotions are correct responses to severe violations, harmful results are attributed to the same on a daily basis. The therapeutic goal, therefore, is in assisting the client in working towards educating the client regarding healthy forgiveness as a choice. The authors advise that â€Å"Robust results have been found when FT has been applied to certain populations† and â€Å"has been shown to decrease the frequency and severity of anger, anxiety and depression rather than simply improving individuals’ ability to cope with these emotions† (Lin et al, 2004, p. 115). Lin et al, (2004) chose support for the validity of FT by presenting the hypothesis that inpatient clients for substance abuse treatment who received FT would demonstrate â€Å"less anger, depression, anxiety, and vulnerability to substance abuse† than similar clients who received traditional anger management treatment. Subjects were randomly chosen within a treatment center to receive either FT or Alcohol and Drug Counseling (ADC) treatment from a group of suggested participants. All were diagnosed as substance abusers. Each participated in four instruments: The EFI, which is a sixty item self-report measure of self forgiveness, the BD1-11, which measures symptoms related to depression, the CSE1 which evaluates attitudes towards self, and STAI which assesses anxiety. Each participant also became involved in a 12 week program, either within the FT procedure or the ADC procedure. The ending result verified the original hypothesis for the researchers in that the FT group â€Å"demonstrated significantly greater improvement from pretest to posttest† (Lin et al, 2004, p. 117), as well as a marked difference in retention of improvements between the two therapeutic groups after four weeks apart from the therapy sessions. The authors did present five cautions. The first was the lack of being able to generalize the findings of the study due to the size of the testing. The second is the degree to which resentments are the norm within client’s treatment histories. The third caution is related to the need for the client to persevere within the therapy due to the length and depth of the therapy involved. The fourth caution is related to providing time for follow up data beyond the initial four month time frame which was provided for the purposes of this study. The fifth caution is that there may have possibly been some unforeseen effects by the therapist involved within the experiment since only one therapist conducted therapy for both groups. The authors summarize their findings by stating that chemical dependency issues may be linked to or are a result of unresolved negative emotional issues such as anger and resentment, and that future study of comparing and contrasting FT with more traditional anger management may continue to reinforce the advantage of therapeutically engaging in root issues rather than simply reinforcing traditional anger management daily coping methods. Critique of the Title From this researchers perspective the overall title is effective and appropriate. It is sufficiently specific while remaining properly concise. The wording provides a descriptive picture of the contents of the article while remaining under twenty words. The title also properly identifies the type of participants in the study, as well as the variables which are analyzed. The authors remain clear of utilizing jargon and acronyms which â€Å"might be unknown to the audience† (Pyrczak, 2008, p. 20). Pyrczak advises that it is normally unwise for the title of an article to reveal the results of the study (Pyrczak, 2008, p. 16). The authors of this article prove to be careful to not reveal the ultimate findings, while still causing interest by the use of their description. It is clear that the authors of this article took careful consideration in the formatting of this preliminary descriptor. Critique of the Abstract Overall this abstract is effective and appropriate. It clearly presents the purpose of the article in a clear and concise manner. The authors reveal the foundational underpinnings, the resulting hypothesis as well as the study group utilized for the overall experimentation. Highlights of the study are provided in the form of mentioning a general overview of the Forgiveness Therapy as well as indicating a favorable outcome linked to the hypothesis. The abstract did not become encumbered with titles of specific measures, except to indicate that there was a 12 week time frame of counseling sessions. While not giving specific statistics, the abstract was clear in concluding that not only were the results of this research positive, but that the authors felt confident to advise that this study substantiated the role of FT as a viable alternative for residential drug treatment. Critique of the Literature Review Overall, the literature review portion of this article is appropriate as well as informative. The purpose of the article along with the stated hypothesis logically flows from the abstract. For example, while reading the article the specific problem area which the authors are addressing is identified within the first paragraph, and this topic of concern is carried throughout the course of the article. Not only do the authors identify the problem area, that of â€Å"levels of anger and violence observed among alcohol and other substance abusers† (Lin et al, 2004, p. 114); but they also emphasize the gravity of the situation by providing specifics regarding the correlation between said negative emotions and the inability of addicts to remain sober. This provides the reasoning behind why greater development in this area within therapy needs to be addressed. In so doing the authors were also careful to properly cite sources for factual statements which reinforced their supposition. In so doing, they were careful to not inundate the article with an over abundance of cited material, leaving sufficient room for their own findings. While drawing out the concerns related to the anger and resentment issues at hand, the authors provide a well developed summary of both the Forgiveness Therapy model as well as the Anger Management Modules. The authors also provided clear and concise definitions of the instruments utilized within the study as well as providing well illustrated table in cooperation with the results of the study, and how those results can be interpreted with each instrument, and how they correlate with each other. For example not only does the article provide a Topic List for each group, (Lin et al, 2004, p. 1117 Table 1) it also provides a significant breakdown of the Means and Standard Deviation for Dependent Variables related to both study groups (Lin, Table 2, p. 1118). The only area in which this researcher may see the Literature Review as somewhat weak is in the fact that the latest research which is available within the article is from the year 2004, due to the age of the article in question. That being said, however, over all this is a well crafted review. Critique of Research Questions The hypothesis stated in this article leaves no room for questioning what it specifically entails. After providing a detailed foundation of why FT is a viable alternative in various counseling arenas as opposed to ADC, the authors then clearly state that they hypothesized that individuals in residential treatment for alcohol and drug dependence after receiving treatment augmented by FT, would demonstrate less anger, depression, anxiety and vulnerability to substance use and more self esteem than those receiving ADC treatment†¦. Lin et al, 2004, p. 1115). This hypothesis clearly provides not only a reference and a background of a therapy; it also provides specific measurable goals, and goals which can be contrasted by other measurable goals, within and on behalf of a specific demographic. Each of the specific parts of the hypothesis are logically developed within the literature review, and the developed research proves to be appropriate for the investigation at hand, albeit with specific concerns related to limitations which naturally apply due to the limited nature of the study in regards to amount of participants, limited amount of time for follow up study for the initial research, and some concern over possible biases inherent due to the fact that one therapist facilitated both study groups.

