Mystery of capitalism

In the book ‘the mystery of capitalism: Why Capitalism Triumphs in the West and Fails Everywhere Else† Hernando De Soto, the Peruvian economist presents a detailed study of several countries and their failure to benefit from capitalism. It is important to mention here that while most economists understand that land is as important a factor of production as liquid capital still many have failed to understand the significance of property and property rights when it comes to the success of a particular economic system. The core purpose of writing this book is to answer the question that the author has posed in the very first chapter: â€Å"But if people in countries making the transition to capitalism are not pitiful beggars, are not helplessly trapped in obsolete ways, and are not the uncritical prisoners of dysfunctional cultures, what is it that prevents capitalism from delivering to them the same wealth it has delivered to the West? Why does capitalism thrive only in the West, as if enclosed in a bell jar?† While we are aware of the fact that land itself is important, we rarely ever delve deeper into this subject to find out how property and its legal rights can play a vital role in the success or failure of an economic system. This is where Hernando De Soto stepped in and has offered a detailed study of property and its legal title in various poor countries with reference to capitalism in those areas. The main purpose of this book is to illustrate the reasons why capitalism has failed in poor countries and why only the developed countries in the West have been able to benefit from this system but the book carefully ignores the reasons which other economists have mentioned often and only focuses on property and its role in the economic system. The author maintains that failure of this system in poor countries is a cause of concern not only for the developing countries but also for the West. â€Å"In the business community of the West, there is a growing concern that the failure of most of the rest of the world to implement capitalism will eventually drive the rich economies into recession. As millions of investors have painfully learned from the evaporation of their emerging market funds, globalization is a two-way street: If the Third World and former communist nations cannot escape the influence of the West, neither can the West disentangle itself from them. Adverse reactions to capitalism have also been growing stronger within rich countries themselves.† It is clear from his book that the most important reason why capitalism has failed to influence the poor countries is because of the difficulties involved in getting legal title to property that poor sections of the society hold. The western countries fail to understand that capitalism is not exactly about growth of Internet or globalization, it is essentially concerned with movement of capital. It is important to mention here that DE SOTO believes that property is not important only because it provides security and a place to dwell in, but its significance lies in he fact that it is an asset, the problem with poor countries is that while a large section of the society possesses this asset, many of them do not have legal rights to those pieces of land. As a result of which they cannot use this land for any other purpose except accommodation. â€Å"Most of the poor already possess the assets they need to make a success of capitalism. But they hold these resources in defective forms. †¦ They lack the process to represent their property and create capital. They have houses, but not titles. It is the representation of assets in legal property documents that gives them the power to create surplus value.† We need to understand that property is a fixed asset and it can be used for several other purposes including collateral. But since the poor sections of the society do not have legal title to the piece of land they hold, they cannot use it as a source of capital, which is the reason why only western countries have, been able to benefit from capitalist system of economy. He is of the view that every person in small developing countries possess immense talent to mint money and engage in business activities successfully but the problem is that since they are not capable of becoming legal owners of the property that they otherwise own unofficially, their access to finances is also limited. The author has also carefully studied the views and theories of various economists from Adam Smith to Karl Marx in order to make the readers understand why capital plays an essential role in capitalist system of economy and why property is the backbone of this system. The author has also focused on the failure of communism and then builds a strong case in connection with failure of capitalism in developing countries. â€Å"Marx said that you needed to go beyond physics to touch â€Å"the hen that lays the golden eggs†; Adam Smith felt you had to create â€Å"a sort of waggon-way through the air† to reach that same hen. But no one has told us where the hen hides.† There is a new concept of ‘dead capital’ presented in this book. Hernando De Soto is of the view that the assets which cannot be used in place of capital becomes dead capital as it has no other value than the one purpose for which it was originally owned. He presents the example of some poor cities including Cairo, Lima, Manila, Mexico City and Porto Prince and shows how these cities are suffering from abundant dead capital. For example in Cairo, the city possesses dead capital worth $ 241.4 billion, which is six times more than the total value of all saving deposits in Egyptian banks. The country itself is thus suffering from its dead assets because they cannot be used as capital and therefore the economic system has failed to reap benefits of capitalism. This brings us to another important question. Why don’t people who unofficially own a piece of land try to gain legal rights to their property? It is a very important question because the answer to it also highlights the dismal performance of various economic and administrative units of developing countries. There are so many difficulties involved in legalizing a piece of property and usually the process takes so long that most poor people simply do not bother to get legal rights. For example in Egypt it takes some 31 agencies and 5-14 years to legally own a piece of land and close to 77 steps are involved in this process. De Soto has taken a serious look at the situation that has consistently suppressed Third World countries. He argues that people in these countries are constantly being oppressed because they lack knowledge about legal rights to property and their governments fail to offer adequate help. Karl Marx first discussed the function of property or its role in the development of nations in detail and De Soto recognizes his contribution. He argues that when property is legally recognized, it is only then that poor people can use it in the way that would be productive and lucrative. Without legal rights to a piece of property, its occupation comes to no production use. De Soto maintains that property rights do not only facilitate legal and productive use of land, they also offer host of other benefits such as creating a sense of responsibility, more commitment from citizens, more politically aware people etc. The most important lesson of the book is the topic of extra-legality. This refers to the sector of illegal property that has created extra-judicial ways to gain and use property. It was removed from West in the 19th century but still plagues third world countries. De Soto writes: â€Å"†¦ The reason capitalism has triumphed in the West and sputtered in the rest of the world is because most of the assets in Western nations have been integrated into one formal representational system.† (p. 52) explaining the way West got rid of extra-legality, De Soto further adds that, â€Å"This integration did not happen casually. Over decades in the nineteenth century, politicians, legislators, and judges pulled together the scattered facts and rules that govern property throughout cities, villages, buildings, and farms and integrated them into one system. This â€Å"pulling together† of property representations, a revolutionary moment in the history of developed nations, deposited all the information and rules governing the accumulated wealth of their citizens into one knowledge base. Before that moment, information about assets was far less accessible. †¦For knowledge to be functional, advanced nations have to integrate into one comprehensive system all their loose and isolated data about property. Developing and former communist nations have not done this†¦.It was this â€Å"revolutionary† development in the 19th century that sparked the Industrial Revolution the economic progress that is the hallmark of Western society.† (p. 52) De Soto informs his readers that in the West during the 19th century, the private property laws were introduced to tackle the problem of extra-legality. This led to a capitalist revolution in these parts of the world and led to enormous economic growth. We need to understand that De Soto has found a close connection between integration of systems and codified laws. He argues: It may surprise the Western reader that most of the world's nations have yet to integrate extralegal property agreements into one formal legal system. For Westerners, there supposedly is only one law — the official one. Yet the West's reliance on integrated property systems is a phenomenon of at most the last two hundred years. In most Western countries, integrated property systems appeared only about one hundred years ago; Japan's integration happened little more than fifty years ago. As we shall see in detail later, diverse informal property arrangements were once the norm in every nation. Legal pluralism was the standard in continental Europe until Roman law was rediscovered in the fourteenth century and governments assembled all currents of law into one coordinated system. (p. 53) But is it correct to say that in the absence of centrally controlled legal system, we cannot have an integrated property system? Well I guess that is wrong to assume because the two can exist independently of each other. This is because these two deal with completely different things. One deals with access of information and the other is concerned with protection of property. From where I am looking at the situation, I feel that these two could exist without each other. But the way De Soto connects them makes sense too. He believes that without protection of property, we cannot have accurate information about ownership of property and vice versa. De Soto is of the view that common law is a problem in the third world countries because it was the same kind of law that caused property problems in the West too. He claims that common law could not â€Å"provide guidance for how courts should handle cases involving people who had bought or inherited land of dubious title,† and that, â€Å"more importantly, the English common law of property was often ill suited to deal with the problems that confronted the colonists.† (p. 111) But this may not be entirely true. Customary law or common law has its own benefits. Its strength lies in its ability to raise solutions as problems arise. But De Soto sees it differently. The book definitely has its share of merits. Its one of the best books written so far on the subject of third world oppression because of property. I don’t think anyone really understood the significance of having legal property before the publication of this book. The author has chosen a different route for seeking a solution to the third world development problems. This solution may or may not work depending on its implementation but it sure offers a new way to study the problem. REFERENCE: 1)  Ã‚  Ã‚  Ã‚  Ã‚   The Mystery of Capital: Why Capitalism Triumphs in the West and Fails Everywhere Else (New York: Basic Books and London: Bantam Press/Random House, 2000)      

