Greeces Economic Crisis Research Paper Example | Topics and Well Written Essays - 1250 words

Greeces Economic Crisis - Research Paper Example 2-3). In a research paper of Cardiff Business School the researcher has concluded that the macroeconomic fundamentals like the inflation, the exchange rate arise for Greece which is more than the European average (Arghyrou and Tsoukalas, 2010, p.5). In a research paper of Capitalvia the researcher has opined that the economic situation of Greece and U.S.A. is similar as both of them are depending on the foreign investors for funding of the budget deficit. For the crisis the value of Euro would come down and the fact is that United States’ trade with EU is the highest. As a result the investor would lose confidence on U.S. economy and U.S. economy also would come down. According to this research though the U.S. investors’ investment is low in Greek bonds, if Greece would default the investors would lose money and U.S. economy gets hampered (Capitalvia, 2010, p.11-12). According to a research paper published by Konrad Adenauer Stiftung for improving the economy of Greece the euro countries are providing bridge loan and the tight austerity program introduced in Greece. As the countries are providing loan in a lower rate it is also necessary for them to tight the monetary policy in their countries. As a result the growth would be slow in those countries. As the Euro slow down, as an effect the dollar would go down. Then U.S. also has to tighten its monetary policy and as a result the economy would get hampered (Wagner and Machnowski, 2010, p.2). In a research paper of CEPS the researchers have compared the economic crisis of Argentina in 2001 and the crisis of Greece in 2011. Argentina has defaulted as there was lack of support from the outside of the country. Argentina has tried... The paper tells that the economy of the European Union is facing problem due to this crisis. As the investor is losing their confidence in Euro, the value of the currency is going down. As a remedial measure the governments of the European countries are providing bridge loan and as a result the countries have to tighten the monetary policies. The governments are providing monetary package to the banks which are in problem due to the crisis of Greece. In turn the bank interests come down and the world economy is facing certain problem. As the trade of U.S. is mainly with the European Union countries so the economic crisis of Greece would surely affect U.S. As the European countries are going to tighten their monetary policy for the economic crisis so certainly they would decrease their import and the main trading partner of Euro zone is U.S. The export would get hampered and the economic growth would not be much. As a result U.S. has to tighten its monetary policy and the overall econ omy of U.S. gets hampered. For the short term remedial measures the European Union countries have to provide loan in low cost to Greece and for long term remedial measures the European zone can take some policies like introducing common Euro bonds. The share of the capital would be as per the share of the countries and the interest rate would be provided by the countries would be like they are providing the interest rate they are providing in the domestic market. For the short term measures Greece should restructure its debt using some process like debt swap.

Uptake of heavy metals (arsenic and lead) by earthworms in a Literature review

Uptake of heavy metals (arsenic and lead) by earthworms in a contaminated soils - Literature review Example Despite healthy soil formed in the absence of earthworms, their presence within the soil indicates the soil is productive. As a result of the tedious activities by earthworms their importance for the soil community includes enhancing mixing and aggregation of soil (Weeks et al 2004, p.820). While looking for food, Weeks et al. (2004, p.821) observe that, earthworms engage in a task of moving to the surface and back down, ingesting particles of soil and other organic substances in their way. Further, earthworms excrete the substances it takes in to the soil, and the excreted matter by the earthworms, are nutrient-dense casts. The result in this sense, involves a process that shift the top layer of soil down to the lower strata, and dragging the bottom soil to the upper surface. When earthworms burrow through the dust, this enhances the soil structure by loosening the soil that are compact and establish numerous tunnels under the surface. The importance of such tunnels includes enhancing soil porosity and creating pathways that allows the intake of water and air into the soil. The process further facilitates absorption and the retention of water, and minimizing run offs and soil erosion (Weeks et al 2004, p.822). ... the soil surface and in the process, mix the organic material as a result of tearing the organic materials and depositing these materials deep within the soil. Their cast also deposits on the soils surface thus, contributing to the soil content. In addition, they enhance bacteria and fungi activity in the soil that consumes organic materials and transforming these materials to humus. Earthworms largely, forms part of the food web within the soil, which presents a large community, composed of organism that plays a significant role in soil formation. In the same note, soil food web encompasses soil-inhabiting organisms that include algae, insects, plants, reptiles, fungi and small mammals. The organisms, impacts on soil formation through burrowing, breaking down materials (both animal and plant materials) that is significant in adding organic matter when they die. Earthworms often provide a food source to the soil community and their cast is important in facilitating the survival of ot her organisms within the soil community. They assist in terms of facilitation the provision of oxygen, water and nutrition for other organisms (Hobbelen et al 2006, p.644). The ecological groups of earthworms and their feeding behaviors According to ecology studies on soils by Nahmani, Hodson and Black (2007, p.402), that focuses on linkages between fauna and microbes, identifies earthworms, as a significant soil invertebrate within the ecosystem and contributes, to biomass and activity which operate as ecosystem engineers. Nahmani et al (2007, p.402) agree that, soil consists of various microorganisms and forms part of earthworm’s diet. In this regard, three ecological groups related to earthworms and their feeding behaviors, exists in literature. They include epigeic, which is

Where Are You Going, Where have You Been Essay Example for Free

Where Are You Going, Where have You Been Essay Vanity can be exposed as ones greatest weakness. Where Are You Going, Where have You Been, a short story written by Joyce Carol Oates, describes Connies misconception of beauty as her only value, and also the ways in which Arnold Friend, a potential rapist and murderer, manipulates and takes advantage of Connies vanity. Connie is a fifteen year old girl who knows the extent to which her beauty can be used to her advantage. Connie knew she was pretty and that was everything. However, beauty causes Connie to become vain, and thus gives Connie the misconception that she is more powerful than the boys that are attracted to her. This proves that Connie believes her beauty allows her to transcend above other people, especially boys. As a result, although her beauteous physique can be seen as a benefit to Connie, her vanity proves to become her ultimate weakness and it leads to her demise as seen when Arnold Friend states I took a special interest in you, such a pretty girl. Connie becomes powerless in Arnold Friends presence because he manipulates and takes advantage of her vanity and desire for attention. Connies newly found sexuality as a teen gives her control over the boys she encounters at places such as the fly-infested drive in, which she describes as a haven and blessing they yearned for. The drive- in, which is fly-infested in reality, is the sacred building where Connie believes that her beauty can be truly appreciated, whereas at her home, beauty is not acknowledged at all. As a result, Connie further embraces her beauty in order to satiate her need for attention. In her trashy daydreams, Connie describes boys as dissolved into a single face that was not even a face but an idea. Connie is more enticed by the idea of having a boyfriend, which shows that she does not care much for the actual boy. This allows Connie to be more easily overpowered by Arnold Friends disguise when he first comes over to her house to take her away. This is evident when Connie states that for a moment [Arnold] wasnt even in focus but was just a blur standing there against his gold car This shows that Arnold becomes the concept of a  boyfriend to Connie, which is not even a face but an idea. Arnold eventually uses his opportunity as a potential boyfriend to flatter and ultimately overpower Connie in the end. A desire can undermine ones ability to guard ones self from tempting factors. Connies lack of attention from her family, especially her father, engenders her desire to be wanted by a man. Her desire for attention is noticed by Arnold Friend, and thus he uses that desire to his advantage. By turning Connies desire into her weakness, he uses manipulative tactics to overpower her vain personality. As a teenager, Connie is not able to truly identify herself. Connie is both a daughter and a sister to her family. However, her vanity and superficiality causes her to become a sexual object to boys as well, and thus she is flustered as to which role she can truly identify herself with. As a result of Connies identity crisis, Arnold Friend uses this to his advantage and overpowers Connie by further disorienting her with mixed feelings of both violence and passion. This is evident when Arnold threatens to hurt Connies family while attempting to seduce her with flattery, such as I like them the way you are, honey, as well. Arnold Friend psychologically manipulates Connie by acting both loving and violent, and this causes Connie to become powerless in Arnolds presence because she is not accustomed to a males who are so bipolar in emotions towards her. However, there is no rush or urgency as Arnold Friend casually speaks with Connie. This builds up to the suspense up until Connie finally realizes the danger she is in and all she could do is scream into the phone. Although Connie is caught up between the identities of being a