Succubus Shadows Chapter 21

Maddie claimed that even Seth's family didn't know where he was. According to her, he'd really just†¦vanished. He wasn't answering his phone. He wasn't showing up at the bookstore. When people disappeared, I immediately jumped to supernatural conclusions, but Maddie then added – through more tears – that she used her key to get her belongings from Seth's place and found a suitcase and some clothing missing. Feeling guilty about having the key anymore, she then shoved it into my hand and told me to return it. Or throw it away. I did my best to comfort her some more and then offered to take her over to Doug's. Roman shot me a warning look as we were about to leave. â€Å"Don't do anything stupid,† he said out of Maddie's hearing. â€Å"I knew your nice bedside manner wouldn't last,† I returned. Despite Doug's slacker rocker-boy lifestyle, I knew Maddie'd be in good hands with him. I dropped her off there and found Doug a mixture of personas. To Maddie, he was astonishingly kind and gentle – the caring brother as opposed to the usual teasing brother. Once she was lying down in the other room, he made sure I knew exactly what he thought of Seth in very explicit detail. There wasn't much I could say to that except that they should call me if they needed anything. I left. In spite of Maddie's words, I drove to Terry and Andrea's anyway. Seth ending things with Maddie so abruptly was crazy – almost crazier than him proposing to her in the first place. But him disappearing without telling his family? No. He wouldn't do that. He was too responsible. Most likely he'd told them not to tell Maddie where he was. Kendall opened the door when I arrived, her face lighting up like Christmas morning. â€Å"Georgina! Georgina's here!† Morgan and McKenna, who had been watching cartoons, came tearing over and each wrapped themselves around a leg. â€Å"Nice to see you guys too,† I laughed. Terry had been sitting on the couch near the twins and came over to me with a little less zeal. â€Å"Hey, Georgina,† he said, face typically friendly. He was shorter than Seth and a few years older, but overall, they bore a notable resemblance. â€Å"Sorry for the mass assault.† â€Å"No problem.† I unwound Morgan from me, but McKenna proved a little more resistant. Glancing back at Terry, I said hesitantly, â€Å"I was wondering if I could talk to you, uh, about something.† Terry wasn't stupid. None of the Mortensens were. â€Å"Sure,† he said. â€Å"Girls, let go of Georgina and go back to the cartoons. We're going to go into the kitchen.† â€Å"But we want her to watch TV with us!† â€Å"Can we come?† Terry laid down firm but friendly fatherly law, and with great reluctance, the girls returned to the couch. I was impressed. I wasn't sure I could have refused that group anything. He led me to the kitchen, but before either of us could say anything, Andrea came in from down the hall, smiling in surprise when she saw me. I smiled in surprise right back at her, but it was more from her appearance than anything else. It was the middle of the day, but she wore a robe over pajamas. Her mussed blond hair and dark eye circles suggested she'd been sleeping. Terry had been leaning against the counter but jumped up when he saw her. â€Å"Oh, honey, you should go back to bed.† She shrugged him off. â€Å"I wanted to see who's here. How's it going?† â€Å"Fine,† I said. Then, unable to resist: â€Å"Are you feeling okay?† â€Å"A little under the weather. Fortunately, Terry's manning up today. He does almost as good a job as me with the girls.† I laughed politely at the joke, but it soon faded. We stood awkwardly for a moment, everyone knowing why I was here but no one doing anything about it. Finally, I took a deep breath. â€Å"I've come to ask you where Seth is.† â€Å"Funny,† said Andrea. â€Å"We were going to ask you the same thing.† I was taken aback. â€Å"How would I know?† They both just stared. â€Å"I don't!† â€Å"When this happened a couple days ago†¦this thing with Maddie†¦Ã¢â‚¬  Terry glanced uneasily at his wife before continuing. â€Å"We just assumed, well, that it was because of you.† â€Å"Why would it be because of me? I just found out about this today.† â€Å"It's always been because of you,† said Andrea gently. â€Å"There was never anyone else. We like Maddie. He likes her. But that's the problem. Throughout it all, we could just tell that you were always the one. Now, whatever happened between you guys to make it go bad isn't any of our business. We're just not that surprised to see this new development.† â€Å"We would, however, like to know where he is,† said Terry more pragmatically. â€Å"I don't know,† I said helplessly, still a little stunned by Andrea's words. â€Å"Maddie said he'd packed up, and I figured you guys were keeping his location a secret from her.† I eyed them suspiciously. â€Å"And me?† â€Å"No,† said Terry. â€Å"We really don't know.† I didn't have an angel's talent, but I believed he was telling the truth. Andrea nodded in agreement. â€Å"He just called us a couple days ago and said he'd ended things. Didn't give any explanation – but well, you know how he is. He doesn't explain much anyway. Then, when Maddie and no one else had seen him, we started to get worried.† A couple days ago. Seth had ended things with her a couple days ago – when the whole soul retrieval gig had gone down. â€Å"We actually tried calling you,† added Terry. â€Å"But never got an answer.† â€Å"Ah, yeah. I've been sick this week too.† Eyeing Andrea – who looked exhausted – I suddenly felt bad for taking up any more of their time. â€Å"Look, I should go. Thanks for the info. Will you†¦let me know if you hear from him?† Andrea smiled again. â€Å"Something tells me you'll hear from him before we do.† I wasn't as confident. Leaving the house was a little tricky since the other girls didn't want me to go, but I managed to escape their adorable clutches at last and make a break for it. I was walking toward my car when a voice said, â€Å"She's sick, you know.† I turned, startled, and saw Brandy standing near a gate that led to their backyard. She had the same sullen look about her she'd had for so long. â€Å"Hey,† I said in greeting. â€Å"Where'd you come from?† â€Å"I was around. I heard you talking to Mom and Dad.† I replayed Brandy's initial words. â€Å"Your mom†¦you mean she's sick, right? I could tell.† â€Å"No, I mean she's really sick. She's really sick, and they won't talk about it.† Brandy gave a nod toward the front door. â€Å"No one else knows. Not even Uncle Seth knows just how sick she is.† A chilly breeze stirred dried leaves around my feet, but it was nothing compared to the cold starting to fill me. â€Å"Just how sick are we talking, Brandy?† Brandy scuffed her feet against the driveway, eyes averted. â€Å"She has ovarian cancer. It's bad†¦but they're still trying to figure out just how bad it is.† â€Å"She was going to the doctor that day I was here,† I recalled aloud. Andrea had been so bright and cheery, I'd assumed something routine was going on. I also realized I hadn't technically been here; I'd seen it in a dream. Fortunately, Brandy was too distracted to notice my slip. â€Å"She's been at the doctor a lot. Dad's missing tons of work. Uncle Seth's helped out sometimes, and I've been babysitting all the time.† I suddenly felt incredibly selfish. I'd been assuming Brandy's moodiness was all over me and Seth breaking up. But that was only a symptom of the larger problem. Her mother was dangerously ill, and every part of her world was destabilizing. Her own life was probably being put on hold to watch her sisters, and even something like her uncle's romantic life could ripple what she'd regarded as the norm. All the constants in her world were disappearing. â€Å"Brandy, I – â€Å" â€Å"I have to go,† she interrupted, heading back toward the gate, face stony. â€Å"Kayla'll be up from her nap soon. I'm supposed to keep an eye on her today.† Brandy disappeared around the corner before I could say anything. I stood there, feeling lost. I didn't know who I felt worse for: Brandy and Terry for knowing what was going on or the little girls for being oblivious. I felt bad enough for myself because there was nothing I could do. There was never anything I could do. I had powers beyond human imaginings, but they were nothing that could actually help humans. I drove downtown with a heavy heart, trying hard – and failing – not to overreact. Brandy herself had said things were bad but that they were still learning the extent of it. Surely there were more tests, tests that would give some hope. And surely there was treatment. Humans could do that much on their own. Jerome was where I'd hoped he'd be. Really, I decided, the Cellar was nearly as good as him having an office. Carter was by his side at the back table, both of them doing shots from a bottle of Jà ¤germeister. Those two didn't discriminate among their liquor. I wondered if they were drinking away the hardships of the other day or toasting their success over it. It must have been the latter because Jerome almost smiled when he saw me. â€Å"Georgie, out among the living and back to your petite self. Yet†¦so blue. Blue like always.† Yes, they'd been drinking. Angels and demons could sober up at will, and he was apparently indulging in the full effects. â€Å"I got some bad news,† I said, sitting opposite them. â€Å"What, about losing Mortensen?† asked Jerome. â€Å"How do you know about that?† â€Å"I talked to Roman. He recapped your day – the old man checking in, you comforting your romantic rival†¦it was quite moving.† I scowled. â€Å"Great. You have Roman spying on me.† â€Å"It's not spying. I just demand answers from him. If it makes you feel better, he's never very happy to give up those answers.† â€Å"How often do you do it?† I asked incredulously. â€Å"Not that often.† A waiter set down a new bottle. â€Å"Mostly I wanted to see how you were recovering post-dream.† â€Å"Fine. I'm fine.† I glanced at Carter. â€Å"No comments from you today?† â€Å"Leave me out of this,† he replied. â€Å"I'm just drinking.† So he said, but he was also watching and listening very carefully. He was not letting the alcohol affect him. I turned back to Jerome. â€Å"I've come to call in my favor.† The dark amusement in his eyes turned to suspicion. â€Å"What favor?† â€Å"The one you promised me for helping save you from Grace, remember?† Yes, no amusement at all anymore. â€Å"I just rescued you from another plane of existence from creatures who were torturing your mind.† I flinched but pushed on with my words. â€Å"You promised a favor, and I didn't call it in for that. Besides, you would have done it anyway so that you wouldn't get in trouble.† â€Å"That favor offer was brought on by the drama at the time,† he countered. â€Å"I probably said all sorts of things.† â€Å"You promised,† I repeated. â€Å"I can understand you just fine without putting italics in your voice, Georgie,† he snapped. â€Å"You did, though,† pointed out Carter. Demons could lie – and did – but certain deals they were bound to. Jerome had said he'd grant me a favor out on the beach, and it had been a true promise. â€Å"Fine,† he said irritably, gesturing for another shot. â€Å"What is it you want? And I don't have to grant it if it's something totally unreasonable.† â€Å"I want to know – â€Å" â€Å"Careful,† interrupted Carter. I paused, and Jerome glared at the angel. Carter offered no other insight, but those gray eyes were still watchful – and cautious. Which was what I needed to be. Jerome had promised me a favor, and like all demons, he would try to find as many loopholes in it as possible. I had been about to ask where Seth was, but that wouldn't necessarily do me any good. I wouldn't be able to get to Seth. â€Å"I want you to send me to Seth so I can spend a few days with him.† Jerome studied me, expression shrewd. â€Å"There's a couple problems. One is that you've kind of asked for two things. The other is that I'm not omniscient. I don't know where he is.† â€Å"You can find out,† I said. â€Å"At least, if he's flown anywhere, you can find out.† Seth packing indicated serious travel. Maddie had said his car was still at the house, meaning he hadn't driven somewhere. If he had, he'd be harder to track. But airports had records, and Hell had its hand in that kind of thing. Jerome could easily get an imp or lesser demon to access Sea-Tac's records this week and see where Seth had gone. I probably could have asked Hugh to do it, but that wouldn't have gotten me leave to actually go to Seth, hence my wording. â€Å"And we both know it'd be stupid for you to send me right there and right back. Asking for a few days makes it worthwhile or else it's a shitty favor.† â€Å"Debatable,† Jerome replied. â€Å"It could be worse,† said Carter. â€Å"She didn't ask for world peace or anything.† â€Å"Stay out of this,† returned the demon. â€Å"I know what you want.† Carter shrugged and ordered another drink. â€Å"Fine,† said Jerome at last. â€Å"I'll have Hugh check travel records. You know there might not be a paper trail.† â€Å"I know. But if you find him?† â€Å"Then you can go to him. For now, go home. You're ruining my good mood. I'll find you if there's news.† I didn't need to be told twice. â€Å"Soon,† I said. â€Å"You have to search soon.† Jerome's lips quirked. â€Å"You didn't put that into the wording.† Carter elbowed him, and I had to take it on faith that Jerome would act in a timely manner. My words had implied that I wanted to be where Seth was now. One could argue that waiting meant Seth would change locations, meaning I couldn't have what I wanted. I also had to believe that Carter had a point in saying this was a relatively easy favor. I could have demanded more. Simple or not, it was hard to wait to hear back. Roman was gone when I returned to my condo, and I had nothing to do but ruminate. I'd given myself a leave of absence at work and didn't regret it. Still, being alone with my thoughts was never a good thing, and I had far too many to trouble me: the Oneroi, Seth, Andrea†¦ â€Å"Okay, Georgie.† It was four hours later when Jerome appeared in my living room with a pop. I sagged in relief. â€Å"You found him?† â€Å"I did.† â€Å"And you'll send me to him – for a worthwhile amount of time?† â€Å"Three days,† the demon said. He sounded irritable and impatient. I'd wondered if he'd been drinking this entire time and was angry at the interruption. â€Å"I want you back here in seventy-two hours, and you're on your own as to how you do it. Do you understand?† â€Å"Yes,† I said eagerly. â€Å"Just send me to him.† I had to talk to him. I had to find out exactly what had happened. I had to make sure he was okay. â€Å"And that settles the favor. Agreed?† â€Å"Agreed,† I said. There was power in that word, just as there had been in Jerome's initial promise. I could ask for nothing else. â€Å"Then go,† he said. I vanished from my living room†¦Ã¢â‚¬ ¦and reappeared on a busy sidewalk. People swarmed around me, none of them seeming to notice I'd appeared out of thin air. The sun was on its way down, but the sky was bright and clear – and hot. Very hot. The masses around me were dressed in beach clothes and had the feel of tourists. I stepped out of their path and found myself standing in front of a large, resort-type hotel. The abrupt change in location – and discomfort of teleportation – had left me disoriented, and I needed to get my bearings. Taking in more of my surroundings, I could hear people speaking in both Spanish and English. I turned to the closest person near me, a short, deeply tanned man in a hotel uniform who was directing taxis around the building's driveway. I started to ask where I was and decided that would be a little too stupid sounding. I pointed at the hotel and asked him what its name was. I knew tons of languages perfectly, and Spanish rolled off my lips easily. â€Å"El Grande Mazatln, seà ±orita,† he replied. Mazatln? This time, I did ask a stupid question: â€Å" ¿Estoy in M? ¦xico?† He nodded, giving me the are-you-crazy look I'd expected. It was probably made worse by my jaw dropping. Well, I supposed if you were going to run away, you should run away somewhere warm.