Emergency Operations Plan Essay

Brownsville Texas is located in approximately 30 miles from the Gulf of Mexico and it is vulnerable to a major hurricane like Hurricane Katrina that devastated much of Louisiana in 2005. During Hurricane Katrina many of the things when wrong because emergency leaders were because, emergency managers were not prepared for the after mass of the hurricane. It is important for a city to have a structured Emergency Operations Plan in place in the event of a major hurricane. This will help make emergency operations run smooth and emergency managers make important decisions. Hurricanes are measured in Saffir-Simpson Hurricane Wind Scale. This gives the hurricane a rating of 1 to 5 based on its sustained wind speed (NOAA, 2013). The rating is also based on the amount of damage a hurricane can create once it makes land fall. For example â€Å"any storm that reaches a sustained wind speed of 74-95 miles per hour (mph) is considered a category 1 hurricane† (NOAA, 2013). Any hurricane tha t reaches a sustained wind speed of 111-129 mph is category 3 hurricane and it falls in a major hurricane category. Category 3 hurricanes and higher are considered the most dangerous and have the potential to create the most damage (NOAA, 2013). 1.Purpose of the plan The purpose of this plan is to establish an Emergency Operation Plan (EOP) that will provide guild lines and procedures for emergency managers in the event of a major hurricane in the South Texas area. The Emergency Operations Plan will show the vulnerabilities of the City of Brownsville, major concerns that city managers have, contact information for local hospitals, Fire Department, Police Station and it will also help emergency managers coordinate operations with local, State and Federal Agencies. It will also indicate the location of the Emergency Operations Center (EOC) and the Unified Command Center. The EOC leader or manager will have complete command and control of all emergency operation, before, during and after the hurricane has made landfall in the city of Brownsville. The EOC will be the primary base of operations throughout the disaster. This means that all emergency operations will be coordinated through the EOC and all emergency managers and team leaders will report to the EOC, as soon as they arrive on scene and before any operations start. The EOP will establish a chain of command that will be followed by all agencies and private organizations  involved in emergency operations. This will include all local, State and Federal agencies assisting or participating in the EOP. The EOP will also indicate the locations of the primary and secondary EOC. The secondary location for the EOC will be used in the event that they primary location of the EOC is damaged during the hurricane and can no longer be safely used to conduct emergency operations. The EOP will also indicate who will participate in the emergency operations and what role they will have throughout emergency operations, before, during and after the hurricane. This will help emergency managers better utilize the resources that will be available to them. This will also help emergency managers plan and execute emergency operations in a safe and protective manner. The goal of the emergency plan is to provide as much information as possible to the community before the hurricane makes land fall. During and after the hurricane mission is to save as many lives as possible. This will be done through conducting emergency operations, providing medical care to the injured and by establishing temporary shelters to people that have had to evacuate their homes. 2.Situation Brownsville, Texas is located in South Texas and is a city that is approximately 30 miles from the Gulf of Mexico. The cities or communities along the Gulf of Mexico coast line are vulnerable to a potential hurricane during hurricane season. Hurricane season normally starts on June 1st and ends on November 30th (Brownsville Herald, 2014). This is the time when tropical storms form out in the Gulf of Mexico. But not all storms that form are considered hurricanes. When a storm becomes a hurricane, they are considered very dangerous storms because they have the potential cause a lot of damage. This EOP is designed to be put into action in the event of a category 3 hurricane or higher threatens the city of Brownsville. A category 3 hurricane can bring rains that can last for a long period of time. This can cause floods in certain parts of the city, the high winds are also a major concern because â€Å"framed homes may incur major damage or removal of roof decking and gable ends (NOAA, 2013). These high winds can also break trees that can cause roads to be blocked for long periods of time. A category 3 or higher hurricane can also affect the electricity and running water in the city. This means that people in many communities  throughout the city can be left without running water or electricity for days. 3.Assumptions Assuming a category 4 hurricane in enroute to the Gulf of Mexico coast and it will directly affect the city of Brownsville, emergency managers have a plan in place to start warning the community of the threat the 4 hurricane poses. This is done by using the media and providing up to date information on the status of the hurricane. At least five days before the hurricane makes land fall emergency managers need to start providing the community with up to date information on the hurricane. This will include strength of the hurricane and the potential damage it will create. Emergency managers should make plans to conduct emergency operations for at least 24 to 48 hours after the hurricane makes land fall. This will include the first responder’s response time and evacuation operations if they are needed. Evacuating people from the local hospitals is a priority. At least five days before the hurricane makes landfall hospitals should need to contact and make arrangements for the hosp itals to be evacuated (DSHS.TX, 2013). 4.Concept of Operations The concept of emergency operations plan is to create a unified response to the threat of a category 4 hurricane. The will be done by creating establishing a chain of command that all agencies and private organizations can follow. The EOP will keep the community informed of any changes or any important information that they will need before, during and after the hurricane. The EOP will also establish a Unified Command Center where different agencies can work together with one common goal. The goal is to save and protect as many people as possible from the threat of hurricane. This can be done by providing early warning of the hurricane and establishing a chain of command. This is will also help emergency managers effectively us all the resources that they have at their disposal. The EOP will also establish a list of agencies and organizations that will be involved in the emergency planning and any operations during the disaster. 5.Organization and Assignment of Responsibilities The Brownsville Office of Emergency Management and Homeland Security will be  the lead agency in charge of all emergency operations (OEMHS). OEMHS is responsible for planning and efforts to mitigate the effects of, prepare for, respond to, and recover from emergencies and disasters whether natural or man-made (COB, 2011). The local, State and Federal agencies and private organizations that will be involved in the EOP will be: A.Brownsville Police Department B.Cameron County Sherriff’s Office C.Brownsville Public Works Department D.Texas Department of Public Safety E.Brownsville Fire Department F.United States Border Patrol G.United States Coast Guard H.Texas Army National Guard I.American Red Cross J.Local Hospitals K.Private Businesses These agencies are considered first responders and will play a very important role in the EOP. Each of these agencies will have specific mission and will provide assistance to the community as it is needed. The assistance can be anything from helping people evacuate from their home to assisting in the city evacuation route. Each agency will have a representative at the Unified Command Center. This means that all operations and assignments will be given to the first responders from the Unified Command Center. A.Brownsville Police Department The Brownsville Police Department will maintain a command post at the Brownsville Police Department. Their representative will coordinate any and all operations through the Unified Command Center. The Brownsville Police Department will also assist in closing street or roads that are considered dangerous or that might possibly flood. They will also maintain public order and ensure that the public stays away from areas that are considered dangerous. They will also enforce any curfews that are order by emergency managers. B.Cameron County Sherriff’s Office The Cameron County Sherriff’s Office will assist the Brownsville Police Department in enforcing road closers and any curfews that are set in place. They will also maintain a command post at the Sheriff’s Office. They will also maintain a command center at the Sherriff’s Office. This will help coordinate emergency operations and asses the needs of their officers. They will also assist in the evacuation of any people that are need of assistance. The Sherriff’s Office will also help identify disabled and elderly people that might need to be evacuated before or after the hurricane has made landfall. C.Brownsville Public Works Department Brownsville Public Works Department will in charge of placing closer sign around the city streets that have been identified as flood areas. They will also place signs on the highway that will identify the emergency evacuation routes. The Public Works Department will also be in charge of evaluating the damage to the roads and street in Brownsville after the hurricane has passed (COB, 2001). This will help emergency managers identify the streets that can be used during emergency operations and will also identify the streets that need to be fixed during recovery operations. They are also in charge of clearing the city’s drainage system. Clearing the drainage pipes is very important task, because it will help clear the water from some of the flooded areas. This will also help speed up the recovery operations around the city. They will also maintain an agency representative at the Unified Command Center to help coordinate any emergency operations within their agency. D.Texas Depart ment of Public Safety The Texas Department of Public Safety (DPS) will in charge of all evacuation routes (TXDOT, 2014). They will coordinate with city managers and establish an evacuation route 72 to 60 hours before the hurricane makes landfall (TXDPS, 2013). DPS will also coordinate with the city’s public works and coordinate the road closers along the highway. This will limit the access to the evacuation route to only controlled entry points. This will help DPS maintain control of the traffic coming in and out of the evacuation route. DPS will also coordinate with other law enforcement agencies in the area and will assign specific duties in regards to the evacuation routes. DPS will set of refueling station for vehicles that need gas along the  evacuation route. DPS will also have a representative at the Unified Command Center. They will also set up a command center at their main office, this will help them coordinate and support their operations. E.Brownsville Fire Department The Brownsville Fire Department (BFD) will play a very important role in any and all emergency operations. The BFD is highly training and equipped to handle any emergency. They have boats and breaching equipment that could be used to get people out of flooded areas. The BFD will also help establish a triage center that will help evaluate any injuries and help prioritize any medical emergencies. The will maintain personal in the Unified Command Center and will help coordinate with emergency operations from their main office. They will also assist as a liaison between the local hospitals in the immediate area. This will help evacuate the injured and facilitate operations in the triage center. F.United States Border Patrol The United States Border Patrol will maintain a show of force during all emergency operations in the Brownsville area. They will assist DPS with any and all evacuation operations and they will help enforce road closers throughout the city. This will establish a base of operations at their local Border Patrol Station and will respond to any emergency that might arise. The Border Patrol will also maintain a law enforcement presence in the city and the surrounding areas. The Border Patrol has the capability to respond to any emergency and can sustain law enforcement and emergency operations before, during and after the hurricane makes landfall. G.United States Coast Guard The United States Coast Guard will assist in the evacuation of people in the immediate and mandatory areas. They will also help supply small boats that the emergency responders can get into flooded areas. The Coast Guard will also maintain a representative at the Unified Command Center. H.Texas Army National Guard In the event that the Texas Army National Guard is needed, the Brownsville Office of Emergency Management and Homeland Security will make a formal  request to the Governor’s Office. The Texas Army National Guard will be notified of their activation at least 72 hours before the hurricane makes landfall (TXDPS, 2013). The Texas Army National Guard will assist agencies evacuate people if needed. They will not assist in any enforcement operations as per State law. After the hurricane makes landfall they will assist in rescue operations and they will set up food and water distribution sites. Any medical personal will report to the triage center, they will then help treat and evaluate the injured. The Texas Army National Guard will coordinate with the Fire and Police Departments and will assist them in any rescue operations that they are needed in. The Texas Army National Guard can provide assistance with personal, equipment and air support. I.American Red Cross The American Red Cross and provide assistance in many different ways during a major emergency. In the event of a hurricane or any major disaster American Red Cross will be in charge of establishing shelters around the city of Brownsville. They will also register and keep track of the number of people at a shelter at any given time. They will also be in charge of distributing food, cloth and personal items to the people that need them. They will assist emergency managers set up food distribution locations throughout the city for emergency responders. They will provide assistance to people that been separated from their family members. This will help reunite families that have been separated during rescue or evacuation operations. J.Local Hospitals Brownsville has two main hospitals that will need to be kept informed of the statue of the hurricane. In the event of a category 4 hurricane the hospitals will shut down and will only take in emergency patients. This would be patients that need immediate medical attention or that have life threating injuries that need to be attended too. The two hospitals in the city of Brownsville are: †¢Valley Regional Medical Center is located at 100A E. Alton Gloor Bvd, Brownsville, Texas. †¢Valley Baptist Medical Center Brownsville is located at 1040 West Jefferson Brownsville, Texas K.Private Businesses In the event of a major disaster the Brownsville Office of Emergency Management and Homeland Security will make arrangements with local businesses to coordinate supplies and equipment that might be needed during a hurricane. The business will provide food, water and any equipment that might be needed by first responders, for example pumps, generators and shovels. The OEMHS’s finance department will keep track of all the equipment and supplies that are received are ordered and received by private businesses. This will help keep track of what is being used and what supplies are needed. Any special equipment that needs to be ordered or requested will be done by the OEMHS’s finance department. This will help keep track of the money that is being spent. 6.Administration and logistics The Brownsville Office of Emergency Management and Homeland Security will coordinate all emergency operations in the City of Brownsville. The Unified Command Center will have a team of representatives of each agency that are involved in emergency operations as well as representatives from the State and Federal government. The will get continuous updates of the situation and will make decisions on any issues. They will also provide logistical support to all emergency operations as it is needed. This means that they as they receive information or requests for any equipment or support the OEMHS will address this situation and take action. 7.Plan development and maintenance The OEMHS is responsible for developing the EOP in coordination with the agencies that will be involved in the plan. This means that the OEMHS will meet with the different agencies that will participate in the plan and address any issues they might have with the EOP. It is the responsibility of the OEMHS to keep the EOC updated. Every year there are changes to roads, hazards and other things that might affect emergency operations. It is the responsibility of the OEMHS to maintain the plan and to ensure that it is up to date. It is the responsibility of the OEMHS to coordinate training with the agencies involved. The OEMHS should also coordinate ensure that the city managers that will in charge of the EOP be certified and maintain their certification through FEMA. 8.Authorities The authorities that will be in charge of all emergency operations will be the Brownsville Office of Emergency Management and Homeland Security. The OEMHS is responsible to address any and all jurisdictional issues that an agency might have. This EOC is designed to be used during a major hurricane but it is flexible and can be used for any other kind of disaster. Communications Communications is a very important part of the EOP. In the event of a major hurricane or any other kind of disaster, communications will play a very big part in emergency operations. During emergency operation all agencies involved will use TXLAW 1, as the primary radio frequency. This will ensure that all agency managers and team leader are able to communicate with the EOP. All agency dispatchers and agency managers will monitor TXLAW 1 throughout emergency operations. This will continue until all emergency operations have stopped or the agency in no longer participating in any emergency operations. If an agency does not have radios with the TXLAW1 frequency, the OEMHS will provide radios to the agency command post and team leaders during emergency operations. Radios will be provided to private organizations like the Red Cross that will set up staging areas, establish shelters and coordinate distributions site. Team leaders and managers will remain in contact with the Unified Command Center all times. In conclusion the EOP will establish guideline that emergency managers can follow. This will help them set up a structured chain of command and establish emergency operations in the event of a major disaster or hurricane. This plan is flexible and can be changed or modified as it is required for any disaster. It is very important the OEMHS provides continu es training and maintain the EOP up to date. This will ensure that emergency operations are conducted in a safe and productive manner. References Reagan, M., (2014, April 10) Early hurricane outlook predicts light season. The Brownsville Herald. Retrieved from

