Lactate & Enzymes Essay Example | Topics and Well Written Essays - 1750 words

Lactate & Enzymes - Essay Example If pyruvate does not break down, it usually turns into lactate. When pyruvate is produced, the muscle cell will try to use it for aerobic energy. However, if the cell does not have the capacity to use all the pyruvate produced, it will be changed chemically to lactate. Some cells have a large capacity to use pyruvate for aerobic energy while others have very little. With training, many cells can adapt to use more pyruvate and, thus, produce less lactate. Lactate is present in our system at rest and as we go about our every day activities, although at low levels. However, as exercise or work activity increases in intensity, large amounts of pyruvate are produced very quickly. Because pyruvate can be produced quickly, not all of it may be used for aerobic energy. The surplus pyruvate will turn into lactate. This is why lactate is such a significant marker for training. When it is produced, it is a sign that aerobic energy is limited during the activity. There is a different reason why more lactate is produced as exercise intensity increases. As exercise increases, extra muscle fibers will be recruited. These fibers are used infrequently at rest or in light activity. Fast twitch fibers are not very good at turning pyruvate into aerobic energy. Hence, a lot of this pyruvate turns into lactate. Lactate is a major metabolic intermediate. Its fate depends on the conditions of the cell. In aerobic oxidation of glucose, glucose is converted to pyruvate, which is then converted to acetylSCoA (or AcetylCoA), a high-energy thioester. Under anaerobic conditions, pyruvate is reduced to lactate to regenerate the NAD + needed in Step 6 of glycolysis to keep glycolysis pathway going. 3. Which enzyme is responsible for lactate production Write out the equation for this reaction. Lactate Dehydrogenase (LDH) is an enzyme responsible for lactate production, which is present in varieties or organisms including plants and animals. This will catalyse the inter-conversion of pyruvate and lactate with concomitant inter-conversion of NADH and NAD+. As it can also catalyze the oxidation of hydroxybutyrate, occasionally called Hydroxybutyrate Dehydrogenase (HBD). Or D(-)Lactate + -NAD + Hydrazine LDH> Pyruvate Hydrazone + -NADH Abbreviations used: -NAD = -Nicotinamide Adenine Dinucleotide, Oxidized Form -NADH = -Nicotinamide Adenine Dinucleotide, Reduced Form LDH = D-Lactic Dehydrogenase 4. The student decided to use this enzyme to measure blood lactate levels. He reasoned that if he could produce reaction conditions that allowed the enzyme to metabolise all the lactate present, he would be able to calculate the lactate content of his sample by reading the change in absorbance at 340nm. Explain the reasoning behind this idea. LDH catalyzes the reduction of pyruvate to L-lactate with concomitant oxidation of NADH2 to NAD. Since the oxidation of NADH2 is directly proportional to the reduction of pyruvate in equimolar amounts, the LDH activity can be calculated from the rate of decrease in absorbance at 340 nm (334 nm or 365 nm). 5. In order to obtain suitable conditions for an assay to measure plasma lactate levels, the student chose a buffer containing 1.5% (w/v) hydrazine. Hydrazine reacts covalently with pyruvate to form a hydrazone: CH3 CH3 | | C=O + NH2.NH2 C=N.NH2+H20 |

Business Plan for a Startup Business Term Paper

Business Plan for a Startup Business - Term Paper Example gers, grilled chicken burger; side dishes such as French fries, green salads; and beverage items include shakes, coffee, tea along with orange and lemon juices. The primary targeted group of consumers of the proposed food truck business will be young adult professionals, tourists and college/university students. In the context of ownership, the proposed venture will be operated by a group of three individuals passed out from their entrepreneurship degree in Al Ain City. With regard to the present market statistics in the food industry, it can be estimated that the mobile food service or the process of offering food items through food truck will generate a sustainable position with strong financial performance and brand image. It is projected that the start-up food truck business may attain satisfactory results in the initial years of its operations through considering the above-discussed important factors effectively. The sales plan for the proposed food truck business will focus on performing direct sales. The strategy of conducting direct sales in terms of transporting food items will enable the proposed business of food-truck to provide quality based foods and services to each individual or group of consumers. Moreover, the sales strategy of the proposed business will also emphasize on generating greater customer awareness within the marketplaces of Al Ain City of UAE. The proposed business plan of Food truck for burgers in Al Ain City UAE will be highly focused on selling quality burgers along with fast-food items towards gaining attention of the increasing food-lovers across the city. According to the proposed plan, the organization will be highly responsible to meet the customers with emerging trend of the changing food habits along with their growing interests on consuming wide range of fast-food items irrespective of different locations in the city. The organization will centrally focus on designing a unique concept of selling food items through

Risk Factors For Neutropenic Fever Health And Social Care Essay