Economic development and social standing of women in low income countries Essay

‘The hand that rocks the cradle is the hand that rules the world’ is a famous saying that is pertinent to the argument that analysts make about development of women in low income countries depending on the raising of social standing of women in these countries. Because, Women are the nourishing ground of human resource of any society. Children are the future citizens of a Nation and the global world. High standards of women in society lead to a rich human resource. A productive human resource is the most important potential of a country for economic growth and prosperity, which further brings about a total development of that nation. Women are the grassroots of such a growth. Therefore it is very logical to argue that economic development in low income countries highly depends on women and their empowerment, the raising of their social standing in that society. â€Å"Family is a social institution found in all cooperative groups to oversee the bearing and raising of children throughout the world† wrote John J Macionis (2006). Children who are raised by equal status, educated mothers, in developed countries grow up to go to higher levels of education and become responsible adults of the nation. The women thus use their time and resources to development of their children. But the women in under developed low income countries do not have an access to such resources like education and good health. Their social standing is low and hence these nations give rise to an underdeveloped population which in turn results in low economy of the country. These countries are patriarchal and believe in supremacy of Economic development men. Women are a neglected section and thus they remain at the lowest strata of that society. â€Å"Gender stratification plays a vital role in socialization of families, peers, schooling, and mass media† says John J Macios (2007). Raising standards of women will therefore bring about an elevation in the standards with which they raise their own children. Upliftment of women, their empowerment, providing these women social dignity, facilities of good health and sanitation, education and career skills is an important factor that needs attention in low income Countries. With an equality of genders both, men and women could make valuable contributions to the economy of their country. Not only economic development but the overall enrichment of the human resource of the whole world will then take place. Sociologists the world over argue about the dependence of social status of women in low income countries with their economy because investment in human resource is the only answer to development and optimization of natural resource. Respected, educated, healthy, happy mothers are the only answer to a well developed world. Not just for a few countries and not just for economy but for the good health of the Universe, women all over the world deserve a high status in society. They really are the ones who teach children to become good and responsible adults, and this is the only way economic development can take place. Therefore sociologists agree and analysts argue that economy of the country depends upon the social standing of women in that country with special reference to the low income nations of the world. References Macionis, J. J. (2006). Society: The Basics. Pearson Education.

Merger Control Essay Example | Topics and Well Written Essays - 4000 words

Merger Control - Essay Example In order to ensure free competition in the Single Market, agreements which not only have a significant effect on the trade between the Member States but also prevent, restrict or distort competition in the Single Market are prohibited by Article 81. Prohibition of behaviour which discourages competition is described in Article 81 (1) of the EC Treaty. In respect of investigations relating to mergers, to determine whether Article 81 EC will be applcable and to justify exceptions to the rule that there exists a distinction between merger control and the general competition law, a casual link must be established between the merger and the restriction of competition. In the absence of such a link, "the relevant coordination of the participants must be assessed in a separate proceeding under Article 81 (1) EC rather than as part of the merger control investigation under the E.C.M.R." An assessment under Article 81 of the EC, leads to the stoppage of the merger from going through and this constitutes an early attack on the parties. Investigation under Article 81 EC results in leaving the concentration untouched and this necessitates the intervention of the European Commission to correct this behaviour. ... The European Commission, while analyzing a merger under Article 81 (1) of the EC, considers in particular whether "two or more participating companies retain to a significant extent activities in the same market as the joint venture, or in a market which is downstream or upstream from that of the joint venture, or in a neighbouring market closely related to the relevant market." The final issue to be decided is whether the coordination, resulting from the creation of the joint venture, enables the participants to eliminate competition in respect of a major portion of the products or services being dealt with. The interstate clause defines the boundary in-between the areas respectively covered by the law of the Member States and the Community law. Agreements which do not affect trade between member states are not covered by Article 81 EC. These agreements are the exclusive domain of the national authorities. This basic test of whether or not interstate trade was affected or not was dealt with by the E.C.J. in Socit Technique Minire v. Maschinenbau Ulm1, the E.C.J. held that "it must be possible to foresee with a sufficient degree of probability on the basis of a set of objective factors of law or of fact that the agreement in question may have an influence, direct or indirect, actual or potential, on the pattern of trade between Member States." In respect of B2Bs, the test developed in Socit Technique Minire v. Maschinenbau Ulm, is apparently cleared without much difficulty, because of the type of the platforms, which function by utilizing the Internet. It is required by Article 81 (1) EC for every agreement to have as its objective or effect the prevention, restriction or distortion of fair competition. "The E.C.J. has held that these

Working under the influence Coursework Example | Topics and Well Written Essays - 500 words

Working under the influence - Coursework Example Schulte et al. (2014) further intimate that after notification to the counselor, the next step would be gathering the known concerns raised by the employees and the patient with respect to the conduct of Clark while on duty. These documentations would assist in mapping out potential issues for discussing with Clark against the expected conduct of employees as expressly stipulated in the employee guide and regulations. Here there will be documentation of specific mistakes in the performance of Clark while at work that raise concerns. I will seek the counselor’s help in proofing the documentation that concerns the conduct of Clark at work. Having the counselor go through the documentation would help equip the supervisor with material facts and complaints sequence against Clark. This arrangement would allow for flexibility in dealing with the misconduct in the case any of us approaches Clark for mentioning the mistakes and accusations leveled against her. In the case of Clark, intervention may also be another source of creating flexibility into the issue. In this case, there could be a session scheduled with Clark with the very important people in her life would be present such as fellow colleagues, the clergy, close friends and her spouse. This session has to go on through the guidance of a well-trained professional, in this case, a counselor. In this session, these important people in Clark’s life would directly inform Clark how her working under the influence affects them and what how it affects their co-existence. This method could best help Clark to avoid going into denial of her unacceptable and antisocial demeanor while at work. If this method leads to acceptance of the malpractice, it can be a very effective tool for having Clark acknowledges that she has a problem, which she needs to drop, and this may enable her to seek help. It is

Business Strategy Essay Example | Topics and Well Written Essays - 1000 words - 4

Business Strategy - Essay Example Here it is essential to note that Bord Gais has a wide range of options to choose from in terms of the suppliers. Hence if one the arrangements with the suppliers do not work effectively, the company has a choice to change over the suppliers. Considering the threats of the new entrants, it is clear that the company has built a strong brand image for itself and has also been able to effectively retain its customers by staying in track with the latest market changes and requirements. Hence here the company faces Low to medium levels of threats. Although new entrants can enter into the markets, the company’s current customer base as well as the goodwill will permit Bord Gais to effectively fight against the newer entrants. The company however faces a High and Very High levels of threats in terms of the substitute products and the rivalry respectively in the current markets. The current trend in the markets where customers are opting for the ‘debt hopping’ option, the rivalry and substitute products prove to be a major level of threat for the company. However although the company does lose out on customers, they do gain customers who have hopped from other companies as well. The above figure provides a clear overview of the threats faced by the company and the intensity of the threats has also been displayed. The strategic group analysis helps the management to gain a better idea of the direct competition for the company. Here the main competitors for Bord Gais are: a) Mott MacDonald Group Limited, b) Papierfabrik Palm GmbH & Co. KG, c) Tembec Inc., d) Mainstream Renewable Power Ltd., and e) Phoenix Natural Gas. The figure below provides a clear view of the position of each of these companies in terms of each other and their strategies. It is essential to note that not all of the above mentioned companies act as direct competition to Bord Gais as this is determined more so by the size and the market position of the companies (Kotler, Keller,

The Gender Roles And Working Culture In The Nursing Industry Essay - 4

The Gender Roles And Working Culture In The Nursing Industry - Essay Example Workplace culture and gender roles have been changing very radically in the past few decades. For instance, workplace roles traditionally associated with men or those ascribed to females have seen a shift in acceptance of the opposite gender. More women are taking up roles that were traditionally reserved for men (Mills, 2002). At the same time, men are also venturing into career lines that were assumed best suited for women. For instance, nursing was for a long time considered the preserve of women. Recently, more men have taken up nursing as a profession and can be found in many health facilities across the world (Cross & Baglihole, 2002). Meanwhile, it is not always easy for men to venture in professions culturally considered the preserve of women such as nursing. This essay explores the gender roles and working culture in the nursing industry with regards to sharing of roles among male and female nurses. The traditional nursing industry has been stereotyped in favour of women. Un known to many quarters, this was not always the case. In fact, the domination of women in the nursing profession only began to emerge in the 1800s with largely unskilled female nurses providing the essential medical services. As early as 250 B.C. E nursing schools existed but admitted only men for training (Thompson, 2014). The oldest documented nursing school is believed to have been set up in India, which also recruited male students to care for the sick. In continental Europe, nursing services were provided by Christian organizations such as churches. For instance, when the Bubonic plague broke out in Europe, church organizations took over the role of caring for the sick and disposing of the dead. The Benedictine Nursing Order established by St. Benedict, as well as the Knights Hospitallers, are some of the earliest nursing institutions.

Prepare budgets and financial plans Essay Example | Topics and Well Written Essays - 750 words

Prepare budgets and financial plans - Essay Example Baby monitoring devices can also be concentrated upon as parents are devoting much of their time to work. For example, the use of USB/ Flash Disks is currently on the rise. What features of the Flash Disks do they give most importance to Is it the slimness Is it about high memory There is a need to know this - Advertisements and other sales generating and improving activities require funds. It is well known that the degree of effectiveness of promotions campaign is directly related to the customer appeal of products. An inventory of prices, survey on product features and another survey of current marketing strategies of other companies can give the following data that will surely help in decision matters in the degree of intensity of sales activities. b. Policies on International Trade - there is a need to know what the government is planning with regards to the international market. Government initiative on establishing diplomatic and business relations with other countries can open up new markets. An embargo to a certain foreign market can greatly reduce opportunities for sale. An up-to-date inquiry in appropriate government offices, past government measures regarding the business environment and analysis of the current political situations can provide the necessary information needed for this field. concerns about the toxici... 3. Budget for Personnel Development a. Training - determines how well-versed a sales personnel is making a sale b. Incentives - determines how much a personnel can expect for his performance given a rewards and bonus system Competition An inventory of prices, survey on product features and another survey of current marketing strategies of other companies can give the following data that will surely help in decision matters in the degree of intensity of sales activities. 1. Product Price Comparison Table 2. Product Specifications, Features and Qualities Comparison Matrix 3. Marketing Strategy of Other Companies 4. Competitor's Market Share These data will serve as a basis of comparison for the company's own products. It can give details on how to best improve the product's customer appeal thereby increasing sales. Government Policies 1. Economic Policy Settings a. Taxation Measures - tax imposed on product sales can greatly affect the resulting net sales revenue and the selling price of the product b. Policies on International Trade - there is a need to know what the government is planning with regards to the international market. Government initiative on establishing diplomatic and business relations with other countries can open up new markets. An embargo to a certain foreign market can greatly reduce opportunities for sale. An up-to-date inquiry in appropriate government offices, past government measures regarding the business environment and analysis of the current political situations can provide the necessary information needed for this field. Environmental Policies 1. Location Restrictions -