Aspects Of Adolescent Reproductive Health Health And Social Care Essay

Aspects Of Adolescent Reproductive Health Health And Social Care Essay Adolescent means â€Å"to grow to maturity† and is an important period in life span. Reproduction means â€Å"production of offspring â€Å". Health means â€Å"state of complete physical, mental, and social well being. After birth the child grows towards maturity and makes them a contributing member of the society. ADOLESCENT REPRODUCTIVE HEALTH: ANATOMY AND PHYSIOLOGY OF FEMALE SEXUAL ORGANS: The principal organs are ovaries, uterus, uterine tubes, and vagina. Female reproductive cycle includes both ovarian cycle and menstrual cycle. Female reproductive function begins with the development of â€Å"ova† in the ovaries. The oogonia (primitive germ cell) are dominant from fetal period and are transformed to mature oocyte at puberty. OVARIAN CYCLE OR MENSTRUAL CYCLE: A single ovum is expelled from an ovarian follicle in to the abdominal cavity in the middle (14th day) of each month (28 days) menstrual cycle this process of rupture of grafian follicle with release of the ovum is called ovulation. Thus the 12-18 days in a 28days cycle is called fertile period. This ovum is engulfed by fimbrae and is transported to a uterus by the fallopian tube. When fusion of sperm and ovum which develop in to fetus, thus menstruation stops. This process is called as fertilization. When the ovum is not fertilized then menstruation starts which is cyclical discharge of blood, mucus, unfertilized ovum, and torn endometrial from the uterus per vagina. PUBERTY: Puberty is the period during which the secondary sex characteristics begin to develop and capability of sexual reproduction is attained where boys attained manhood and girls attained womanhood. PUBERTY IN FEMALES: Girls begin there growth spurt between 9-13 yrs of age Increase in body fat Development of sexual character like pubic hair, and auxiliary hair appear. Development of breast tissue Rapid increase in height and weight begin to menstruate ASPECTS OF ADOLESCENT REPRODUCTIVE HEALTH: Menstrual hygiene Te enage pregnancy Sex education and sexual behavior Sexually transmitted disease Contraceptive devices MENSTRUAL HYGIENE Menstrual hygiene refers to the hygiene during menstrual period. It includes use of clean pad changing of soaked pad proper disposal of used pad, perineal and personal hygiene with daily activities like diet, exercise, and rest. During menstruation Daily twice bathing is essential because to reduce body heat and fatigue. Washing the genital region daily with soap and water to prevent genital infection. The diet should consist of vegetables and fruits which gives nourishment and normal diet. During menstruation iron rich foods helps to maintain the hemoglobin level. Sanitary napkins can be used to observe the menstrual flow. Use sanitary napkins or use clean cotton cloth. If cloth is to be reused wash with soap dry in sunlight and preserve in with napthalin balls in plastic bags. Change the napkin three times a day and every 4-6hrs per day. Used napkins should not be reused because its very unhygienic and lead to reproductive tract infection. Used napkin should be burned immediately. When the blood stained napkin rub against the thigh the skin of the thigh gets sore and walking may become uncomfortable. So the thigh region should be kept dry.

MARKETING Assignment Example | Topics and Well Written Essays - 2500 words

MARKETING - Assignment Example In sum the fortunes of the firm are dependent on how well its management deals with business opportunities and threats, while using the strengths of the firm to take advantage of the opportunities and minimize the effect of the threats through clever planning and strategic implementation of its vision for the company. This is what is called strategic management- or the planning and implementation to achieve its desired plans in the marketplace in the face of these internal and external forces. The legal, political, sociological, economic and other environments may pose a number of challenges that must be overcome by the business if it is to survive and prosper in the marketplace. Barclays Bank PLC is one of the key players in the worldwide banking industry as well as in the UK and this paper will discuss how successfully it has managed to meet the challenges faced by the banking sector in the UK. The Banking Sector in the UK The banking sector in the UK is one that is full of intense competition. Lately the banking sector which had been hit by the 2007-2008 economic recession has been in recovery mode and efforts are still being made to put the sector back on track and increase regulation which would prevent greed and excessive remunerations from wreaking havoc on our lives once again. Efforts are being made so that banking executives’ salaries, perks and other remunerations like bonuses and stock options will be reviewed by the Governor of the Bank of England and the Finance Secretary prior to payout. The Bank of England had committed a sum of around ?7 billion to bail out the banking sector in the UK but thankfully Barclays Bank PLC did not ask for assistance, rather it managed to raise the required capital through a number of share offerings in the equity market. Banking today can be characterized by the different products that are being dealt with, such as investment banking, asset management or debt management, or by the type of customer dealing, su ch as Wealth Management for high net worth clients and Retail Banking for all types of customers (Harrison, 1994). There are also a number of channels for service delivery, like online banking and ATM transactions, cash deposits and withdrawals, wire transfers etc. But never mind what classification you choose, it all deals with saving, lending, spending, deposits and investments and withdrawals. These are the primary functions of banking which we cannot deny (Lee, 2002). A Brief History of Barclays Bank The origins of Barclays Bank date back to the days of the goldsmiths who were acting as the earliest English bankers on London’s Lombard Street. A partnership was established between John Freame and Thomas Gould in 1690. In 1736, James Barclay, the son in law of John Freame became a partner in the business. In 1738, the business moved to 54 Lombard Street and at this time also began using the black spread eagle as an identifiable logo that is still associated with the bank to day. In 1896 two more banking businesses united with this operation under the name of Barclays & Co, by then converted into a joint stock banking company. During 1905-1916, Barclays further extended its network by acquiring other small banking operations in the UK. Amalgamations with other banks in 1916 and 1919 saw the Barclays name expand ever further. After World War II, Barclays UK established a US affiliate by

The Conflict in Rights Essay Example | Topics and Well Written Essays - 1250 words

The Conflict in Rights - Essay Example The conflict in rights is actually the result when individuals or sectors in a democratic society begin to assert their respective rights that would result in the reduction or the violation of those of others. It must be pointed out that before rights could be identified and recognized there were the material bases for these, which were the diverse interests of different sectors in society. Aside from the diversity, there is also the reality of contradicting interests, such as that of the workers and the employers. The labor sector’s interest is to achieve to get their fair share of the income resulting from their work in production. On the other hand, the business sector’s interest is to continuously increase their profits. These interests are obviously contradictory for when the workers insist on higher wages, the business sectors profits are reduced. If the business owners wish to increase their profits, the wage values also fall. This basic conflict of interest shou ld well be considered as the very core of the conflict in rights. The labor sector would insist that it is their right to push for higher wages since they are the ones who created new value. The capitalists, on their part, would insist that it is their right to peg wages at a certain level which they think does not badly affect their profit targets. They would insist that they, after all, are the owners of the machines that the workers use. The conflict in rights between the workers and the capitalist is not only evident in the economic sense. This contradiction between the two parties could also be seen in the political and cultural senses. In politics, the workers establish their own political organization and parties for the purpose of having their own center of gravity. The capitalists, on the other hand, also establish their own parties or spread their influence on those that are already in existence. The result of these actions is that the respective sectors in society now hav e the means for asserting their respective rights not only as dictated by law but also as mandated by the fact that they are bigger in numbers. Since the capitalists, although fewer have been able to establish a foothold on government, they would naturally anchor their concepts of rights on what is provided by the laws which they themselves made. They would then insist that since there is already a law on wages and on how these should be increased, the workers are morally bound to oblige to such laws. Kant articulates that â€Å"nothing in the world—indeed nothing even beyond the world—can possibly be conceived which could be called good without qualification except a  good will† (55). However, Kant’s standard of good will is the law to which people, including workers, should obey. This Kantian perspective on the workers’ movement for the promotion of their rights could then be viewed as immoral and utterly wrong. The workers, on the other hand, would naturally embrace a utilitarian viewpoint. It is act-utilitarianism that they would tend to grasp, which is â€Å"the view that the rightness or wrongness of an action is to be judged by the consequences, good or bad, of the action itself† (Smart 9). Such mindset when first asserted at time when capitalists are considered as sent by the heavens in order to provide opportunities of livelihood to those who do not possess the means of production would indeed seem a case in ingratitude. The Kantians

Unit 1 Coursework Example | Topics and Well Written Essays - 250 words - 2

Unit 1 - Coursework Example Cisco is no longer supporting IGRP because further improvements on the RIP platform were needed thus Enhanced IGRP was developed. IGRP was replaced by the EIGRP protocol. This is because there are fewer IPv4 addresses left, and IGRP assumes all element of a class belong to same subnet while EIGRP uses VLSM to maximize the IPv4 addresses left. Change of algorithm to Diffusing Update Algorithm (DUAL) used by EIGRP is also a contributing factor to the phasing out of |IGRP (Lammle, 2014). EIGRP takes features of both link-state, and a distance vector protocol thus is a hybrid dynamic routing protocol. EIGRP is event driven and routing information are sent in case of change in network or during startup. This is a link state characteristic. EIGRP also sends routing table information to its immediate neighbors, which is a distance vector characteristic (Donahue, 2011). OSPF has many advantages over EIGRP namely: OSPF is usable on a multi-vendor platform while EIGRP is a CISCO only solution which is limiting. As written by Southwick et al. (2011), SPF supports hierarchical networks while EIGRP is mostly used in flat networks and does not support scalability (p.

Principles of Structural Design Essay Example | Topics and Well Written Essays - 3750 words

Principles of Structural Design - Essay Example Analysis of a structural collapse involves the study of the basic architectural principles, properties and operation of the different components of the structure, as well as knowledge of different possible causes of structural failure. The Seongsu Bridge is 11th bridge constructed over the Han River in Seoul, South Korea. Construction of this cantilever bridge was set about on April 9, 1977 and completed on October 15, 1979, 2 years and 6 months later. It was a four-lane bridge with 19.4m width and 1,160.8m length [20]. It became infamous when it collapsed on October 21, 1994. The bridge collapsed early in the morning when one of its concrete slabs fell in to river due to a failure of the suspension structure. Around 07:40 hours on October 21, 1994, Seongsu Bridge connecting Seongsu-dong and Apgujeong-dong of Gangnam-gu, Seoul, collapsed. The slab (48 m) between the fifth and the sixth leg of the Bridge collapsed so 32 people died and 17 people were injured while they were on the way to office or school. Seongsu Bridge is one part of arterial road that connects the Kanan district which is residential section in the southern in Seoul City and city center of Seoul City, and its has a lot of traffic volume. The steel truss digit division where the accident occurred was the 672m length, and it was one of the suspension digits of the center part. ... In addition, Seongsu Bridge complained that it had been trembling in motion, so the authorities in Seoul City also carried out the repair work of the emergency in the night in accident the previous day. It was said that the traffic jam arose, because especially, it was for commutation attending school hour in the accident-generation, and because the rain fell, the rolling stock was crowded [20]. Cause of collapse: Various reasons can be associated with the collapse of bridge. Major of them are as listed below [19]: Bad welding of the suspension which member of the I-type cross section, which was hanging the suspension digit of the center from the steel truss, seems to be a main cause. There was visibility cutting corners between surface and splice plate of the fillet welding, so construction management and inspection method in the construction of Seongsu Bridge seemed to be remarkably slipshod. Calcium chloride, which was scattered in order to prevent the road surface freezing, chloride ingress was uppued for the cracks by poor weld or stress corrosion, and so that the corrosion of steel product might be promoted. There is a possibility to produce unexpected partial cracks in the steel surface because in the cross-sectional shape of suspension steel product, the cone angle ( the relaxation curved surface ) for easing stress concentration was insufficient. Though there is no error at the content for the design, there was some possibility that the immature construction level was not sufficiently assumed. There were no technical standards on in-service maintenance repair of Seongsu Bridge. Because of the fiscal resource constraint (budget) of Seongsu Bridge while it was in service, the periodic check was

Organizational Culture Analysis Essay Example | Topics and Well Written Essays - 500 words

