An Image of Africa Essay - 1050 Words

An Image of Africa Heart of Darkness by Joseph Conrad has been depicted as â€Å"among the half-dozen greatest short novels in the English language.† [pg.1] Chinua Achebe believes otherwise. In Chinua Achebe’s An Image of Africa: Racism is Conrad’s Heart of Darkness he simply states that, â€Å"Joseph Conrad was a thoroughgoing racist† [pg.5] Achebe argues that the racist observed in the Heart of Darkness is expressed due to the western psychology or as Achebe states â€Å"desire,† this being to show Africa as an antithesis to Europe. He first states Conrad as â€Å"one of the great stylists of modern fiction.† [pg.1] He praises Conrad’s talents in writing but believes Conrad’s obvious racism has not been addressed. He later describes in more detail that†¦show more content†¦3] Achebe believes that Conrad deliberately showed Mr. Kurtz’s mistress as a â€Å"savage counterpart to the refined, European woman.† [pg.4] As he moves into more detail of the difference, he moves into the subject of the black’s lack of speech. He states that â€Å"It is clearly not part of Conrad’s purpose to confer language on the rudimentary souls of Africa.† [pg. 4] Instead of speech they are represented with sounds (i.e. grunting). My first critique was that of the blacks’ lack of speech, where Conrad presents speech on the motorboat. Interestingly enough, Achebe analyzes these points as, at first, being â€Å"acts of generosity from Conrad.† [pg.5] But, later states their purpose as showing the Europeans their â€Å"unspeakable craving† [pg.5] or cannibalism. I do however disagree with this viewpoint. Though initially the speech of the cannibals can be viewed as â€Å"some of his best assaults,† [pg.5] the actions of the cannibals speak louder than their words. The cannibals’ restraint towards eating humans in the novel shows them in a positive light. If you view Africa as a whole, both blacks and whites should be viewed the same. Mr. Kurtz, being an example, can also b e viewed as a cannibal as it is strongly believed by the Company that he has become a savage, like the Africans. My point being that the blacks confining from eating humans, does not show Conrad’s as a racist but quite the contrary. Mr. Kurtz’s involvement of the African customs and beliefsShow MoreRelatedThe Negative Image Of Africa1511 Words   |  7 PagesAfrica has had a negative image for many years and even today, this image persists but to a less extent. This bad image of Africa did not always exist. There was a time where all races were not constantly at each other’s throat. Europeans did not immediately see Africans as inferiors because of their cultures or their skin color. At that period, everyone was considered as humans. But there came a point where Europeans thought that they were a bit superior to other races. Europeans did not just thinkRead MoreAnalysis Of Chinua Achebe s An Image Of Africa 2459 Words   |  10 PagesNathaniel Oehl 4/4/2016 In Defense of Conrad: A Response to Achebe’s â€Å"An Image of Africa† In â€Å"An Image of Africa†, Chinua Achebe comes to the bold conclusion that Joseph Conrad â€Å"was a bloody racist† (788), with his discussion centering primarily on Conrad’s Heart of Darkness as a racist text. Achebe’s reasoning for this branding rests on the claims that Conrad depicts Africa as â€Å"a place of negations at once remote and vaguely familiar in comparison with which Europe s own state of spiritual graceRead MoreEssay on Images of Africa in Heart of Darkness and Things Fall Apart2228 Words   |  9 PagesImages of Africa in Heart of Darkness and Things Fall Apart  Ã‚        Ã‚  Ã‚   Joseph Conrads novel Heart of Darkness portrays an image of Africa that is dark and inhuman.   Not only does he describe the actual, physical continent of Africa as so hopeless and so dark, so impenetrable to human thought, so pitiless to human weakness (Conrad 94), as though the continent could neither breed nor support any true human life, but he also manages to depict Africans as though they are not worthy of the respectRead MoreArguments Against Chinua Acebes An Image of Africa: Racism in Conrads Heart of Darkness1622 Words   |  7 PagesKody Han Mr. Burgess AP Literature and Composition 6 March 2013 An Image of Africa: Not Racism in Conrad’s ‘Heart of Darkness’ People of dark skin have been wrongly discriminated against by racists for hundreds of years. 