History response 10 Assignment Example | Topics and Well Written Essays - 250 words

History response 10 - Assignment Example The sudden halt of opium trade greatly affected the British since they were the main exporters and therefore the new rules meant that they would no longer conduct any opium trade with the Chinese citizens who were their main clients (Gibson). It is because of this that the Britons took up their weapons and headed for china in one of the most controversial war that has ever happened, â€Å"the opium war† (Gibson). The war resulted to massive loss of lives all in the name of free trade between China and Britain. Trade between China and Britain resulted large acquisition of wealth, this is because whereas the British obtained their wealth from the selling of opium to the Chinese, Conversely, the Chinese also benefited a lot from the trade since they also took this position to sell their tea to the Britons who were their major clients as well (Gibson). The British were real lovers of the Chinese tea to the extent that by the 18th century they would import about six million pounds of tea on an annual basis. The opium that was being exported to China was mostly used in the manufacture of drugs but the reason why the Chinese government suddenly decided to declare the trade illegal was the fact that the drug was being mixed with tobacco then smoked for more pleasure which later resulted to drug abuse and opium addiction(Gibson). Although the opium war caused massive loss of lives, but finally it resulted to development of a much greater China- Britain relations both in terms of trade and economic boost. Trade between the two nations received a boost after the construction of five ports in a move to promote foreign trade

Nine-banded armadillo Research Paper Example | Topics and Well Written Essays - 500 words

Nine-banded armadillo - Research Paper Example This species is found in western Trans-Pecos portion of Texas and the east, although they can occasionally be located in the south, Missouri and South Carolina. Their natural habitat includes woods, brush, scrub and grassland. Life cycle of the species- Describe the life cycle of the organism you have chosen. The life cycle of an organism refers to the series of changes in both development and growth from its beginnings as an independent life form up until maturity, when it is able to reproduce. Organisms like bacteria have relatively simple life cycles; however other organisms (e.g., plants) have very complex stages to their life cycle. Breeding in Nine-banded armadillo occurs in the summer. During this period the embryo is not implanted and remains like that until the 14 week following the mating season. Following the gestation period that lasts for four months, females almost at all times give birth to four identical young ones, all of the same sex. The young Armadillos are born with opened eyes and start walking after a few hours. Their skin is usually soft but gradually hardens as they grow older. They are nursed for the next two months although they continue staying with the mother for some couple of month even after being weaned. Breeding for the young armadillos of both sexes may start as early like summer after their birth, but only come to full sexual maturity after two years. Full growth and sexual maturity comes at age 3 -4. Typically, this species live for about 7-20 years in the wild but for the caged ones it may go up to about 23 years. Structure and Function- Describe the structure and function of at least one major organ system of the species (e.g., digestive system, reproductive system). Choose one system and explain how this organisms system is structured anatomically and physiologically. Identify any species-specific characteristics or adaptations that are particularly unique to this organism and

Capital Markets and Investment Banking Process Essay

Capital Markets and Investment Banking Process - Essay Example Investment banks usually perform three tasks: first, they assist the companies in designing the securities which have features that are most appropriate for a certain market; second, they buy these securities and third, they resell them to the investors. (Fabozzi, 2008) Investment banks raise capital for their client companies through underwriting in which it purchases a whole block of new securities and resells them to investors. In this way, the income earned is the difference of the amount given to purchase the new block of shares and the amount received by the investors. Apart from Merger & Acquisition (M&A) advisory services, a bank’s another integral and core function nowadays is Investment Management in which the bank manages the investments of clients. Security services are also an important feature for investment banks which include prime brokerage, financing and securities lending. Regardless of the activity undertaken by the investment bank, it needs to focus on its portfolio construction and management which will be done according to the portfolio strategy of the investment bank. This means the bank needs to make investments which ensure successful trading that could be done by making risk management a top priority. This would mean that if a company incurs a loss of on one of its investment, it should earn a profit of over 11% on another to make it even. In this way, the company needs to construct a portfolio of investments which ensures a favorable position for the company. (Fabozzi, 2008) Factors to Be Considered Selecting Asset Classes For An Investment Portfolio: Asset class means the different kinds of assets (e.g. bonds, equities and cash equivalents etc.), while making an investment portfolio, different classes of assets are added according to investment policies and objectives. For making an investment portfolio, it is generally considered that a well diversified portfolio is beneficial as it outweighs the losses through other profita ble investments. On deciding upon the asset classes, the companies need to consider asset allocation among different classes of assets. Studies show that 85 to 95% of investment’s returns are due to asset allocation policy and not selection of specific stocks or bonds. While selecting classes of assets, major considerations should be given to the capital market expectations as to which classes of assets are expected to outperform others in short, medium or long term. For example, if the stock market is expected to be weak, there should be more bonds in the portfolio. Other factors that need to be considered while deciding upon the asset allocation are the objectives of investment which would consider the timings, the need of the investment and the expected return of the investment by the client. Risk tolerance and risk policies need to be given special consideration in deciding upon the allocation of assets that should be in accordance to the bank and clients. Constraints ass ociated with asset classes like liquidity, taxes, regulations etc and capital market assumptions are also few factors that should be considered. (Chandra, 2009) Describe the Capital Market Instruments Used in Investment Portfolio Construction: The capital market is vital for a country as it matches the players who have excess funds with the ones who are in need of funds. The instruments are traded in these markets incurring a gain/loss on these securities.