Organizational Culture Analysis - Essay Example Today, organizational leaders are confronted with many complex issues during their attempts to generate organizational achievement. A leaders success will depend, to a great extent, upon understanding organizational culture. This paper take Nike as an organization and looks into its cultural orientations that have for a long time made the firm to be one of the outstanding companies in the world. Organization culture forms part of an organizational success factors and many companies rely on the organizational culture to determine their performance and competitive advantages in the industry. Nike is one of the companies reaping effectively from its culture. With an innovative and design culture, Nike has a well-adapted and suited culture that runs through generation to generation (Goldman & Papson, 2000). Its employees have the company’s maxims at finger tips and enjoys in the company’s enviable brands which are known worldwide and are deeply appreciated by sportsmen and sportswomen all around the world. With a cultural origin and background of digital and design innovator, Nike products have increasingly found the interest and association with millions of customers around the world. The company’s reputation has been built on the extreme commitments of its workers who have maintained their zeal out of motivations and better working environment (Rothacher, 2004). The sense of value, history of quality, and customer satisfaction are the mysteries and secrets of Nike’s corporate culture. The company’s logo shown below is a symbol of inspiration, unity, innovation, and cultural progress in achievement of success. It is one of the observed artifacts that impacts the values and behaviors of employees of Nike. As argued by Carbasho (2010), Nike, Inc.s heritage is deeply rooted in innovation and cultured in diversity, inclusion, and inspiration as the key drivers of creativity and innovation. For more than the 30,000 employees of Nike, the driving pool

Improving Organisational Performance Essay Example | Topics and Well Written Essays - 3000 words - 1

Improving Organisational Performance - Essay Example Performance management is considered to be one of the most regarded Human Resource (HR) functions in an organisation. In most of the organisations, the performances of the subordinates are measured either formally or informally. Effective communication regarding performance appraisal generally takes place once in a year or once in a quarter. Nevertheless, performance management is a continuous phenomenon (Armstrong, 2006). When the performance management is utilised in a proper way then the management gains numerous benefits. It has been noted that most of the United Kingdom based organisations operate periodic performance appraisal systems. However, it has been noted that most of the employees as well as managers are found to be discontent with the schemes utilised in the organisations (Keshav & Sharma, n.d.). Appraisals are incapable of motivating the employees in an organisation and it has been claimed by the respondents to an Industrial Society Survey that such appraisals do not have any positive impact upon the workforce. Therefore, it becomes significant for the organisations to monitor the way in which performance management is being practiced (Management Today, 1998). The main objective of the paper is to evaluate business cases for the use of performance management at Barclays Bank and Lloyds Bank. ... will also present the practical difficulties, challenges as well as implications identified by the use of the performance management in Barclays Bank and Lloyds Bank. The methods that the two banks can use in order to mitigate the difficulties related to the performance management will also be recognised in a detailed way in this paper. Finally, the study will attempt to find out the potential limitations or shortcomings related to the proposals provided to the banks. Business Case for Performance Management at Barclays Bank People tend to differ in terms of their abilities as well as aptitudes. There will be major disparities between the size and the value of the same work upon the same job done by two distinct people. Therefore, under such note, it can be assumed that the organisations need performance management so that they are capable of comprehending the abilities of the employees, proficiencies as well as their comparative worth for the organisation. Offering rating to the emp loyees in terms of their performance can be done with the assistance of performance appraisal. Barclays Bank tends to extend its assistance in terms of financial services in approximately 50 countries all over the globe (Barclays, 2012). Barclays Bank is considered to be one of the famous companies in the banking sector and thus it states that the way in which the employees tend to perform their operations has a direct influence upon the business performance. The team members working for the bank are well aware of the goals that they are supposed to attain. In order to manage the performance, the bank has designed numerous actions in which the employees participate. Coaching is recognised to be one of the actions where a crucial objective is to make the employees aware of their job

Different topic about BUSINESS INFORMATION SYSTEM Essay

Different topic about BUSINESS INFORMATION SYSTEM - Essay Example Information technology has been instrumental for the improved performance of various companies and business houses across the globe. It has also increased the over all productivity. The development of information technology has also increased the accuracy level in almost all the related aspects of it. Like all most of the other aspects of our life, technology has made its appearance in the entertainment industry also. Today, almost all of the movies produced and released at Hollywood depend highly on technology as special effects have been the indispensable part of the motion pictures. One such movie released in 1993 was the Jurassic Park (directed by Steven Spielberg). In fact, the movie created a sensation among the viewers and is regarded as the landmark in the use of computer technology in the field of movies. The on-screen dinosaurs created by special effects was a major hit. Technologies like Dinosaurs Input Devices were used which allowed the computer to create its own animation when inputs were fed into it. Also, the sound of the movie was based on special effects. Today, not just the development, but also the sales and marketing of every movie relies highly on technology. As the information technology has been the integral part of our life, the usage of Microsoft-Office (better known as MS-Office) software has been on constant rise. With in the package of MS-Office, Microsoft-Excel deals with all sorts of calculations. Excel has been crucial for all those who are related with number crunching. The above link is a perfect online tutorial for excel. The link has been from the website of The University of South Dakota. The university was founded in 1862 and is located at Vermillion of South Dakota. University of South Dakota has the only law and the medical school of the state. The reputed university uses USD as its symbol (also it is known as simply U). The university has whole lot of academic

American history Essay Example for Free

American history Essay Sternberg ultimately suggests that Intelligence can be improved, and there are a number of findings to support his theory. There have been 2 very controversial pieces of research and publications however which not only disagree with the main principals of Sternbergs theory, but have also provoked uproar since they have been released. The first publication which was to cause huge heated debate all over the world was that published by Jenson (1969), who said that those of Black origin scored on average 15 points below that of White people. He suggested that this was mainly due to the genetic makeup of Black people and that although environment may have been a factor; the main reason is the hereditability of intelligence. The next piece of literature which caused so much commotion when it was released was the Bell Curve by Herrnstein an Murray (1994), which agrees with Jensons research, and also points out that those of low intellectual ability will generally lead difficult lives, are more likely to be inadequate parents themselves, and are also more likely to turn to drink, drugs and crime. Although these comments are highly controversial and politically incorrect, some of the points made are more than likely to be true, and can go some way to explaining why people find themselves in that position, however it would only be accurate if two factors did not play huge parts in the intelligence levels of individuals, the culture that individuals are exposed to, and the fact that intelligence is not fixed, and that there are plenty of studies that give evidence to back this up. The test that Jenson gave to the Black and White subjects in 1969 was no doubt culturally biased towards the white subjects, due to the levels of prosperity and education that each group were subjected to previously. Further studies have shown that Black children who were adopted by prosperous white families, and were subjected to the same level of schooling demonstrated improved levels of intelligence over children who had a similar genetic background. Adoption studies like these have often proven to be strong evidence for the nurture side of the debate; however one final area of concern in the nature/nurture debate is the topic of eugenics. Eugenics is the idea created by Sir Francis Galton (1822-1911), who was interested in the success of English dog breeders, who bred the strongest and best dogs together, and created many different varieties. He decided to start a movement which looked at the possibility of weeding out the bad individuals from the good stock by getting humans to breed with those who have good properties and attributes, a fairly sick proposition even for the 19th century, and it was soon shut down because people decided to breed for love rather than genes. But nonetheless the term eugenics was created, and perhaps the most relevant example of eugenics in history is the Immigration Restrictions Act (1924) which was passed in America by President Coolidge, who was said to have proclaimed America must be kept American as he signed the bill. On that day eugenicists are known to have won one of the greatest scientific racist battles in American history. Bibliography Cardwell, C. M. (2000). Psychology for A-level. London: Harper Collins. Dworetzky, J. (1994). Psychology. Minneapolis: West Publishing Company. Gross, R. (2005). Psychology, The science of mind and behaviour. London: Hodder Arnold. Hill, G. (2001). AS Level Psychology through Diagrams. Oxford: Oxford University Press. Handouts T. Kearns

Analysis and Review of Andrew Niccols Film Gattaca Essay Example for Free

Analysis and Review of Andrew Niccols Film Gattaca Essay Man has already landed on the moon, and Sputnik has enabled research on other solar planets. Lives have become healthier, longer, with modern hygiene, sanitation, medicine, and surgery, conquering more physical and mental illnesses by the month. Science has also presented a means of cloning and genetically modifying organisms and food, and shows little to slow it’s pace of evolution. I belonged to a new underclass, no longer determined by social status or the color of your skin. No, we now have discrimination down to a science. Vincent Gattaca, directed by Andrew Niccol, gives a perspective of what the future of discrimination is to evolve into: no longer determined by skin color, gender, or social status, but scientific DNA. The civilization portrayed is a discriminatory one, in which status and quality of lifestyle is determined solely by a DNA profile. Children are created by DNA manipulation to produce an impeccable genetic composition, with parents able to buy whatever traits are deemed fanciable for their child. The movie hypothesizes this as a potential practice in the not too distant future, as one where technology’s influence in everyday life is at peak. True or False? It is impossible for our society to become like the one in the movie, ‘Gattaca’, because we don’t have the technology or the capacity to discriminate that way. This essay will argue false, that it is possible that our society is able to become that of Gattaca (sterile, genetically enhanced, and derogatory) although it’s morality is questionable in regards to pros and cons, due to various reasons such as the development of genetic engineering and IVF babies, as well as examples of genetic discrimination in the past presented. * * Recently scientists have made rapid advances in our knowledge of the human genome, as well as our abilities to modify genes. Nowadays, society is able to determine the gender of their child, just like that of Gattaca. An example of an advanced reproductive technique endorsed by society is the InVitro Fertilization (IVF), in which eggs are fertilized with sperm in test tubes to allow parents to reduce the chance of gen etic disorder in the child – with the world’s first IVF child Louise Brown turning 30 this Friday 25th. Parents are now able to choose the type of sperm that will fertilize an egg, which determines the gender and genes of the baby, and allow Pre-Implantation Genetic Diagnosis (PGD) to screen embryos for potential disease. â€Å"We might see a move towards artificial chromosomes and genetic cassettes that can be inserted at the embryonic stage to correct particular diseases, including Huntington’s†, wrote Prof. Trounsen in the scientific journal nature. One day we may be able to choose cosmetic or desirable characteristics and cure genetic diseases, just like we can modify embryos and undergo surgery to change eye color successfully today. * * Make the child perfect in the test tube, and save money in the future, is a testimonial presented in Gattaca. The current technology of society is quite competent, especially in regards to future development. In essence, genetic engineering may be defined as the manipulation or alteration of the genetic structure of a cell or organis m in medical, industrial, and agricultural fields. It has enabled the successful cloning of Dolly (1996 – 2003) the sheep by Ian Wilmut using a cell from a mammary gland, which is a revolutionary example of the windows opened due to genetic engineering; a hint at what the future could bring. In fact, the successful cloning of many animals (including CC the kitten, Idaho the colt, and Snuppy the dog) will most certainly one day evolve into human gene manipulation at birth; due to this the foundation of Gattaca as humans artificially perfected is theoretically possible. * * * The main character, Vincent (Ethan Hawke) is discriminated against due to his ‘in-valid’ genetic makeup; he doesn’t have a chance in the society of Gattaca because potential employees were not tested for skills or knowledge, rather, their physical and mental possibilities. This form of discrimination refers to treatment or consideration based on genetic status or category, rather than individual merit, and occurs when employers/insurance companies treat people differently because they have a gene ‘mutation’. Many examples in the past depicting this theory include a 1995 survey of people with a known genetic condition in family history found that 22% quoted being denied health insurance due to genetic status, regardless of whether they were already sick. Another case of genetic discrimination is Terri Seargent’s, who, having Alpha-1 antitrypsin deficiency, was abruptly fired after her employer received a bill for preventive treatment, despite having consistently referred to her job performance as exemplary. Furthermore, if society didn’t have the capability to discriminate genetically, the Genetic Information Nondiscrimination Act (2008) would need not be introduced. To the question of lacking the capacity to discriminate this way, it is justifiable to conclude that society is capable of such derogatory action. * * In conclusion, the genetically modified world presented in Gattaca is possible due to competent and developing technology in the fields of genetic engineering. Scientific advances like the IVF baby and successful cloning techniques have huge implications for future human reproductive technology: genetic diseases such as Huntington’s could be corrected using artificial chromosomes, and the production of replacement organs from a person’s cells made a reality. In addition, we are also capable of genetic discrimination, as is consistent with Gattacan society.