daughter, sister, and an object of sexuality, Connies basis for these different roles is fixed upon physical appearance. Connie compares her beauty to her mother and sister, and she is always checking other peoples faces to make sure her own was all right. This shows that Connie fundamentally values physical beauty over all other factors. Although a grotesque encounter is foreshadowed when Arnold warns Connie gonna get you, babe, Connie allows Arnold to converse with her because she liked the way he was dressed. This further proves that Connie is immersed with only the superficial, and this  gives Arnold the chance to overpower Connie by becoming what she desires. Arnold is aware that Connie is primarily concerned with outer appearances, and this allows him to present himself in a desirable manner towards Connie. Connies inability to disregard the superficial in time resulted in her failure to recognize Arnolds disguise, and thus he was able to overpower her. Although Connie thinks of herself as a skilled flirt, she is soon stereotyped as nothing more than the pretty girl. Arnold Friend says, What else is there for a girl like you but to be sweet and pretty and give in? This proves that Connie, a girl who values beauty as the greatest worth, will be inevitably overpowered by a man who values and desires beauty as well. Music is both a shelter and exposure to Connie. Whenever Connie hears music, she feels a glow of slow pulsed joy that seemed to rise mysteriously out of the music itself. Connie was all about the the music that made everything so good. Music is made into such an important entity that it is almost given its own character. Music symbolizes security and safety, and she even describes the music at the drive- in as music at a church service; it was something to depend upon. By comparing it to church, she indicates that music is a form of religion to her. However, music as a religion does not bring Connie salvation. Although music is seen as Connies refuge, it leads to her powerlessness in front of Arnold Friend. One way in which Arnold is able to gain Connies trust is through his disguise and poor attempt to become like the man in the popular teenage songs. However, music is also a factor manipulated by Arnold and he uses it against her. Music is a refuge for Connie and Arnold is aware of that. The same song that was playing both Connies home and Ellies car seemed to blend together. The music, car, and outfit is all used by Arnold Friend as a way to become the type of lover described in the teen songs, and Connie falls for this guise and accepts his facade. Arnolds speech was spoken with a slight rhythmic lilt and Connie somehow recognized them Connie believes that she recognizes Arnold only because he seems to have come out from the teen songs she always listens to. As Connie realizes Arnold is not the idealized man in the songs, she loses recognition of everything that she is familiar with. She says that the kitchen looked like a place she had never seen before. This shows that  Arnold takes away more than Connies music; he takes away Connies life and everything else she is familiar with. Connie misinterprets that everything is the way it was in movies and promised in songs. She believes that her life will replicate the exact lover and life that is promised in the songs, which is just a mere fantasy and delusion in Connies case. As a result, Arnold seduces Connie by appearing to be what was promised in the songs, and overpowers Connie by using music as a tool. Arnold Friend is further able to overpower Connie because she is unsure of her identity that she has at home and everywhere else that is not home. Teenagers often are troubled by the fact that they are no longer children, but they are still not yet adults. As a result, Connie embraces the only thing she is certain of; her beauty. By overemphasizing the value of beauty, she becomes vain and self centered. Although she is troubled by her teenage turmoil, her family does not provide her with any moral support or guidance. Like Arnold Friend, her family is not what they seem. Arnold puts on a guise in order to become the idealized man in popular teen songs. In similarity, her parents appear to be typical parents, but they prove to be partly detached from Connies need. Connies father was away at work most of the time, and didnt bother talking much to them. As a result, Connie needed to seek for male attention elsewhere, such as from the boys at the drive in. Arnold Friend was aware of Connies desire for attention, especially from males, and thus used it to his advantage to overpower her. Even her mother seems to not be concerned about Connies desire for attention. Although at times Connie and her mother are almost friends over coffee, an issue arises that causes the two to argue over something of little value to either of them. Connie indicates that her mother had been pretty once too and as a result, Connie believes that her mother prefers her over June, who is plain and chunky and steady. This encourages Connie to believe that real value lies in beauty, and thus she makes the mistake of embracing vanity. This leads to Arnolds manipulation of Connies beauty and desire, which leads to his empowerment over Connie. As a result of her parents lack of concern and guidance, Connie is powerless when confronted by Arnold Friend. She does not know how to defend herself,  and only relies on her flirting, her beauty, and the fantasy that music represents. Connie was not taught by her parents how to act towards strangers. This is evident because Connies parents would not even ask her obvious parental questions such as Where are you going? or Where have you been? Due to the parents lack of concern, Connie takes advantage of her parents apathetic trust and goes out to places where parents would usually disapprove of. However, Connie feels guilty about deceiving her mom, who is simple and kind enough But the temptations of the drive- in and the boys overpower that guilt. This foreshadows Connies inability to overpower the temptations that Arnold Friend represents. Connie and her mom still manages to share a bond, as seen when Connie thinks to herself Im not going to see my mother again. Connies powerless ness is inevitable because her family did not emphasize true moral values, and as a result Connie embraced her beauty as her only value, which ultimately leads to her end by Arnolds hands. It is evident that Connie was overpowered by Arnold Friend because she embraced vanity as her only value, and also that Arnold took advantage of Connies desire for attention from men. Where are you Going, Where have you Been describes the eventual self awareness of Connie. Throughout the story, Connie has disregarded everything but her beauty. As a result, she only had her vanity as protection from Arnold Friend. This was clearly ineffective because it was obvious that it was Connies beauty and vanity that Arnold had desired since he first saw her. Arnolds desire for Connie overpowered Connies desire for attention, and thus Connie had no choice but to follow Arnold in the end. Although it music was something that made everything good and was something to depend on, Arnold manipulated music as well, and as a result he took away everything that provided joy and a sense of certainty to Connie. Connie had neither moral support nor guidance from her parents, and therefore she overemphasiz ed beauty as a value to the point where it blinded her from viewing Arnold Friend as an old fiend. Arnold Friend was able to disguise himself as an old friend by attempting to be the idealized man portrayed in the songs. He succeeded as a result of Connies misconception that everything is the way it was in movies and promised in songs. When Connie first sees Arnold, she cannot see anything  but her reflection in Arnolds sunglasses. This indicates that Arnold gives Connie the opportunity to see what herself as the stereotypical pretty girl, which Arnold replies what else is there for a girl like you but to be sweet and pretty and give in By manipulating her vanity, her desires, and her music, Arnold is able to take away her identity as a teenager, and thus Connie becomes powerless in the presence of Arnold. However, Connie matures when she casts aside her vanity by sacrificing herself for her familys safety. She eventually overcomes her own vanity in order to protect her family from Arnold, but only after she was completely overpowered by Arnold Friend. Although she was caught be tween the role of being a daughter, sister, and an object of sexual desire, she takes on the role of a hero at the end by giving her life for her family. Despite the fact that Connie became powerless in Arnolds presence, she was still able to overcome her vanity and selfishness for her familys sake, and this proves that Connie became powerful by the end of the story. Works Cited Oates, Joyce Carol. Where Are You Going, Where Have You Been?. Literature: Reading, Reacting, Writing, Compact. Ed. Laurie G. Kirszner., and Stephen R. Mandell.. New York: Heinle, 2006. 579-591 Quirk, Tom. A SOURCE FOR WHERE ARE YOU GOING, WHERE HAVE YOU BEEN?. Studies in Short Fiction 18.4 (Fall 1981): 413. Academic Search Premier. EBSCO. Santa Monica College Library, Santa Monica, CA. 4 Apr. 2008 http://libdb.smc.edu/login?url=http://search.ebscohost.com/login.aspx?direct=truedb=aphAN=7133354site=ehost-live Hurley, C. Harold. CRACKING THE SECRET CODE IN OATESS WHERE ARE YOU GOING, WHERE HAVE YOU BEEN?. Studies in Short Fiction 24.1 (Winter 1987): 62. Academic Search Premier. EBSCO. Santa Monica College Library, Santa Monica, CA. 4 Apr. 2008 http://libdb.smc.edu/login?url=http://search.ebscohost.com/login.aspx?direct=truedb=aphAN=7151290site=ehost-live

The Chisholms Kitchen