Patient Education And Epidural Pain Management Essay Example for Free

Patient Education And Epidural Pain Management Essay The term pain pertains to a sensation that is communicated by the sensory neurons that are located around the human body to the brain. This sensation is described as an unpleasant feeling that is generally related to a form of damage to a particular tissue in the body. Pain thus activates a specific physical and psychological reaction that tends to find a mechanism to terminate the unpleasant feeling. The ability to sense pain serves as the body’s warning system that informs us of any form of injury to our bodies. Pain is generally described in terms of its intensity and its duration. Intensity can be expressed through a range of descriptors from slight to agonizing, while the duration of pain may be depicted as constant or intermittent. Other characteristics that are commonly employed to describe pain include sharp, dull, throbbing and nauseating. The threshold of pain varies among individuals hence a numeric rating scale, with rating from 1 as the least painful situation to 10 as the most painful condition, has been employed for a more specific quantification of pain in patients. The numeric rating scale identifies level 4 as the cut-off score for pain that impedes an individual from performing his normal functions (Krebs et al. , 2007). In order to relieve an individual from pain, pain management is often provided at hospitals and clinics. In cases wherein the patient only suffers from acute pain, temporary medications are commonly administered to correct the medical problem. However, if the patient is experiencing chronic pain that is related to a condition that is currently being treated or is still undiagnosed, pain conduits are often put up to alleviate the sensation of pain in the patient. These conditions generally include cancer and neuropathy, wherein the pain is distinguished from the major medical condition of the patient. Pain management usually employs that administration of pharmacologic drugs such as analgesics and pain modifiers. In addition, other non-pharmacologic treatments may also be provided, which as normally interventional methods such as physical therapy, heat or cold compression and psychological therapy. One of the major interventional methods for pain management involves the administration of epidural analgesia, which is provided through the introduction of a catheter into the epidural space which is the space between the spinal cord and spinal canal. The effect of the injection of pain medications is to essentially remove the pain that the patient is experiencing by inhibiting further conduction of pain signals along the nerves or the spinal cord. Epidural analgesia is considered as a common technique for pain management because aside from reducing the pain felt by the patient, it also promotes vasodilation of blood vessels. Such result is actually a side-effect of epidural analgesia, yet it still benefits a patient if he has been diagnosed with a peripheral vascular medical condition. In addition, the utilization of epidural analgesia extends the effect of the pain medications for several days, instead of just a few days. In specific conditions that have associated pain such as childbirth, epidural analgesia is the favored pain management regimen because it does not cause any changes in muscle movement or power and it still retains its main role in pain conditions that may or may not require surgery. Epidural analgesia is also commonly used as an accessory to general anesthesia to decrease the patient’s need for opioid analgesics. Its use as an adjunct pain management scheme has been applied in a broad range of surgical procedures including hysterectomy, hip replacement, laparoscopy and open aortic aneurysm repair. Epidural analgesia is commonly used as the primary method for surgical anesthesia especially is Caesarean sections, which keeps the patient conscious during the entire surgical obstetric procedure (Halpern et al. , 2004). However, in such situations, the amount of anesthesia administered is generally much higher that what is usually employed for analgesia. Post-operative pain management may also involve epidural analgesia for the first few days after the procedure, which involves the introduction or retention of a catheter. There are certain situations when the patient is allowed to regulate the amount of pain medications that will be passed through the catheter. Such patient-controlled analgesia makes use of an infusion pump which the patient himself controls. Epidural analgesia is also used as remedy for back pain, as well as for palliative care. It has been established that epidural analgesia is most effective for the treatment of pain in specific regions such as the abdomen, pelvic and legs. This pain management technique is less effective in treating pain in chest, neck or arms, and is not effective for pain treatment in the head. It has been proven that epidural analgesia is more effective in relieving pain than intravenous narcotics and has been identified as the second most frequently used pain medication (Leighton and Halpern, 2002). Majority of women who give birth in hospitals are usually given only two options with regards to pain management, namely epidural analgesia or intravenous narcotics. It should be noted that alternative pharmacologic treatments for pain are also available, such as nitrous oxide and paracervical blocks. In addition, there are also doulas and continuous labor support, which typically requires less medical treatment and results in better outcomes with regards to the health of the mother and child. Also, these women are generally more satisfied with the results they observed after such alternative treatments. However, these alternative options are generally much more expensive (Simkin and OHara, 2002). It is interesting to note that even though epidural analgesia is reported to be significantly effective and common treatment for pain during child labor, there are a number of major side-effects that are associated with such use. It has been reported that epidural analgesia prolongs labor for an extended and considerable duration. In addition, its administration also influences the need for operative vaginal delivery and increases the chances for perineal laceration (Lieberman and ODonoghue, 2002). It has also been observed that the administration of epidural analgesia during obstetric procedures causes the mother to run a fever, which then results in the provision of antibiotics to the newborn child, as well as monitoring for symptoms and signs of sepsis in the infant. To date, great controversy envelopes the issue of whether epidural analgesia increases the risk of delivering a baby through Caesarean section as well as induces difficulty during labor. Research surveys show that most women have not been educated with regards to the possible side-effects of epidural analgesia (Declercq et al. , 2002). Hence the role and need for patient education has been an issue of close scrutiny in the past 5 years. Specific medical and non-medical groups have expressed their concern over the risks and benefits of epidural analgesia. More importantly, there has been concern that such type of patient education of pain management regimens should be given during pre-natal visits, and not during the actual labor stage of pregnancy. Hence, there is an urgent need to determine the amount of information that mothers know in relation to pain management and epidural analgesia because this option strongly influences the behavior of the newborn child, the breastfeeding conditions and the bonding between the mother and infant. In the United States, the dominant delivery method is composed of the induction of labor, administration of epidural analgesia, constant electronic fetal monitoring and Caesarean section. It has been analyzed that when the frequency of epidural analgesia is high, the alternative methods for childbirth are usually not available in the medical institution. These include sessions in childbirth education, doulas, non-pharmacologic pain management regimens, as well as the provision for nurses especially trained in assisting in medication-independent childbirth. Hence what is observed now in most of the hospitals are labor stages that are mainly supported by epidural analgesia and parenteral analgesics. In addition, medical healthcare professionals providing labor support are often overworked due to the huge number of delivery cases in a week. The issue of the shortage of nurses in the healthcare industry has also complicated the problem on the usage of epidural analgesia in hospitals. There are certain obstetricians who prefer to maintain a patient at labor that is supported by an intravenous line in order that they still find time to monitor their other patients in the hospital. It has been considered that the availability of healthcare professional during a patient’s labor and delivery is a luxury. More so, the inability to provide epidural analgesia to a patient during labor has often been a topic that has frequently been investigated in court malpractice cases. The importance of patient education with regards to epidural analgesia as the pain management scheme is thus very important in order to provide the patient with more than the regular two pain management choices that could be administered during her delivery. Patient education should also include the provision of information on the Caesarean delivery, wherein the patient must be able to carry enough knowledge to know that it is her right to request for a Caesarean delivery even when it is normally not recommended if there are no maternal or fetal complications for childbirth. There has been controversy with regards to the competence of smaller hospitals to could not universally provide epidural analgesia. It is unfortunate to know that not a single medical organization supports the concept of establishing a wide range of support methods during labor and pain management schemes, which is strongly associated with patient education and choice. In other countries, Caesarian delivery is the preferred delivery method by women because they are aware the other forms of labor and delivery schemes are not associated with sufficient medical care and attention (Behague et al. 2002). At the same time in the United States, women perceive that epidural analgesia is the sole and effective method for pain management. Actually, family physicians are not the main healthcare professionals that are responsible for the unbelievably high rates in the use of epidural analgesia during labor and childbirth. This medical professional observes when the patient is experiencing pain during labor and he relays this condition to the attending nurses, who in turn, will communicate the information to the anesthesiologist. Such relay of message from the patient to eventually the anesthesiologist is generally comprised by a simple nod from the family physician, which then triggers a battery of messages that eventually end with the administration of epidural analgesia to the patient. Such translation of patient pain to epidural analgesia administration is actually inappropriate and this is where patient education related to epidural analgesia comes into the picture. It is actually the family physician responsibility to educate his patient with regards to the choices in pain management. Instead of having a family physician that advocates epidural analgesia because it provides him freedom to look at his other patients while a particular patient is in labor, the family physician should be an advocate for the patient herself. Patient education entails spending time to teach and coach his patient which pain management schemes are currently available, as well as describing to the patient the effectiveness, side-effects and complications of each pain management scheme. The patient should also be educated of the limitations of each of the available pain management options. It is also ideal that the patient knows that she has the right to choose which pain management scheme she wants to receive, but this can only be done if the patient has sufficient understanding of pain management. It is also ideal that family physicians learn more of the details of the other alternative methods in managing pain. It has been observed that such patient education regarding pain management choices are important so that the patient has knowledge of what to expect during the actual medical procedure (Marmor and Krol, 2002). Patient education also involves the explanation of patient-controlled epidural analgesia (PCEA), which is a labor and delivery pain management option that uses bupivacaine with or without opioids. The theory behind PCEA is that the patient can personally adjust the amount of epidural anesthesia that is needed to remove the pain he is experiencing. Such option for pain management often results in a high degree of patient satisfaction because it allows the patients to be free of the uncomfortable sensation of pain, as well as provide a way for the patient to feel a sense of control over the entire hospital procedure (Standl et al. 2003). It is thus important the patient education be provided to a patient, in order for him to understand the entire scenario of the procedure as well as to help him draw an image of the expected events that could unfold during his stay at the hospital. PCEA is currently in high demand because the patients often want a quick solution to the pain they are experiencing. In addition, these patients are not patient enough to wait for the next round of administration of pain killers when they are experiencing constant pain. It is also essential that patient education in relation to epidural analgesia must explain that PCEA is inefficient during the first stages of labor and thus a higher concentration of epidural analgesia is needed to relieve the patient from pain. Patient education also diminishes the expectations of patients that PCEA always results in the complete removal of the feeling of pain when they choose PCEA. Knowledge and understanding of epidural analgesia will thus result in patient satisfaction in terms of pain management. Patient education as related to epidural analgesia also includes a description of the possibility that an extensive spinal block in the positioning of the catheter may happen (Bernard et al. , 2000). This event often results in the decrease in the motor abilities of the legs and that once the patient observes this, he must inform a healthcare professional immediately for medical attention. In addition, patient education should also alert the patient that the catheter employed in epidural analgesia has a chance to migrate within the blood vessels, which is also known as intravascular migration. Such event is associated with a slower rate of infusion of analgesia which in turn generates systemic effects. The patient should also be educated with regards to the toxicity of epidural analgesia. Providing patient education in relation to epidural analgesia often results in patient satisfaction because the patient has a better understanding of the mechanisms and principles behind the pain management scheme, as well as its similarity and difference to other pain management options, such as continuous epidural infusion (CEI). Patient education also involves explanation on the receptors that are involved in controlling pain. These include the N-methyl-d-aspartate (NMDA) which acts in the central sensitization of the patient. Simple explanations regarding antagonists that decrease the sensitization for pain without reducing hemodynamic or respiration activity should also be included, and the other options that results in negative physiological effects such as opioids should also be described. The provisions for instruction is especially important to patients that suffer from pain due to general musculoskeletal tumor resections and those that have other medical conditions that are related to wakefulness and full orientation. There are also options in combining a N-methyl-d-aspartate receptor antagonist such as dextromethorphan with PCEA, which often circumvents the issue of sedation in PCEA (Weinbroum et al. , 2004). Reports have described that such combination generally results in better feelings of well-being in the patient. Dextromethorphan is relatively safe for orthopedic oncological patients who are commonly administered massive dosages of analgesics. There has also been reported the patients could not distinguish the feeling of PCEA and dextromethorphan, although there is a significant difference in a lack of inhibition of motor abilities using this combination. CONCLUSION This report suggests that patient education in relation to epidural analgesia results in patient satisfaction. Patient education generates a better understanding of the principles and mechanisms behind pain management schemes. In addition, the patient is given the right to reject or accept epidural analgesia based on his own comprehension that was earlier provided by the healthcare professional. Patient education also supports a PCEA setting that improves analgesia, as well as patient satisfaction during labor. This supports a better setting for the patient himself and decreases the need for rescue analgesia. Also, the increase in analgesia consumption can also be controlled through patient education, thus minimizing the side effects that are generated by particular pain killers. More importantly, patient education removes the discontent and disappointment that the patient may experience from insufficient knowledge and understanding of epidural analgesia.