Risk Factors For Neutropenic Fever Health And Social Care Essay Cancer patients, who receive cytotoxic antineoplastic therapy sufficient to harmfully affect myelopoiesis and the developmental integrity of the gastrointestinal mucosa, are at high risk for invasive infection due to the translocation of colonizing bacteria and/or fungi across intestinal mucosal surfaces. Since the level of the neutrophil-mediated component of the inflammatory response are typically attenuated in neutropenic patients 1, physical findings of exudate, fluctuation, ulceration or fissure, local heat, swelling, and regional adenopathy are all less prevalent in the neutropenic patient1. Thus, fever might be the earliest and only sign of a severe underlying infection 2. With the increasing use of myelo-suppressive agents in the treatment of neoplastic and nonneoplastic diseases, the increased rate of infection in patients with neutropenia has been clearly established 3. Sadly, many of these commonly fatal infections go unrecognized until autopsy 4. Therefore, in order to avoid unfortunate outcomes such as sepsis and possibily death, it is critical to recognize neutropenic fever early and to start empiric systemic antibacterial therapy promptly. It is also crucial to assess the risk of serious complications in patients with febrile neutropenia, since this assessment will dictate the approach to therapy, including the need for inpatient admission, IV antibiotics, and prolonged hospitalization 2. An overview of the concepts related to neutropenic fever, including definitions of fever and neutropenia and categories of risk are reviewed here. The risk assessment and the diagnostic approach to patients presenting with febrile neutropenia are also discussed. This topic also provides a general approach to the management of neutropenic fever syndromes in cancer patients at high and low risk for complications, and the prophylaxis of infections in such patients. DEFINITIONS Fever: The definition of fever as an indicator of infection in patients with neutropenia has varied. Carl Wunderlich proposed in 1868, that the mean normal body temperature was 37 ¿Ã‚ ½C (98.6 ¿Ã‚ ½F) with an upper limit of normal of 38 ¿Ã‚ ½C (100.4 ¿Ã‚ ½F), above this limit, fever was defined 5,6. Although it has been observed that there is a range of normal body temperatures, according to a survey of 270 medical professionals, 75 percent of subjects reported that normal body temperature is 37 ¿Ã‚ ½C (98.6 ¿Ã‚ ½F)5,7. While, a survey of members of the British Society for Hematology concerning their institutional definitions of fever identified ten definitions of fever, ranging from a single temperature >37.5 ¿Ã‚ ½C to either a single temperature >39 ¿Ã‚ ½C or two successive temperatures >38.4 ¿Ã‚ ½C 5,6. Despite these beliefs, the mean oral temperature was reported as 36.8 ¿Ã‚ ½0.4 ¿Ã‚ ½C (98.2 ¿Ã‚ ½0.7 ¿Ã‚ ½F) with a range of 35.6 ¿Ã‚ ½C (96.0 ¿Ã‚ ½F) to 38.2 ¿Ã‚ ½C (100.8 ¿Ã‚ ½F), after observation of 148 healthy adults ages between 18 and 40 years 6. The definition of fever in neutropenic patients, according to The Infectious Diseases Society of America, was proposed as a single oral temperature of >38.3 ¿Ã‚ ½C (101 ¿Ã‚ ½F) or a temperature of >38.0 ¿Ã‚ ½C (100.4 ¿Ã‚ ½F) sustained for >1 hour2. Similar definitions have been provided from South America, Europe, and Asia. It has been approved to use this definition of fever in neutropenic patients9 ¿Ã‚ ½11. Neutropenia: The definition of neutropenia differs from institution to institution, but it is usually defined as an absolute neutrophil count (ANC) The absolute neutrophil count (ANC) is defined as the product of the white blood cell count (WBC) and the percentage of polymorphonuclear cells (PMNs) and bands: ANC = WBC (cells/microL) x percent (PMNs + bands)  ¿Ã‚ ½ 100 Based upon the level of ANC, neutropenia is categorized as mild, moderate or severe. An absolute neutrophil count between 1000 and 1500/microL corresponds to mild neutropenia. While, an ANC between 500 and 1000/microL corresponds to moderate neutropenia. Severe neutropenia is usually defined as an ANC As the neutrophil count drops below 500 cells/microL, the risk of clinically serious infection increases and is higher in those with a prolonged duration of neutropenia (>7 days). However, the risk is also related to the adequacy of the marrow reserve pool of granulocytes. Two terms, leukopenia and granulocytopenia are often used interchangeably with neutropenia, although they are somewhat different:  ¿Ã‚ ½ Leukopenia is defined as a low total white blood cell count that may be due to any cause such as lymphopenia and/or neutropenia; yet, almost all leukopenic patients are neutropenic since the amount of neutrophils is so much higher than the amount of lymphocytes.  ¿Ã‚ ½ Granulocytopenia is defined as a reduced absolute number of all circulating cells of the granulocyte series (neutrophils, eosinophils, and basophils); yet, almost all granulocytopenic patients are neutropenic since the amount of neutrophils is so much higher than the amount of eosinophils and basophils.  ¿Ã‚ ½ Agranulocytosis is defined as the absence of granulocytes, but the term is often inaccurately used to denote severe neutropenia. CATEGORIES OF RISK RISK FACTORS FOR NEUTROPENIC FEVER The risk factors for the development of neutropenic fever can be divided into three sub-categories including patient-related, disease-related and anti-cancer treatment-related predictors. Patient-related predictors include: age = 65 years, female sex, high body surface area, poor performance status based upon preexisting active comorbidities (e.g., cardiovascular, pulmonary, renal, endocrine, etc.) and poor nutritional status12 ¿Ã‚ ½19. Disease-related predictors include: Elevated lactate dehydrogenase (LDH) in patients with lymphoreticular diseases, bone marrow failure due to replacement of hematopoietic tissue by anomalous tissue which is know as myelophthisis19, lymphopenia20,21 and advanced stage of the underlying malignancy 13,16,20 ¿Ã‚ ½22 Treatment-related predictors include: administration of the planned dose-intensity of high-dose chemotherapy regimens15,20 ¿Ã‚ ½23 and failure to administer prophylactic hematopoietic growth factor support to patients receiving high-risk regimens14,21. RISK OF SERIOUS COMPLICATIONS This risk assessment is essential to determine the management of patients, including the need for inpatient admission, IV antibiotics, and prolonged hospitalization. High-risk patients require hospital admission for IV antibiotics, and