E-tailoring Online: Customer Views and Impacts on Services

E-tailoring Online: Customer Views and Impacts on Services Abstract An increasing number of customers are turning to the Internet to make their purchases, as a vast array of goods and services are now only a mouse click away. E-tailing clothes is even more challenging, with new e-tailers hoping to attract and retain satisfied online customers, are constantly creating new opportunities for them, and in order to do that they need to know what evaluative criteria customers use when selecting an e-tailer as well as what they will purchase online. Past research has provided some insight into what characteristics customers assess whilst making this choice. This report has not been without its limitations. Consequently, the present study utilizes a literature review, qualitative and quantitative research to identify the core customer behavior towards this channel, In addition, results of the analysis show that the type of product on offer and the web attributes (determinants) are predictors of customers attitude toward online shopping for clothing and their perception hence, providing an understanding of how they are responding to the new online buying opportunities. 1. Introduction This research report is divided into 5 Chapters. Chapter 1 is meant to introduce the background of the research area with aims and objectives and focus of the study providing guidelines into subsequent chapters. This then will be followed with Chapter 2 having literature review of the matter giving an insight of the research area that will be referred, compared with the data collection and analysis will be made in Chapter 4. However, Chapter 3 will be discussed prior to the actual data collection as it is necessary to identify Research Methodology to be used for the research. Finally, Chapter 5 will have conclusions and recommendations with any limitations faced and with the mention of area for further research if any. The expansion in electronic commerce (E-commerce) has been phenomenal, with most of todays business transactions being conducted through the Internet. The emergence of this electronic retail (E-tail) market has been extraordinary. E-tailing is also a gaining popularity and changing the retail landscape, it is pervasive in what we thought of it six months ago is probably different to what we think of it today and also what we will think of it in six months time. Customers decision making process has also altered greatly with the introduction of this medium and more so as an alternative channel for shopping. Online shopping concept has already caused a stir in the retail industry in the UK, as more people are opting to buy online due to various reasons, a vast array of goods and services are increasingly being made available now through a click of the mouse, creating a new experience and culture. Many retailers are already delivering high value, personalised products and services at a fraction of the cost thereby making it more low cost and also appealing to the consumers (Birch et al, 2000). The number of consumers shopping online has increased markedly, according to Jardine (1999) people have increasingly become price sensitive and often compare prices of goods both online and offline before making the final purchase, in turn increasing competition amongst the retailers. This is the general overview of the e-tailing concept, as understood b y most of us. However, the purpose of this study is to concentrate on the online clothing market in the UK specifically London, in order to determine predictors of customers purchase intentions for clothing products via this channel. E-tailing of clothing items online has always been debatable, especially since clothing are â€Å"feel-and-touch† products, and cannot be bought without engaging this sensory aspect, unlike other cognitive products like books, computer software, dvds and music which do not really require this. Nevertheless, customers tend to buy more clothing products when they perceive the features of the online store, such as a convenience and secure system of ordering and payment, returns policy, the focus on product display, and the offering of products that have a range of acceptable fits as opposed to a precise fit and most of all choice this are some of the most general attributes a customer considers whilst shopping online for clothes. The attributes that enhance the online experience can be particularly influential for products such as clothing, which generally require physical interaction and evaluation prior to purchase. Web experience attributes can affect early decision making stages (search and pre-purchase evaluation) and influence purchase intent of the customer. With the current fragmented nature of the subject area and to keep up with the rapidly developing technology as well the customer attitudes, the author aims to build on the current body of knowledge, investigating and drawing together the key aspects which influence online shopping for clothes, so as to understand how the customers are responding to the new buying opportunities presented to them by the e-tailers in UK then concentrating on London where the survey was conducted by collecting data from a sample of participants, which aided in exploring the capabilities and further to determine consumer behaviour and customer relationship management p atterns in relation to E-tailing, thus the research objectives being set as: 1. To explore the impact of e-tailing in London. 2. To determine customers attitude towards shopping online. 3. To investigate customers perception of shopping online for clothing in London. In order to achieve the results of the set objectives, the author has explored the determinants the customers consider most important when making a purchase online and to what extent they create an impact on their perceptions. The first hand elements collated from the survey has helped to gain rich insights into customers behaviour and attitudes towards this channel. The secondary data which is covered in the second chapter under the literature review the author here has studied and explained the general E-tailing concept and picked relevant data to help understand the subject matter and provide a better insight into the field of e-commerce, covering a wider area (UK), then narrowing it down to specific location (London) which in turn has helped to achieve the set objectives and later also support the resultant findings in terms of the primary data collected via the survey by the author. 2. Literature Review Xing (2001) stresses that â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business†. 2.1 The Commercialisation of the Internet The Internet, once a tax-sustained and a government-regulated endeavour, is no longer restricted to non-commercial traffic. The early commercialisation of the Internet, in the mid 1990s gave rise to the e-commerce phenomenon. The Internet population has since grown tremendously, as a result of its opening to the commercial traffic in 1991. Its utilisation has since become remarkably more wide and varied in businesses; the application of internet has grown rapidly over the last several years, due to its contribution of the ever evolving new information technology and its positive gains to the business organisations. Its use apart from being internal its also employed externally and its used more commonly referred to as E-business (electronic business) derived from such terms as e-mail and e-commerce, which is the conduct of business on the Internet, not only buying and selling but also servicing customers and collaborating with business partners. IBM was one of the first organisations to use the term E-business (electronic business) when, in October 1997, it launched a thematic campaign built around the term. Today, major corporations have reconsidered their businesses in terms of the Internet and its new culture and capabilities. Companies are utilising the Web to buy parts and supplies from other companies, to collaborate on sales promotions, and to do joint research, exploiting the convenience, availability, and world-wide reach of the Internet, using it successfully. 2.2 The E-tailing Concept â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business† says Xing (2001). It was seen as a new channel for sale of products and services along with the traditional channels as well as a market penetration strategy for others. E-tail or E-retail the term, came into discussions or rather its origins as early as 1995, its an addition in the computing subject such as, e-mail, e-business and e-commerce. The business of e-retail has been defined as the sale of goods and services via internet or other electronic channels, for personal or household use by consumers (Harris and Dennis, 2002). Its more efficiently used as a marketing tool, which is integrated into traditional business strategies, and also being viewed as a new marketplace by existing businesses as well as new business ventures as the market place becomes more competitive and unpredictable, due to this, the growth of the electronic retail market has been rapid, significantly expanding reach in terms of people, location and range being variety of information, the World Wide Web has created benefits for both the marketers as well the consumers. For consumers, the Web can provide access to a wide range of products and services with low cost (Bakos, 1997), extensive and tailored information, at home convenience for product comparisons, enhanced interactivity (Cross and Smith, 1995), hence facilitating the formation of virtual communities for users with common interests. E-tailing and E-trading operates in all four of the major market segments; business to business, business to consumer, consumer to consumer and consumer to business. Initially, much direct selling (or e-tailing) was taking place on the internet of computer-related equipment and software, one of the first to report successful sales in the millions of dollars directly from the Web was Dell Computer, there after other businesses started employing the concept in various fields from; Travel bookings, Holidays, Books, Clothing and other accessories, this has particularly grown in the Business to Consumer market segment directly or indirectly as a result of the wide usage of the internet. The Internets greatest commercial advantage is said to be the reduction in transaction cost that directly lowers the prices for consumer (Pavitt, 1997), and therefore E-tailing is said to be a low-cost, efficient way to display merchandise, attract customers, and handle purchase orders (Bellman, 2001). 2.3 Online shopping in the UK Home shopping in various forms has been available to the consumer market for more than 100 years in the UK, paper catalogue being the first and the oldest form illustrated with Victorian ladies and do-it-yourself house kits a lot has changed since, in terms of improvements and choice, then came the emergence of home shopping television, however none has had the influence or the expected impact of shopping, as much as the World Wide Web. E-commerce has grown steadily in the UK since the early 1990s. According to Exley (2006, cited in Haymarket, 2006) consumers have become comfortable shopping on the internet and e-tailing is clearly a part of retails future. He adds that e-tail does not have to replace traditional bricks and mortar stores, â€Å"all retailers need to do is to provide a good in-store experience† (Exley, 2006, cited in Haymarket, 2006). â€Å"Since 2000, Internet shopping has soared by over 5,000% with UK consumers spending an astounding  £200 billion during this period. Internet shopping is clearly the bright spot in the UK retail sector, but this industry is still young and has potential for further growth.† (Tina Spooner, director of information, Interactive Media in Retail Group (IMRG), cited in press release, May 2009). No doubt, online shopping is rising steadily in the UK (from a consumers perspective) as internet access has become cheaper, high street cyber cafà ©s are increasing and Internet service providers (ISPs) have already eliminated subscription fees (Daniel, 2000). Furthermore as technology is set to get even more advanced, hand-held devices have become internet-enabled and nowadays most mobile phones connect to the web (Daniel, 2000). With all the above possible ways of shopping more customers are getting accustomed to the online shopping experience and utilising the new channel. This exc eptional growth of Internet shopping is also driven by greater emphasis on customers efficient use of time, as well as the ever increasing number of computer trained customers, hence giving it a positive outlook and a further opportunity for growth to the existing and perspective e-tailers. A wide range of products and services are available for the customers in the UK to buy online from a variety of retailers, which also gives them a better choice, so why would they go buy anywhere else? Although one reason may be convenience, sadly another is fraud; fraud poses the biggest threat to online shopping (Economist, 2004) but according to Pavitt (1997) consumers fear of shopping online is already resolved by the use of encryption technology. Moreover, the security systems are rapidly improving by the day, further dispelling the notion which is perceived by a majority of people worldwide that online shopping is a risky business. For example, secure digital systems such as encryption tools, digital signatures and the guarantee about security or privacy concern provided by the e-tailers have reduced security inhibitors and thus have increased consumers willingness to visit or purchase from sites (Ah-Wong et al., 2001; Han and Maclaurin, 2002). UK is the second largest e-taling market in Europe like Germany, it combines a large consumer market with internet penetration above the European average (Datamonitor, 2002). There are six leading online shopping companies that dominate the UK e-tailing market. These are; streetsonline.co.uk, Jungle.com, Amazon.com, Lastminute.com, Thomascook.com and Egg.com, all these providing a variety of products and services. What is the future of high street stores when most analysts agree that in five years time, online shopping could be worth  £200billion? This does represent some form of concern to high street stores in the UK as a percentage or it could be of the sales they lose. Nevertheless according to Brewer (2006); cited in Haymarket (2007) the future is brightest for those high street stores that could adopt a multi-channel strategy. However, Murphy (2006); cited in Haymarket (2007) says that â€Å"we have the most vibrant, competitive high street in the world and high street shopping is one of our biggest leisure pursuits. Can high street shopping be our biggest leisure pursuits since they boast to sell a variety of diverse products in-store? It is the refore inconceivable that the future of retail would be solely online†, although the number of customers making purchases online is also on the rise in the UK as mentioned earlier in this report. 