The Speech On Parkinson s Disease Essay - 1314 Words

Imagine a scenario where our countries safety is in danger, and the president has to release our nuclear weapons at a specific time. What would happen if the president freezes, or has tremors and is not able to give the command at the correct time? The role of the President is very important to American society; Parkinson’s inhibits a person from completing daily or strenuous tasks. The video in question argues that Hillary Clinton is in the 1/100 percentile that has been diagnosed with Parkinson’s. Parkinson’s disease is a disorder of the nervous system that affects the movement of the body. Parkinson’s is caused by nerve cell damage in the brain, where brain cells are gradually breaking down and dying. This disease begins at a low rate; this stage is shown through tremors in the individual’s hands. While tremors are the warning signs of Parkinson’s disease, this disease can also cause an individual to have slow movements, rigid muscles, imp aired posture or balance, speech change and loss of automatic movements. Some complications that come from Parkinson’s are thinking difficulties, emotional changes, and sleep problems and disorders (Parkinson’s Disease, 2015). The video that we are using in this analysis is Hillary Clinton Illness Revealed, and it was found on YouTube. As a doctor, Ted Noel uses this video to help explore the possibility of Hillary Clinton having Parkinson’s disease. The analysis of Parkinson’s disease and the symptoms it expresses will help usShow MoreRelatedParkinson s Disease Is A Progressive Loss Of Functioning Of The Brain1361 Words   |  6 PagesIntroduction: Parkinson’s disease is a progressive loss of functioning of the brain that results in stiffness, trembling and loss of fine motor control. This disease mainly affects the neurons in the particular area called the substantia nigra with a total loss of dopamine, the absence of these dopamine-producing cells causes the loss of the brain’s ability to control the body movements progressively (Parkinson’s disease, 2016). Parkinson’s disease is very common, with about 70000 Australians asRead MoreImplement And Monitor Nursing Care For Clients With Chronic Health Problems1427 Words   |  6 Pages INTRODUCTION: Parkinson disease mainly defined as the death of certain brain cells. These brain cells mainly control the body parts movement and the coordination. The disease mainly decrease the mobility which leads difficulty in walking (Medline Plus, 2016). Currently, Parkinson has no known cause which mainly effect people to develop this disease. 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Once Parkinson Disease (PD)Read MoreThe Disease Of Parkinson s Disease1648 Words   |  7 Pages Abstract Parkinson’s disease has been cataloged as one of the most serious and slowly progressive neurodegenerative disease that affects a wide array of motor and non-motor aspects that impact the function of a person. Afflicting over four million Americans and the second most common neurological disorder after Alzheimer’s disease, Parkinson’s continues to take its toll on the neurological health of many(Constantinescu et al, 2007 ). James Parkinson, a British physician first coinedRead MoreSymptoms And Symptoms Of Parkinson s Disease Essay831 Words   |  4 PagesParkinson Disease by Melissa Green Topical Bibliography In partial fulfillment of the writing requirement for Anatomy and Physiology 304 and the Department of Speech-Language Pathology SUNY Buffalo State Fall 2016 Parkinson’s disease is a neurodegenerative disorder characterized by motor symptoms or tremors, rigidity, (bradykinesia) or slowness of movement and posture instability. Parkinson’s involves the malfunction and death of vital nerve cells in theRead MoreThe Common Types Of Dementia1013 Words   |  5 PagesIt’s a progressive disease which means it gets worse over time. If diagnosed early on, the quality of life for people with dementia as well as their family members can be significantly improved. There are many different types of dementias although some are far more reciprocal than others. One of the most common types of dementia is Alzheimer’s disease. Other few types of dementias are â€Å"Vascular dementia, Mixed dementia, Parkinson s disease and Frontotemporal dementia (Krishnan, D. S)†. All of the variousRead MoreParkinson Disease : A Brain Disorder1109 Words   |  5 Pages Parkinson Disease By Teri Gordon BIO 202 Harrisonburg Campus â€Æ' Teri Gordon BIO 202 Kevin Chakos Harrisonburg Campus Research Paper Parkinson Disease Parkinson Disease is a brain disorder that affects movement, loss of muscle control and balance. The first symptoms usually include a tremor of the hand, foot, or leg which is often termed as a â€Å"shaky palsy.† The disease usually slowly progresses with symptoms getting more intense over many years. Some patients who develop Parkinson’s inRead MoreParkinson s Disease : Disease3496 Words   |  14 Pages Parkinson s disease Twanda H. Lewis North Carolina Wesleyan Dr. Quinan Parkinson s Disease Twanda H. Lewis North Carolina Wesleyan Dr. Quinan Outline Abstract†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦5 Introduction†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 Symptoms†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 6 Tremor†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.†¦ 6 Slow Movement†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 Rigid Muscles†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 Disfigured Posture†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 Loss

City Planning City Building Infrastructure

Question: Write about theCity Planningfor City Building Infrastructure. Answer: Transport interchange is a designated designed area/place that facilitates the exchange of cargo and passengers between available means of transport the likes of vehicles, train, ships, aero plane among others. The interchange is mostly referred to as transport hub that includes bus stops, airports, ferries, and harbor and railway stations. Interchange creates opportunities for growth and development especially in transport sector that greatly contribute to positive growth in the economy. Most developed countries the likes of United Kingdom, United State Of America, Australia, Japan, China among others have witnessed the benefits associated with interchange terminal especially in urban set ups. Transport interchange in urban centers shapes peoples way of life through quick access to use of their land for economical purposes hence illustrating the interlink impact of transport system in metropolitan form. Its therefore not possible to separate transport interchange with the urban form basically because they mutually interrelate. However, transport interchange must always meet the required technical threshold capacity of operation so as to adequately serve the users efficiently. Interchange designing involves provision of architectural and engineering services in re-creation of transport hubs on the land and above sea as is being illustrated during construction of the Lake Macquerie Transport Interchange in West Australia where architects involved are skilled and experienced. An interchange should function smoothly for road operators the likes of pedestrians, self - propelling machines among other transport operators. Interchange construction