often a prolonged length of stay. In contrast, low-risk patients may be treated as outpatients with oral antibiotic after a short period of observation or hospitalization. Definitions of low-risk and high-risk patients: The Infectious Diseases Society of America (IDSA) and National Comprehensive Cancer Network (NCCN) use different definitions in their guidelines:  ¿Ã‚ ½ Low-risk patients are those who are expected to have neutropenia (absolute neutrophil count [ANC]  ¿Ã‚ ½ High-risk patients are those expected to have neutropenia (ANC 7 days. While, neutropenic febrile patients with comorbidities or evidence of significant hepatic or renal impairment are considered high risk, regardless of the duration of neutropenia. Some experts have identified patients at high risk as those who are expected to have profound neutropenia (ANC = 100 cells / microliter) for > 7 days on the basis of experience that these patients are more likely to have serious and potentially fatal complications2,24. Nevertheless, formal studies to clearly differentiate between patients with a neutrophil count Some studies combine these groups to define high-risk patients. Deep prolonged neutropenia (ANC = 100 cells / microL expected to last > 7 days) is more likely to occur in the pre-transplant hematopoietic cell transplantation (allogeneic in particular) and in patients undergoing induction chemotherapy for acute leukemia. Risk based on underlying disease Patients who suffer from neutropenia after induction chemotherapy for acute myelogenous leukemia or as part of the conditioning regimen for allogeneic hematopoietic stem cell transplantation (HCT) are at a high-risk for serious infections. Other factors that are considered as high-risk status include gastrointestinal and oral mucositis, uncontrolled cancer, chronic obstructive pulmonary disease, advanced age and poor functional status. Patients receiving consolidation chemotherapy for leukemia or undergoing autologous HCT may also have long periods of neutropenia, but seem to be at somewhat lower risk, especially if they received prophylactic hematopoietic growth factors. In contrast, patients with solid tumors are mostly at low risk for serious infections. Guidelines An assessment of risk (high versus low-risk) for medical complications related to neutropenic fever should be obtained at the initial assessment of neutropenic fever episode. The Infectious Diseases Society of America (IDSA), the European Society for Medical Oncology (ESMO), the National Comprehensive Cancer Network (NCCN) as well as the American Society of Clinical Oncology (ASCO)2,24,25 , has recommended this. The IDSA and ASCO defined high-risk neutropenic patients as those who are expected to have profound neutropenia (ANC = 100 cells / microliter) for > 7 days or those with evidence of current comorbidities or hepatic or renal dysfunction2,24 . The National Comprehensive Cancer Network (NCCN) has used similar criteria for definition, but also includes a category of intermediate risk [21]. Multinational Association of Supportive Care in Cancer (MASCC) risk index that can be used as an alternative to clinical criteria, is a validated tool to assess the risk of medical complications associated with neutropenic fever (calculator 2)26 ¿Ã‚ ½29 . IDSA Risk assessment: The Infectious Diseases Society of America (IDSA) has established the following criteria for the definition of high risk or low risk patients with neutropenic fever 2: High-risk febrile neutropenic patients are defined as having one or more of the following criteria: ? Profound neutropenia (ANC = 100 cells / microliter) expected to last for > 7 days. ? Proof of current comorbidities, such as (but not limited to): ? Hemodynamic instability ? Oral mucositis limiting swallowing or gastrointestinal tract mucositis causing severe diarrhea ? Gastrointestinal symptoms such as abdominal pain, nausea and vomiting or diarrhea ? Changes in neurological status or mental appearance of new onset ? Intravascular catheter infection ? New pulmonary infiltrates or hypoxia ? Underlying chronic lung disease ? Signs of hepatic insufficiency (serum transaminase> 5 times normal) or renal insufficiency (creatinine clearance Low-risk febrile neutropenic patients are expected to have a relatively short duration of neutropenia for 7 days or less, with an absolute neutrophil count (ANC) Patients with evidence of severe sepsis (sepsis syndrome in end organ dysfunction) should be considered at high risk and managed as in-patients with initial intravenous antibacterial empirical treatment. While, patients with signs of septic shock should be managed in an intensive care unit based upon goal-oriented therapy30 . NCCN risk assessment The National Comprehensive Cancer Network (NCCN) has developed certain criteria to classify patients as high risk or low risk, which must be performed during the initial evaluation [21]. High-risk febrile neutropenic patients are those having one or more of the following criteria: [21] ? The patients are hospitalized at the time of the development of fever ? Evidence of significant medical comorbidity or the presence of clinical instability ? Expected profound prolonged neutropenia (ANC = 100 cells / microliter expected to last> 7 days) ? Hepatic insufficiency (serum transaminase> 5 times normal) or renal insufficiency (creatinine clearance ? Any patient with leukemia not in complete remission, or any non-leukemic patient with signs of disease progression after more than two courses of chemotherapy. ? Any complex infection such as pneumonia at clinical presentation ? Alemtuzumab (antineoplastic agent) in the last two months ? Grade 3 or 4 mucositis ? MASCC risk index score Low-risk febrile neutropenic patients are those who do not meet any of the criteria for high-risk described above and meet most of the criteria as follows [21]: ? Ambulatory status at the time of the development of fever ? No acute comorbid illness requiring hospitalization and close monitoring ? Expected short duration of severe neutropenia (ANC = 100 cells / microliter should last for 7 days or less) ? Good performance status (Eastern Cooperative Oncology Group [ECOG] 0-1 (Table 2)) ? No hepatic or renal insufficiency ? MASCC risk index score of = 21 risk index Intermediate risk neutropenic patients are defined as those meeting one or more of following criteria: [21] ? Patients undergoing autologous HCT ? Lymphoma ? Chronic lymphocytic leukemia ? Multiple Myeloma ? Patients receiving purine analogue therapy ? The expected duration of neutropenia is 7 to 10 days For patients at intermediate risk, the NCCN recommends consideration of fluoroquinolone prophylaxis. Multinational Association of Supportive Care in Cancer (MASCC) score As an alternative to the IDSA and NCCN risk assessments described above, the MASCC risk index is validated for assessing the risk of medical complications associated with febrile neutropenia. Using the MASCC risk index, the following features are assessed and given a weighted score2,26 : ? Burden of disease (clinical condition of the patient at the time of presentation with neutropenic fever): ? No symptoms or mild symptoms (5 points) ? Moderate symptoms (3 points) ? Severe symptoms or dying (0 point) ? No hypotension (systolic blood pressure> 90 mmHg) (5 points) ? No chronic obstructive pulmonary disease COPD (4 points) ? Solid tumor or hematologic malignancy without prior history of fungal infections (4 points) ? No dehydration that requires parenteral fluids (3 points) ? Ambulatory status at the time of the onset of neutropenic fever syndrome (3 points) ? Age The highest possible score is 26. Patients with a score = 21 are considered to be at low risk of serious medical complications, and for whom outpatient treatment with oral empirical antimicrobial can be safe and effective29 . While, patients with a score The MASCC risk index has classified 98% of patients as low-risk and 86% as high risk with a sensitivity and specificity of 95%, and positive and negative predictive value of 98, and 86 percent, respectively 28. Patients with complicated infections have been reclassified as high risk for serious medical complications, which further increased the predictive value of the model. Complicated infections include non-necrotizing skin or soft tissue infection (SSTI) of >5 cm diameter, necrotizing SSTI of any size, grade 2 oral mucositis, sepsis syndrome or the presence of a visceral site of infection. [28]. The classification error rate has been 10 to 29 percent. [4] In addition, the MASCC risk index can predict the probability of death as follows:27 ? Score = 15: 29 % ? Score = 15 but ? Score = 21: 2 % The MASCC risk index has been criticized for the lack of a standard definition of this criterion the burden of febrile neutropenia, which could be a source of confusion2, or it could be interpreted differently by different clinicians. I addition, the MASCC risk index does not include the duration of neutropenia as a criterion, though it is considered as an important predictor of risk2. The MASCC risk index has been also criticized because it was developed using heterogeneous patient populations; thus, it might not function optimally in all populations. For example, in a retrospective study of patients with solid tumors who seemed to be clinically stable, the MASCC risk index had a low sensitivity to detect complications (36 percent)31. The low sensitivity was likely to be attributed to the fact that patients were all outpatients, and the rates of hypotension, dehydration and invasive fungal infections were low; hence, only three criteria were present to distinguish prognosis. The serious medical complications are provided by the MASCC risk index as follows 26: ? Hypotension defined as systolic blood pressure ? Respiratory failure defined as arterial oxygen pressure ? The admission to ICU ? Disseminated intravascular coagulation ? Presence of confusion, delirium, or altered mental status ? The development of congestive heart failure documented by chest imaging and requiring treatment ? Bleeding diathesis sufficient to require a blood transfusion ? Electrocardiogram changes or arrhythmias requiring treatment ? Renal failure sufficient to require an investigation and / or treatment with IV fluids, dialysis, or other intervention ? Other complications judged serious and clinically significant by the health care team All patients who were treated with systemic antineoplastic therapy six weeks prior to a systemic inflammatory response syndrome (SIRS) are assumed to have neutropenic sepsis syndrome until proven otherwise. SIRS is defined by the presence of two or more of the following conditions: temperature >38 ¿Ã‚ ½C or 90/minute, respiratory frequency > 20/minute, PaCO2 Patients presenting with altered mental status, hypotension, hypoxia, oliguria or any other sign of new organ impairment must be managed emergently for severe sepsis. RISK OF TREATMENT FAILURE The risk of failure to respond to initial empirical antibacterial therapy is a composite outcome to be considered clinicians. Treatment failure is proposed if one or more of the following events occur within 30 days after the start of treatment 33,34: ? Persistence, progression or recurrence of signs of infection ? Modification of the initial empirical antibacterial treatment ? Readmission to the hospital for outpatients ? Death Patients with documented clinical or microbiological infections are more likely to be at risk for treatment failure, clinical or microbiological than for unexplained neutropenic fever (39 against 18 percent33. High-risk patients are more likely to be at risk for treatment failure than those with low risk. For example, patients with hematologic malignancies have a higher percentage of treatment failure than those with solid tumors (44 against 18 percent) 33. Observations have shown that among all febrile neutropenic patients at low risk of medical complications, adult patients at higher risk for treatment failure than children with 16% against 5% respectively34. PREVENTION In order to prevent neutropenic fever and infectious