2.4 The extent to which e-tailing builds relationships The impact of e-tailing will be felt differently and at different times by various retailers. In the context of buyer behaviour preferences (Daniel, 2000) says that e-tail is a transactional-sales medium rather than a relationship-building medium which means that e-tail cannot substitute personal contact such as customer service advisors, that makes it the most critical differentiation aspect to high street stores today. This emphasises the need further research on the customers perception of e-tail, i.e. to what extent does e-tailing build relationships? If empirical research suggests that e-tailing is a transactional sales medium then ultimately there may be an opportunity for e-tail to focus building relationships with customers that will create the need for further research on how e-tail may be able to become a relationship-building medium. Personal contact with highly trained and motivated salespeople, the service factor is still the critical differentiator for such businesses, and on-line experiences have yet to match that or offer a suitable counter value (Quelch, 1999 cited in Maruca, 1999). As Pavitt (1997) states that the impact of e-tail on high street stores may result in changes on three key fronts; â€Å"change in the nature of product offerings, customer buying patterns and its place in the value chain†. The changes in product offering may alter as a result of advances in digital technology. For example media products delivered via the internet or newspapers being published electronically, that would be a direct impact on high street stores (Pavitt, 1997). There is lack of empirical evidence to show what customers perceive of digital medium against physical goods, as an simple example, would customers prefer buying a DVD from a high street store, so as to get a feel of the physical aspect of this product as well as more information from the back cover of the DVD case, or from the Internet where information on the product is limited in two dimensional form. â€Å"There will be a great deal of change in the value chain as well due to shrinkage in distribution channels†, (Bellman, 2001). E-tailing eliminates traditional chain of wholesalers, agents, and other intermediaries thus creating a new distribution model focusing on manufacturer to consumer direct that implies a great potential for savings (Bellman, 2001). Today, majority of the manufacturers do not want to take the responsibility of dealing with single customer queries, which is one reason why they sell their products through intermediaries even on the Internet. With lack of evidence it still remains to be investigated as to what extent is the internet an intermediary? Another common question which arises in this case is; do e-businesses have any storage for products they advertise or do they order them directly from the manufactures or other traders as required? However, this can also be different in the case of businesses which use internet as a secondary channel for sell or distribution of their products, which they also sell in their physical store. Another issue that arises is to investigate potential shoppers perception in relation to price. Smith et als (1999); cited in Lii and Lee (2005) indicated that online shoppers believe that online stores enjoy a cost advantage over traditional channels in terms of administrative cost, overheads and transaction cost. These features of the online retail channel add to the perception of online shoppers that prices generally tend to be much lower online than that of the high street stores. Considering this then, do customers shop online because they perceive it to be cheaper? If so then how and in what w ays is online shopping cheaper compared to the high street stores where lots of products are reduced at competitive prices even at times with offers such as buy one get on free or a second product at half price, are always there. Is price an issue of concern or is it about building relationships? Would customers be willing to pay that extra price in exchange for good service, remains to be investigated? Good service may be classed by online shoppers such as providing a tracking system for their ordered goods, free return policy and delivery of the goods or a full money back guarantee on items that customers return which is in place with most e-businesses today. With regards to customers online shopping behaviour, Brown (2000) states that a survey by BT found out that consumers choose well-known brands when shopping online and those consumers want to be served immediately, be remembered and treated as individuals. Therefore, in what ways can e-businesses build relationships? According to Kalyanarm and Winer, (1995); Chandrashekaran, (2001); cited in Lii and Lee (2005) prior studies have revealed that in the off line retail channels, customers may use the advertised original price as a frame for reference to assess the accompanying sale price. The resulting price comparison between the original price and the sale price makes the price promotion more appealing (Biswas and Blair, 1991; Grewal et al, 1996; cited in Lii and Lee, 2005). On the other hand on line retailing enables potential customers to have quick and easy access to price and other product attributes and information necessary for price evaluations. An example is amazon.co.uk websit e. The Internet has empowered on line shoppers to better detect price discrepancies and bargains (Balasubramanian, 1997; Bakos, 1997; Hoffman and Novak, 1997; cited in Lii and Lee, 2005). Today Majority of e-tailers attract customers through promotion codes normally available through advertisement and marketing media from which customers, can usually claim some money off or some percentage of discount on their online shopping. What remains to be assessed is whether the promotional codes attract new customers and also retain existing customers to shop online? If e-tailers start providing regular promotion codes to new customers as well as regular customers with this, then will it add up to building a relationship? 2.5 Customers general online shopping preferences in the UK On the basis of the objectives of this research, its crucial to investigate customers e-tail shopping preferences in the UK in general first, since ultimately perception leads to action. â€Å"When consumers are confronted by new forms of retail channels such as on line shopping, they may decide whether the difference between the on line shopping and off line shopping is significant to them. If the difference is perceived to be insignificant, customers may classify the two retail channels as the same. On the other hand, if the differences are perceived as significant, customers may classify the two shopping channels as different and make their purchase decision differently† (Lii and Lee, 2005). â€Å"Perception involves the process of categorization, and people tend to place new experiences into existing classifications of familiar experiences† (Monroe, 1990; cited in Lii and Lee, 2005). Late night shopping in the UK is fast becoming a way of life and a new culture, since for many people 24-hour high street shopping is invaluable as it allows them to fit it around their lifestyles, this is very common in the larger cities like London where this sort of service fits in well with the metropolitan lifestyle whereby time is crucial, however having said that, its also being almost equally favoured by people living in smaller towns or suburbs. The changes occurring in buyer behaviour patterns are alarming to high street retail stores as more and more people are beginning to work partly or wholly from home and they may prefer their goods bought online to be delivered at home, this is also rapidly picking up for supermarkets where the consumers prefer their grocery as well as other items shopped on line to be delivered at their doorstep (Haymarket, 2006). Whatever may be the case, Cottam (2006, cited in Haymarket, 2006) says that high street retailing is facing stiff competition with on line ‘anytime culture, meaning that customers are shopping 24/7 and therefore even high streets supermarkets such as Asda and Tesco have also launched 24-hour stores. Customers perceptions about 24/7 shopping remain to be investigated, since some high street supermarkets that tend to provide 24/7 services are closed on Sunday afternoons due to Sunday trading laws, but this has also changed in recent years. Once more it raises the question, what are customers perception of 24/7 culture in relation to the internet and high street stores, a fair example to portray, the 24/7 concept proved to be costly, in comparison to profitability against cost, for a superstore like Sainsburys as Sainsbury failed in its attempt, even though it believed it had the winning formula (Haymarket, 2006). The reason behind the failure was that Sainsburys could not attract enough customers as there is no guarantee that a fair percentage of existing or new customers will change their habits to take advantage of 24-hour shopping (Haymarket, 2006). Indeed this is a lesson for others (organisational learning) and thus most retailers are being cautious in their approach to 24/7 services. Bearing this in mind customers are constantly taking advantage of such facility and are trying or even getting used to shopping around the clock says Gladding (2006, cited in Haymarket, 2006). Analysts argue that 24-hour retailing is less likely to grow beyond its current levels as retailers have raised little awareness of the fact, hence stores such as Asda and IKEA are being cautious about this approach by advertising their long opening hours in the form of outside signage and flyers (Haymarket, 2006). The key question that arises from this scenario is the customers perception of the availability of 24/7 online shopping versus the high street 24/7 timings. Do customers really want go to shopping at high street stores and supermarkets at night (freely) compared to doing online shopping at night? Security is another issue that could be a vital sign of failure for high street stores or supermarkets to remain open 24/7 and be able to achieve their budget. Depending on the type of product, Andrew and Currim,(2004) have highlighted some key characteristics of customers shopping on line, despite the additional aspects. They say that consumers shopping online for products such as groceries differ from those who shop in high street stores claiming that on line grocery shoppers tend to be more frequent, heavy shoppers, less price sensitive, prefer larger sizes and do more screening on the basis of brand names. Alternatively, Morganosky and Cude ,(2000) suggest that convenience is the main motivation for on line shoppers, and according to Keh and Shieh,(2001) on line shopping is ideal for time-starved customers such as couples with two careers, children, and above-average income who want to spend time with their families instead. These suggestions are valid and can be applied to the reasons for consumers behaviour towards shopping online, however it also differs to the type of market and the products on offer. Hence, for those people, conven ience is more of a priority than price stresses, Keh and Shieh, (2001). Also Professionals, working women and single independent hard working individuals are just some of the people who do not have time on their hands and their perceptions of online shopping especially for items such as grocery remains to be determined. Keh Shieh, (2001) simply claim, with being deficient in practical evidence, that such customers dislike grocery shopping and only those with busy schedules will consider on line purchasing as a viable option. Online shopping may save time and money as the frustration of dealing with children at a store or supermarket that involves pushing carts up and down the aisles, waiting in long lines at checkout counters, and finding parking spaces, could be eliminated, Keh Shieh,(2001).Whilst on the other hand, as more people today having the opportunity to â€Å"surf† from their offices, they are more likely to shop during office hours and thus may prefer to collect their online shopping at ‘convenient stores on their way back home (Pavitt, 1997). Vaughan (1999); cited in Jardine (1999) head of consulting at Retail Intelligence says that â€Å"consumers might do their main shopping on the internet once a week but will still need to stock up on fresh foods locally† and this is the alternative method that supermarkets have taken by opening ‘convenience stores such as Tesco Express, Sainsburys Local, and MS Simply Food, (Jardine, 1999). According to Lii and Lee (2005), their study on examining customers perception of shopping on line suggests competitive pricing being the main reason. It allows them to compare prices of products more quickly and easily than when shopping in stores. (Korgaonkar and Wolin, 1999; Ernst Young, 2001; cited in Lii and Lee, 2005). According to the author, Mysupermarket.co.uk is a classic example; The website allows registered shoppers to compare their online shopping from high street supermarkets in the UK which are Tesco, Asda, Sainsbury and Ocado which is fully online based. Furthermore it allows users to switch at a click if they decide to change their preference to the cheapest supermarket. The problem associated with this is that it may be time consuming going through the tedious process of comparison because consumers may dislike switching from their preferred supermarket. In the authors view high street supermarkets also offer this service. A good example is that