involves parties with different expertise skills like architects, engineers, city planners, inter change designers experts, financers of the project and its operations. In Australia we have interchanges constructed to ease vehicle congestion in the just normal usable roads the like the one along Ryde Road whereby due to the high number of road users dropping off and picking up of passengers by the public vehicles used to create traffic since there were no transport interchanges along Ryde Road. Interchanges have greatly contributed to the growth of cities in Australia both economically and infrastructural. The City of Lake Macquarie and its suburbs is expected to growth better as the plan of constructing The Lake Macquarie Transport Interchange (LMTI) is underway. It will clearly illustrates how interchanges have impacted positively to development of cities in Australia. Lake Macquarie Transport Interchange is an expected important infrastructure in New South Wales whereby it will facilitate reliability in transport system through minimization of usage of vehicle as car transport as well as provision of economic, social welfare benefits to the community around. Transport hubs other than road means that have been seen over the years to dominate transport sector due to the good road network systems invested by the Australian Government there is investment done on rail, ship and of course air. Lake Macquarie Transport Interchange is likewise going to contribute to the social lives of the citizens of Glendale-Cardiff Area that is currently classified to be among the best super hub in the world. The interchange connects Glendale and Cardiff forming a transit that is to meet over the time transport needs of the dwellers of Lower Hunter. The easy accessibility nature of the interchange brought about by its strategic location nature to the Lake Macquarie and its environs is further going to be linked to the north-south rail line. Lake Macquarie Transport Interchange provides linkage to all modes of transport for purposes of enhancing economic levels and job opportunities. Cultural lifestyle of Lake Macquarie Community is nurtured by the civic opportunity spaces created by LMTI. This passenger transport interchange of Lake Macquarie facilitates drop off and pick up of passengers as they go to their day to day activities hence promoting inconveniences. Provision of car park bays by the interchange is also going to be of a great importance to the owners of Lake Macquarie City as well as to the city council of the city Council, (1998). Since Infrastructure is the key to economy development the need to invest on it is required. Australia has been at the forefront on this deeming it as key priority for development. This has been supported by the fact that weve numerus transport hubs all over the continent from transport system to environmental sustainability. Conservation of environment is further enhanced by regulating the emissions from vehicles as well as from greenhouse. LMTI is going to significantly impact the economic activities in Cardiff areas and Glendale upon completion. Its further expected to solve the current problem at Lake Macquarie of the frequent usage of private vehicles as a means of transport to other better efficient mode of transport. Generally LMTI is greatly going to create unimaginable railway and bus interchanges that links business and industrial center to the community around as well as reduction of traffic congestion in the city, improvement of pedestrians and cyclists bay hence reducing accidents. Great investments are expected in Glendale and Cardiff areas that will go hand in hand with creation of jobs as well as increase in economic activities, introduction of social amenities will like hospitals, schools, entertainments bazaars, tourism boosting and significantly improving peoples standard of living. Economically, socially and environmental wise great benefits resulting from the interchange of Lake Macquarie Transport is direly expected. This interchange will greatly provide solution to an efficient optional means of transport inclusiveness. The parties therefore should therefore be aware that interchange has both negative and positive impact on; Transport-whereby it eases and reduce traffic congestion as well as reduction of air pollution whereby vehicles arent spending most of their time in traffic with engines running, the parties involved both beneficiaries and non-beneficiaries should be aware of this positive impact of the interchange. It further provides quick access to good road network as it in seen North Western part of Australia whereby extensive mineral, agricultural and tourist development, needs were easily accessed to after construction of Mandurah Bridge in Northern Australia. Efficient movement of high traffic as well as the volumes of vehicles in urban sector contributes to development of infrastructures like recreation centers, industries, and social amenities in the city because of its easy accessibility nature. This greatly invites investors to come and invest their money hence help in the growth of the economy of the city. Economy in Sydney Australia has greatly improved over the years because of its financial strengths and market hence creating opportunities for investors. Most financial institution have invested in Sydney hence making it to be Asians best financial hub. Tourism has further contributed towards the growth of the economy whereby tourist visits Sydney to see man made features like Sydney Harbor Bridges that has great relation to the interchanges in Sydney. Sydney City has therefore rapidly developed as a result of the infrastructures features set in place interchanges greatly contributing to this as is seen in the images; However, traffic congestion reduction may fail to be achieved if there are no rules and regulation guarding access to intersecting highways that end up creating unfriendly and unsafe driving condition that creates disturbance on the freeway, therefore the body in charge of the transport should work on the aforesaid rule to safeguard freeways. Other road users the likes of the pedestrians, cyclists and runners may find it unsafe and uncomfortable to travel in the interchange therefore affecting their operations, hence the need to accommodate them may be through setting aside paths to be used by them or creation of foot bridges and tunnels to serve them. Planning Ideally to construct smooth interchange in an urban set up a need to plan is therefore required tasking designers, architects and engineers are to come up with landscape plan like the one used when constructing. Its achieved through implementation of policies and regulation framework set in place guarding construction of highway-road infrastructures like interchange. The need to seek approval from the sectors responsible for geology and environment is important in planning so as to provide assurance and compliance that the whole process is less harm to the environment both for fauna and flora just as witnessed in WestConnex whereby there was approval by the Minister of Planning to proceed with the construction. After ensuring compliance/approval of set regulations and framework in place the process is good to commence. However, its clear that its only through planning that; The land area for use in the construction of the interchange is set