The Chisholms Kitchen Task 2 a A description of kitchen workflow, with a diagram to analyse workflow in â€Å"The Chisholms† kitchen. Workflow can be defined as It can be described as the progress (or rate of progress) in work being done. In the kitchen terminology it is the sequence of operations incurred in the processing of materials or (performing of essential functions) is called the flow of work. Conventionally, a good workflow in a kitchen means that materials and staff will move smoothly from the stores through preparation areas into cooking sections and then to the servers and the guest tables. Similarly, the dirty items will move back from the guest tables to wash up and back to the servers. http://www.expresshospitality.com/20060215/management08.shtml The work is always divided in the different sections and each section are joined into a layout and should follow a certain rules relating to the delivery (end product) Is know as the flow of work. Such flow of work is a natural and logical sequence that provides an ease of operations in the processing of materials i.e., food materials or doing of work. The need is to identify factors that make professionals achieve work with minimum movement and well within limited time. The basic crux of good designing is the intrinsic information of space (or would-be-kitchen) that should give optimum benefit. http://www.expresshospitality.com/20060215/management08.shtml For example for a small business its owner can manage his business freely but for a bigger restaurant it is necessary to have a clear work system that indicates the duties of each employee. For instance the reception takes care of the customers on arrival and guides them to the table. The waiters takes the order, the kitchen prepares the food and waiters later serve the process continues until the customers left the restaurant. In a restaurant in the kitchen has its own set of operations and a workflow to successfully carry out these tasks. The primary stage in design of workflow is to identify the work centre, which will exist in any kitchen There are two stages that help in making a workflow Identification of the work centre Production layout Production layout Product layout the equipment used in specific food production Process layout the technique of cooking is used in production http://zalite.org/resources/_wsb_488x367_kitchen+concept.jpg Lets take an example of fish and chips in a fast food outlet. Product layout where work centre where specific food product is made by using own equipment process for example; chilling fat fryers. Process layout where work centre perform a particular process for example; frying, chilling In kitchen operations the workflow systematically starts right from the receiving of materials to storage of materials, to preparation, to preparation to finish holding to service, to dish washing and pot washing and other cleanup to garbage disposal of the leftover materials that cannot be used. The stages of the workflow are closely linked to the central points of food safety management system. While working in the kitchen the equipment needs the minimum worker attention and the materials and tools should receive minimum handling. Kitchen space should allow service operations space in order to work and keep things. There should be maximum utilization of space and equipments should be achieved through the proper workflow. At all times the quality control must be sought at all critical points and minimum cost of production should be sought. WORKFLOW (SEQUENCE OF OPERATIONS) The Chisholm hotel is currently operates on a cook-fresh method of food production. The ordering is done by word of mouth and fresh food items are delivered thrice a week. All the food items are issued as and when required the Chisholm hotel is undergoing the refurbishment program to increase its conference and banqueting services. As if now the Chisholm kitchen consists of a chest freezer, a walk in chill room and a small store facility. Proper Workflow always aims to minimize the criss-crossing and back tracking between the sections. Effective workflow help in a prompt, effective, smooth production and service with the minimum expenditure of worker time and energy. Reduces the time incurred in delays and storage of materials in processing and serving. Ensuring workers and materials should travel minimum distances. Ordering At present ordering is done by the head chef over the telephone. All the food items are ordered as and when required the communication mishap leads to unnecessary chaos. As this method of ordering involves no paperwork or use of any computer software, it states that there is no formal records are maintained while ordering. Receiving Fresh food items are delivered three times a week as ordered by the head chef. All the receiving is done y the store person with the help of a storekeeping assistant. Storing The Chisholm hotel is equipped with a small dry store facility a walk in chill room and a large chest freezer. When the food items arrives at the Chisholm hotel it is stored in the conventional fridges and frozen item is stored a chest freezer. Issuing All the food items are issued as and when required. There is one storekeeper full time and a storekeeper assistant working part time. The store person does the issuing. Preparation All the mise-en-place and other preparations before actual cooking is done takes place in this section and this section is connected with pot wash as every food preparation requires a constant supply of clean kitchen equipments. Cooking At present â€Å"The Chisholm† hotel is operating on a cook-fresh method of food production. This section is very well connected with the pot wash for the constant supply of clean kitchen equipments and utensils. A proper system of waste removal is done from preparation and cooking section to prevent any contamination of food. Service of food As soon as the food is prepared it is ready to be served. The food service is done immediately to the customer. Task 2b Identification and brief explanation of factors that may influence the workflow in a hotel kitchen Techniques used for preparation of workflow Identification of work centre Techniques used for work centre Equipments used Production process Staff required An effective workflow design and its proper implementation always help to reduce cost and increase efficiency in the kitchen. Layout of kitchen Availability of raw material (seasonal/frozen) Planning of menu Equipments in use Service operation style Production system in use Number of covers served Employees / training Budget and costing Type of clientele Law and regulations Layout of kitchen The plan or the layout of the kitchen is always determined by the policies, which the catering establishments follow. Each catering establishment policies are different from the other and all the pre production, production and postproduction all the activities includes the following. Receiving, pre-preparation area and storage. Cooking area Dispatching and wash up areas. Floorings Resources (gas, electricity, water) Ventilation Work space Workflow plays a very significant role in designing a layout of the kitchen. Considering the expansion of the hotel the layout of the Kitchen has been redesigned and revised. Since now the hotel is expanding its number of covers there is bound to be more people, more space and varied menu involved thus influencing directly over the layout of the kitchen. Thus if there is more business a hotel would need more people for the production and more space so as they are able to perform as per the needs which thus in turn states clearly workflow influencing layout. If the kitchen is not designed as required, it will affect workflow in not been able to cook properly due to lack of cooking areas and washing areas and accidents due to lack of space thus affecting the business. Availability of raw materials In any catering establishment all its production is dependent on the availability of the raw materials. It is the basic necessity of any catering establishment to have enough suppliers policies and procedures for the smooth operations. In the hotel it is always kept in consideration that the availability of raw materials is limited and as per the season. Always fresh items are not available so if there is a need the frozen items should be used. To ensure a smooth workflow availability of ingredients are must. Without which consistency in menu cannot be achieved which would directly affect the business. There must be ample storage of such items to avoid any disruption in the level of service. For example if the raw material is not available at time the chefs cant start the preparation thus it will lead delays and smooth operation of workflow. Planning of menu Menu planning plays an important role. Menu planning is done in before hand keeping the function and the availability of raw materials in that particular time in mind. Workflow plays a very significant part in designing a menu. To have an effective workflow availability of resources, which includes availability of space and equipments for preparation, raw ingredients, specialized people to carry out the task must be present. The combination of these factors creates an effective workflow plan in the organization, which in turns helps in creating an effective menu. Thus making a Chinese menu in the hotel without have the appropriate kitchen and people would indeed disrupt the workflow of the organization as food would be prepared in inappropriate utensils by inexperienced business clearly affecting the service of the place. Equipments in use As there is lot of equipments are available in the market for the specific use. For any catering establishment it is not possible to have all the equipments. So what ever is available in the kitchen the maximum utilization of that equipment should be done for the smooth workflow and each catering establishment should have the minimum equipments to ease the food handlers in day-to-day preparation. Kitchen must be well equipped with the basic equipments mentioned and enforced by the food safety laws. Lack of appropriate equipments does disrupt the workflow as if the food is prepared in non-suitable equipments, it might take more time, spoil the preparation of the food and also may lead to accidents. All these factors would clearly hamper the service and workflow of the place. Thus setting a Chinese menu without having woks and high flame gas burners would affect the workflow of the place and may result in non-satisfactory results. Service operations / style It is always considered to set a style of service operations before hand and should be followed the same way to eliminate miscommunication and mishandlings. Workflow is affective when there is a consistency in the set of styles followed. If the rules of operations are preset and staff is trained on that there is always a chance of smooth running of the operations. As the staff is clearly are of what is expected of them and how they have to achieve it. Since the chances of a consistent services are higher business operations runs smoothly without any disruption. This is the reason why hotel is designed through a step-by-step process to get the task done to have a better workflow in the organization. Production system in use For any catering