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It has often been argued that Africa isn’t a continent when, in actuality, it is the second largest continentRead MoreEssay about Heart of Darkness989 Words   |  4 Pagestitle of Joseph Conrad’s novella, it is also a main theme. This is portrayed through different images of darkness, black and evil throughout his story. The setting is often used with images of darkness; even as Marlow tells his tale, it is night. This ‘darkness’ is inside many concepts of the novella such as Africa, women, black people, maps, the ivory trade corporation and Kurtz. Through these images on his journey, Marlow has a realization about the inner darkness of man, and thus brings out theRead MoreHeart of Darkness971 Words   |  4 Pagessee Conrad from the point of view of an African? Is it merely a matter of view point, or does there exist greater underlying meaning in the definition of racism? br2. How doe s Achebes personal history and the context in which he wrote An Image of Africa: Racism in Conrads Heart of Darkness reflect the manner in which he views Conrads idea of racism in the novel? br3. Taking into account Achebes assumptions and analysis of racism in Heart of Darkness, how does this change Conrads novelRead MoreThe Perception of Africa as a Single Entity Essay708 Words   |  3 PagesLooking at Africa as a single entity has been an issue facing how the world perceives it. When news of Africa hits the stands it is rarely talking about specific places but rather a story about the whole of Africa. Viewing Africa as a single thing has lead most of the world, especially Western cultures, to see it in a generalized way which has led to a negative stereotype of Africa and its people. During the time of European expansion, many in Europe only knew of Africa, though the letters

I Am Like a Burrito free essay sample

Tortilla: God is the tortilla of my life. Call Him whatever you want – Savior, Shepherd, Father – Ill just stick with tortilla. Hes the thin skin that protects me and holds me. If I screw up, I know that my tortilla will be there for me, no matter what. Rice: You can reach me by mail, just address the letter straight to my town. This sheltered bubble is the place I call home. Its where I brush my teeth and paint my nails. Its where I munch on black bean salsa from Kramers and create spontaneous YouTube videos. Feel like watching shiny Mercedes sports cars pull into long driveways? Care for a fine wine tasting party at the Laneys? Come on down to my lovely ZIP code. Its the classiest rice around. Beans: Upon entering the double doors of my high school on my first day, I saw masses of students threatening to re-create the stampede scene from â€Å"The Lion King. We will write a custom essay sample on I Am Like a Burrito or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page † Oh, geez, I thought. And, 952 days later, I still feel the same way each time I walk into school. Im just one of the thousands of students. Im just another bean. A bean with flavor extraordinaire. Chicken: Greenish-blue eyes. Chocolate brown hair. Five feet, seven-and-a-half inches. Yep, thats me. I cant touch my tongue to my nose, but I can stretch my toes to unbelievable distances. Sports arent exactly my thing, so I lack bicep muscles. Could that be why Ive never been able to pass the pull-up test? I guess from the outside, Im just an average piece of chicken. But dont worry: Ive got wings, and some day Ill be the first chicken to fly. Mild salsa: The girl who cuts my hair told me that Im pleasant. Pleasant!? I thought, suddenly the victim of a complete and utter mental meltdown. I clung to the sides of the black vinyl chair, trying to wrap my head around the dullness of her diction. Sure, Im nice and all, but couldnt she have chosen a spicier word? Like brilliant. Or dazzling. I would have been happy with that. Oh, well. I guess a mild salsa personality isnt so bad. Cheese: â€Å"Melanie, would you mind reading your paper aloud to the class?† Ever since my second grade teacher told me that I had a knack for writing, Ive devoted my time to words. My friends practiced cheerleading and painted pictures; I wrote stories. Every time I open a blank Microsoft Word document, I swear I can hear angels singing the Hallelujah chorus. Cheese is the glue that holds my ideas together. Lettuce: Every year on January first, I sit down in front of my iMac and come up with 10 New Years resolutions. No more, no less. From trivial to incredibly meaningful, my goals reflect who I am and who Id like to be. Number 10 on the list? Get into Northwestern. If my dreams are lettuce, then Northwestern is the greenest leaf.