aside in a manner that There is no interference with the growth and development in the area. Factors that limits economic benefits to the community and that which put authorities In place under financial constraints are monitored and controlled effectively and progressively. Interchange urban planning dictates development to be set in place and the strategic location of the development as well. Planning involves different stake holders in this case it constitutes architects, engineers, city planners, inter change designers experts, financers of the project and that department of government that oversees and control the whole process. Its therefore clear that when interchange planning and plans involved in construction of the roads transport system are linked and synchronized towards the goal of provision of efficient transport services economic development benefits are attained. Failing to plan and improper planning creates unmanageable issues in the interchanges developments both after completion and before completion. The following are the repercussions of not planning while constructing interchange; Increase in traffic congestion Inadequate building setback Unplanned and excess number of access location. Incompatible multiple uses of land conflict whereby developments along an interchange constructed out of plan falls victim of noise and air pollution as well as traffic congestion. Urban Process Planning is a gradual current and long term processes that take place to achieve efficient maximum utilization of land, orderly development, provision of access by cyclists and pedestrians and finally upholding the standards of traffic carrying capacity ceilings. Interchange plan reality is achieved through zoning, access control and implementation of the set policy framework set in place guiding development of the interchange. Sydney is a city whereby motor vehicle is the common tool for transport and this was as result of good road network system especially as a result of the large number of interchanges that surround the city. Sydney citizens way of life has been made affordable because of the infrastructures available making Sydney to be classified as one of the best places to live in the world. Conclusively there is no now doubt that transport hubs significantly contributes to development both by infrastructure as well as economic wise. Australian citizens are the great beneficiaries of the interchanges constructed in respective places all over the country. This is well seen whereby yearly it doesnt miss people visiting the place because everything development wise and socially is in order. Mostly when there is growth in urban areas we like wise experience the same in its outskirts hence when interchanges are created in urban centers there is also the need to develop the same within the suburbs of the city and gradually going outside the city. This will assist interlink of infrastructures and transport system between urban to urban, urban to rural and finally rural to rural. When this is done development spreads across the country creating employment as well as boosting the economy of the state. Similarly equality and equity is witnessed among the provinces facilitating fair distribution of resources hence improving the standards of living of the communities around. Knowledge, skills, and abilities remain important for economic growth for a state. More fundamentally, the government in operations should always oversee the repair, maintenance of the transport interchanges by engaging the community voluntarily in the whole process of ensuring that the hubs are in a stable state i.e. if its the street lights they are in good order, if toilets they are clean and well maintained, if its drainage system its well maintained. This goes all the way to employing security personnel who will be ensuring that the facilities at the hub a re safe as well at the users of the Hub. Its through this act that full sense of ownership is felt by all parties hence working towards its improvement and upgrading it. Transport hubs has proved to be dynamic in the sense that it improves standard of livings as well the economy a city. References Stokes, G., 1994. The role of public transport interchange in improving public transport. In public transport planning and operations. Proceedings of seminar e held at the 22nd ptrc european transport forum, university of warwick, england, september 12-16, 1994. Volume Duc, E., Dick, H., Bohlsen, T., Squires, A., Christie, S. and Stewart, D., 2011. Hunter Public Transport Inquiry-the role of the professional. In Sustaining Our Regions: The Engineering Challenge: Proceedings of the 2011 Regional Convention, Newcastle Division, Engineers AustraliaHeld at University of New England, Armidale, NSW 16th-18th September 2011 (p. 35). Engineers Australia. Ghaderi, H., Cahoon, S. and Nguyen, H.O., 2015. An investigation into the non-bulk rail freight transport in Australia. The Asian Journal of Shipping and Logistics, 31(1), pp.59-83. Rauscher, R.C. and Momtaz, S., 2017. Planning in Greater SydneyParramatta City Case Study. In Cities in Global Transition (pp. 179-198). Springer International Publishing. Arndt, O., Cox, R., Lennie, S. and Whitehead, M., 2011. Provision of sight distance around concrete barriers and structures on freeways and interchanges. Transportation Research Record: Journal of the Transportation Research Board, (2262), pp.22-30. Walker, D.H. and Shen, Y.J., 2002. Project understanding, planning, flexibility of management action and construction time performance: two Australian case studies. Construction Management Economics, 20(1), pp.31-44. Hensher, D.A., 1998. The imbalance between car and public transport use in urban Australia: why does it exist?. Transport Policy, 5(4), pp.193-204. Council, L.M.C., 1998. Lake Macquarie Flood Study Part 1Design Lake Water Levels and Wave Climate Report. Manly Hydraulics Laboratory, Report MHL, 682. Siemiatycki, M., 2006. Message in a metro: building urban rail infrastructure and image in Delhi, India. International Journal of Urban and Regional Research, 30(2), pp.277-292. Kasarda, J.D. and Rondinelli, D.A., 1998. Innovative infrastructure for agile manufacturers. Sloan management review, 39(2), p.73. Bunker, R. and Troy, L., 2015. The changing political economy of the compact city and higher density urban renewal in Sydney. Feng, F.Y. and Murillo, J.A., 2000. Design and Construction of the I-15/US 95 Interchange, Stage 2. Concrete International, 22(6), pp.19-25. Garry Mason, B.E., BAppSC, M. and Craig Wooldridge Dip CEng, F.A.I.T.P.M., 2013. Coping with the boom: transport strategies for Perth, Australia. Proceedings of the Institution of Civil Engineers, 166(5), p.36. Mees, P. and Dodson, J., 2011. Public Transport Network Planning in Australia: Assessing current practice in Australias five largest cities. Research paper, 34. Balcombe, R., Mackett, R., Paulley, N., Preston, J., Shires, J., Titheridge, H., Wardman, M. and White, P., 2004. The demand for public transport: a practical guide. Ruming, K., Mee, K. and McGuirk, P., 2016. 3 Planned derailment for new urban futures?. Actor Networks of Planning: Exploring the Influence of Actor Network Theory, p.44. Lee, S.W., Song, D.W. and Ducruet, C., 2008. A tale of Asias world ports: the spatial evolution in global hub port cities. Geoforum, 39(1), pp.372-385.