establishment it is very important to have a set production system that they will follow and according to that the workflow charts are prepared. A catering establishment should follow cook fresh, cook- chill, cook freeze or combination of these production systems as per their needs. It is very important for an organization to understand its operations before designing the systems. For an organization catering a large number of guests cook fresh method is not suitable, as it will directly affect the workflow of the place. Number of covers It is always estimated before hand the serving capacity of the catering establishment. The number of covers i.e. the maximum number of customers the catering establishment can serve at a given time. For an example a restaurant of 100 covers it is not possible to cater to 300covers, as there is not sufficient kitchen space present to cook, not enough equipments and not enough people who can prepare and cater to these covers. Thus it will affect the workflow, and can create inconsistent service and accidents. Employees / staffing plays a crucial role. In any catering establishment there are both skilled and un skilled food handlers to achieve the maximum output the employees have to mixed up in such a way that the catering establishment production output doesnt get affected. In any work scenario effective staffing plays a very crucial role in creating an effective workflow. This would mean that if hotel has a large banqueting function ahead then the staffing should be done in such a manner that there should be enough experienced skilled chefs to handle the situation. Budget and costing Every catering establishment works for making profits. To achieve the profits there are certain set standards in terms of money investments and returns. A budgeting and costing is done to ensure that the establishment is on a right track and cutting down on each and every unnecessary move that involves expenditure of money. Effective workflow would also mean correct budgeting and ordering. This means that assigning proper cost and proper ordering for every department. If it is ordered more than required it may mean surplus of items and thus need more storing space and thus blocking the money. On the other hand that blocked money can be utilized for buying an extra machine or day-to-day stuff for an effective workflow And takes the work pressure from the chefs. Type of clientele Every establishment is unique in its own serving customers and each establishment aims to satisfy a set type of clientele. For example Chinese restaurant it serves Chinese delicacies and aims to serve the person who loves Chinese food. To cater to Chinese clients the hotel should have appropriate kitchen and resources, which can provide effective services. Thus workflow and resources should be developed keeping clientele in mind. Law and regulations It is mandatory for every food production-catering establishment to abide by the rules and regulations laid by the government. Every establishment should always fulfill at least the minimum requirements of food safety and food handling procedures. Kitchen should be designed in such a way that it should not disrupt the food safety principles which would mean that if a person is cutting meat in the restaurant, sink should be present near to the desk to avoid any spillage and unnecessary movement in the kitchen area which may leads to accidents. All the above-mentioned factors are thoroughly reviewed by any catering establishment or food production organization before setting up the workflow in the production areas. As it is said that any kitchen is not perfect it is very important to follow up and work hard to keep up the good work for a smooth and successful workflow in any catering establishment kitchen. Effectiveness of the workflow: The workflow carried out is very effective, as it will help to apply HACCP. The workflow is very simple without any blocking and is processed according to the stages. After cooking the food is chilled in blast chill which helps to reduce the temperature of the food and is than stored in freezer, if the food is stored directly in freezer it will increase the temperature of the other food and will lead to the bacterial growth with less storage life of food. The food is regenerated on event days, which help to reduce the cooking time and the staff involved. Thus the workflow carried will be effective. TASK 2C A structured appraisal of the effectiveness of the current workflow in the Chisholms kitchen explaining the impact of the influencing factors. The diagram illustrates the recommended workflow of the Chisholm hotel after refurbishment. The above-illustrated diagram suggests a wide scope of improvements in the current Chisholm hotel kitchen with a little addition of new equipments and implementing new technologies. As per scenario the Chisholm hotel and conference centre is using a cook fresh production system. The stores are purchased by a word to mouth from the head chef to the store person; no written communication is carried out thus, leading to the communication breakdown. Workflow in the Chisholm hotel is as follows Workflow Pre-Preparation Production Servery Service to customers The key factors that will influence the above-mentioned workflow in the Chisholm are: The layout and design of the kitchen Storage area Production system Equipments Food safety procedures Staffing structure and training of staff Importance of communication at all levels At every level these key factors are kept in mind and the ways of improving the existing workflow is based upon. Ordering As the present scenario there is no formal method of ordering or documentation of the same is done that impacts in communication breakdowns and hinders the production as it leads to the shortage of the food supplies for the production. A new ordering system should be implemented which will be easy to refer back to. It is recommended to have an ordering sheet and should be filled up properly so that it can be referred back easily if there are any communication breakups. As Chisholm hotel wants to implement new technologies for hassle free work a computerized system is the best option for this purpose itll not only help to do things faster as well as minimize the paperwork and save time and money. Receiving As there is an urgent need of proper training for the store assistant schedule to be fixed to provide him the basic food safety and hygiene training. A logbook should be made to register the entries for items received. All the items for food preparation should be thoroughly checked before receiving and any item, which is not up to the set standards or doesnt fulfill the Chisholm set policies should be returned as later if the food items are received without checking and getting spoiled in the fridges it can cross contaminate with the other food items and when it is needed there is nothing to prepare and will lead to impact on the workflow. A proper documentation of temperature records of goods and items received is maintained in order to avoid any issues arising at the time of checking done by the food and safety inspector. Storing At present the storage space at the Chisholm hotel is very limited as there is a small dry storing area, chest freezer and a walk in chill room that is not sufficient to store large quantities of frozen foods which will be required to serve the increased capacity of the Chisholm hotel and conference centre. The current storing area is small and its difficult to keep the food items separate according to the food hygiene regulation 2006 England, with the current storing area there is always a probability of food getting cross contaminated as the lack of space the raw food and the cooked food are kept in the same storing areas. Storing facilities needs to be reviewed as the hotel is undergoing the process of refurbishment and aiming to cater 1500 covers thus an efficient storing system will help in maintaining a good shelf life of the food items and reduce the process of deteriorating of the food items. Issuing A new approach of issuing is to be implemented in the Chisholm hotel rather than issuing whatever is needed at that point of time. A computerized inventory system must be introduced for issuing of all the production items. A fixed time of issuing the stores should be carried out this will help to plan in advance for the banqueting functions and helps in reducing wastage of food items thus, providing the Chisholm hotel a better control of stock keeping and lowers down the cost and the discrepancies it will help the staff in well advance as they will plan according to it and can work smoothly. Pre-Preparation /Cooking As the current production system that is cook-fresh, would increase the work pressure on the kitchen brigade and thus leads to the smooth running of the kitchen functions. It is very difficult to prepare a cook- fresh method of food production to cater a large number of guests with the current staffing and lack of cooking equipments. Planning plays an important role in pre preparation stage for a better service and to provide best service to the customer. Its all about planning all the preparation is done correctly in advance in a convenient manner while following the food safety and hygiene regulations. It is very important in this stage to protect the food items from any contamination due to negligence or mishandling of food or the processing techniques. All the food items should be cooked according to the set standards and HACCP guidelines should be followed. A written document of temperature records should be maintained at all times. While cooking meat joints and other food items the temperature of the thickest part should reach at least 70*c to avoid any bacterial growth. Regeneration/holding of food As the equipments currently used in the Chisholm are not very effective for its increased catering objectives. With the introduction of the cook-chill and cook-freeze methods special kitchen equipment know as a blast chiller should be installed in the Chisholm hotel food production area. The Chisholm Hotel should improve on the regeneration area where the cold food is kept cold and hot food is kept hot for service. The additions of new equipments will helps the kitchen brigade to cook and store accordingly and thus, leads to an efficient workflow as the food items are cooked and stored in advance. The other main problem with the Chisholm kitchen is that the frequent breakdown of the equipments, as the failure of the equipments at the