Modern Portfolio Theory and Capital Asset Pricing Model

Modern Portfolio Theory and Capital Asset Pricing Model Introduction The Capital Asset Pricing Model developed by William Sharpe has significant similarities with Harry Markowitz’s Portfolio theory. In fact, the later is rightly considered as the next logical step from the latter, with both based on similar foundations. There are also differences in how each model/theory is calculated, pertaining to risk considerations. This paper’s main objective is to identify these differences while highlighting the similarities as well to put things into perspective. The report will open with an overview of Markowitz’s portfolio theory and explain it further by means of describing the efficient frontier, the Capital Market Line, risk free asset and the Market Portfolio. The report will then switch its attention to the Capital Asset Pricing Model and explain it further through the Security Market Line. The report will then close by outlining the differences between the two with a view of answering the main objective. What will come through in this report is that Markowitz’s portfolio theory uses standard deviation as its risk measure and takes into account all risk in an efficient portfolio, while the Capital Asset Pricing Model uses the beta co-efficient to measure risk and takes into account both efficient and non-efficient portfolios – further more it measures the risks of individual assets within the portfolio. Modern Portfolio Theory Modern Portfolio Theory (MPT) was introduced by Harry Markowitz, way back in 1952. At a high level it proposes how rational investors use diversification to optimise their investment portfolios and give guidance on pricing risky assets. MPT assumes that investors are risk averse, i.e. given two assets A and B offering the same expected return, investors will opt for asset A if it is less risky. In effect, an investor who expects higher returns would need to accept more risk. The expected trade-off between risk and return depends on the individual’s level of risk aversion. The implication of this is a rational investor (a risk averse investor) will not invest in a portfolio if another one exists offering a better risk-return profile (Fabozzi Markowitz, 2002). For any given level of risk, investors will opt for portfolios with higher expected returns instead of those with lower returns. Another assumption under MPT is that investors are only interested in the expected return and the volatility of an investment, as measured by the mean and standard deviation respectively. Investors do not consider any other characteristics, for example, charges. In effect, based on the assumptions above, investors are concerned about efficient portfolios. To explain portfolio theory further, let us consider the formula for the expected return and risk of a portfolio under MPT. Suppose two assets A and B formed a portfolio in proportion (X) each, the expected return for that portfolio would be: R(p) = X(a)R(a) + X(b)R(b), where: R(p) = expected returns from portfolio R(a) = expected returns from asset A R(b) = expected returns from asset B The standard deviation or risk of that portfolio would be: SD(p) = √(XÂ ²aSDÂ ²a + XÂ ²bSDÂ ²b + 2XaXbRSDaSDb), where: SD(p) = standard deviation of expected returns of portfolio SDa = standard deviation of expected returns of asset A SDb = standard deviation of expected returns of asset B R = correlation coefficient between the expected returns of the two assets The efficient frontier Under MPT, Markowitz examined the efficient frontier curve. The efficient frontier curve gives a graphic presentation of a set of portfolios that offer the maximum rate of return for any given level of risk (McLaney, 2006). According to Markowitz, an efficient investor will opt for an optimum portfolio along the curve, based on their level of risk aversion and their perception of the risk and return relationship (Fabozzi Markowitz, 2002). Figure 1: Efficient Frontier Source: www.riskglossary.com The curve in the diagram above illustrates the efficient frontier. Portfolios on the curve are efficient – i.e. they offer maximum expected returns for any given level of risk and minimum risk for any given level of expected returns. The shaded region represents the acceptable level of investments when risk is compared against returns. For every point on the shaded region, there will be at least one portfolio that can be constructed and has a risk and return corresponding to that point (www.riskglossary.com) As aforementioned, each portfolio on the efficient frontier curve will have a higher rate of return for the same or lower level of risk or lower risk for an equal or better rate of return when compared with portfolios not on the frontier. It is important to note that the efficient frontier is really made up of portfolios rather than individual assets. This is because portfolios could be diversified, i.e. investors can hold assets which are imperfectly correlated (Fabozzi Markowitz, 2002). This will help to ensure that investors can reduce their risks associated with individual asses by holding other assets – a kind of set-off. The Capital Market Line The Capital Market Line (CML) is a set of risk return combinations that are available by combining the market portfolio with risk free borrowing and lending (www.lse.co.uk/financeglossary). The CML defines the relationship between risk and return for efficient portfolios of risky securities. It specifies the efficient set of portfolios can investor can obtain by combining the portfolio (which contains risk) with a risk free asset. The formula for CML is: E (r_c) = r(f) + SD(c)*[E(r_m)-r(f)]/SD(m) Where: E(r_c) = expected return on portfolio c R(f) = risk free rate SD(c ) = standard deviation of portfolio c E (r_m) = expected return on market portfolio SD(m) = standard deviation of market return The CML indicates that the expected return of an efficient portfolio is equal to the risk-free rate plus a risk premium. Both risk and return increase in a linearly along the CML. Figure 2: Capital Market Line Source: www.riskglossary.com In Figure 2 above, the CML is the line touching the efficient frontier curve. It passes through the risk free rate (assumed to be 5%). The point where the CML forms a tangent with the efficient frontier curve is the point called the super-efficient portfolio. The Risk free asset, Sharpe ratio and the Market Portfolio The risk free asset pays a risk free rate and has a zero variance in returns, e.g. government short-term securities. When combined with a portfolio of assets the change in return and risk is linear. The Sharpe Ratio is a measure of the additional return to be obtained about a risk free rate for a given portfolio compared with its corresponding risk. On the efficient frontier the portfolio with the highest Sharpe Ratio is known as the market portfolio. The CML is the result of a comparison between the market portfolio and the risk free asset. The CML surpasses the efficient frontier with the exception of the point of tangency. The Capital Asset Pricing Model While the CML focuses on the risk and return relationship for efficient portfolios, it would be useful to consider the relationship between expected return and risk for individual assets or securities. The Capital Asset Pricing Model (CAPM) would be used for this. CAPM is an extension of Markowitz’s Portfolio Theory or MPT. It introduces the notions of systematic and specific risks. Let us define each: Systematic risk – this is the risk associated with holding the market portfolio of assets Individual assets are affected by market movements Specific risk – this risk is unique to an individual asset and represents that portion of an asset’s return which has no correlation with market movements. CAPM assumes the following (McLaney, 2006, 199): Investors are risk averse and maximise expected utility of wealth The capital market is not dominated by any individual investors Investors are interested in only two features of a security, its expected returns and its variance or standard deviation There exists a risk free rate at which all investors may borrow or lend without limit at the same rate There is an absence of dealing charges, taxes and other imperfections All investors have identical perceptions of each security This lends credence to the assertion that CAPM follows a natural progression from MPT. The assumptions are identical with the main difference being how risks are categorised and treated. This will be explored in detail in a later section. Under CAPM, the market place will compensate an investor for taking a systematic risk but not a specific risk. The rationale for this is that specific risks can be avoided or minimised through diversification. The formula for CAPM is as follows: r = Rf + Beta x (RM-RF), where: r = expected return on an asset Rf = rate of risk free investment RM = return rate of the appropriate asset class Beta is the relative risk contribution of an individual security to the overall market portfolio. It measures the security risk relative to the market portfolio and ignores the specific risk. The beta equation is as follows: Cov (i,M)/(SDm)Â ², where: Cov (i,M) = covariance between market portfolio and security i (SDm)Â ² = variance of the market’s return The betas for all assets are measured in relation to the market portfolio beta which is 1. In effect, if individual beta is greater than 1, then individual asset has a higher risk than the market risk. If individual beta equals 1, then individual asset risk and market risk are the same. If individual beta is less than 1, then the risk of that individual asset is less than the market risk. The value of beta provides an idea of the level or size of the change in an asset’s return when a corresponding change in the returns of an overall portfolio is experienced (McLaney, 2006). Beta has come under criticism from academics and investors who do not appreciate the value of beta as an appropriate risk measure. However, this is somewhat challenged by actual performance of the betas of portfolios and mutual funds. These are regarded as stable and can be used to predict future betas. Security Market Line CAPM can be applied by using the Security Market Line (SML). SML is a graphical representation showing the linear relationship between systematic risk and expected rates of return for individual assets. In the case of the SML, risk is measured by beta. It plots the expected returns on the y axis and the risk as denoted by beta on the x axis. In other words, the SML expresses the linear relationship between the expected returns on a risky asset and its covariance with market returns. Its formula is: Figure 3: CAPM and SML The line in the diagram above is the SML. Differences relating to MPT (CML) and CAPM (SML) To explain the differences, it is useful to consider the relationships between risk and return in the perspective of CML and SML. CML compares the relationship from an MPT perspective, while SML does from a CAPM perspective. The main difference pertaining to MPT’s relationship with CAPM is pertaining to risk. Under Portfolio theory, CML gives an indication of expected returns in comparison with risk. Here the risk is measured in terms of standard deviation of returns. The rationale for this is CML represents the trade-off for efficient portfolios, i.e. the risk is all systematic risk (McLaney, 2006). The SML on the other hand, indicates the risk/return trade-off, using beta as the measure of risk. In this case, only the systematic risk element of the individual asset is taken into consideration. The reason why CML shows no individual security’s risk profile is because all individual securities have an element of specific risk, implying that they are inefficient. CML only looks at efficient portfolios. The table below summarises the main differences between CML and SML Table 1: Tabular difference between CML and SML Summary As has been shown above, CAPM has been developed along the lines of Markowitz’s Portfolio theory. They both use expected returns and risk as the investor’s main determinant of their investment decisions. They both assume that investors are risk averse and do not consider anything else other than risk and returns. However, there are some subtle differences which will now be summarised below: Under Portfolio theory, the CML measures risk by standard deviation or total risk. The SML measures risk by beta or systematic risk under CAPM – it ignores specific risks The CML graph is interested in providing information on efficient portfolios only. The SML graph on the other hand provides insight into both efficient and non-efficient portfolio and securities REFERENCES AND BIBLIOGRAPHY Books Bodie, et al (2006) ‘Investments’ (7th edition), McGraw-Hill/Irwin, London Elton, E et al (2003) ‘Modern Portfolio Theory and Investment Analysis’, Wiley, London Fabozzi, F. Markowitz, H. (2002) ‘Theory and Practice of Investment Management’, Wiley, London McLaney, E. (2006) ‘Business Finance – Theory and Practice’ (7th edition), Prentice Hall, London O’neill, W.J. (2002) ‘How to Make Money in Stocks’, (3rd edition), McGraw-Hill, London Internet Sources www.lse.co.uk www.riskglossary.com www.wikipedia.com