Birth Control Education Essay Research Paper Birth free essay sample

Birth Control Education Essay, Research Paper Birth Control Education The issue of birth control being taught and/or distributed in public schools is one worth debating. In biological science and wellness categories pupils are educated in reproduction and gender, but non about such birth control methods such as rubbers and birth control pills. While parents may touch briefly on the subject, some feel excessively embarrassed to discourse it with their kids or hold it unneeded. This is a really bad class of action because the universe is now teaming with hormonally driven adolescents missing critical information about personal safety. They have a yearning to pattern the oldest inherent aptitude that humans possess, which is to reproduce. The schools have no ground to non be learning the other, more of import, half of sex instruction. This action makes every bit small sense as larning how to add, but non subtract. The metropolis is merely one of the many facing this job in the face. We will write a custom essay sample on Birth Control Education Essay Research Paper Birth or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page It is a job that knows no category, faith, or gender. If every community took it upon themselves to turn to this issue with young person, so they could extinguish a national job. It is easy to see that deficiency of cognition refering birth control is a sever job confronting today? s young person. While the adolescent gestation rate is far lower than it has been in the yesteryear, the figure of teens infected by sexually transmitted diseases is on the rise. One-half of sex instruction is non plenty. Even though 98 % of pupils get # 8220 ; gender instruction # 8221 ; , 55 % of them still have inquiries refering birth control methods, the bar of STDs, and how to buy protection confidentially. The challenge of STD bar in the United States is clearly illustrated by the fact that 85 % of the most common infective diseases in the U.S.A. are spread sexually. This is the highest out of all the industrialised states in the universe. Why, in the U.S. the rates of infection are 50- 100 times greater than in any other of the industrialised state. A friend of mine, whom we will name Miss. Q for confidentiality grounds, is a merchandise of this backwards learning. Miss. Q is a fresher in college, and was sing place for thanksgiving this past twelvemonth. While reading an article in a adult female? s magazine sing birth control she crossed a term she did non acknowledge. It turned out to be a term for a method of birth control, which she found out when she asked her female parent, who was horrified to detect her 19-year-old girl, had neer been exposed to the word before. Miss. Q? s female parent assumed that her kid was taught this either in biological science or wellness category, so she had neer bothered to discourse it with her. However, after this disclosure she sat down with her girl and had a long in deepness talk about the subject. Narratives like this one can be heard all over the state. Even in towns that offer easy entree to deliver control to pupils, this job plagues the community. Take St. Paul Minnesota for illustration. With a prescription/voucher from a physician, a pupil can travel pick up protection from a local free clinic. However, 80 % of the male pupils and 30 % of the female pupils who receive such a prescription neer go to pick them up. A recent study in St. Paul discovered an dismaying statistic that two out of every 10 boys is or has been infected with chlamydia. In fact, teens 15-19 old ages old accounted for 41 % of chlamydia instances and 32 % of gonorrhoea instances in Ramsey County Minnesota. Nothing can demo us this job better than a study from 1995 of 15-24 twelvemonth old adult females asked about their usage of preventives. It was shown that merely 37.3 % used birth control on a regular footing. In add-on to this, merely 4.4 % on a regular basis used protection against STDs. Another study from 1990 of adult females of all ages in this state reported that while 70.7 % used protection, merely 7.9 % used birth control that besides protected against STDs. The major ground birth control is non taught in this school territory is because cipher has thought of conveying up the inquiry for many old ages. The last clip the policy of sex instruction was brought up ; there was an overpowering sense of disapproval from the community. Some parents were even caught doing remarks on the moral unity of the school territory. # 8220 ; I? m non happy about this, I? m non happy about a school territory who says it doesn? t affair what your household values are. # 8221 ; A female parent said this whom has three girls in the public school system in Oswego who wished to stay anon. in this paper. This quote high spots another possible cause for the job, deficiency of parent engagement. If parents are so set against holding birth control added into category treatment, they can non pretermit holding a talk about birth control with their kids. Parents who do non cognize what is involved in a category? s course of study may non hold this treatment with thei r progeny because they merely assumed the school taught it. Besides, they may experience this a nonmeaningful conversation because, # 8220 ; Their childs won? Ts have sex until they are married, # 8221 ; they are abashed themselves, or they do non believe a adolescent can manage this mature capable affair. Why should a parent be embarrassed to speak about this you inquire? It is because they themselves neer got the instruction. Not merely do kids non cognize how different signifiers of birth control work, but besides neither do their parents. Despite old ages of added experiences and adulthood, non all grownups know that some signifiers of birth control merely protect against gestation, non STDs. This deficiency of assurance and cognition gets passed right on down the household tree to the kids, and when they become sexually active they won? t us proper protection for those grounds, deficiency of cognition and embarrassment. If we do non get down educating young person in birth control, the figure of 15-19 twelvemonth olds enduring with sexually transmitted diseases such as gonorrhoea, chlamydia, herpes, and HIV will go on to increase