time of service leads to panic in the kitchen staff and hinders to the smooth workflow. Service Currently there is no training is provided to the staff at the time of hiring or any kind of induction at the time of joining the organization. The new staff faces a tough challenge in knowing the working system, the food safety and hygiene procedures that prevails in the Chisholm hotel. The untrained staff thus leads in the unwanted situations and cause disruption in the workflow. For every conferencing or banqueting function to be successful prompt service is the most important thing. The success of any food and beverage establishment depends on the skill and ability to deliver in any situation with excellence to their customers provided by the food handlers. Apart from all these factors communication as whole plays a vital role as the smooth communication leads to the effective and smooth workflow. Whether at the time of ordering the food requisitions to the suppliers or at the time of following the standard recipes, while working in a busy environment an effective communication can solve any disruption or issues and helps an organization with a smooth and effective workflow. Bibliography Peter Jones (2002) Introduction to hospitality operations: an indispensable guide to the industry, Cengage Learning Fine A.G. (2002) Kitchens: The Culture of Restaurant Work, University of California Press Malhotra R. K. (1997) Encyclopaedia of Hotel Management and Tourism,Anmol Publications PVT. LTD Heinemann e,tal (2007) Level 2 Diploma in Professional Cookery, Heinemann Foskett, D etal (2008)the theory of cookery,hooder education. http://www.expresshospitality.com/20060215/management08.shtml http://mulinet9.li.mahidol.ac.th/e-thesis/4237676.pdf http://dualittoasters.vox.com/library/post/kitchen-equipment-factors-influencing-their-selection.html http://www3.interscience.wiley.com/journal/119138221/abstract?CRETRY=1SRETRY=0

Pathophysiology of DORV and Surgical Management

Pathophysiology of DORV and Surgical Management Advances in genetic techniques and ability to detect the chromosomal abnormalities in the cellular structures; have had a great impact on the detection of congenital cardiac defects. Although in the past congenital heart diseases have long been recognised as a constituent of complex genetic syndromes, a genetic cause for specific congenital heart diseases has less been apparent; as the sources of these defects has been believed to be multifactoral. In addition, with the advancement of the molecular genetic studies, it has come to light that in many instances, congenital heart diseases exhibit classic Mendelian transmission. It is also possible to trace the direct involvement of a gene with a particular congenital cardiac defect. Tetrology of Fallot has been found to have genetic predisposition, it is estimated that offspring of a parent with tetrology of Fallot is more likely to suffer from the disease in comparison to offsprings whose parents do not suffer from congenital heart disease. Studies estimated that about 1.5% of live births will be affected by tetrology of Fallot if the parents suffer from the defect and about 0.1% will be affected by the presence of tetrology of Fallot if parents do not suffer from congenital heart disease. In comparison in DORV chromosomal abnormalities have only been identified in some cases. In the Baltimore-Washington infant study, DORV was diagnosed in a few patients with downs syndrome and in trisomies 13 and 18, although the incidence was quite low compared with that morphologically similar lesion, tetrology of Fallot. In addition the related conotruncal abnormality, complete transposition of the great arteries, was not found in any patient with trisomy in reported study, this suggests that DORV and transposition of great arteries may be etiologically similar and may be fundamentally different form tetrology of Fallot in terms if developmental mechanism. Also DORV and Transposition of Great arteries are rarely found in patients with CATCH 22 syndromes, although tetrology of Fallot is not uncommon. In a large sample study of patients with conotruncal abnormalities to evaluate the frequency of 22q11 deletions, only 1of 20 patients with DORV as compared to 15.9% of the patients with tetrology of Fallot. The studies have also reported that DORV may be a part of complex CHD in patients with DiGeorge, velocardiofacial and conotruncal anomaly-face syndrome. In a resent animal study it was reported that DORV occur in mouse embryos homozygous for the JMJ mutation, which affects the nuclear protein jmj coded by chamber-specific genes. Surgical Management Surgical management for the DORV and tetrology of Fallot is determined by the anatomy and physiology of the defect as well as the age at which the diagnosis is made and at which the need for surgical intervention arises. Indications for operation are similar to those for defects that lie on each side of the DORV spectrum (VSD, tetralogy of Fallot, and Transposition of great arteries). In addition the presence of associated cardiac defects may modify the approach. In DORV the position of VSD and the presence and severity of pulmonary stenosis are probably the most important considerations. In tetralogy of Fallot most patients have satisfactory systemic arterial oxygenation saturation at birth and require no treatment. However when the oxygen saturation drops below 75-80% operative intervention becomes imperative. Hypoxemic spells may occur from the transient reductions in pulmonary blood flow, due to sudden increase in right ventricular outflow tract obstruction and the decrease in systemic vascular resistance, so a surgical approach takes into consideration the number and location of ventricular septal defects, anatomy and severity of right outflow tract obstruction, coronary artery and aortic arch anatomy and the presence of other cardiac and non cardiac anomalies. Depending on the severity of the cyanosis two types of surgical streams are available. There are two basic possible types of surgical strategies for newborn infants with tetralogy of Fallot. One of the strategies consists of a staged repair; where initial palliation is followed by a complete repair and other one being a complete repair in the neonatal period. Palliative surgical correction, which often does not require the use of cardiopulmonary bypass, is the creation of systemic to pulmonary shunt. This correction is achieved by connecting systemic blood flow source to a the pulmonary blood flow, as already mentioned the main feature of this congenital defect is the reduced flow to the pulmonary system which is the basis of cyanosis. The palliative repair is done by fitting a tubular prosthesis between a systemic artery and a pulmonary artery as shown in the figure (?) (a, b and c). The commonest type of systemic-to-pulmonary arterial shunt is a modified Blalock-Taussig anastomosis which is a communication between a subclavian and pulmonary artery of the same side. Another form of palliative correction is done by creating a connection between ascending or descending aorta and the trunk of pulmonary artery. The connection which connects the posterior ascending aorta to anterior pulmonary trunk is called Waterston shunt and connection bet ween posterior pulmonary artery to anterior descending aorta is called potts shunt. Both of these techniques have there advantages and disadvantages (figure (S) e and f). Figure ( ? ) The most common types of palliative procedures for tetralogy of Fallot. The modified Blalock-Taussig shunt (MBTS) using a Gore-Tex graft either from the right subclavian artery (A) or the right innominate (INN) artery (B). C, A central aortopulmonary shunt using Gore-Tex. D, A right ventricular outflow patch without ventricular septal defect closure. Pathophysiology of DORV Once the anatomic variables of DORV are understood, the various physiologic manifestations become both logical and predictable, at the tetrology end of the DORV spectrum; pathophysiology is similar to that in the tetrology of Fallot. The most important variables determining the physiology of a given heart are the position of the VSD in relation to great arteries, the relation of the great arteries to each other and the presence of associated defects (in particular, outflow tract obstruction). In general patients with large VSD and no pulmonary stenosis or severe pulmonary vascular resistance are not clinically cyanotic. This is because Qp is high and the resultant mixture of blood in the right ventricle has a high enough oxygen saturation to prevent clinically evident cyanosis; however there is some arterial desaturation. Although both great arteries arise from the right ventricle, often incomplete mixing of oxygenated and unoxygenated blood occurs at the ventricular level because of streaming. This streaming of blood within RV is usually determined by the relationship of semilunar valves to the VSD and the position and presence of the infundibular septum. The blood in the great artery most closely related to the VSD and therefore most aligned with LV outflow tract tends to have the highest oxygen saturation. Likewise, the great artery that due to streming, preferentially receives systemic venous return, tends to have a lower saturation. This phenomema is somewhat different from true single ventricle physiology. In DORV with subaortic VSD and no pulmonary stenosis, pulmonary blood flow will be determined by the relationship of pulmonary to systemic vascular resistance. What is usually the case after the first few weeks of life pulmonary vascular resistance is less than systemic vascular resistance, pulmonary blood flow will be greater than systemic flow, resulting in higher than normal pulmonary arterial saturation and congestive heart failure. As the pulmonary vascular resistance increases in response to this abnormal volume load, pulmonary blood flow correspondingly decreases. Eventually, if left untreated, this usually results in pulmonary vascular obstruction disease with severely and irreversible elevated pulmonary vascular resistance, causing progressive cyanosis and early mortality. However if when the VSD is in subaortic position with pulmonary stenosis, whether valvular or subvalvular, obstruction to pulmonary blood flow is found. Conduction System In tetrology of Fallot the sinus and atrioventricular nodes are normal in location, and the bundle of His follows the same general course as in patients with isolated perimembraneous and juxtatricuspid VSDs. Thus it emerges through