Stakeholder Theory free essay sample

Before it was thought that business and ethics were an oxymoron, two terms that could never coexist together in our society, however this video on Stakeholder Theory has proven otherwise. The video talked about various ideas/topics concerning Stakeholder Theory from what is a stakeholder to the effects of technology in our fast paced society today. R. Edward Freeman started the video by explaining how stakeholder theory started off. He gave an example early in the video of himself and few colleagues who wanted to put out an article around 30 years ago presenting the idea of Stakeholder Theory through a local newspaper. The newspaper editor called back and advised Freeman he had a typo in the title from â€Å"Stakeholder† to â€Å"Shareholder. † At that time the newspaper editor had no idea there was a difference between the two. Well what is the difference? A shareholder owns part of the company through stocks, or other various forms. We will write a custom essay sample on Stakeholder Theory or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Stakeholders are not products, or accounts, or assets, but rather they are actual living, breathing humans with faces. Since they are actual humans they are also customers who are directly affected by the behavior of an organization and they hold a stake in its performance. The job of a stakeholder is to find an approach to value creation. In order to do so, they must find an intersection of interests; almost like a graph you would draw in economics where the supply and demand curve intersects creating equilibrium. To find intersects of interest it involves finding and searching for opportunity, or essentially the art of not having to make tradeoffs. Freeman gave us an example of tradeoffs and searching for opportunity. It involved a chemical company who was notorious for an extreme amount of pollution. The CEO had a change of heart and wanted to completely eliminate pollution and advised his engineers that they needed to figure out a way to end it. The engineers immediately responded and advised there was no possible way, so the CEO stated that they would have to shut down the company. Eventually, the engineers found a plan to help eliminate the pollution. In this example the company did not accept the trade-off. Long story short, if you look to see how interests go in the same direction, you might find a solution, but you might not find one either, but it’s better than not trying at all. Another example would be to think about this idea in terms of music. It’s as if everyone was playing different notes and their own instruments, but when they all work together and go in the same direction they may create a harmony. Stakeholder Theory was developed as a business strategy; however there was a sense of integration missing between the term business and ethics. This video helped explain that when thinking about stakeholders it’s thinking about business, but also when you’re thinking about stakeholders you must also think about ethics. So the idea of business and ethics being an oxymoron is senseless. This relates back to a topic titled â€Å"Saints and Sinners† that was featured in the film with R. Edward Freeman. He discussed that saints ran business ethically and the sinners paid no attention to ethics. However, why does it have to be one or the other? A business involves human beings and ethics is the study of human behavior. This is what Freeman was saying; these two terms correspond with each other. However, the Stakeholder Theory was also missing the integration among other areas. Managing for stakeholders is about what businesses and capitalism is. It’s also about ethics, strategy, corporate responsibility, civil society, but it’s mostly about all of that and how you put those things together and tell a new story about capitalism. In the end capitalism is about how we create value for each other, or our stakeholders, not about competition. How well we all cooperate with each other helps determine the amount of value we can create for each other, which in turn creates more trust, because when the public doesn’t trust a business, who does? Stakeholder Theory is complex when you have to take the time to write it out and explain it, but if you take a step back and look at businesses today, you will see Stakeholder Theory is a very common, everyday theme, it is just a matter of what you are looking for. If individuals are looking for tradeoffs, they will find a multitude of tradeoffs available for them, but the real success lies with those who achieve and find the integration and intersection point of everything that really matters in capitalism, creating Stakeholder Theory. Stakeholder Theory free essay sample Part A: Introduction – Organisation background Part B: Market Stakeholders for BIFF Sdn Bhd 1. Supplier 2. Customer 3. Employer Part C: Non Market Stakeholders for BIFF Sdn Bhd 1. Local Community 2. Media 3. Government Part D: Suggestion on how to develop and maintain the relationship with identified stakeholders 1. Have a direct dialog 2. Provide variety of monitoring method 3. Organise activity to develop interest of stakeholder Part E: Conclusion References 2 OUMM 3203 INTRODUCTION Berkat Ilham Frozen Food Sdn Bhd is a frozen food supplier. This company was founded on 26th December 2000 and began commercial operation in 2002. It was located at Bandar Baru Senawang, Negeri Sembilan. It now has 100 staff including General Manager, Human Resource Manager, Quality Safety Manager, Sales Manager, Finance Manager, Production Manager and Logistic Coordinator. The products offered are of various type of local food and western food that has been upgrade as a frozen food to fulfil the customers need. This business was inspired by former curry puffs maker that doing business in small scale, after getting guidance from FAMA on frozen food processing and technical advice in this process, it has been commercialise to support food market business. We will write a custom essay sample on Stakeholder Theory or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page This product has been supply to all 711, Hypermarket, Mini Market and also to the cafeteria around Negeri Sembilan. Now this company are planning to expand their business worldwide through Small Medium Enterprise under guidance of government. Our Mission ? To become the pioneer in the food and beverage industry through our high quality food and beverage variety as well as superior customer service. ? To select, retain and educate a highly skilled, motivated and responsive staff for the growth of the organization and the nation. ? To meet all challenges with dedication and commitment and to set standards that other will strive to emulate. ? To become 1st Halal food supplier that will be recognise worldwide. Source from: http://foodking. com. my/about-us/ 3 OUMM 3203 An organization chart for Berkat Ilham Frozen Food Sdn Bhd. General Manager Secretary Human Resource Manager Quality Safety Manager Sales Manager Finance Manager Production Manager Asst. HR Manager QC Supervisor Asst. Sales Manager Asst. Finance Manager Production Supervisor Clerk 1 Incoming QC Clerk 2 Process QC Accountant Logistic Coordinator Logistic Supervisor Technician General worker Finish Product QC Document Controller 4 OUMM 3203 PART B : MARKET STAKEHOLDERS FOR BIFF SDN BHD Stakeholder has been defining as a person, group or organization that has interest or concern in an organization. They can affect or be affected by the organizations actions, objectives and policies. Some examples of key stakeholders are creditors, directors, employees, government (and its agencies), owners (shareholders), suppliers, unions, and the community from which the business draws its resources. Source from : http://www. businessdictionary. com/definition/stakeholder. html 1. Supplier A party that supplies goods or services. A supplier may be distinguished from a contractor or subcontractor, who commonly adds specialized input to deliverables. Also called as vendor. To ensure that there is enough ingredient for production to run. It is important to ensure that the supply will be available on time. For that the reliability of the contract and guaranteed of payment within stipulated period should be given priority. Source from: http://www. businessdictionary. com/definition/supplier. html 1. 1 Reliability of contract With the reliability of contract give. It will ensure that the ingredient will be supply as per quality requirement and reduce the market price from fluctuation. By signing a contract, they are bound to fulfil to the company quality and standard requirement to ensure that this problem will not affect our productivity and it also it will help to ensure there is no contract fraud occurs. With good supplier we can maintain our quality and productivity. 5 OUMM 3203 1. 2 Method of payment It is importance in order to be reassure the business growth , the payment are expected to be paid promptly to ensure both party interest being maintain so as to assure business growth, payment is expected to be paid promptly to ensure the interests of both parties can be maintained for a longer period. In the meantime the confidence should be planted so that the quality of materials is maintained. 