complications in patients at increased risk, the administration of an antimicrobial drug should be used as a prophylaxis. Antibacterial prophylaxis Pseudomonas aeruginosa and other gram-negative bacilli is the target of the antibacterial prophylaxis, because these pathogens are virulent and may cause life-threatening infections. INDICATIONS The beneficial effect on clinical outcomes has been sought from the administration of prophylactic antibacterial agents. The fluoroquinolones, levofloxacin (500 mg orally once daily) and ciprofloxacin (500 mg orally twice daily) have been the most studied antibacterial agents. Levofloxacin in particular is preferred in patients at increased risk for oral mucositis-related Streptococcus viridans infection 2. Results have been mixed with respect to effectiveness and have incited concern about toxicities and antibacterial resistance35 ¿Ã‚ ½37. A systematic monitoring of the prevalence of fluoroquinolone resistance among gram-negative bacilli should be done, at the intitutions that use fluoroquinolone prophylaxis. Based upon the available data, high-risk neutropenic patients defined by those who are expected to have an absolute neutrophil count Fluoroquinolone should be used with caution in patients at risk of a prolonged QT interval particularly in those who may require other QT prolonging agents, such as voriconazole. In addition, the potential to promote resistance among gram-negative and gram-positive should be considered when deciding whether to give a fluoroquinolone prophylaxis or not37. Concerns about the possibility of increasing the risk of Clostridium difficile infection has also been present, though this has not been proven in neutropenic patients receiving fluoroquinolone prophylaxis37. The use of prophylactic agents in institutions and geographic areas where the levels of resistance to fluoroquinolones are high is less likely to be efficient36,38.The use of antibacterial prophylaxis varies from one center to another with some centers avoiding such practices. For most patients with chemotherapy-induced neutropenia expected to be of short duration particularly patients with solid tumors, the use of antibacterial prophylaxis is not recommended. TIMING The ideal timing for the initiation and cessation antibacterial prophylaxis has not been sufficiently studied2. Many clinicians begin anti-bacterial prophylaxis, the first day of chemotherapy or the day after the administration of the last dose of chemotherapy cycle. Antibacterial prophylaxis is usually withheld when neutropenia resolves, or when empirical antibacterial regimen is initiated for patients who become febrile during neutropenia. Antifungal prophylaxis Among cancer patients and HCT recipients, a high rate of life-threatening invasive fungal infections such as candidemia has been observed since the late 1980s, which incited interest in antifungal prophylaxis for patients receiving chemotherapy. Antiviral prophylaxis INFLUENZA Annual immunization with an inactivated influenza vaccine is recommended for all cancer patients undergoing treatment2. The influenza vaccine is generally administered >2 weeks before the initiation of chemotherapy or, when circumstances dictate, between chemotherapy cycles and at least seven days after the last cycle. However, the best timing for such immunization has not been established2. All family members and other close contacts should get annual immunization too. HSV and VZV Reactivation of herpes simplex virus (HSV-1 and HSV-2) and varicella-zoster virus (VZV) occur commonly in HCT recipients who are not receiving prophylaxis and are important causes of morbidity. However, reactivation of both HSV and VZV infections can be effectively prevented with antiviral prophylaxis. Antiviral prophylaxis with acyclovir (400 mg orally three to four times daily or 800 mg orally twice daily) or valacyclovir (500 mg orally once or twice daily) is recommended in all patients who are seropositive for HSV and who are undergoing allogeneic HCT or induction chemotherapy for acute leukemia39. Antiviral prophylaxis with acyclovir or valacyclovir is also recommended in all HCT recipients who are seropositive for VZV. Based upon randomized trials, benefits of antiviral prophylaxis in these populations have been demonstrated; thus, recommended41. CMV CMV prophylaxis is indicated for HCT recipients because they are at are at significant risk for reactivation. In contrast, prophylaxis is not indicated in patients with chemotherapy-induced neutropenia, because it does not occur commonly. HEPATITIS B Antiviral prophylaxis should be considered for the following categories of patients and should be sustained for at least six months after the completion of chemotherapy40 : ? Patients receiving chemotherapy who have a previous history of hepatitis B virus infection, due to the risk of reactivation and hepatic failure. ? Patients with elevated circulating hepatitis B DNA or detectable levels of circulating hepatitis B surface antigen (HBsAg) ? Patients with a previous history of infection with detectable levels of antibody to HBsAg or to hepatitis B core antigen. This has been demonstrated to be able to reduce the risk of reactivation from 24 to 53 percent to 0 to 5 percent. Colony stimulating factors Granulocyte colony stimulating factors (CSFs) have been widely evaluated for prophylactic use following the administration of intensive cytotoxic chemotherapy when neutropenia is expected (primary prophylaxis). CSFs have been also evaluated for their prophylactic use during retreatment after a previous cycle of chemotherapy that caused neutropenic fever (secondary prophylaxis), and have been shown to minimize the extent and duration of severe chemotherapy-induced neutropenia in afebrile patients (afebrile neutropenia). Their use is not recommended in febrile chemotherapy-induced neutropenia2. However, prophylactic use of granulocyte CSFs has not been shown to have an effect on survival in most clinical situations. PRIMARY PROPHYLAXIS Primary prophylaxis denotes the use of