the right fibrous trigone at the base of the noncoronary cusp of the aortic valve and courses forward toward the papillary muscle of the conus along the inferior VSD margin or slightly to the left side of the defect edge. In addition, hearts which show marked clockwise rotation of the aortic root with overriding, the right trigone is carried more rightward and superiorly and directly into VSD margin. By contrast, the bundle of His does not lie on VSD margin when a muscle ridge is present, since the ridge projects superiorly above the right fibrous trigone. In DORV with concordant AV connections the AV node lies in the usual position in the muscular portion of the AV septum. The bundle of His penetrates the fibrous right trigone of the central body and lies along the posteroinferior margin of the VSD in lesions that are juxtatricuspid wheter the defect is subaortic, doubly committed, or sub-pulmonary. When muscle is interposed between the defect and the tricuspid valve, this muscle protects the bundle, which no longer runs along the posteroinferior free margin of the defect. Oxygenation Hemodynamic representation of Tetrology of Fallot (indicating right to left shunting) Supply of oxygen to the body Due to the mal-alignment and deviation from the normal physiology, the main issue of the patients with tetarology of Fallot is hypoxemia due to inadequate pulmonary blood flow caused by the inadequate pulmonary blood flow, which is determined by the right ventricular pressures and degree of obstruction. Since the right and left ventricular and aortic pressure is equalized, a drop in systemic arterial pressure will result in a reduction in pulmonary blood flow. Oxygen carrying capacity of blood depends mostly on haemoglobin concentration and greater the haemoglobin concentration in the blood that perfuses the lungs, the greater the amount of oxygen extracted per unit of blood flow. In neonates the haemoglobin concentration is relatively high (15 to 18 g/dL), however it drops to about 10 or 12g/dL by 3-4 months after birth. In neonates with tetralogy of Fallot there is an increase in blood level of erythropoietin due to hypoxemia. Iron is required to maintain or increase in haemoglobin levels; however suckling infants have very low stores of iron and food intake in early infancy provides little iron. Therefore there is a high incidence of anaemia in children with tetralogy of Fallot. On the other hand tetraology spectrum of DORV, where the great arteries lie side by side with aorta to the right of pulmonary artery and both semilunar valves lying in the same transverse and coronal plane the physiology is similar to tetralogy of Fallot. In these neonates the VSD is closer to aortic valve thus oxygenated blood form left ventricle is directed to the aorta and the deoxygenated blood is directed to pulmonary artery but the degree of pulmonary stenosis directs portion of deoxygenated blood into aorta. In addition due to the presence of large VSD both ventricles are subjected to similar pressures. Due to the pulmonary stenosis the blood flow to the lungs is restricted causing drop in the pulmonary systolic pressure, which in turn causes hypoxemia. The pulmonary stenosis is most often infundibular, but may be valvular, with or without a small pulmonary valve ring. In doubly committed VSD category of the DORV spectrum the conoventricular septal defect is both subaortic and sub-pulmonary owing significant conal septal mal-development and mal-position. The hemodynamics change in that case will also be determined by the presence or absence of subaortic or sub-pulmonary stenosis. Therefore cases with sub-pulmonary stenosis will have reduction in the pulmonary blood flow and will result in the hypoxemia and thereby cyanosis corresponding physiological characteristics of tetralogy of Fallot. Also in cases of non-committed DORV majority of great vessels arise form right ventricle thus right ventricle is subjected both pulmonary and aortic circulation resistance. Oxygenated blood form left ventricle gets mixed with non-oxygenated blood through VSD making systemic and pulmonary circulation equal. In addition due to left and right shunting right ventricle is volume overloaded and results in congestive heart failure. Additionally, the stimulation for the formation of red cells continues and very high counts of red cells are achieved, but the cells are microcytic and hypochromic, since the average corpuscle volume and average corpuscle haemoglobin are markedly reduced. Also the rise above 60% increases the blood viscosity. This raised viscosity of blood leads to greater resistance to flow through the tissues and ultimately capacity to transport oxygen vanishes. In transposition spectrum of DORV the physiology is different then described above, since the presence of large sub-pulmonary VSD and its commitment to the pulmonary artery; the course of circulation is dependent on the afterload on each ventricle, as shunting could occur in either direction. In this type of defect the oxygen saturation in the pulmonary artery is higher than in systemic circulation. The high oxygen saturation of pulmonary arterial blood will however decrease the pulmonary vascular resistance and consequently will result in right to left shunting during systole. This will result in some decrease in PO2 of blood distributed to the lungs as well as through ductus arteriosus. On the other hand during diastole a larger volume of blood will return from the pulmonary veins to the left atrium and ventricle and thus results in a left to right shunting. As a result, the oxygen saturation of the blood going to systemic circulation is increased and thus tends to limit the abnorm al decrease in the upper body PO2. A characteristic of this defect is the presence of a large unrestrictive VSD with which the mixing of pulmonary and systemic blood takes. This phenomena result in a relatively large pulmonary to systemic blood flow ratio and consequently high systemic oxygen concentrations; therefore limiting the tissue hypoxia. However the inability of the ventricles to maintain the physiological normal pressures cardiac failure is often associated in infants with transposition spectrum of DORV. Infants with this type of physiology usually appear with mild cyanosis and in congestive heart failure. In addition if there is effective mixing but pulmonary flow is reduced by the presence of pulmonary stenosis or increased pulmonary vascular resistance, pulmonary to systemic flow ratio decreases and arterial saturations will be lower and subsequently will result in tetrology of Fallot type pathophysiology. Right to Left Shunts. Now just for a moment let us consider a large VSD assocoiated with pulmonary valve stenosis which is severe enough to have a resistance greater than systemic vascular resistance. Just like the last case, this ratio of resistances results in reversal of the shunt. This is in fact an unusual combination, but the point here is that the situation mimics the haemodynamics of tetralogy of Fallot. Also it shows how associated pulmonary stenosis can have a great influence on cardiac malformations on many sorts. We will meet it again in the commom mixing situations. On the other hand with no pulmonary stenosis look at the difference Right to Left Shunts. I am making a morphological point here: tetralogy of Fallot is not a coincidence of pulmonary stenosis and VSD but the consequence of right ventricular outflow tract and central pulmonary artery hypoplasia. The diagram can be adjusted to accentuate this, as above. Tetralogy has a variable and sometimes spasmodic stenosis of the muscular right ventricular outflow tract. Sometimes, particularly early in life, the degree of obstruction is not great and the infant may present with signs of a VSD shunting left to right. Qp:Qs (Ratios Pulmonary to systemic Ratios) Double outlet Right ventricle hemodynamic representation (DORV -Common mixing) In many cases of complex congenital cardiac disease it can be quite difficult to understand how the degree of systemic desaturation reflects the flows in malformed heart. It helps to realise that many of them fall into this group of common mixing circulation, which is to say that all pulmonary and systemic venous blood streams are obliged to come together at some point in the circulation. They are: Totally anomalous pulmonary venous drainage. Univentricular heart. Double outlet right or left ventricle. All simple valve atresias. Fallot pulmonary atresia. Truncus arteriosus. And any of the above in combination with any other defect. If there is complete mixing of the systemic and pulmonary returns, it follows that pulmonary and systemic arterial saturation will be identical. Due to streaming effects, the mixing may not be quite complete but the saturations will still be nearly identical. This all means that some degree of systemic desaturation will be present. The degree of cyanosis is dictated by the ratio of pulmonary to systemic flow as shown in the figure above, in which Qp is pulmonary flow and Qs is systemic. Often, particularly in the univentricular heart and in the double outlet ventricles, it is asssociated pumonary stenosis which determines the ratio of Qp to Qs. Some patients with a Qp high enough to keep systemic saturation above 94% or so will not be clinically cyanosed. Time and space do not allow a full descrtiption of all the pathologies so we will take one example, double outlet right ventricle. Double outlet right ventricle is a good example of the haemodynamic variability of this group. The figure above shows the circulation in a case where there is a large ventricular septal defect, no pulmonary stenosis and no significant rise in the pulmonary vascular resistance. Pulmonary blood flow is elevated and the radiograph will show plethora. The high ratio between pulmonary and systemic venous return means that the saturation of the mixed flow, and therefore of the aortic blood, is 90%, which is barely detectable clinically as cyanosis INTRODUCTION  Ã‚  In 1888, Etienne-Louis Arthur Fallot described three cyanotic patients with four similar anatomic features [1]: Stenosis of the pulmonary artery Intraventricular communication Deviation of the origin of the aorta to the right Concentric right ventricular hypertrophy This constellation of findings has since become known as tetralogy of Fallot (TOF). The prevalence of TOF in the United States is about 3.9 per 10,000 live births [2]. This defect accounts for about 7 to 10 percent of cases of congenital heart disease and is one of the