of Sainsburys supe rmarket where there is often a price comparison sheet placed next to their own shelf edge price tags showing their prices as compared to Tesco and Asda. If not then Sainsburys have opened small kiosks often located towards end of an isle where the customer advisor can compare their prices for customers with other competing supermarkets and if their prices are high then they do price match or sell the item even cheaper. This shows that the high street physical stores are also doing their best to match the benefits of on line shopping. Another factor that may drive away consumers from shopping on line is transportation cost. Bellman (2001), says that growing numbers of e-tailers are eliminating these costs as they find that customers often cancel orders after going through the entire ordering process and then considering the transportation cost being high, and this may be the key factor that drives potential customers away. The other fear of shopping online is privacy. Most web users refrain giving out their details, especially data in the form of credit card details as they fear exploitation of their privacy (Bellman, 2001). Insufficient product information on screen also contributes to decline of purchase. Apart from this, all secured websites do have a ‘time-out function where user sessions are based on time limits. If ‘time-out occurs, customers risk losing their entire shopping basket, which is quite frustrating from a customers point of view. These are some of the most common factors which may keep away customers from shopping online and reason their preference to shop in high street stores simply because they are well aware of the location, store layout, product selection and return policies as well as the stores reputation (Greenbury, 1999; cites in Maruca, 1999). Online e-tailing has a great and growing future, but the high street is still an important destination for customers. The limiting factor of e-businesses could be, a simple example, such as one cannot buy a piece of fruit via shopping online but can do so from a store. Furthermore, there is no empirical evidence to justify what drives customers to shop on line instead of high street stores, ultimately questioning what customers online shopping preferences are? 2.6 The E-tail clothing sector in UK Fashion is a sensitive and rapidly moving market which is growing at a faster pace in the UK, in comparison to its other European counter parts. Shopping on line for clothing products is also fast gaining popularity in the UK. Although buying over the Internet remains small in comparison with buying through the traditional channels, such as the brick-and-mortar physical stores, it is growing and clothing is a substantial portion of the e-tail sector in the UK. The online clothing sector caters for almost all segments of the UK market starting from the low cost value clothing to high end designer clothing including bespoke tailoring to couture clothing, the choice is unlimited and the options ever increasing. One can buy a single handkerchief to a full suit online, even clothing and accessories for all age ranges are available, whereby the customer can buy clothes for new born babies to clothes for senior citizens, therefore making this shopping Diabetes: Questions and Answers Diabetes: Questions and Answers DIABETES Diabetes Mellitus The medical name for diabetes mellitus comes from the Greek word that means to siphon and the Latin word that means sweet like honey. Diabetes mellitus is the name given to a group of conditions where there is too much glucose in the blood. It affects approximately 3% of the population. There are currently 1.4 million people with diabetes mellitus in the UK and it is expected that by 2010 that there will be a further 1 million. It costs the NHS 4.9 billion a year and affects a million people without them even knowing that they have it. (Devendra et al 2004) RELATED BIOLOGY Which organ is involved in the regulation of Blood Glucose Levels? The pancreas. Where is it located? Retroperitoneally, within the curve of the duodenum and with the tail extending to the posterior surface of the spleen. What type of tissue is it made up of? Primarily glandular tissue that has both endocrine (Insulin) and exocrine (Pancreatic digestive enzymes) functions. Which area of this organ is responsible for producing the hormones involved in the regulation of blood sugar levels? The Islets of Langerhans What are the main functions of insulin? To reduce the levels of blood sugar by facilitating the uptake of glucose from the bloodstream into the cells. It increases the rate of glycogen synthesis in the liver It promotes the synthesis of fatty acids in the liver It inhibits the breakdown of fatty acids in adipose tissue It stimulates the uptake of amino acids It increases cell permeability to potassium (after Wills C et al 2003), What type of substance is insulin made of? Circle the correct answer. Carbohydrate Protein Fats Name the calls that produce the hormone glucagon. Alpha cells What are the main functions of glucagon? An insulin antagonist, it raises blood glucose levels by increasing hepatic glycogen breakdown. It activates hepatic glyconeogenesis It enhances lipolysis of triglycerides One of these hormones has a Catabolic action and the other an Anabolic action. State what these terms mean and identify which hormone falls into which category. CATABOLIC Catabolism is the breakdown of complex biological molecules into smaller component ones Glucagon ANABOLIC Anabolism is the synthesis of complex biological molecules from simpler components. Insulin What are considered normal limits of blood sugar readings? Fasting blood sugar 3.0 to 6.1 mmol/l (Client note: this is variable I have quoted WHO figures – check what your tutor recommends and add it here!) Those with levels of 6.1 to 7.0 mmom/l are said to have impaired glucose tolerance (WHO 1985) CLASSIFICATION OF DIABETES MELLITUS State the 4 main categories. To the client: this is a loaded question. There are many different classification schemes. I quote the categories as defined in RECD 1997 Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus Secondary diabetes mellitus – includes: Genetic defects of beta-cell function Genetic defects in insulin action Diseases of the exocrine pancreas Pancreatitis Trauma/pancreatectomy Neoplasia Cystic fibrosis Hemochromatosis Endocrinopathies Acromegaly Cushings syndrome Glucagonoma Pheochromocytoma Hyperthyroidism Somatostatinoma Aldosteronoma Drug- or chemical-induced Vacor†  Pentamidine Nicotinic acid Glucocorticoids Thyroid hormone Diazoxide Beta-adrenergic agonists Thiazides Phenytoin Alfa-interferon Infections Congenital rubella Cytomegalovirus Uncommon forms of immune- mediated diabetes Other genetic syndromes sometimes associated with diabetes Down syndrome Klinefelters syndrome Turners syndrome Wolfram syndrome Friedreichs ataxia Huntingtons chorea Lawrence-Moon Beidel syndrome Myotonic dystrophy Porphyria Prader-Willi syndrome (RECD 1997) Diabetes mellitus can be due to a deficiency in insulin synthesis, secretion and also in some cases resistance. It is also thought that some diabetics may have a combination of both. State 5 causes of Primary Diabetes Mellitus [aetiology]. Primary Diabetes Mellitus is subdivided into Type 1 and Type 2 varieties Aetiology of Type 1 is multifactorial. It is auto immune and trigger factors can be genetic or environmental Environmental causes include exposure to Coxsackie B virus, Rubella virus and Cytomegalovirus and exposure to cows milk. Aetiology of Type 2 is also multifactorial. It includes genetic factors and environmental factors including: western diet, lack of exercise, obesity and hypertension (Todd W et al 2000) NB Causes are still unknown, the above are thought to be trigger factors. State 4 causes of Secondary Diabetes Mellitus. Causes of secondary Diabetes Mellitus. There are several types of secondary Diabetes Mellitus including: gestational diabetes malnutrition-related diabetes pancreatic diseases causing diabetes endocrine diseases causing diabetes drugs and chemicals causing diabetes genetic conditions causing diabetes Causes depend on the variety but include pregnancy, pancreatitis and various drugs including: steroids thiazide diuretics phenytoin diazoxide streptozotocin Pancreatic diseases can cause Diabetes Mellitus including: acute and chronic pancreatitis pancreatic carcinoma cystic fibrosis haemochromatosis Disease processes can also cause secondary Diabetes Mellitus including: acromegaly Cushings syndrome glucagonoma phaeochromocytoma Complete the following chart by using the recommended textbooks to compare the two main types of Diabetes. TYPE 1 TYPE 2 Age at onset juvenile ( % of all cases about 10% about 90% Acute/insidious acute insidious Body build lean obese Genetic link high low Prone to ketoacidosis yes no Autoimmune Disease yes no Treatment insulin diet, oral hypog’s (Harris M 1995). What age group in the general population has the highest incidence of Type 2? Typically the 55-75 age range (Harris M 1995). Certain groups in the general population have an increased risk of developing Type 2 and currently Diabetes UK is promoting a campaign to identify those most at risk earlier, so that they do not develop the major complications associated with this chronic disease. This is called the Missing Million Campaign. Names these â€Å"At Risk† Groups 1. History of Heart Disease 2. History of Stroke 3. Obese (BMI>30) 4. Over 50s 5. Over 40s if from African Caribbean or Asian backgrounds PATHOPHYSIOLOGY / CLINICAL FEATURES DEFINITIONS Define the terms:– Gluconeogensis Biosynthesis of glucose from sources other than glycogen Glycogenolysis Oxidisation of hepatic glycogen into glucose Briefly describe how insulin deficiency / absence can cause the above processes to occur. Insulin deficiency and/or low glucose levels promote the secretion of glycogen Glucagon promotes the activation of the enzyme adenylate cyclase in the liver which triggers glycogenolysis. This is exactly the opposite process to gluconeogenesis and is mediated by a number of enzymes, the most significant being pyruvate kinease Clinical Presentation – Complete the following When blood glucose levels arise above a certain amount the renal threshold in the kidneys is exceeded and glucose spills over in to the urine. This is called glycosuria. This excess glucose sucks up the water so that it can flow from the body; this is called. Large amounts of urine are excreted. This is called polyuria. Excessive thirst is called polydipsia. Excessive urination can result in lowered blood pressure and shock. Blurred vision can be caused by fluctuations in the amount floaters and water in the lens of the eyes during periods of dehydration. This is called osmotic myopia of the lens. Cells are not able to access glucose so they do not receive any fuel and as a consequence cannot produce energy. This triggers the brain to send a message of hunger. This excessive hunger is called polyphagia. Lack of energy makes the individual feel tired and weak. Other sources of energy are sought. Fat stores are broken down to provide energy. This may result in ketosis. Breakdown of fats results in the production of ketone bodies which are excreted in the urine. These are acidic and alter the blood PH. There is a sweet smell of ketones on the breath. This is called ketotic respirations. Weight loss also results. Breakdown of protein stores results in muscle wastage. Skin infections are common e.g. Staph boils, erysipelas . Excess glucose suppresses the natural defence mechanisms and the action of the lymphocyte* cells. Electrolyte imbalances occur. The electrolyte potassium affects cardiac muscle causing arrythmias if deficient. Urea and electrolyte imbalances also result in the following symptoms 1. Dry mouth 2. Thirst 3. Muscle weakness 4. Lethargy 5. Cardiac arrythmias. Numbness and tingling in the feet and cramps may result from peripheral neuropathy. Client Note (*)– this is debatable – your tutor may have a specific answer in mid for this one The recommendations of the W.H.O â€Å"Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications† were formally adopted in the UK on the 1st June â€Å"2000. The key recommendation, with regard to diagnosis is that fasting plasma glucose should be lowered from 7.8mmol/L to 7mmol/L. What is an OGTT? The Oral Glucose Tolerance Test In the oral glucose tolerance test the patient, after fasting for 15 hours, drinks 75 g of glucose in 300 ml of water, over 5 minutes. Blood glucose is measured before the drink and after 30, 60, 90 and 120 minutes. Urine is collected before the drink, and after 60 and 120 minutes. Before the test, for a period of 6 hours, the patient should avoid smoking and drinking coffee. There is a normal glucose tolerance if the venous plasma value is less than 7 mmol/l after the 2 hour period, If after 2 hours after the glucose load the value is between 7 and 11 mmol/l, then there is impaired glucose tolerance. If glucose is greater than or equal to 11.1 mmol/l this is diagnostic of Diabetes Mellitus OTHER TESTS / SCREENING PROCEDURES What is an HbA1c Test and why is it carried out? This is a measure of glycosylated haemoglobin in the blood. It is a longer term measure of the degree of blood glucose control. (DCCRG 1993) NICE target is 6.5 7.5 HbA1c When would Urea and Electrolyte levels and Blood Gases be tested? Normally only if metabolic imbalance is suspected, dehydration, renal involvement or occasionally as a screen for end-organ pathology (kidneys). U’s + E’s may be requested as part of a monitoring procedure. Blood gases may be useful if severe ketoacidosis is present. When would a Full blood count, specimen check and chest X-rays be carried out? This is more likely to be done as a screening or monitoring procedure (FBC or Urinalysis) unless there was an obvious clinical reason for doing them such as suspected anaemia etc. A CXR would be less likely to be carried out unless pulmonary or cardiac pathology was suspected (Client: this is contentious – as different clinicians have different rationales for these investigations.) When would and ECG and Lipid levels be checked? ECGs are likely to be checked on diagnosis, as a monitoring procedure or if arrythmias have been detected. They may also be done as a baseline investigation, with