granulocyte CSFs during the first cycle of myelosuppressive chemotherapy in order to prevent neutropenic complications. The goal of primary prophylaxis is to decrease the incidence of neutropenic fever and the need for hospitalization, to maintain dose-dense or dose-intense chemotherapy strategies that have survival benefits. Updated 2010 guidelines from the European Organization for Research and Treatment of Cancer (EORTC), the Infectious Diseases Society of America (IDSA), consensus-based guidelines from the National Comprehensive Cancer Network (NCCN), and The 2006 guidelines from the American Society of Clinical Oncology (ASCO), all recommend primary prophylaxis when the expected incidence of neutropenic fever is over 20 percent, to reduce the need for hospitalization for antibiotic therapy2,22,41. These recommendations are based upon randomized trials that have shown that primary prophylaxis was cost effective when the risk of neutropenic fever with a specific regimen was over 20 percent42,43 . In contrast, guidelines recommend against the routine use of granulocyte CSFs for primary prophylaxis in adult patients receiving chemotherapy regimens with an anticipated low probability ( However, when the anticipated risk of neutropenic fever is between 10 and 20 percent, the decision of primary prophylaxis should be individualized and may be appropriate in a number of clinical settings in which patients are at risk or increased complications22,41 :  ¿Ã‚ ½ Age >65 years  ¿Ã‚ ½ Preexisting neutropenia  ¿Ã‚ ½ More advanced cancer  ¿Ã‚ ½ Poor performance and/or nutritional status  ¿Ã‚ ½ Renal or hepatic impairment  ¿Ã‚ ½ In the case of epithelial ovarian cancer  ¿Ã‚ ½ Extensive prechemotherapy surgery, particularly if it included a bowel resection. In patients receiving concomitant chemoradiotherapy for either head and neck cancer or lung cancer, the use of granulocyte CSFs has been associated with adverse outcomes, therefore, it better be avoided. Despite the lack of comparative data from randomized controlled trials, that could recommend one CSF over the other for prophylaxis of infection during chemotherapy-induced neutropenia, in practice, most institutions use G-CSF. SECONDARY PROPHYLAXIS Secondary prophylaxis denotes to the use of a granulocyte CSF in subsequent chemotherapy cycles after a prior cycle has caused neutropenic fever. Secondary prophylaxis with CSFs reduces the risk of reccurence of neutropenic fever by approximately one-half 44. ASCO and EORTC guidelines recommend that secondary prophylaxis with granulocyte CSFs be limited to patients for whom primary prophylaxis was not given and who experience a neutropenic complication from a prior cycle of chemotherapy if neutropenic fever would prevent the administration of full dose chemotherapy and if reduced dose intensity might affect treatment outcome22,41 . TIMING G-CSF and GM-CSF therapy is usually initiated 24 to 72 hours after cessation of chemotherapy and is frequently continued until the absolute neutrophil count reaches 5000 to 10,000/microL. A reasonable alternative is continuation until clinically adequate neutrophil recovery. MANAGEMENT Initial Assessment Since, fever might be the first and only sign of infection in a neutropenic patient, its occurrence should be considered a medical emergency. Therefore, empiric broad-spectrum antibacterial therapy should be started immediately after blood cultures have been obtained and before any other investigations have been completed. The Infectious Diseases Working Party of the German Society of Hematology and Oncology and the Northern Ireland Cancer Network has recommended this. It has been recommended that empiric broad-spectrum antibacterial therapy should be administered within 60 minutes of presentation for all patients suffering from neutropenic fever at presentation. (algorithm 1) Diagnostic Approach At presentation, a detailed history and physical examination should be done, as well as a complete laboratory, microbiologic and imaging work-up for all febrile neutropenic patients. The table below summarizes the diagnostic approach to patients with febrile neutropenia.

Rates Of Reaction :: Papers

Rates Of Reaction Aim: To find out the effect of acid concentration in dilute hydrochloric acid and magnesium ribbon, and how much hydrogen gas is given off. Prediction: I predict that as the concentration of the hydrochloric acid increases the time taken for magnesium ribbon to dissolve will decrease. Apparatus: Saturated test tube Rubber bung Bowl water Magnesium ribbon Concentrated hydrochloric acid Plastic tube Stopwatch Conical flask Measuring cylinder The concentration of the acid is going to be my only variable. It will vary the time taken for the magnesium ribbon to dissolve into the acid. Other things that I will be using are not going to be varied these are volume of hydrochloric acid and magnesium ribbon. The magnesium ribbon dissolves into the hydrochloric acid because then it collides with the particles inside the hydrochloric acid. Activation energy is minimum amount of energy required for a reaction to take place. For each of the concentrations I use the activation energy will be different. If the activation energy is high then only a small amount of particles will have enough energy to react but if the activation energy is low then a lot more particles can react. The reaction will also be exothermic because it will be giving off heat and hydrogen gas. A change in concentration is a change in the number of particles in a volume. If we increase the volume the particles will collide more because they are crowded. Factors: The factors that could affect the rate of reaction are as follows: Concentration of Acid This could affect the rate of reaction because the higher that concentration of the acid the more particles there are so there is more collision per second. Temperature: If the starting temperature of the acid is different each time then the speed at which the atoms will collide will increase or decrease depending on what the temperature is.