most common congenital heart lesions requiring intervention in the first year of life [3]. TOF occurs equally in males and females [4]. The pathophysiology, clinical features, and diagnosis of TOF will be reviewed here. An overview of the management of this disorder, including postoperative complications and issues related to pregnancy, are discussed separately. (See Overview of the management of tetralogy of Fallot.) ANATOMY  Ã‚  The exact embryologic abnormality that accounts for TOF is unknown. What is recognized is that during development, there is anterior and cephalad deviation of the infundibular septum. This results in a malaligned ventricular septal defect (VSD), with the aortic root overriding the defect and leading to subsequent right ventricular outflow obstruction (figure 1). The ensuing right ventricular hypertrophy is thought to be a response to the large VSD and right ventricular outflow obstruction with resultant systemic right ventricular systolic pressure. Ventricular septal defect  Ã‚  The VSD in TOF is most commonly a single large malaligned subaortic defect located in the perimembranous region of the septum (picture 1). The VSD can extend into the muscular septum. There are rarely other muscular ventricular septal defects. (See Pathophysiology and clinical features of isolated ventricular septal defects in infants and children.) Right ventricular outflow obstruction  Ã‚  The right ventricular outflow obstruction is often at multiple levels (picture 2): The anterior and cephalad deviation of the infundibular septum results in subvalvar obstruction Hypertrophy of muscular bands in this region can further accentuate subvalvar obstruction The pulmonary valve annulus is usually hypoplastic, although in some instances it is of normal size The pulmonary valve itself is frequently bicuspid and stenotic In addition, it is not uncommon to identify an area of supravalvar narrowing in the main pulmonary artery at the sinotubular ridge. There may also be further obstruction at the branch pulmonary arteries. These may be diffusely hypoplastic or have focal areas of stenosis, most commonly at the proximal branch pulmonary arteries. The proximal left pulmonary artery near the site of ductal insertion is a frequent location for stenosis (picture 3A-B). Overriding aorta  Ã‚  Overriding aorta is a congenital anomaly, in which the aorta is displaced to the right over the VSD rather than the left ventricle. This results in blood flow from both ventricles into the aorta. The degree of aortic override of the VSD can vary widely and is one of the major factors used by some groups to differentiate between TOF and double outlet right ventricle. If one defines double outlet right ventricle as the presence of aortic/mitral valve fibrous continuity, then the degree of override is not relevant to diagnosis. If, however, one defines double outlet right ventricle as a condition with greater than 50 percent aortic override, then, by definition, the degree of aortic override in TOF is limited. Associated cardiac features  Ã‚  There are a number of frequently associated anatomic features that are important to look for when evaluating a patient with TOF, since they affect therapy. Associated cardiac anomalies occur in about 40 percent of patients with TOF. Approximately 25 percent of patients have a right aortic arch. This is particularly important to identify if one is contemplating a palliative shunt. Abnormalities of the coronary arteries, such as the left anterior descending arising from the right coronary artery, are seen in about 9 percent of patients [5]. These are important to identify prior to complete repair, since the course of the artery may run directly across the right ventricular outflow tract; inadvertent transection could have catastrophic consequences. Occasionally, patients have significant aorticopulmonary collateral vessels that may require attention prior to or at the time of surgery. A patent ductus arteriosus, multiple ventricular defects, and complete atrioventricular septal defects may be present. Infrequently, aortic valve regurgitation is present due to aortic cusp prolapse. GENETIC FACTORS  Ã‚  Although TOF may present as part of a known syndrome, this lesion typically occurs sporadically without other anomalies. Surveys of patients with nonsyndromic TOF have reported the following genetic abnormalities: In one study of 114 patients with nonsyndromal TOF, 4 percent of patients had mutations in transcription factor NKX2.5., which appears to have a role in cardiac development [6]. In genome-wide surveys of patients with nonsyndromic TOF and their parents, de novo copy number variants were estimated to be present in about 10 percent of sporadic cases of TOF compared to less than 0.1 percent in controls at several chromosomal locations [7]. Tetralogy of Fallot has also been reported in association with mutations in TBX1 and ZFPM2 [8-10]. Further investigation is required to determine the role of these mutations in the evolution of Tetralogy of Fallot. Approximately 15 percent of patients with TOF present with associated syndromes, including Down syndrome (trisomy 21), Alagille syndrome (mutations in Jagged1), and DiGeorge and velocardiofacial syndromes (deletion on chromosome 22q11) [8,11-17]. There may be susceptibility genes for TOF within the latter region of chromosome 22q11 in children without extracardiac anomalies [16,18,19], and 22q11.2 deletion syndrome is unrecognized in many adult patients with TOF [20]. (See DiGeorge syndrome: Pathogenesis, epidemiology, and clinical manifestations  and Inherited disorders associated with conjugated hyperbilirubinemia, section on Alagille syndrome.) PATHOPHYSIOLOGY  Ã‚  The physiologic consequences of TOF are largely dependent upon the degree of right ventricular outflow obstruction. Since the VSD is typically large and unrestrictive, the pressure in the right ventricle reflects that of the left ventricle. As a result, the direction of blood flow across the VSD will be determined by the path of least resistance for blood flow, not by the size of the VSD. If the resistance to blood flow across the obstructed right ventricular outflow tract is less than the resistance to flow out of the aorta into the systemic circulation, blood will naturally shunt from the left ventricle to the right ventricle and into the pulmonary bed. In this situation, there is predominately a left-to-right shunt and the patient will be acyanotic. As the degree of right ventricular outflow obstruction increases, the resistance to blood flow into the pulmonary bed also increases. If the right ventricular obstruction is significant enough to increase resistance, it will be easier for blood to cross the VSD from the right ventricle into the left ventricle and go out the aorta, which now becomes the path of least resistance. This right-to-left shunt across the VSD will result in a large volume of desaturated blood entering the systemic circulation and cyanosis and polycythemia will ensue (figure 1). One of the physiologic characteristics of TOF is that the right ventricular outflow obstruction can fluctuate. An individual with minimal cyanosis can develop a dynamic increase in right ventricular outflow tract obstruction with a subsequent increase in right-to-left shunt and the development of cyanosis. In the most dramatic situation, there can be near occlusion of the right ventricular outflow tract with profound cyanosis. These episodes are often referred to as tet spells or hypercyanotic spells. The exact etiology of these episodes is unclear, although there have been a number of proposed mechanisms, including increased infundibular contractility, peripheral vasodilatation, hyperventilation, and stimulation of right ventricular mechanoreceptors [21]. CLINICAL PRESENTATION  Ã‚  The clinical presentation of the patient with TOF is dependent upon the degree of right ventricular outflow obstruction: Children with severe obstruction and inadequate pulmonary flow typically present in the immediate newborn period with profound cyanosis Children with moderate obstruction and balanced pulmonary and systemic flow may be noticed during elective evaluation for a murmur Children with minimal obstruction may present with pulmonary overcirculation and heart failure Most children with this lesion are symptomatic and cyanotic; there is a subgroup, however, with typical morphology and hemodynamics that remains clinically asymptomatic for a period of time (pink variant). In general, the earlier the onset of systemic hypoxemia, the more likely it is that severe pulmonary outflow tract stenosis or atresia is present. Physical examination  Ã‚  On inspection, individuals with TOF are usually comfortable and in no distress. However, during hypercyanotic spells, they will become hyperpneic, and infants will often become agitated. If cyanosis is present, it is most easily seen in the nail beds and lips. On palpation, one may appreciate a prominent right ventricular impulse and occasionally a systolic thrill. Hepatomegaly is uncommon. Peripheral pulses are usually normal, although the presence of prominent pulses may suggest the existence of a significant patent ductus arteriosus or aorticopulmonary collaterals. Cardiac auscultation  Ã‚  On auscultation, the first heart sound is normal, and the second heart sound is most commonly single because the pulmonic component is rarely audible. Third and fourth heart sounds are uncommon. An early systolic click along the left sternal border may be heard, which is thought to be due to flow into the dilated ascending aorta. (See Auscultation of heart sounds.) Murmur  Ã‚  The murmur in TOF is due primarily to the right ventricular outflow obstruction, not the VSD. The murmur is typically crescendo-decrescendo with a harsh systolic ejection quality; it is appreciated best along the left mid to upper sternal border with radiation posteriorly. It can, however, have a more regurgitant quality that can be easily mistaken for a VSD. (See Auscultation of cardiac murmurs.) The murmur is due both to the degree of obstruction and to the amount of flow across the obstruction. In TOF, unlike isolated valvar pulmonary stenosis, the amount of flow across the right ventricular outflow tract will decrease as the obstruction increases, due to the shunting of blood right-to-left across the VSD. Thus, as the obstruction increases, the murmur will become softer. During severe hypercyanotic spells, the murmur may actually disappear due to the markedly diminished flow across the obstruction.