by dismaying intervals. Young person is missing critical information that can salvage their lives, and the lives of others. Recently in Washington the senate appropriations commission approved a $ 287.6 billion dollar financial 1999 disbursement measure for the Departments of Labor, Health, and Education. However, the president threatened to blackball the house measure because its proposed disbursement cuts and a host of legislative riders on issues like necessitating parental presentment before bush leagues receive birth control at federally funded clinics. Legislation locally has been limited due to the deficiency of enterprise on behalf of all the people this would profit. Right now wellness instructors at the Oswego high school are prohibited to learn birth control and safe sex, even if the pupil asks a inquiry about it that pertains to a category treatment. With all the benefits of birth control instruction why shouldn? t it be taught in schools? There are a figure of things the school could make in order to assist the job of teenage STD infection. They could establish a condom handiness plan for illustration. Having birth control on manus when it is needed is the best manner to vouch its usage. To frequently you hear of childs that are excessively abashed to travel purchase rubbers, or are merely excessively faineant to travel acquire them. By administering them in school whether it? s through traveling to the school nurse and inquiring for some, or if you can merely travel pick one up out of a basket, it can extinguish these feelings of uneasiness and slothfulness. However, some critics would reason that holding rubbers around and ready to be used merely encourages sexual activity. They would reason that by offering a manner to hold safe sex, the school territory would in fact be advancing sex, which would wholly get the better of the intent of the prescription in the first topographic point. Others say that it is non the school territories duty to supply protection for sexually active pupils. After all, this is a plan that would be a good trade of money and clip, neither of which public instruction can presently save. Of class this is non the lone route available for the school territory to take. There are many options to passing out rubbers in school, such as offering workshops on the subject. The school could offer after school categories about the different types of birth control available, and its usage. Many instructors would reason that there is non clip to include anything else into a category? s course of study, so offering a category after school would be a great option. Students could go to if they wished to so the morality issue would non be a job, and the school nurse, a wellness instructor, or a physician whovolunteered their clip could learn the category. Of class there is ever the issue of money when it come to utilize of school installations after school is out for the twenty-four hours, and at that place wouldn? T be a warrant that anyone would be willing to learn the category. Another possible ruin would be deficiency of engagement in the category. Students may avoid go toing such categories for fear their friends would label them promiscuous. ( I use the te rm promiscuous in this paper merely for tact intents ; accurate vocabulary used by pupils would be abhorrent. ) Then one time once more you have to factor in pupil indolence, and other pupil activities such as athleticss to the low category sizes. So clearly the costs of this plan would out weigh the benefits, so this brings us to a concluding pick, really adding birth control instruction in with what is already learned in wellness category. By holding the school territory add birth control instruction to the high schools wellness course of study we have the chance to learn everyone about birth control since it is a compulsory category for graduation. This is the lone manner to guarantee that the full pupil organic structure will cognize what their options are, how they work and are used, and they won? t be every bit nervous when the clip comes to discourse birth control with their spouse. This alteration would besides include larning in deepness about STDs, including the symptoms of them, after all, the early sensing you have the more likely a opportunity of acquiring better. The option of holding a physician or nurse come in and learning this lesson would be unfastened, seeing as how some of the instructors would non be up to par on this subject, or have a moral expostulation to learning it. It is clearly obvious that this is the preferable policy since the costs can so easy be avoided and the benefits are so great. This preferable policy would acquire a batch of support from many groups, particularly the Student AIDS Awareness Group. This is a group of pupils that devote their clip to ending the AIDS virus, which is spread by many agencies including sexually. Besides, as pupils they would be straight affected by the alteration. By being a group they hold more power than a solitary pupil. Peoples are more likely to listen to a big group than one individual, so this gives them the power of persuasion. This is a group whose lone end is to hold the spread of the AIDS virus, so this would be figure one on their list of precedences. By learning categories about birth control the figure of new instances of HIV, which causes AIDS, could be fewer so of all time earlier. Another group probably to back up this category merely every bit much as the Students AIDS groups is the parents of high school pupils. This is a category that has the potency of salvaging their kids? s lives down the route, so they would be behind it 100 % . Unfortunately the instruction of their kids sometimes has to take a backseat to issues such as measures, and callings, so they are non ever be cognizant of what is, or is non being taught to their progeny. Nevertheless, small else is every bit of import to them as their kid? s wellbeing and safety. What? s more they are the electors, and taxpayers in the community and they have the right to find what their kids should and should non be taught, whither it is they themselves who vote on the rightness of the capable affair, or whom they select as the board of instruction members. One last group that would rebelliously be in favour of these categories is household physicians and