2. Customer A party that receives or consumes products (goods or services) and has the ability to choose between different products and suppliers. Source from: http://www. businessdictionary. com/definition/customer. html When we look from the point of view of the customer, they are the consumer of our product. It show that the important role as a major stakeholder and give big influence in our market. Their exclusive power will influence local community. Therefore it is important to get their attention and to gain their trust. 1. 1 Quality and variety of food. It is important to ensure the quality and variety of food accordance with international food standards set by the Ministry of Health Malaysia and Good Manufacturing Product (GMP). It will help to gain customer confidence in our product quality. It will also help to promote our product variety. When we can met this requirement. There is no reason the we can’t fulfil customer needs. 2. Employer A legal entity that controls and directs a servant or worker under an express or implied contract of employment and pays (or is obligated to pay) him or her salary or wages in compensation. 6 OUMM 3203 Source from: http://www. businessdictionary. com/definition/employer. html Next we evaluate from the point of view of those employee under the company. They are the assets of our productivity in daily operation. Therefore, any change of policy or management will be affecting the performance of company. Proper planning and benefit to gain interest of the employee will help to gain productivity. It is important to get cooperation from employee in order to achieve our mission. 2. 1 Change working hour Due to productivity, it is important to plan effective working hour without sacrifice our productivity. Proper arrangement man power according to working hour provided will help them to give full commitment in their work. Without proper planning there will be wasting of time. 2. 2 Welfare Offer to the employees To gain interest of the employee the suitable offer is necessary gain their interest. Therefore employee welfare should be taken care. Most of employee are having a family, so one aspect that always been taking care by every company is medical coverage for the family. 2. 3 Skill requirement It is important to train employee to specialize in certain job scope in order to maintain the quality of product but it is also important to create proper work design, therefore they will not get easily bored doing the same thing every day. It also will help productivity and maintain the productivity since everyone can cover other works without affecting the productivity. 7 OUMM 3203 PART C : NON MARKET STAKEHOLDERS Non market stakeholder refers those who although they do not engage in direct economic exchange with the business are affected by or can affect its actions. Source from : http://en. wikipedia. org/wiki/Stakeholder In regard of the food industry, examples of non-market stakeholders classify to the local communities, the media and the government. I. Local community The factory has been built in the industrial area that has good environment and proper access. So that the products are easily being distributed to local community and also to ensure that the products reach the consumer without delay. Local community also play important roles in order to get fast feedback regarding our product. Therefore direct feedback are being practice to ensure that we can fully understand what are their need. II. Media Media is one of important part to ensure that the community are being update by our product. It also playing an active role in conjunction to report on the activities on the local communities by highlighting the product promotion. Indirectly, it’s act as a bridge to communicate in between the local resident. As a consequence, the positive image will be gain through advertisement in the media. Therefore, media plays an active role to connect the people and breaking the barriers among the community. III. Government By setting up a Frozen Food Industry, there are numbers of rules and regulation been set up to ensure the quality and nutrition of food. For example, Good Manufacturing Product, Malaysia Halal Procedure, Malaysia Diet Guide from Ministry of Health. This guideline will help to ensure all the product will be complying with the requirement therefore is will help the consumer safety from food poisoning. In order to ensure that there is no violation of rules. 8 OUMM 3203 Inspection will be done time to time from Health Department and Jabatan Kemajuan Islam Malaysia (JAKIM). The certificate will be renewing yearly to avoid halal certification withdrawn. In this we will gain trust from the community. For the local community it is important to have this kind of certificate. It will help customers to not hesitate doubt about our prducts. PART D : WAYS TO DEVELOP AND MAINTAIN RELATIONSHIP WITH STAKEHOLDERS It is important to build strong and continuous relation with the stake holder in order to achieve company goal and maintain good relationship. There are several ideas had been decide as mention below: 1. Open feedback During feedback period we can solve and minimize the risk about product quality. In order to find out the need and requirement of the utmost important customer to them, the management will conduct an internal review meeting and report to the quality department for improvement. With fast feedback we can gain customer satisfaction. It is important to get customer satisfaction in our product because it will increase our business. 2. Promotion of product through media. Print and electronic media play an important role in promoting the products. By using the right advertising we are able to ensure that the information related to the products reaches the users. For example, nutrients found in each product. The products produced by this company can also be identified to ensure that no counterfeit products in the market. This is to ensure that the customer will get our product without been cheat. 9 OUMM 3203 3. Organise Activities To manage a close relationship with their stakeholder in term of maintaining each other continuous interest in the business. By organizing activities such as Family Day, Sport Day, Concert and etc. could serve as an effective communication for all stakeholders. It also can remove barrier between stakeholder in order to get good cooperation. It can be done without sacrifice code of ethic. 10 OUMM 3203 PART E : CONCLUSION Stakeholder theory has its origins in the field of strategy (Freeman 1984). ‘The stakeholder theory is â€Å"managerial† and recommends the attitudes, structures, and practices that, taken together, constitute a stakeholder management philosophy’ (Donaldson and Preston 1995, p. 87). It has gradually been adopted by scholars in the business and society fields. Stakeholder management has been utilised as the leading red line through several recent handbooks on business ethics (e. g. , Crane and Matten 2004; Carroll and Buchholtz 2006). It has become the grille de lecture in the analysis of corporate responsibility (Attarc? a and Jacquot 2005). The stakeholder approach has, therefore, come to be presented as a theory of ethics for the business world. A pragmatic conclusion that could be deduced from the present analysis of stakeholder reciprocity, seen as reciprocity in stakeholder responsibility, is that while the impact of stake watchers on corporations has to be studied from a strategic point of view when using the stakeholder theory, pressure groups and stake watchers formulate their strategy using a political resources perspective that ignores the ethical dimension of stakeholder theory. Various categories of stakeholders demonstrate different stakeholder attributes. If one considers the broader definition of stakeholders, including stake watchers and other stakeholders that lack a need or obligation for reciprocal loyalty, then the stakeholder concept is applied from a strategic theory perspective that corresponds to the instrumental genre of stakeholder theory. In a more restricted interpretation of the stakeholder, limited to stake owners or genuine stakeholders who reciprocate loyalty, responsibility and fairness, stakeholder theory could constitute an ethical framework. Corporate social responsibility then implies corporate stakeholder responsibility. For stake owners, there is congruence between the company’s legitimate objectives and the process of value creation for all stakeholders. Stake owners own and deserve a stake in the firm. Our analysis of stakeholder reciprocity has practical implications for corporate governance. A stream of studies on stakeholder theory and corporate governance has 11 OUMM 3203 investigated new ways to integrate more stakeholders into the governance of corporations through representation on the governing boards of directors. Stakeholder reciprocity could be an innovative criterion in this corporate governance debate. The analysis presented