Discuss Naturalism and the Importance of the Dog to Understand the Theme in “To Build a Fire”

Chad Mead April 5, 2013 ENGL-227 World Fiction Discuss Naturalism and the Importance of the Dog to Understand the Theme. The author of this short story is none other than Jack London. One of the most influential novelists of his age, Jack London was the author who wrote â€Å"Call of the Wild† and â€Å"White Fang†. Both books were excellent and even share some similarities with the story, â€Å"To Build a Fire†, which is the story we are going to discuss. â€Å"To Build a Fire† is a story of a man fighting the harsh weather of the Yukon with only his dog, where he is ultimately defeated by it. Also read The Story of an Eyewitness Essay AnalysisThis story has a strong Naturalistic presence in it, and shows it primarily through the means of the man’s dog. Through this style of writing, we begin to understand that this story is about survival in the wilderness using one’s instinct rather than sheer will. Naturalism is a type of writing style that is direct, no sugarcoated words, and shows us the harsh realities of daily life. Jack London used naturalism, the most realistic literary movement, to show how violent and uncaring nature really is, and how no matter what you do- nature will always be there. This is where the dog comes in as naturalism’s main contributor.The first time the dog is introduced in this story, it was described as submissive yet questionable, in regards to the man’s unwonted actions towards not building a fire or not finding shelter from the cold. The reason the author gives us as to why the dog is questionable is because  "the brute had its instinct. † (Jack London 655). Just from that one line the author gave, it showed that the dog and the man would have two contrasting roles to play in his story. The dog embodies pure instinct, who only wants to survive the harsh, cold weather by lying next to a fire or in a shelter.The man, adversely, shows us willpower because he does not wish to build a fire or find a shelter, but only seeks to push through the cold weather to get to his camp and â€Å"The Boys†. This shows us the beginning of the differentiation between instinct and will, and it only gets stronger from then on. The second appearance of the dog is when the man stops for the first time to build a fire and eat his lunch. When the man finished eating and smoking his pipe, he started along the trail back to his camp again, with the dog, leaving the fire behind. As soon as this happens the dog is mentioned in a long dialogue about how it earns to return towards the fire, and how the man did not know what real cold was. The line that really identifies with naturalism was that, â€Å"The dog knew cold; all its ancestry knew, and it had inherited the knowledge† (658). Through the dog’s environment and instinct, it knew what to do to survive a climate that it had known its entire life, and then some. The man, however, was described as the polar opposite of the dog, as â€Å"the man who did not know cold and possibly all the generations of his ancestry had been ignorant of cold† (658). This distinction between the two is now very evident, which brings up the turning point in the story.The last appearance of the dog with the man is when the man is at the point of freezing to death, because he had dropped into water and did not succeed in building a fire. The man starts up a plan to kill the dog and use its entrails to warm himself up. This is the part of the story where it truly becomes survival of the fittest, because the man is on the verge of dea th so he starts to depend more on his instinct to survive rather than his willpower. The man decided to carry out his plan and began calling to the dog, however, in the man’s voice, there was fear.As soon as we read that the man is so afraid that it can be heard in his voice, the dog recognizes it immediately. â€Å"Something was the matter, and its suspicious nature sensed danger-it knew not what danger, somewhere, somehow, in its brain arose an apprehension of the man† (662). Throughout the whole story, the dog follows the man, even if sometimes it did not wish to. With one sudden change in the man’s behavior, the dog instinctively knows that something is amiss. The man also realizes that the dog is scared of him because of his new attitude, so he tries his best to remain calm and calls for the dog once more.This time the man tricked the dog, however it was already too late for the man to rely on his instinct rather than his will; he could no longer clutch any thing with his frost-bitten fingers to try and kill the dog with. In the end, through the naturalistic story telling of the famous author Jack London, we can ascertain that when it comes to survival in the wilderness, it is best to survive on instinct rather than ones willpower. Mother Nature will not accept the will of fools who are not afraid of, or do not respect her power.