gynaecologists. These are the people who see first manus the effects that STDs and gestation have on young person. They are the 1s who have to state parents that their kid is pregnant or will decease from the AIDS virus. This is by far non a occupation that they enjoy making. They want urgently for the AIDS epidemic to be terminated, and to halt seeing so many kids diagnosed with a STD and become impregnated. Like the parents, they excessively are taxpayers and electors, but they have one more ball in their tribunal. They are experts in this field, and have the ability to change peoples positions B y merely stating them what they see every twenty-four hours. These are the people the school board will name and inquire the sentiment of while seeking to make up ones mind an appropriate class of action. Unhappily this is a minor issue to physicians, whom are faced with malignant neoplastic diseases and bosom disease on a regular bases. Everybody already knows that the Catholic Church is earnestly against the pattern of utilizing birth control due to the Bible. The church has the power of words on its side, which can be merely every bit powerful as a ballot. Devote followings take the word of priests as if it were the word of God himself. Through this mode the church has the chance to rock a good figure of the ballots onto their side. Of class this is non the lone issue the churches of this community have to cover with, so this is non likely tobe high on their precedence list. This is an issue that would hold to take a back place to such things as verifications, nuptialss, baptisms, funerals, church school and multitudes of class. In add-on to the Catholic Church, instructors might be against this every bit good. After all they are the 1s who need to learn this subject to the pupils. Some wellness instructors would kick that their categories have excessively much jammed into them right now, and adding another subject to learn would coerce them to pass less clip on more of import subjects. The wellness instructors alone nevertheless could non alter the heads of the school board and community members. As a effect of their brotherhood, O.C.T.A. , they have the adequate sway to state they do non desire to learn birth control methods and usage to pupils. However there is still the affair of money jobs they have to cover with. Money jobs like schoolroom budgets to wages they have to worry approximately, and while they might non desire to learn this subject, they likely wouldn? Ts take the enterprise to protest it. While the church and wellness instructors might take some resistance to this alteration, it is non a really high precedence to them. On the other manus the school board has nil else to worry about than school policy. Presently there are a smattering of conservative school board members that would protest the instruction of birth control to the pupil. While there are other things to worry approximately, such as the budget, school force, and preparation regulations, some members would take this under their weaponries as a undertaking to concentrate on. This is a group that has the power of veto, and is the 1 who finally decides whether or non they want to do the alteration to the course of study. If the members opposing the alteration outnumber those back uping it, it dies. While parents, and pupils, and the Catholic Church might act upon their determination, it is in fact, their determination. The fact that people would be against protecting the future leaders of the state from life changing diseases is so sick fated. By disregarding the fact that the United States has the highest percentile of people infected with STDs out of any other industrialised state in the universe, we are simply vouching our place. It is executable that in merely two old ages the figure of 13-19year olds in the United States with a sexually transmitted disease will lift from 3 million to 4 million, doing up.83 % of the entire figure of instances in the universe, and 33 % in this state. On the other manus, if this policy is implemented we could see a possible lessening of one million instances every two old ages. The instruction system must step in someplace. Ignoring the job has merely forced us deeper and deeper into a hole that there is mounting out of. If left unnoticed, shortly most of the young person in this state will be infected, and they will hold kids who are infected and so on and so on. It has been said that cognition is power, so why is the universes? most powerful state so naif? Does Sex Education Work? Should arouse instruction be taught in schools? The inquiry is no longer should arouse instruction be taught, but instead how should it be taught. Over 93 % of all public high schools presently offer classs on gender or HIV. ( 1 ) More than 510 junior or senior high schools have school-linked wellness clinics, and more than 300 schools make rubbers available on campus. The inquiry now is are these plans effectual, and if non, how can we do them better? Why do youth necessitate sex instruction? Childs need the right information to assist protect themselves. The US has more than double the adolescent gestation rate of any western industrialized state, with more than a million adolescents going pregnant each twelvemonth. ( 2 ) Adolescents have the highest rates of sexually transmitted diseases ( STDs ) of any age group, with one in four immature people undertaking an Venereal disease by the age of 21. ( 3 ) STDs, including HIV, can damage adolescents # 8217 ; wellness and generative ability. And there is still no remedy for AIDS. HIV infection is increasing most quickly among immature people. One in four new infections in the US occurs in people younger than 22. ( 4 ) In 1994, 417 new AIDS instances were diagnosed among 13-19 twelvemonth olds, and 2,684 new instances among 20-24 twelvemonth olds. ( 5 ) Since infection may happen up to 10 old ages before an AIDS diagnosing, most of those people were infected with HIV either as striplings or pre-adolescents. Why has sex instruction failed to assist our kids? Knowledge entirely is non adequate to alter behaviours. ( 6 ) Programs that rely chiefly on conveying information about sex or moral precepts-how the organic structure # 8217 ; s sexual system maps, what teens should and shouldn # 8217 ; t do-have failed. However, plans that focal