in this article argues for new criteria that will confer representation on loyal stakeholders who respect stakeholder reciprocity and who contribute to the process of value creation. Within existing corporate law and governance principles, it suggests, at the very least, restricting voting rights to loyal shareholders with a long-term commitment. Our approach is based on ‘normative cores’ (Freeman 1994; Phillips et al. 2003) because reciprocity and stake-holder responsibility towards the firm and towards the other stakeholders falls within the ethical genre of stakeholder theory. It also meets the essence of stakeholder theory. (Fassin, Aug 2012) In this stakeholders studies we can see how important for us to maintain a good relationship with the stakeholder without scarifies our quality. It had been widely gaining recognition to be focus on the key parties that important to the organisation. Stakeholders are the person who be holding the same perception and have vested interest about the service deliver by the organisation. No doubt stakeholders need and satisfactory is the utmost important when running the day to day business, In this case study stakeholders we can see how important it is for us to maintain a good relationship with stakeholders without scarifies our quality. Recognition is important for all parties to ensure that the focus of the parties that are significant for the organization. Stakeholders are the people who hold the same perception and an interest in the services delivered by the organization. No interested party should satisfy skeptical and are important when conducting day to day business. 6 sample sets as relevant stakeholders here are suppliers, customers and employees. Closely related to their business. This is a group of people who have high expectations from the organization. Meanwhile, the non- interested parties such as the media, government and the community is a group of people who have no direct interest as strong as stakeholders but however each party will change either after both indirect basis. By looking at the important role of stakeholders, so many different ways have been proposed to maintain in the long run. The most important way to keep long-term 12 OUMM 3203 relationship is to keep them to join and become part of all activities. When they go into the atmosphere, a better understanding can be sent to either the appropriateness of goals for yourself or a specific organization, especially in online promotion where participation is an important part of success. We can see clearly the important and role of stakeholder that affect our business. With proper arrangement and communication we able to achieve our goals.

Biography of Margaret of Anjou, Henry VIs Queen

Biography of Margaret of Anjou, Henry VI's Queen Margaret of Anjou (March 23, 1429–August 25, 1482) was the queen consort of Henry VI of England and a leader of the Lancastrian side in the  Wars of the Roses  (1455–1485), a series of battles for the English throne between the houses of York and Lancaster, both of which descended from Edward III.  Her marriage to the ineffectual, mentally unbalanced Henry VI was arranged as part of a truce in another conflict, the  Hundred Years’ War between  France  and England.  Margaret appears many times in William Shakespeares history plays. Fast Facts: Margaret of Anjou Known For: Henry VIs queen and a fierce partisanAlso Known As: Queen MargaretBorn: March 23, 1429, probably in PontMousson,  FranceParents: Renà © I, Count  of  Anjou; Isabella, duchess of LorraineDied: Aug. 25, 1482 in Anjou province, FranceSpouse: Henry VIChild: Edward Early Life Margaret of Anjou was born on March 23, 1429, probably in PontMousson,  France, in the Lorraine region. She was raised in the chaos of a family feud between her father and her fathers uncle in which her father, Renà © I, Count  of  Anjou and King of Naples and Sicily, was imprisoned for some years. Her mother Isabella, duchess of Lorraine in her own right, was well educated for her time. Because Margaret spent much of her childhood in the company of her mother and her fathers mother, Yolande of Aragon, Margaret was well educated as well. Marriage to Henry VI On April 23, 1445, Margaret married Henry VI of England. Her marriage to Henry was arranged by William de la Pole, later duke of Suffolk, part of the Lancastrian party in the Wars of the Roses. The marriage defeated plans by the House of York, the opposing side, to find a bride for Henry. The wars were named many years afterward from the symbols of the contending parties: the white rose of York and the red of Lancaster. The king of France negotiated Margarets marriage as part of the Truce of Tours, which gave control of Anjou back to France and provided for peace between England and France, temporarily suspending the fighting known later as the Hundred Years War. Margaret was crowned at Westminster Abbey. Henry had inherited his crown when he was an infant, becoming king of England and claiming kingship of France. The French dauphin Charles was crowned as Charles VII with the aid of Joan of Arc in 1429, and Henry had lost most of France by 1453. During Henrys youth, he had been educated and raised by Lancastrians while the duke of York, Henrys uncle, held the power as protector. Margaret played a significant role in her husbands reign, responsible for raising taxes and for match-making among the aristocracy. In 1448, she founded Queens College, Cambridge. Birth of an Heir In 1453, Henry was taken ill with what has usually been described as a bout of insanity; Richard, duke of York, again became protector. But Margaret of Anjou gave birth to a son, Edward, on Oct. 13, 1451, and the duke of York was no longer heir to the throne. Rumors later surfaced- useful to the Yorkists- that Henry was unable to father a child and that Margarets son must be illegitimate. Wars of the Roses Begin After Henry recovered in 1454, Margaret became involved in Lancastrian politics, defending her sons claim as the rightful heir. Between different claims to succession and the scandal of Margarets active role in leadership, the Wars of the Roses began at the battle of St. Albans in 1455. Margaret took an active role in the struggle. She outlawed the Yorkist leaders in 1459, refusing recognition of York as Henrys heir. In 1460, York was killed. His son Edward, then duke of York and later Edward IV, allied with Richard Neville, earl of Warwick, as leaders of the Yorkist party. In 1461, the Lancastrians were defeated at Towton. Edward, son of the late duke of York, became king. Margaret, Henry, and their son went to Scotland; Margaret then went to France and helped arrange French support for an invasion of England, but the forces failed in 1463. Henry was captured and imprisoned in the Tower of London in 1465. Warwick, called Kingmaker, helped Edward IV in his initial victory over Henry VI. After a falling out with Edward, Warwick changed sides and supported Margaret in her cause to restore Henry VI to the throne, which they succeeded in doing in 1470. Warwicks daughter Isabella Neville was married to George, duke of Clarence, son of the late Richard, duke of York. Clarence was the brother of Edward IV and also brother of the next king, Richard III. In 1470, Warwick married (or perhaps formally betrothed) his second daughter Anne Neville to Edward, prince of Wales, son of Margaret and Henry  VI, so both Warwicks bases were covered. Defeat and Death Margaret returned to England on April 14, 1471, and on the same day, Warwick was killed at Barnet. In May 1471, Margaret and her supporters were defeated at the battle of Tewkesbury, where Margaret was taken prisoner and her son Edward was killed. Soon afterward her husband, Henry VI, died in the Tower of London, presumably murdered. Margaret was imprisoned in England for five years. In 1476, the king of France paid a ransom to England for her, and she returned to France, where she lived in poverty until her death on Aug. 25, 1482, in Anjou. Legacy As Margaret and later Queen Margaret, Margaret of Anjou has played major roles in various fictional accounts of the tumultuous era. She is a character in four of William Shakespeares plays, all three Henry VI plays and Richard III. Shakespeare compressed and changed events, either because his sources were incorrect or for the sake of the literary plot, so Margarets representations in Shakespeare are more iconic than historical. The queen, a fierce fighter for her son, her husband, and the House of Lancaster, was described as such in Shakespeares The Third Part of King Henry VI: She-wolf of France, but worse than wolves of France, Whose tongue more poisons than the adders tooth Always strong-willed and ambitious, Margaret was relentless in her efforts to secure the crown for her son, but she ultimately failed. Her fierce partisanship embittered her enemies, and the Yorkists didnt hesitate to allege that her son was a bastard. Sources Margaret of Anjou. Encyclopedia.com.Margaret of Anjou: Queen of England. Encyclopedia Britannica.Margaret of Anjou. New World Encyclopedia.10 Facts About Margaret of Anjou. Historyhit.com.