hypertension or if cardiac involvement is suspected. Lipids are very likely to be abnormal in Diabetes Mellitus. They would be checked as a monitoring investigation at most visits. (DCCRG 1993) When would a neurological assessment and inspection of the lower limbs be carried out? Peripheral neuropathy and vascular impairment are common sequelae to Diabetes Mellitus and this would be actively considered and evaluated at each monitoring visit. Probably at least twice a year or more frequently if indicated. (DCCRG 1993) Why are protein levels checked? Proteinuria is a good indicator of diabetic nephropathy. Urine protein should be checked at every monitoring appointment. Serum proteins are less sensitive but if renal pathology is established then it may be a useful investigation. (DCCRG 1993) When is urine checked for ketones? In the presence of dehydration, clinical suspicion of ketonuria, pregnancy and as a monitoring procedure. (DCCRG 1993) When would an eye inspection / photography be carried out and why is this done? Retinopathy is a potent cause of visual impairment and commonly found in the diabetic state. It is commoner with poorly controlled Diabetes Mellitus and Type I diabetes mellitus. It is one of a number of ophthalmic complications seen with diabetes and should be actively screened for at every routine visit. (DCCRG 1993) Why would a diabetic require having their blood pressure regularly recorded and what value is recommended? Hypertension is a common cardiovascular complication of Diabetes Mellitus and is an independent risk factor in Type II diabetes mellitus. The presence of hypertension and Diabetes Mellitus coexisting in the same patient will increase the overall morbidity risk of both cardiovascular disease and cerebro-vascular accident. A blood pressure reading below 130/85 mmHg is an ideal goal for most people with diabetes who dont have kidney complications, but some authorities may recommend an even lower blood pressure goal (below 120/75 mmHg) for people with diabetes who have kidney complications. (DCCRG 1995) State the main complications Short-Term Hypoglycaemia, dizziness, lethargy, impaired conscious level – drowsiness. Hyperglycaemia, nausea, headache, malaise, ketosis. Coronary heart disease, Cardiovascular disease (macro- microvascular disease) Retinopathy which can lead to blindness Nephropathy, which can lead to kidney failure and the need for dialysis Neuropathy which can lead to, among other things, ulceration of the foot requiring amputation Microvascular Retinopathy, Nephropathy Neuropathy These are generally related to HbA1c levels with the highest incidence of complication occurring when HbA1c levels are above 12% Atherosclerosis Arteriosclerosis Both processes can lead to : heart disease stroke peripheral vascular disease (Stratton I et al 2000) What are the SIGN Guidelines and name those that relate to Diabetes. A set of guidelines originally drawn up by Scottish Intercollegiate Guidelines Network. They include: visual impairment (SIGN 4) pregnancy (SIGN 9) children and young people (SIGN 10) renal disease (SIGN 11) foot disease (SIGN 12) cardiovascular disease (SIGN 19). Treatment- Give Principles   Type 1 Always insulin dependent. Active treatment involves titrating insulin dose against glucose levels and then maintaining levels by manipulation of the insulin regime Constant monitoring by either patient or physician Constant vigilance for complications Type 2 Depends on cause, but in most cases treatment involves lifestyle modification, weight loss, dietary carbohydrate restriction. If not successful then progression to oral hypoglycaemics and occasionally to insulin. Constant monitoring for the presence of complications Reduction of secondary causes of complication i.e. cessation of smoking. INSULIN Insulin was identified as a substance that prevented diabetes in the early 1890’s. Banting and Best extracted insulin from the pancreas of a dog in 1921 and the first human received a crude extract of insulin from the pancreatic glands of cattle in 1922. Over the years there have been many advances in the synthesis of insulin. Insulin is a protein. Insulin injections are vital for people with Type 1 diabetes as they are unable to produce insulin them selves and also for many with Type 2 diabetes whose condition has progressed to a point where tablets and diet cannot control it adequately. The aim of this treatment is to ensure that blood glucose levels are maintained at less that 6.5 mmol/l. (Client: see previous comments) Name 4 factors which influence control 1. Weight 2. Severity of disease process 3. Diet 4. Level of exercise (Wing RR, et al 2001) There are a variety of insulins available on the market. The two main sources are animal and human. How is human insulin produced? By recombinant DNA technology inserting human genes into bacteria such as E.coli which then produces insulin in commercial quantities. The majority of diabetics are now on Human insulin but unfortunately some people are still required to take animal insulin. Many drug companies are wishing to phase out animal insulin and at present Diabetes UK is campaigning to maintain these. Why does insulin have to be given by injection? Being a protein it cannot be given by mouth as it would be denatured in the gastro-intestinal tract. What other route is being researched as an alternative? A great deal of research has been lavished on alternative modes of drug delivery. Transdermal routes do not give reproducible and consistent blood levels. Oral insulin has not been a possibility in the absence of a specific peptide carrier system that would work in the gut. Nasal administration has been tried, but there was low bioavailability and absorption enhancers were needed, in addition the clinical effect was only over a very short period. Pulmonary routes appear to be promising but we already know that the pulmonary route is comparatively inefficient and requires ten times the amount of insulin to achieve the same clinical effect. Initial clinical trials show no side effects and research is currently continuing. (Heinemann L 2001) SIDE EFFECTS Initially on the commencement of insulin people may experience sensitivity around the injection site. How would you recognise this? This is a form of allergy. It can be local, in which case the local skin becomes red and itchy at the injection site. It may (rarely) be systemic giving rise to a uticarial reaction, tachycardia and tachypnoea. Very rarely a patient may experience anaphylaxis. Symptoms of hypoglycaemia may occur if too much insulin is injected or if not enough carbohydrate is consumed or if there is increased exercise without taking extra food. Hard lumps under the skin may occur at injection sites if they are not rotated. What is the correct medical term for these? Lipodystrophy The number of units prescribed is calculated depending on time of day, age, weight and lifestyle. Typical dose is 0.7-1.0 units per Kg of body weight. WARNINGS Insulin should never be administered in cases of HYPO. The body may get used to low levels of blood glucose and therefore the warning signs for HYPOs are reduced. Individuals who have lost these may be advised to raise their blood glucose levels slightly for up to 3 months to resensitise themselves to symptoms. Some people have also found that they have lost some or all of their symptoms of HYPO when transferring from animal to human insulin. Insulin dosages may have to change if there is disease of the adrenal pituitary and thyroid glands and also in the presence of liver and kidney disease. Taking of steroids will increase the insulin requirement. During illness, puberty or emotional trauma glucose levels can become elevated and therefore insulin doses require to be adjusted and more regular blood sugar monitoring is essential. During pregnancy insulin requirements may decrease in the first trimester and increase in the second and third trimester. The following drugs may increase blood glucose levels and therefore lead to a need for more insulin – Steroids Contraceptives Asthma Inhalers Some drugs lower blood glucose levels and therefore result in a reduction in insulin. These are:- Aspirin Beta blockers Mono-amine oxidase inhibitors. There are four categories of insulin. Give an example of each. Very short acting [ANALOGUE] – e.g. Humalog. Short acting [SOLUBLE, NEUTRAL] – e.g. Actrapid, Human Velosulin. Medium and long acting [ISOHANE, PROTAMINE ZINC] e.g. Human Insulotard. Combination of short and medium acting [MIXED, BIPHASIC] e.g. Human Mixtard. Who would most likely be prescribed very short acting insulins? The very unstable or out of control diabetic. Children more likely than adults. How long before a meal does short acting insulin require to be injected? Depends on type. Sol. Insulin starts working within 30-60 mins and lasts about 6-8 hrs. Other types such as Insulin aspart and insulin lispro both start working within 15 minutes and last for up to five hours. The glucose rise after a meal typically begins within about 15 mins so the insulin should ideally be in the system to counteract it. How often daily would you require to take the following insulins:- Short acting – about 2-4 times a day( when stable) Medium acting – about twice a day Long acting – Once (or perhaps twice) a day These answers depend on the age and size of the patient, as well as the severity of the disease process. Why is short acting insulin sometimes given with medium acting insulin? To give a smoother blood glucose profile and also to â€Å"fill in the gap† before the medium acting insulin becomes biologically active. Where should insulin be stored? In the fridge, but not frozen. Briefly discuss the types of equipment that are used to administer insulin? Commonest is still the disposable insulin syringe. Syringe should always be calibrated to match the insulin type. Most are U-100 now. Other options include the pen devices (expensive but convenient and largely â€Å"fool proof†). Jet injectors are occasionally seen, but not very common. In hospital surroundings insulin pumps (drivers or infusers) can be used. Ambulatory subcutaneous pumps are increasingly used to deliver continuous infusion. Very expensive but arguably capable of producing the best control. (HSG 1997) What advice would you give to a diabetic who is planning to go abroad on holiday with regard to their insulin? Take plenty with you as your brand may not be available abroad. Make sure you can keep it refrigerated. Run your blood glucose levels slightly higher than you are used to a) because of probable increased exercise and b) to reduce the risk of Hypo whilst away from home. Be extra vigilant with the blood sugar monitoring. Strange diet may have unexpected consequences. ORAL HYPOGYCAEMICS Below are the main categories of drugs. Give an example of each, including daily dosage and side effects? Sulphonylureas Chlorpropamide 250 mg (100 mg in the elderly) This is a very long acting drug, usually taken once daily with breakfast. Alcohol may cause flushing to the face. Biguanides Metformin Start at 500 mg twice a day or 850 mg once daily. The maximum daily dose is 2550 mg given in three divided doses Gastrointestinal side effects are a common occurrence in people taking metformin. Problems often include bloating, flatulence, nausea, stomach cramps and diarrhoea Occasionally a metallic taste in the mouth. Rare complication lactic acidosis (Knowler WC et al 2002) Prandial glucose regulator Repaglinide 0.5 to 4 mg with each meal Occasional gastro intestinal side effects (Bokvist K et al 1999) Alpha glucosidase inhibitor Acarbose 50 mg then titrated against clinical effect. Flatulence soft stools or diarrhoea. Glitazones [new drug] Rosiglitazone 4mg as starting dose increasing to 8mg if required Possible toxic effects on the liver (theoretical rather than practical) (Park JY et al 2004) ACUTE COMPLICATIONS The most common is Hypoglycaemia. It results from an imbalance between glucose intake, endogenous glucose and glucose utilisation. A decrease in the blood glucose level normally leads to stimulation of catecholamine secretion. Identify 5 causes. Insufficient carbohydrate intake Excessive carbohydrate utilisation (exercise) Intercurrent acute illness Overdose of insulin Other illnesses (viz glycogen storage diseases) Alcohol Name 8 clinical features that the patient experiences. Pallor Shaking Perspiration Fatigue A feeling of weakness Rapid heartbeat (Tachycardia) Hunger Agitation Difficulty concentrating Irritability Blurred vision Temporary loss of consciousness Confusion Convulsions Coma. What would be given in order to treat it? Depending on severity. If minor, warm sweet (glucose containing) drinks If major, IM Glucagon. Monitoring essential until fully recovered. What is ketoacidosis? A clinical condition almost invariably associated with low insulin levels. As a result, the blood glucose levels rise and the intracellular glucose levels fall. This requires the metabolism at a cellular level to be fuelled with fat derivatives rather than carbohydrates and this produces acidic ketones. These ketones normally require the presence of insulin for their catabolism. In its absence, they build up causing a metabolic acidosis and spill over into the urine when the concentration is high enough. Identify 5 causes Fluctuations in insulin regime Intercurrent illness Trauma Reduction in carbohydrate intake Dehydration +- severe exercise State 10 clinical features of this clinical state High blood sugar levels Frequent urination (polyuria) and thirst Fatigue and lethargy Dry skin Facial flushing Nausea Vomiting Abdominal pain Fruity odour to breath Rapid, deep breathing (Air hunger) Muscle stiffness or aching Coma The principals of management are:- Prompt administration of insulin (usually on a sliding scale) to reduce the hyperglycaemia and ketonaemia Replacing fluid loss (from polyuria and vomiting) usually by intravenous fluids Restabilising electrolyte imbalances secondary to dehydration, metabolic acidosis and hypokalaemia. Treatment for any underlying cause such as infection. LONG TERM COMPLICATIONS There are 10 steps that the diabetic patient can take to reduce his chances of developing complications. Regular screening of BP and maintain at 140/80 or lower. Regular HbA1c testing. Maintain blood glucose levels between 4-7mmols/L before meals. A