point on assisting adolescents to alter their behavior-using function playing, games, and exercises that strengthen societal skills-have shown marks of success. ( 7 ) In the US, contention over what message should be given to kids has hampered sex instruction plans in schools. Too frequently statements of values ( # 8221 ; my kids should non hold sex outside of matrimony # 8221 ; ) semen wrapped up in misstatements of fact ( # 8221 ; sex instruction doesn # 8217 ; t work anyhow # 8221 ; ) . Should we make everything possible to stamp down adolescent sexual behaviour, or should we acknowledge that many teens are sexually active, and fix them against the negative effects? Emotional statements can acquire in the manner of an indifferent appraisal of the effects of sex instruction. ( 8 ) Other states have been much more successful than the US in turn toing the job of adolescent gestations. Age at first intercourse is similar in the US and five other states: Canada, England, France, the Netherlands, and Sweden, yet all those states have adolescent gestation rates that are at least less than half the US rate. ( 9 ) Sexual activity instruction in these other states is based on the undermentioned constituents: a policy explicitly prefering sex instruction ; openness about sex ; consistent messages throughout society ; and entree to contraceptive method. Often sex instruction course of study Begin in high school, after many pupils have already begun experimenting sexually. Surveies have shown that sex instruction begun before young person are sexually active helps immature people stay abstentious and usage protection when they do go sexually active. ( 10 ) The Oklahoman sex instruction begins, the better, even every bit early as simple school. What kinds of plans work best? Reducing the Hazard, a plan for high school pupils in urban and rural countries in California, used behavior theory-based activities to cut down unprotected intercourse, either by assisting teens avoid sex or usage protection. Ninth and 10th graders attended 15 Sessionss as portion of their regular wellness instruction categories and participated in function playing and experimental activities to construct accomplishments and self-efficacy. As a consequence, a greater proportion of pupils who were abstentious before the plan successfully remained abstainer, and unprotected intercourse was significantly reduced for those pupils who became sexually active. ( 11 ) Postponing Sexual Involvement, a plan for Afro-american 8th graders in Atlanta, GA, used equals ( 11th and 12th graders ) to assist youth understand societal and peer force per unit areas to hold sex, and to develop and use opposition accomplishments. A unit of the plan besides taught about human gender, decision-making, and preventives. This plan successfully reduced the figure of abstentious pupils who initiated intercourse after the plan, and increased prophylactic usage among sexually experient females. ( 12 ) Healthy Oakland Teens ( HOT ) targets all 7th graders go toing a junior high school in Oakland, CA. Health pedagogues teach basic sex and drug instruction, and 9th class equal pedagogues lead synergistic exercisings on values, decision-making, communicating, and condom-use accomplishments. After one twelvemonth, pupils in the plan were much less likely to originate sexual activities such as deep caressing, venereal touching, and sexual intercourse. ( 13 ) AIDS Prevention for Adolescents in School, a plan for 9th and 11th graders in schools in New York City, NY, focused on rectifying facts about AIDS, learning cognitive accomplishments to measure hazards of transmittal, increasing cognition of AIDS-prevention resources, clear uping personal values, understanding external influences, and learning accomplishments to detain intercourse and/or systematically use rubbers. All sexually experient pupils reported increased rubber usage after the plan. ( 14 ) A reappraisal of 23 surveies found that effectual sex instruction plans portion the following features: ( 10 ) 1.Narrow focal point on cut downing sexual risk-taking behaviours that may take to HIV/STD infection or unintended gestation. 2.Social larning theories as a foundation for plan development, concentrating on acknowledging societal influences, altering single values, altering group norms, and constructing societal accomplishments. 3.Experimental activities designed to personalise basic, accurate information about the hazards of unprotected intercourse and methods of avoiding unprotected intercourse. 4.Activities that address societal or media influences on sexual behaviours. 5.Reinforcing clear and appropriate values to beef up single values and group norms against unprotected sex. 6.Modeling and pattern in communicating, dialogue, and refusal accomplishments. What still needs to be done? Although sex instruction plans in schools have been around for many old ages, most plans have non been about as effectual as hoped. Schools across the state demand to take a strict expression at their plans, and get down to implement more advanced plans that have been proven effectual. Educators, parents, and policy-makers should avoid emotional misconceptions about sex instruction ; based on the rates of unwanted gestations and STDs including HIV among adolescents, we can no longer disregard the demand for both instruction on how to prorogue sexual engagement, and how to protect oneself when sexually active. A comprehensive hazard bar scheme uses multiple elements to protect as many of those at hazard of gestation and STD/HIV infection as possible. Our kids merit the best instruction they can acquire. Aegerter, Ernest E. Understanding your Body. Philadelphia, Pa. George F. Stickley Company. Bodanis, David. The Body Book. Boston / Toronto. Little, Brown and Company. 1984 ? Brain. ? Compton? s Synergistic Encyclopedia. 1996 erectile dysfunction. ? Brain. ? The World Book Encyclopedia. Vol 2. ? The Brain: Mystery of Matter and Mind. ? The Human Body. Bibliography Aegerter, Ernest E. Understanding your Body. Philadelphia, Pa. George F. Stickley Company. Bodanis, David. The Body Book. Boston / Toronto. Little, Brown and Company. 1984 ? Brain. ? Compton? s Synergistic Encyclopedia. 1996 erectile dysfunction. ? Brain. ? The World Book Encyclopedia. Vol 2. ? The Brain: Mystery of Matter and Mind. ? The Human Body.