Alzheimer's disease Essay Example | Topics and Well Written Essays - 250 words

Alzheimer's disease - Essay Example It has a slow development and normally starts after the age of sixty (Medline Plus, 2010). The short-term memory is disturbed while long-term memory is still there. The patient starts losing control over his language, reading and writing skills. He begins to forget the names of acquaintances, relatives or even members of the family. When the disease starts getting worse, the patient may even forget how to eat, drink or go to toilet. Stage 1, mild stage, has symptoms like losing way, trouble in calculating bills, asking something repeatedly, taking longer to perform daily tasks, putting things in weird places, and showing attitude problems. Stage 2, moderate stage, shows symptoms like requiring assistance in performing daily tasks, forgetting recent happenings and acquaintances, mixing up distant past with recent past, having language problems, and wandering away. Stage 3, severe stage, has symptoms like being unable to feed oneself, control bowel and urinary movements, speak, read, w rite or recognize members of the family. Memory vanishes away totally (American Health Assistance Foundation, 2010). References American Health Assistance Foundation. (2010). Alzheimer's symptoms & stages. Alzheimer’s Disease Research.

Drugs and Economic Factors on crime Essay Example | Topics and Well Written Essays - 1500 words

Drugs and Economic Factors on crime - Essay Example Pennsylvania in 2000 had approximately a population of 12,281,054. For the year 2000 the State of Pennsylvania had a total crime index of 2,995.3 reported incidents per 100,000 people. Pennsylvania had the 43rd highest total crime index. Pennsylvania had an incident rate of 420.0 per 100,000 people for offences which were violent in nature. The state was ranked as having the 23rd highest occurrence for violent crime among the states. Washington D.C. unlike cities like Pennsylvania has very stringent gun restriction laws. These gun restrictions have not proved to be really effective. The crime rate of Washington D.C. is very high compared to the other neighboring states like Pennsylvania which do not have gun restriction laws. A review of the areas in the United States has shown that areas like Washington D.C., Chicago, New York which have the most regulative gun laws have the highest violent crime rate. Areas in the U.S. with have fewer gun control laws and higher gun ownership also surprisingly has the least crime rate Some scholars like John Lott believe that more gun restrictions lead to increased crime and violence. But scholars like Steven Levitt advocate that neither the presence nor absence of gun control laws have any significant effect on the crime rate. Steven Levitt believes that legalized abortion is one of the most important factors responsible for the crime rate in U.S. Levitt in his book Freakonomics has argued in favor of legalized abortion as the single most important factor responsible for reducing violent crime in U.S. ... Levitt has shown from statistics that legalized abortion has contributed immensely in bringing down the crime rate because he is of the opinion that unwanted children commit more crimes than wanted children. The legalization of abortion has resulted in fewer unwanted children and thus has helped in the reduction of crime over the years (Levitt, 2006). Even a comprehensive review of the published studies of gun control in 2004 by the Centers for Disease Control and Prevention was also unable to arrive at any statistically significant effect that either the pro gun or no gun laws had on the crime rate. (Gun Politics, 2006) A recent study in the journal of the American Medical Association has reported that the 1994 Brady Law has done effectively nothing to reduce the crime rate. Thus it can rightly be said that gun control schemes have no relation to crime or to prevention of brutality (Blanks, n.d.) But the supporters of gun control believe that the crime rate can only be brought down through effective gun control. These supporters by believing so overlook the multifaceted factors responsible for crime and violence (Blanks, n.d.) Thus it is a fallacy to suppose that gun control laws will help to reduce crime and violence in the United States. It is an erroneous belief because then the areas with most guns would not have had the least crime rates. There are multiple factors responsible for crime and violence. If the crime rate has to be reduced then unlawful drug use and addiction, age demographics and poverty are the areas that have to be improved and worked upon. There are multiple population characteristics. Age is one of them. It is widely believed that rising teenage population leads to increase in the crime rate. A separate juvenile justice system is gradually

Case Study of diagnosis and treatment of Gout

Case Study of diagnosis and treatment of Gout A 50 year-old male presented for an evaluation of rapid onset of pain and swelling in his right toe. The patient reported that he had two similar previous episodes with the same symptoms lasting four to five days and was treated by emergency physicians. The patientà ¢Ã¢â€š ¬Ã¢â€ž ¢s past medical history is significant for hypertension and treated with Hydrochlorothiazide. The review of systems was negative for headache, fever, chills, rash, earache, sore throat, cough, rhinorrhea, vision changes, weight loss, or change in appetite or disposition. The patient was afebrile, and this blood pressure was slightly elevated. PHYSICAL EXAMINATION: General: The patient is a pleasant male who appears to be in no apparent distress. Vital Signs: blood pressure 123/48, heart rate 76, Temperature 38.3 and 98% on room air. HEENT: Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Neck: Supple. No jugular vein distention noted. No carotid bruits noted. Lungs: Clear to auscultation bilaterally. No wheezes, rubs or rhonchi. Heart: Regular rate and rhythm. Normal S1, S2. A 2/6 to 3/6 systolic ejection murmur at the right upper sternal border. PMI is nondisplaced. Abdomen: Notable for laparoscopy surgical wound. Positive bowel sounds. Extremities: MTP is red, hot and swollen. Neurologic: The patient is alert and oriented x3. No focal neurologic deficits noted. Pathophysiology Gout is an inflammatory disease characterized by the deposition of uric acid crystals in and around joints, subcutaneous tissues, and kidneys. Although men and women are equally affected by gout, men are six times more