Benifits of Academic Globalization Essay

2. Introduction: Globalization is one of the most discussed issues nowadays. It has several branches which vary from economic, cultural, academic, and industrial and many more. However, the one that is increasing at a very high rate is academic globalization. Since academic globalization includes the act of studying abroad, it can be defined as is the act of traveling of students to study in a country other than the mother one. Nowadays, students are getting many Academic Globalization l 3 opportunities to study abroad, in addition to other reasons, which is why they are studying outside their home countries. â€Å"He [Wiladavsky] stated that 3 million students are now studying outside their home countries, a 57% increase from 2000† (Apurvadesai, 2010, p. 1). These numbers show the tremendous increase in movement of students around the world. Academic globalization has become one of the most debatable issues. People who are against it believe that once the students graduate and see many opportunities to work abroad they would not come back. On the other hand, people who are with it believe that it provides the students with better education and higher experience. In fact, academic globalization can be beneficial in several ways. 3. Literature review: Apurvadesia (2010), comments on the discussion of the World Affairs council which focuses on the rise of academic globalization. According to Wiladavsky, who was among the speakers, there is an increase in the movement of students around the world. Moreover, he discussed the concept of global ranking that motivates students to work and study harder to reach their goals and become part of the top class. In addition to that, Apurvadesia states that the idea of brain drain is actually brain circulation. Wiladavsky (2010), argues that countries should not be afraid from globalization. On the contrary, Wiladavsky tries to shed the light on the benefits of academic globalization. He believes that it helps in expanding knowledge and in trading of minds. Moreover, Wiladavsky tries to shed the light on the opposing point of view and give reasons behind the fear of globalization. Academic Globalization l 4 Wiladavsky (2010), focuses on why colleges should support globalization. Wiladavsky argues by believing that globalization of higher education helps in identifying talents. Moreover, he believes that successful competition is achieved by higher education. Goodman(2013), argues that Americans should study abroad in order to get  international experience. Moreover, he believes that student would appreciate difference and diversity through meeting new people. In addition to that, he considers that by interacting with people from different countries, students would be trained to all sectors of leaders. 4. Better education: One of the main reasons why academic globalization is beneficial is by offering a better education for the students. This is due to the fact that more opportunities and better experience are provided. 4. 1 More opportunities: Students get better education by having a wide variety of majors to choose where they fit. Some countries lack majors which are  available in others and thus, instead of doing a major that they are not interested in, they have the opportunity to study abroad the major they always dreamt of. For example, in Lebanon, petroleum engineering is not available; however, some students are interested in such a major. So instead of looking for another major to study, they can simply apply in another country which includes such majors. Moreover, a master degree is another opportunity provided in some countries and deprived in others. In developed countries such as USA or Europe, the master degree offered provides the students with better credentials. Students  Academic Globalization l 5 would be more knowledgeable and updated to recent discoveries. A student having a BS degree has less opportunity than a student having a master degree when applying a certain job especially, if the master degree was from a country offering a higher education. 4. 2 More experience: Another reason why students are provided with a better education is the high experience they get. The concept of brain circulation applies here, where students get different degrees from different countries. † A student may leave China, go to Singapore for an undergraduate degree, then to US for a Master’s degree, then  Australia to work for a couple of years, then back to China for a job with a multi-national company†(Apurvadesai, 2010,p. 2). In this example, Apurvadesai describes how having the opportunity to study in different countries provides the student with the higher experience and characteristics required for a job in a multi-national company. Moreover, living in a different country, having different culture, language, habits and lifestyle, increase experience. When students travel, they try to accommodate with the changes around them. This process provides them with higher experience when it comes to dealing with other countries. In addition to that, students will be provided with better communication skills. They would learn to speak new languages fluently due to practice and would be familiar with the demand of other countries. In this way, if there was a foreign customer, Academic Globalization l 6 the student will directly provide him/her with the service he/she is more likely to be interested in. 5. Expands global knowledge: Another reason why academic globalization is beneficial is that it helps in expanding knowledge across the world. This is achieved by discovering new talents. Some countries are deprived from a variety of domains. On the contrary,  when students travel to encounter their education, they would be exposed to a wide selection of domains. In this way, students would be able to discover new talents in them and introduce it to their local country. Moreover, academic globalization promotes the sharing of information between countries. When students get their education in a foreign country, they would be introduced to new concepts, studies and researches. People against academic globalization argue that the country offering the higher education takes away from the learning of the native country. However, introducing new concepts is not bad to other countries. In fact, as RAND economist James Hosek told the Cronicle of Higher Education that â€Å"When new knowledge is created, it is a public good and can be used by many†(Wiladavsky, 2010, p. 3). When students return back to their countries, they would share the knowledge they acquired and help in developing their nations. 6. Conclusion: In conclusion, academic globalization is a trend that is increasing at a very high rate. It is a one of the most debatable issues in the society. Some people are with it and think it is beneficial, while others are against it and think it is harmful. However, it can be beneficial in several ways. It provides better education for Academic Globalization l 7 students through having more experiences and opportunities. Moreover, academic globalization promotes global knowledge between different countries leading to the free trade of mind. In fact, people should support academic globalization to develop the whole world. 7. References: Apurvadesai. (May 15, 2010). Academic Globalization- The Emergence of International Universities. In Reading, Writing and Reflecting. Retrieved from http://apurvadesai. com/2010/05/15/academic-globalization-the-emergence -of-international-universities/ Goodman, A. E. , Berdan, S. N. (October 17, 2013). A Year Abroad vs. a Year Wasted. In The New York Times. Retrieved from, http://www. nytimes. com/roomfordebate/2013/10/17/should-more-american s-study-abroad/every-student-should-study-abroad Wildavsky, B. (January 5, 2010). Academic Globalization Should Be Welcomed. Not Feared. In Brookings. Retrieved from, http://brookings. edu/research/articles/2010/01/15- globalization-wildavsky. Wildavsky, B. (April 4, 2010). Why Colleges Shouldn’t Fear Global Competition. In The Chronicle of Higher Education. Retrieved from, http://chronicle. com/article/The-Global-Benefits-of/64932/. Academic Globalization l 8