The risk of malnutrition Essays

The risk of malnutrition Essays The risk of malnutrition Essay The risk of malnutrition Essay Introduction The most of import issue with for the Great Horn of Africa ( GHA ) states is the equal supply of sufficient nutrient. Poor conditions and struggle are some of the factors that cause the nutrient insecurity. Increase in planetary nutrient monetary values besides cause more weakening in nutrient security which increases the hazard of malnutrition. The purpose of this essay is to discourse how addition in nutrient monetary values in general affects lessening in nutrient security in the GHA and increase the hazard of malnutrition of the people in those states of GHA. The United States Agency for International Developments ( USAID ) defined nutrient security based upon the one adopted at the 1996 World Food Summit. This defines nutrient security as all people, at all times holding physical and economic entree to sufficient, safe and alimentary nutrient that meets their dietetic demands and nutrient penchants for an active and healthy life , ( Riely et al. , 1999, FAO, 2006 ) . Food entree, use, nutrient handiness and stableness are the four key elements ( FAO, 2006 ) . These four key elements province that there ever sufficient sum of nutrient, quality of nutrient has to be kept same even it is imported or produced, to fix nutrient and consume nutrient in a alimentary and hygienic mode equal tools or pecuniary resources for its acquisition is needed, and non to lose all these elements the hazard should ever be low. Otherwise, if any of these elements has some lacks so nutrient security will diminish. The states that are portion of GHA which has suffered from long term nutrient insecurity are Somalia, Eritrea, Ethiopia, Tanzania, Dijibouti, Uganda, Sudan, Kenya, parts of the Central African Republic ( CAR ) and the Democratic Republic of Congo ( DRC ) . These states faced nutrient insecurities at critical degree and have required external nutrient aid for at least 10 or more old ages during the period 1988-2005. However, Somalia, Ethiopia, Sudan and DRC faced nutrient insecurities for the full continuance of this period or more ( FAO, 2006 ) . The causes of nutrient insecurity There were still some annihilating factors refering with the nutrient security in the GHA part. First of all, fickle and drought rainfalls combined with deforestation have ruined dirt quality in decreased harvest outputs and grazing land for croping animate beings ( Riely et al. , 1999 ) . The rainfall was below the norm in many parts of GHA bespeaking moderate to badly dry conditions in Somalia, some parts of Kenya, south-eastern Ethiopia and Dijibouti between February to September 2008 ( FEWS_Net, 2008a, FEWS_Net, 2008b, FEWS_Net, 2008c ) . Less sum of rainfall caused to the dirt wet degrees to drop and this affected corn harvest to neglect in some parts of GHA. Political instability and armed struggle are some of the causes that make it hard to get down and go on to administer nutrient to the people in a market substructure mode ( Riely et al. , 1999 ) . As an illustration, between 1991 and 2000, since Somalia has nt got a functioning authorities, it has merely recognized a transi tional national authorities after approximately a decennary involved in internal struggle ( Bureau_of_African_Affairs, 2010 ) . After all these happened, the figure of internally displaced people who can non work and depend on external nutrient assistance increased to 980,000. Due to some internal supplanting doing the post-election ferociousness in 2008, around 257,000 people had nutrient insecurity issues ( FEWS_Net, 2008d ) . All of these factors when they are combined affect people to obtain adequate nutrient in their ain economic system and force them to international assistance and markets. Food handiness and nutrient entree depend on the cost of nutrient. Since the production capacity degrees are lower, the GHA part is a net importer of nutrient particularly cereals from international markets ( IFRC, 2008 ) . In add-on to this, monetary values of cereal including rice and corn additions in the period from 2006 to 2008.

Colt's Manufacturing Company Assignment Example | Topics and Well Written Essays - 1750 words

Colt's Manufacturing Company - Assignment Example Colt's Manufacturing Company is an American manufacturing company that deals with the manufacture of firearms. Samuel Colt founded it in the year 1836. It makes both civilian and military firearms mainly used in America and other countries (Houze, Cooper, Kornhauser, & Colt, 2006). The companies most popular products include single action army, colt walker, Colt Commando, M4 carbine and colt python. The company mainly targets the United States of America government and the civilians. The company serves both the local and international firearms markets. The company split into two in the year 2002. Colt Manufacturing Company mainly deals with the civilian market while Colt Defense serves the law enforcement countries (Houze, Cooper, Kornhauser, & Colt, 2006). The separation mainly helps in increasing the quality of the products by encouraging specialization. It also enabled the company to clearly assess the performance of the two branches of their productions. This is always done with the aim of maximizing the income through separate management and attracting more investors. A company split up can also take place under the government orders mostly due to concern about monopolistic practices. The Colt's Manufacturing Company highly encourages creativity and innovation in their productions. It is due to this, that they have come up with many firearm designs over their many years in operation. It is also due to this innovation that they have managed to have a tight grip on the firearms production industry making it hard for the survival of new entrants (Groover, 2010). Innovation has also seen them come up with firearm designs that have been termed as way past their time. The Colt’s manufacturing Company mainly uses iron, brass, fiberglass, wood, ceramics, aluminum magnesium, zinc, and steel as their major raw material. Local companies