Principles of Acid Base Balance

Principles of Acid Base Balance The purpose of this handout is to educate the student on basic principles of acid base balance. To give a systematic approach to interpretation and understanding of arterial blood gases and appropriate care for the patient who is having a blood gas taken. It is intended that the student will learn from this package but also be encouraged to source other material to broaden their understanding of acid base balance. It is intended that this learning packet will complement their experiences with help of an understanding mentor, who will assist them with questions raised both within themselves and within the book. An arterial blood gas measures the acidity of the blood, the levels of carbon dioxide and levels of oxygen. The blood is taken from an artery prior to the blood distributing the oxygen from blood cells to the body tissues. The values the gas will show are: Partial pressure of oxygen (PaO2) this measures the pressure of oxygen dissolved in the blood Edwards (2009) say this can indicate how good respiratory system is functioning. This can indicate oxygen saturation and how well oxygen can move from the lungs to the blood Partial pressure of carbon dioxide (PaCO2) this measures how much CO2 is dissolved in the blood and how well it can move from the blood to the lungs (and out of the body). Foxall (2008) explains that co2 mixed with water turns in to carbonic acid that the lung must excrete to prevent an acidosis. Bicarbonate (HCO3) Bicarbonate is the form in which a large amount of acid is removed from the cells Schilling (2008) says about 70% is removed from tissues and bicarbonate can be measured as either actual or standard bicarbonate. The standard which is the more important value is obtained by using a PCo2 of 5.6 kPa as a reference for the amount of CO2 in the body. Base excess (B.E.) Springhouse (2008) explains that the base excess indicates the amount of excess or lack of bicarbonate in the circulatory system it can be a negative number indicating too much acid or a positive number indicating too much base. It normal range is -2 to +2 Introduction Skinner (2005) and Adam (2009) concur in that arterial blood gas analysis is an essential part of diagnosis and management a patients ventilation therapy and their acid base balance. Skinner continues to say the usefulness of this intervention is dependent on the ability of the health professional to analyse and interpret the individual aspects of the gas. The intention of this learning packet is to introduce the learner to the individual aspects of a blood gas, and there meaning. Additionally it hopes to show how to bring these values together to formulate a decision on the patients condition and suggest options for treatment. Common reasons for blood gas analysis are: To diagnose and assess existing lung function. To review treatment for lung disease and evaluate its effectiveness. To assess if extra oxygen is required for a patient or if further support is required (CPAP, BIPAP or PPV). To measure the acid base level in patients where it is compromised. Patient would include renal patients, patient with heart failure, severe infected patients uncontrolled diabetes or individuals who have taken an overdose. Preparing the patient. Explain to the patient that they are having a blood test from their artery. It is likely to be taken from a radial artery. Nettina (2005) Describes a test to assess the puncture site prior to puncture called the Allens test procedure. This will evaluate the blood circulation in the hand and whether it is appropriate to use the radial artery for puncture. The site will be cleaned with alcohol and allergy status permitting anaesthetic agents will be applied to reduce discomfort, and increase possibility of success. Dougherty (2008) suggests that the patient should be encouraged to breathe normally through the procedure and the doctor may ask for cessation of supplementary oxygen prior, to give a better understanding of the patients present condition. After the syringe is full, place gauze over the puncture site and apply pressure until bleeding has stopped. This may be some time if the patient is on blood thinners or has coagulopathy. Once bleeding has stopped apply a dry dressing but monitor for any further bleeding. After the procedure there is a possibility of bruising although the longer pressure is kept on the puncture site the lower the risk. Some light headedness or nausea may occur during or after the blood draw. On rare occasions the needle may damage the artery or a nerve causing it to become blocked. As a result care must be taken with the wrist once blood draw has taken place. How it feels Dougherty explains that collecting arterial blood from a patient is a procedure that is often painful. It is more painful than the routine venous phlebotomy your patient may be used to. There are a number of reasons for this, arteries are often deeper than veins and surrounded by nerves. Ideally the patient is given a local anaesthetic and the patient feels just a sting as the needle punctures the skin. Otherwise there is a sharp pain as the needle enters the artery. If the procedure becomes protracted either by the practitioner having difficulty finding the artery or the artery is narrow the pain may more than brief. It is important to note that both pain and fear would cause the arteries to narrow so reassurance is important and if the practitioner continues to have difficulty you must advocate on the patients behalf since fear would impact on future successful arterial blood gas collection. Questions What other sites could a patient have blood gases taken from? Can only arterial blood be used for blood gases? What values would be markedly different in a venous sample blood gas. Why would a patient emotional response make blood draw difficult how can we reduce the affects of this to cause a positive outcome What medications or disease process would make a patients bleeding time prolonged after sampling? Further reading Royal Marsden clinical procedures manual 2008, Dougherty etal Overview The measurement of a blood gas will show a pH value. PH is a value the can range from 1 to 14 and is a measure of acidity or alkalinity of a substance. Springhouse(2008)explains in the blood stream the pH value is inversely proportional to the number of hydrogen ions in the blood. The fewer ions the higher the number (alkalosis) and vica versa, more ions would mean a lower number (acidosis). A solution with a pH of 1 is acidic and a solution of pH 13 would be alkalotic. A solution of pH 7 is called neutral since it is in the middle, it is neither acidic nor alkalotic, and water has a pH of 7. Adams (2009) explains that the normal PH of the body ranges from 7.35 to 7.45. In order for normal metabolism to take place the body must maintain this fine balance at all times. He clarifies that if the pH level rises the blood is said to be alkalotic or acidic if it drops below 7. Hall (2009) says the ability of the body to function normally is impaired if the pH moves from these parameters. Hall also concludes that in acidosis the bodys response to medication is muted, cardiac function is impaired since contractility and vascular response to catecholamines is reduced. If the patients pH is raised then oxygenation is effected which interferes with neurological and muscle function. Adams points out that severe changes in pH that is above 7.8 or below 6.8 will interfere with basic cell function and respiration and if not corrected will result in death. Below is a discussion on how the body regulates this delicate balance. We will elaborate on the processes the renal and respiratory systems use to buffer the bodys processes to keep this fine balance. The respiratory buffer system Hinds (2008) explain that carbon dioxide (CO2) is a normal by product of cellular metabolism. Carbon dioxide is carried in the blood to the lungs where excess CO2 combines with water (H2O) to form carbonic acid (H2CO2) in the blood. The blood pH will change according to the level of this acid in the blood. This fluctuation triggers either a rise or fall in respiration until the level of CO2 is returned to the patients base line. Hinds explain that this system is fairly rapid and can be triggered in a short space of time a few minutes in most cases. The renal buffer system Henessey (2007) simplifies the metabolic system explaining that the kidneys also maintain acid base balance by the excretion or retention of bicarbonate (HCO3). As the pH rises HCO3 is excreted and in return as the pH decreases HCO3 is retained. Although an effective system the renal system is slow to respond to imbalances, requiring hours or days to attend altered pH. Questions If neutral pH is 7 why does the body require a mean of 7.4 a slightly alkalotic environment to operate? The notes above indicate the bodys response to catecholamines is muted what are these and why are they important? Normal values pH 7.35 to 7.45 PO2 11 to 13.3 kPa PaCO2 4.8 to 6.0 kPa HCO3 21 to 28 mmol/l Acid Base Disorders Respiratory acidosis. Henessy (2007) discussion on respiratory acidosis is defined as a pH less than 7.35 with a Pco2 greater than 6.0 kPa. This type acidosis is caused by a build up of CO2 which combines with water in the body to produce carbonic acid thus lowering the pH of blood. Driscoll (1997) says any condition that results in a reduction in ventilation can cause this type of acidosis. Head trauma, which has inflicted damage to the respiratory centre leading to respiratory depression. Sedatives, narcotics, neuromuscular blocking agents or anaesthesia, which can cause central nervous system depression. Impaired respiratory muscle function related to spinal cord injury or neuromuscular disease. Poor lung function such pneumothorax, pneumonia, atelectasis or bronchial obstruction. Hypo inflation due to pain chest injury or abdominal distension. Hasan (2009) simplifies the presentation of the signs and symptoms of respiratory acidosis are centred within the respiratory, cardiovascular and nervous systems. These symptoms can range from shallow breathing or dyspnoea to headaches or altered consciousness and irritability. If left unchecked these symptoms deteriorate towards drowsiness and coma. Increasing ventilation support will correct this type of acidosis. The specifics of how this will be done is dependant on the mode of insult to the respiratory system. Edwards (2009) suggests ventilator support could be oxygen via a face mask, non invasive ventilation (N.I.V.) or positive pressure ventilation (P.P.V.). If medications are inhibiting respiratory function then reversal agents can be deployed whilst supporting the patients respiratory needs. Pneumothorax and pain are problems that can be reversed promptly once the patients condition allows. Marino (1997) say that if the patients symptoms or condition, cannot easily be resolved then it may be appropriate to ventilate the patient mechanically. Commonly patients with respiratory acidosis are hypo ventilating, as a result they will benefit from supplemental oxygen but this only improves the quality of respiration; it does not in fact remedy the problem. Respiratory Alkalosis Respiratory alkalosis is defined as a pH greater than 7.45 with a PaCO2 less than 4.8 kPa. Any condition that causes hyper inflation can result in respiratory alkalosis. These conditions include, Pain Anxiety fear or panic Medications which stimulate the respiratory system Lesions in the brain affecting the respiratory centre Increased metabolic demands such as fever sepsis or pregnancy. Alkalosis will present cardiovascular or central nervous system disorder. Springhouse (2008) illustrates that presentations can be dysrhythmias and palpitations to numbness and confusion. Additional symptoms are dry mouth, blurred vision and titanic spasms of the arms and legs. To resolve the alkalosis the cause of the hyper ventilation must be attended to. These patients are at risk of suddenly deteriorating, they have tachypnea and must be supported to reduce fatigue. If they become tired their own ability to ventilate adequately will be impaired leading to respiratory failure. Questions What would be the signs and symptoms of a patient with a respiratory caused imbalance? Which kind of medications can cause an acidotic condition and what would be the reversal agents? In respiratory alkalosis why do patients suffer with tetany? What are the signs and symptoms of respiratory failure? Metabolic acidosis Metabolic acidosis is defined as a bicarbonate level less than 21mEq/L with a pH of less than 7.35. Schilling (2008) explains metabolic acidosis is caused either by a deficit of base in the blood stream or an excess of acids other than CO2. Excessive bowel action such as diarrhoea and intestinal fistulas may cause decreased levels of base. Increased acids can be caused by a number of factors such as: Renal failure Diabetic ketoacidosis Anaerobic Metabolism Starvation Salicylate intoxication Hall (2009) Signs and symptoms of metabolic acidosis are varied affecting numerous systems. The nervous system presents with headaches, dizziness leading to confusion or later coma. Dysrhythmias are common as conduction pathways are affected and low blood pressure due to desensitivity to catecholamines such as epinephrine. Marino (1997) elaborates to say the respiratory system will attempt to correct imbalances by breathing out more CO2. Kussmaul respirations these are deep and laboured breaths. In the gastro intestinal tract nausea and vomiting is noted as well as warm flushed skin. The Hinds (2008) says treatment of the metabolic acidosis is to resolve the cause, this invariably means an initial review of body systems and their function. By assessing each function and its efficiency, underperfused