likely to have serum concentrations above 7 mg per dL. Gout typically occurs during middle age and is uncommon before the age 30 years old. Women rarely have gouty arthritis attacks before menopause 1. Clinical Presentation Gout attacks are usually associated with precipitated events. Patients usually present with rapid onset of severe pain, swelling, redness, and warmth in one or tow joints. This pain and inflammation are caused by inflammatory response. Acute attack untreated attacks usually last two to 21 days depending on cases. There are four clinical stages of gout according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). The first stage is known as asymptomatic hyperurecemia. During this stage, the patients can have an elevation of uric acid in the blood but they do not have any symptoms yet. After more and more urate deposits around a joint and if any trauma triggers the release of crystal into the joint space, patients will suffer acute attacks of gout. This second stage is known as acute gouty arthritis. The third stage, known as interval or intercritical gout, involves the interval between acute flare gout attacks with persist crystals in the joints. When crystals deposits continue to accumulate, patients are likely to develop chronically stiff and swollen joints. This stage is called chronic tophceous gout. Some permanent damage to affected joints and sometimes to kidneys can be seen. This advanced stage is relatively uncommon if patients receive proper treatment. Differential Diagnosis Gout in the elderly is often polyarticular and involves upper extremity joints (especially proximal interphalangeal joints and distal interphalangeal joints). Women present 70% of the time with polyarticular disease rather than the classic monoarticular arthritis seen in men. Gout can be mistaken for rheumatoid arthritis because tophi may resemble rheumatoid nodules and rheumatoid factors often become weakly positive as people age. It may be difficult to differentiate cellulitis or septic arthritis from gout, particularly when a fever, leukocytosis, redness, or desquamation is present. The term pseudogout, for calcium pyrophosphate deposition disease, belies the difficulty in clinically differentiating it from gout. For definitive diagnosis, joint fluid must be aspirated for culture and a search for urate crystals. Diagnostic Test The gold standard diagnostic test for gout is an arthrocentesis. The American College of Rheumatology has established 12 clinical criteria, 6 of which a patient must have for diagnosis. * Maximum joint inflammation within 1 day * More than one attack over time * Monoarticular arthritis (although gout can be polyarticular) * Redness of joint * Great metatarsophalangeal pain or swelling * Unilateral great metatarsophalangeal involvement * Unilateral tarsal involvement * Suspected tophus * Hyperuricemia * Asymmetrical swelling within the joint on x-ray * Subcortical cysts without erosion on x-ray * Joint fluid culture negative for organisms during attack Treatment and Management The gold of treating gout is to minimize or eliminate the urate crystals from the joints and other structures associated with them. Several aspects must be taken into consideration and each treatment regiment is varied from patients to patients. The three main objectives that FNP take into consideration are treatment for the acute attacks, prophylaxis against recurrent attacks, and management of hyperurecemia. Asymptomatic hyperurecemia: urate-lowering drugs is not recommended to treat patients with asymptomatic hyperurecemia. If hyperurecemia is identified, underlying causes such as obesity, hypercholesterolemia, alcohol consumption, and hypertension should be addressed. Acute gout: NSAIDs are being used as first-line therapy. Indomethacin (Indocin), ibuprofen (Motrin), naproxen (Naprosyn), sulindac (Clinoril), piroxicam (Feldene) are also effective against gout. Corticosteroids: intra-articular, intravenous, intramuscular or oral corticosteroids are effective in acute gout. When one or two joints are involved, intra-articular injection of corticosteroid can be used. Intramuscular triamcinolone acetonide is as effective as indomethacin in relieving acute gouty arthritis. Triamcinolone acetonide is especially useful in patients with contraindication to NSAIDs. Oral prednisone: is an option when repeat dosing is anticipate. Prenisone, 0.5 mg per kg on day 1 and tapered by 5 mg each day is effective. Cochicine is also effective treatment for acute gout. However, majority of patients experience gastrointestinal side effects, including nausea, vomiting, and diarrhea. Patient Education If they are obese, they should be advised to begin a concerted program of supervised weight reduction (see Chapter 233), but to avoid starvation or very low calorie diets that may only exacerbate the risk of gout. Drinkers should be warned against binges. Maintenance of good hydration needs to be stressed to those at risk for nephrolithiasis. On the other hand, patients will find it comforting to know that severe dietary restrictions are unnecessary. Fasting should be avoided because it may precipitate an attack. The importance of treating an acute attack at the first sign of illness also needs to be stressed. For the patient with interval gout, a discussion of the risks and benefits of prophylactic therapy and the importance of compliance is indicated. Those taking allopurinol should be warned of the risk of a hypersensitivity reaction and advised to cease intake immediately and call the physician at the first sign of a rash, fever, or other manifestation. Pain management is the pri mary concern during acute phase of and attack. The patient should be advised to take analgesic medications as schedule. The joint should be rested as much as possible in a position of comfort. Ice, not heat, may help with reducing discomfort. Conclusion Gout is one of the most causes of acute monoarticular arthritis. Primary gout runs in families and follows multifactorial inheritance. The expanded use of agents that decrease uric acid excretion has significantly increased the incidence of secondary gout. The Fremingham Study suggested that almost half of new cases were associated with thiazide use. The FNP should be able to properly diagnose acute gout, treat it, prevent recurrence, and minimize the chances for the development of chronic gouty arthritis. Patients who present with asymptomatic hyperuricemia should be further investigated to prevent complications from this disorder.