Essay --

Compare how Shakespeare and Hardy present situations where their characters’ love and relationships are influenced by the need to uphold appearances within society, with particular reference to Othello and Tess of the d’Urbervilles This essay will explore the social interactions between characters, the effects of appearance on their relationships and how this drives them to make certain decisions. This includes how the claustrophobia of their society is portrayed and its effects through form, style and literary techniques. All four texts explore the conflict between public and private selves. In Othello , Shakespeare reveals the taboo surrounding an interracial sexual relationship between a black man and a white woman during the Sixteenth Century. In Hardy’s Nineteenth Century novel Tess of the d’Urbervilles , we see the clash between sexuality, laws and codes of the time. I will compare these texts to The Franklin’s Tale and Pride and Prejudice , looking at how the rigid codes of courtly love impact on male and female behaviour within relationships and how the social and cultural attitudes and values of Regency England influence young women in their marriage choices. In both primary texts, the parents of the main characters struggle with the practice of exogomein and endogomein. In Othello, Brabantio adopts a motherly role, guiding Desdemona towards an acceptable marriage. Yet the marriage she chooses is exogamous. Brabantio sees through Othello’s high rank, royal blood and Christianity, casting a shadow over the relationship between Othello and his daughter due to Othello’s skin colour, unacceptable within that Venetian society. Desdemona lives within a patriarchal society and is objectified and commodified. Brabantio strugg... ...entally to mete out her demise. Empathy is felt for her as she realises self-worth is the polar opposite to the superficiality of social standing. She finds peace of mind and is reunited with Angel, when Hardy tears her away with death, typical of tragedy. Othello’s military role and social worth do not majorly affect his relationship. Instead, Iago’s ruthless self-interest in enhancing his own appearance within society and disinterest in the welfare of others, kindles the doubt between Othello and Desdemona. The relationships that collapse are those of the characters whose judgments fail them as another controls them. From the study of these two texts and reference to Pride and Prejudice and The Franklin’s Tale, we can now see that it is more strength of self and mind, than efforts to uphold an appearance, which affects love and relationships within all the texts. Essay -- Compare how Shakespeare and Hardy present situations where their characters’ love and relationships are influenced by the need to uphold appearances within society, with particular reference to Othello and Tess of the d’Urbervilles This essay will explore the social interactions between characters, the effects of appearance on their relationships and how this drives them to make certain decisions. This includes how the claustrophobia of their society is portrayed and its effects through form, style and literary techniques. All four texts explore the conflict between public and private selves. In Othello , Shakespeare reveals the taboo surrounding an interracial sexual relationship between a black man and a white woman during the Sixteenth Century. In Hardy’s Nineteenth Century novel Tess of the d’Urbervilles , we see the clash between sexuality, laws and codes of the time. I will compare these texts to The Franklin’s Tale and Pride and Prejudice , looking at how the rigid codes of courtly love impact on male and female behaviour within relationships and how the social and cultural attitudes and values of Regency England influence young women in their marriage choices. In both primary texts, the parents of the main characters struggle with the practice of exogomein and endogomein. In Othello, Brabantio adopts a motherly role, guiding Desdemona towards an acceptable marriage. Yet the marriage she chooses is exogamous. Brabantio sees through Othello’s high rank, royal blood and Christianity, casting a shadow over the relationship between Othello and his daughter due to Othello’s skin colour, unacceptable within that Venetian society. Desdemona lives within a patriarchal society and is objectified and commodified. Brabantio strugg... ...entally to mete out her demise. Empathy is felt for her as she realises self-worth is the polar opposite to the superficiality of social standing. She finds peace of mind and is reunited with Angel, when Hardy tears her away with death, typical of tragedy. Othello’s military role and social worth do not majorly affect his relationship. Instead, Iago’s ruthless self-interest in enhancing his own appearance within society and disinterest in the welfare of others, kindles the doubt between Othello and Desdemona. The relationships that collapse are those of the characters whose judgments fail them as another controls them. From the study of these two texts and reference to Pride and Prejudice and The Franklin’s Tale, we can now see that it is more strength of self and mind, than efforts to uphold an appearance, which affects love and relationships within all the texts.

Rae, We Pray For You :: essays research papers

Rae, We Pray for you â€Å"Murder in the murderer is no such ruinous thought as poets and romancers will have it; it does not unsettle him, or fright him from his ordinary notice of trifles; it is an act quite easy to be contemplated.† Ralph Waldo Emerson Is Rae Carruth unsettled? Is he bothered? Is Carruth in the contemplative mood yet? I certainly hope he is. Rae Carruth has taken away a human life. He has violated that certain enjoyment that exists in life. It is what separates the human race, from all others. Logic and reason that we possess in such high quantities as human beings apparently are lacking in Carruth’s case. It seems to make little sense, especially in Carruth’s situation. He seemed to have everything going for him, having achieved his dream to become a professional athlete and supporting his parents and relatives on this newfound fame as he had always promised. Yet, something was happening to Rae Carruth. Obviously, he was not happy with his li fe at that point. Still, murder is not exactly a sensible action, not even as a last resort to most who have their wits about them. It seemed as though Carruth felt that he had no other choice. He seemed to take the classic, â€Å"I don’t like you, so I’ll beat you up,† mantra of the playgrounds to a much harsher end in this case. With Carruth you must question many things about him, his sanity, his maturity, his intelligence, and above all his reason. Obviously, he soon realized the magnitude of his act, as he fled as a fugitive until he was caught. Murder is not a crime of chance, you have to get the deed done and correctly, that is why Carruth hired a few thugs to do the job for him. Even if Carruth did not pull the trigger, it is very clear that he is still a murderer. His fate is the question to most. This will probably not be determined until Carruth goes to trial, probably in about a year. The prosecution will seek the death penalty for Carruth and rightf ully so. In our current society today, only the most horrific of criminals usually get the death penalty because we do not operate on an eye for eye basis. In the present criminal justice system rehabilitation seems to be the operative word. It is not that Carruth is beyond rehibilition, but that he does not deserve to live.