or hypoxic tissue beds can be identified. Hypoxemia can lead to generalised anaerobic metabolism, but hypoxia of a specific tissue bed will produce metabolic acids even if oxygenation (PaO2) is normal. To reverse this acidosis perfusion must be restored which in turn will cease the anaerobic metabolism. Hinds warns that other causes of metabolic acidosis should be addressed after the possibility of hypoxia and poorly perfused tissue beds have been resolved or ruled out. Metabolic alkalosis Metabolic alkalosis is defined as a bicarbonate level of 28mEq/L with pH greater than 7.45. Metabolic alkalosis obviously is the reverse of the previous condition deriving from an excess of base or a deficit of acid. Adam (2009) suggests that excessive base comes from ingestion of antacids, excess use of bicarbonate or lactate in dialysis. Low amounts of acid come from overuse of diuretics, gastric suction or protracted vomiting. It presents through neurological signs and symptoms varying from light headedness to seizures and coma or musculoskeletal symptoms of weakness, muscle cramps and tetany. Other associated signs might be nausea and vomiting and respiratory depression. This is a relatively uncommon presentation and presents a challenge in treatment. Bicarbonate can be stimulated thought the kidneys by drugs such as Acetazolamide but it is a protracted therapy. Severe cases I.V. administration of acids may be used Questions Which other value is closely linked with the metabolic state of the body? What does it signify? What signs and symptoms would a patient show who presented with a metabolic acidosis? In a very severe alkalosis state what I.V. acids could be administered? Steps to Arterial Blood gas interpretation There are simply 3 steps to interpreting a blood gas result and each must be done in order to prevent confusion and misdiagnosing your patient. The components are pH PaCO2 and HCO3 below are three steps and following are examples to assist you in interpreting them. Step One Review the pH initially is this normal or abnormal? If the pH is above 7.45 it is alkalotic if it is below 7.35 then it is acidotic. Step Two If the blood sample pH is altered then we must consider how this is being affected. Initially assess the PaCO2 this value will move in the opposite direction to the pH when there is a insult to the respiratory system. That is as the pH falls out of normal values the PaCO2 rises from its normal limits. The reverse is true if the PaCO2 falls then the pH will rise. Step Three The third step is to assess the HCO3 value. If there is an altered metabolic function the HCO3 will alter in a similar direction to the pH. As the HCO3 value rises so will the pH and as one decreases so will the other. Examples: Using the table above and your knowledge you have gained try and diagnose the problems below. Example 1 Mr Brown is a 72 year old man admitted with recent chest infection to the assessment unit. He is quite short of breath and has a strong cough his blood gas show the following information Patient: John Brown D.O.B.01:01:38 PH 7.30 PaCO2 8 HCO3 25 Step one, assess the pH is it normal? It is not, it is low therefore it is acidotic. Step two, assess the PaCO2 is it normal? It is not, it is raised which is the opposite direction of the movement of the pH. Step three, assess the HCO3, is that normal? Yes it is within its normal range. Reviewing the grid it can be seen the pH being low, the PaCO2 raised and the HCO3 normal shows a respiratory acidosis. Example 2 Maria 29, who has a long history indigestion and reflux, has come to the drop in clinic with vomiting unresponsive to her usual medications and cramp in her hands. A routine blood gas shows the information below. Patient: Maria Goode D.O.B.: 01:01:1981 pH 7.51 PaCO2 5.5 HCO3 35 Assess the pH, is it normal? It is high indicating alkalosis Assess the PaCO2 is it normal? It is normal Assess the HCO3 is it normal? It is raised, moving in the same direction as the pH. Looking at the chart above a raised pH and a raised HCO3 would indicate a metabolic alkalosis state Discussion on compensation So far we have only looked at a simple blood gas scenarios, with only one system failing. As Hasan (2009) indicates that often if one system fails or falls out of normal range altering the pH the second system will activate and work harder to compensate to bring the pH back in to normal limits. This activity is called compensation. Foxall (2008) describes that when a patient develops an imbalance over a period of time the body will naturally attempt to compensate. The lungs and the kidneys are the primary response mechanisms and so the body will try to resolve any metabolic or respiratory imbalance to return the pH to normal There are varying degrees of compensation initially uncompensated, an altered pH with only one value out of normal range. Partially compensated blood gas, an altered pH value with both values out of normal range. Compensated blood gas, a normal pH value with possibly both values out of range. Previous examples we looked at were simple uncompensated blood gases. Now lets look at more advanced gases such as partial compensation. To review these gases as before break the interpretation down in to three simple steps Assess the pH, is the gas acidotic or alkalotic Assess the PaCO2; is the PaCO2 a normal value? As reviewed before respiratory imbalances will move the pH in the opposite direction to which the PaCO2 moves when causing a primary imbalance. If the PaCO2 is moving in the same direction that is either increasing, or decreasing in value, then this would be a compensatory behaviour and it would indicate the primary insult is coming from the kidneys (metabolic). In a compensatory environment a decreasing PaCO2 would show the lungs are buffering by excreting excess acid by blowing off Co2 in order to equalise the balance of acids and return the pH to normal. Conversely a raised pH and raised PaCO2 would indicate a buffering response by the lungs which would reduce acid excretion in an effort to return to homeostasis. In summary, if there is evidence of compensation, but the pH has not yet arrived back into normal limits then it is only partial respiratory compensation. Assess the HCO3. In our original uncompensated examples the pH and the HCO3 moved in the same direction when the primary insult was metabolic. Following our discussion above in compensatory behaviours the values will work counter to their normal presentation. So if the pH is decreasing when the HCO3 is increasing or decreasing when the pH is increasing this is a compensatory action therefore the primary insult is a respiratory one. The kidneys will hold on to or release HCO3 in response to the abnormal pH to equalise the acid in the body to return the bodys pH to normal The essential difference between these two states is that they are on a journey towards normal from possibly uncompensated , to partially compensated, to fully compensated environment (normal pH). The body is always trying to correct the imbalance however successful, but the body will never over compensate. As can be seen from the above table the pH in fully compensated states is normal. Knowing which side of 7.40 will help in determine the original imbalance that is now compensated. More technical questions Example 1 A patient enters the AE who is known to the renal team. He has been having dialysis 3 times a week for a year but missed his last appointment. He is complaining of being unwell. A Routine blood gas show the following results Using the same 3 steps we have used before: Patient : George Philip D.O.B. : 01:01:50 pH 7.31 PaCO2 3.9 HCO3 18 Is the pH normal? The answer is no it is low therefore it is acidotic Is the PaCO2 Normal? No this is also low. If the PaCO2 was causing the primary insult we would expect it to move in an opposite direction to the pH in this case it is not. We must conclude therefore that the primary insult is metabolic and the paCo2 is out of range in a compenstatory role. The lung are excreting CO2 to reduce the PaCO2 whereby return equilibrium and return the pH to normal. Is the HCO3 normal? It is not it is low moving in the same direction as the pH. Therefore confirming what has already been said that the primary problem is metabolic. If you review the tables above it can be seen that the primary problem is metabolic but the full diagnosis would be a partially compensated metabolic acidosis Example 2 A lady walks in to her local surgery complaining of shortness of breath she is a long term smoker. A routine blood gas shows the following results Patient: Jane OBrien D.O.B. : 01:01:62 pH 7.35 PaCO2 7.2 HCO3 29Assess the pH is it normal? Yes it is, but the low side of neutral Assess the PaCO2 is it normal? No it is raised an acidotic condition. If this is the primary problem we would expect the pH to move in opposite direction to the PaCO2. Assess the HCO3 is it normal? No it is also high which is representative of an alkalotic state. Although the pH is normal both elements are out of range showing there is full compensation being achieved. The pH is lower than 7.40 which shows it is moving in the opposite direction as the HCO3 which show the initial insult was respiratory and that the kidneys are compensating by retaining bicarbonate Her arterial blood gas would be interpreted as fully compensated respiratory acidosis Example 3 A 42 year old man on the surgical unit with history of bowel obstruction has had N.G. on free drainage has become unwell. Routine labs were sent and the blood gas below: Patient: Tom Jones D.O.B. : 01:01:47 pH 7.44 PaCO2 7.1 HCO3 34 Is the pH normal? Yes Raised within normal limits Is the PaCO2 normal? No this value is also raised, so therefore even if this is a fully compensated state it was a metabolic imbalance in origin. Is the HCO3 normal? No this is raised with two value out of range and the pH with in normal limits this is fully compensated gas with the pH raised in normal limits and the HCO3 raised this was an initially a metabolic alkalosis This is a fully compensated metabolic alkalosis. Example 4 David has arrived from a nursing home with altered consciousness into the AE department. His initial labs showed a raised white cell count and this blood gas was taken Patient: David Hawcroft D.O.B. : 01:01:72 pH 7.32 PaCO2 8.2 HCO3 32 Is the pH normal? No it is low therefore it is acidotic. Is the PaCO2 with in normal limits? No it is raised which indicates that respiratory system is causing the primary insult. Assess the HCO3 is that normal? No this is raised also indicating that because it is moving in an opposite direction to the pH it must be in compensation, confirming the insult is respiratory in nature. Since both elements are out of normal limits there is evidence of compensation but since thepH is not achieved normal values it is considered only partial compensation, so this gas is a partially compensated respiratory acidosis Primarily this book has been to discuss the relationship between respiratory and renal systems is maintaining the bodys acid base balance. Arterial blood gases are used also to interpret blood oxygenation using the Po2 value. This value indicates the partial pressure of oxygen, the ability of oxygen to bind to haemoglobin and transfer to tissues, this ability can be affected by the acid state of the body. Below is a discussion on the Oxyhemoglobin Dissociation Curve which is a graph that plots the behaviour of oxygen in the blood comparing saturation against partial pressure and how acid base can affect it. Oxyhemoglobin Dissociation Curve The Oxyhemoglobin curve is a tool used to show the relationship between oxygen saturation and Pao2. Marino (1997)points out that the strength at which oxygen binds to the haemoglobin can vary depending on the disease state of the body. This in turn can affect the oxygenation of tissue beds or end organ perfusion. Adam(2009) simplifies the principle explaining that oxygen can bind too tightly which would which would inhibit of transfer of oxygen to tissues that needed oxygen or alternatively not bind tightly enough an oxygen is lost before it reaches these target cells. This relationship between the affinity of oxygen and the saturation is illustrated below with the Oxyhemoglobin curve. As mentioned above there are a number of conditions or states than can affect this relationship essentially moving the graph left or right. A fever, acidosis or elevated PCo2 levels can cause reduced adhesion of the O2 molecule therefore the graph and its values appear to move to the right (A right shift). Where as if the body is alkalotic, hypothermic or a low PCo2 the graph will shift to the left which would indicate the blood is failing to release the oxygen through increased affinity The curve can be used to assess Pao2 if the oxygen saturation is known. Shown in the illustration is a person with a saturation of 82%. If the curve has not shifted then that persons Pao2 would be 51mm Hg. A value of 80mmHg could indicate hypoxemia. Correction of the patients oxygen level may be facilitated by improving oxygen delivery and resolving conditions affecting the curve. Revision Questions What number indicates extreme acid on the pH scale? What is the range for pH in the blood? The kidneys compensate for acid base imbalances by excreting what substance? Which A.B.G value indicates an excess or insufficiency of sodium bicarbonate? What two values are compared on the Oxyhemoglobin curve? Interpretation revision pH 7.33 PaCO2 8.0kPa HCO3 31 pH 7.49 PaCO2 5.9 kPa HCO3 34 pH7.37 PaCO2 5.3 kPa HCO3 25 pH 7.44 PaCO2 4.0 kPa HCO3 16 pH 7.27 paCO2 5.5 kPa HCO3 15 Further reading Mays DA (1995). Turn ABGs into childs play R.N. 58:1: 36-40 Foxall Kesley (2008) Arterial Blood Gas Analysis: an easy learning guide M K Publishing Keswick Cumbria U.K.