either supply these materials and others imported from foreign countries (Houze, Cooper, Kornhauser, & Colt, 2006). They also reuse some of the local materials as a way of reducing the material price. The company has a huge number of qualified employees who are charged with responsibility of transforming the raw materials into finished products. The machines and equipment that are available at the company for the sake of manufacturing always help the employees. These equipments include gunsmithing lathe, drill presses, riveters, propane torches, rifling cutters; paint both, crimp tools and various others. The company also relies a lot on its researches department, which always makes sure that the necessary information is available. The Colt’s manufacturing Company greatly relies on technology and innovation maintaining their market relevance. The innovation is evident in the encouragement and support they give to their employees during the designing period. Apparently, the company has had many designs that do not make it to the market. This exhibits the level of tolerance that the company accords the designers. The fact that some of the designs by the company have been considered to be way ahead of their time show just how much the level of innovation in the company is high. The company has also avails all the resources and information that the designers might need during the process. The company has highly invested in technology. The development process is enhanced by the use of various machines that facilitate uniformity, quality standards and eliminates the possibility of defects. Such machines include the ones mentioned above. The company

Meditations on First Philosophy Article Example | Topics and Well Written Essays - 250 words

Meditations on First Philosophy - Article Example example of this is given in the â€Å"letter to the Sorbonne† what it says that great people like Archimedes, Apollonius Pappus and the rest and presented facts which have been universally accepted, though very few understand it’s intricacies for the mere fact they’re quite long and only a reader who exhibits good concentration powers could understand them. Another point of great importance that I picked up was that one’s mind should not be filled with preconceived notions and opinions when trying to weigh the pros and cons and decipher between the right and the wrong. On the other hand, the mind should be detached from any involvement with the senses, so as to provide the person with a clear perspective of thinking. Most people just accept the facts as they are and never bother to oppose or refute it. They present a wrong picture that they have understood it completely and sometimes they commit the great mistake in rejecting the truth. In a subject like geometry the desired result is obtained by strictly following the rules. This is not so in a subject like philosophy because there are two sides to the coin which is open to argument because no argument is free from mistakes. It is only when any argument is thoroughly debated, supplemented and can decide to the extent that they are considered to be absolutely authentic, only then can a declaration or a public statement of the same should be exercised. People who are as intelligent as you would be easily subscribe to the genuineness of your opinion. In the case of atheist, the are considered to be posers more than people who learned or

Case Study Of Unstable Angina

Case Study Of Unstable Angina The patient in context is a 61 year old male, Mr. X, admitted to hospital in the late evening for a case of unstable angina. Presenting complaints include left-sided chest pain which was less severe than that of his previous admission and localized pain during rest. Absent symptoms are profuse sweating as well as nausea and vomiting, orthopnea and paroxysmal nocturnal dypsnoea, cough and fever. Patients past medical history includes diabetes mellitus and hypertension diagnosed 6 years ago, ischaemic heart disease (IHD) since 3 years ago, for which the last hospital admission was 11 months ago. In the previous admission for IHD, Mr. X also suffered from pneumonia and ventricular failure, his electrocardiogram (ECG) indicated right bundle branch block, his serum troponin I levels were 0.3 ng/mL (normal levels 0-0.1 ng/mL), and his creatinine levels were 5.0 mg/dL (normal for males 0.2-0.6 mg/dL). Mr. X is also afflicted with chronic kidney disease, for which his baseline creatinine dur ing his last admission was 208 ÃŽÂ ¼mol//L. Mr. X has retired from the military and is living with his wife, who monitors his medications and compliance. He used to be a chronic smoker but has stopped smoking 15 years ago. His previous medication history is as below: Drug and Form Strength Frequency Furosemide tabs 40 mg BD Omeprazole tabs 20 mg PRN Amlodipine tabs 10 mg OD Simvastatin tabs 20 mg ON Perindopril tabs 4 mg OD Table 1: Table showing past medications of Mr. X. Mr. X takes no non-prescription medications and has no known drug allergies. On examination he appears to be alert and comfortable on his nasal cannula for delivery of oxygen 3L/min. His blood pressure is 134/81 mmHg, pulse rate is 76 bpm, body temperature 37oC, SpO2 of 99%, abdomen feels soft and non-tender, and no pedal oedema was observed. A blood glucose strip test reveals that Mr. Xs glucose levels were 10.3 mmol/L. Emergency ECG shows right bundle branch block and no ischaemic changes. The tentative diagnosis was unstable angina and further tests were scheduled, including a full blood count (FBC), renal profile (RP), liver function test (LFT), troponin and creatinine (CKMB) investigations, as well as a urine full examination and microscopy (UFEME). The immediate plan was to give Mr. X subcutaneous enoxaparin 60 mg stat and twice daily thereafter, aspirin 75 mg tablets once daily, lovastatin 20 mg tablets once daily, sublingual glyceryl trinitrate when required, and to continue the 3L/min oxygen cannula. Clinical Progress Day 1 Morning Patient was well, free from chest pain, tolerating orally and suffering from no nausea or vomiting. He had minimal shortness of breath (SOB). Troponin I levels were at 0.15 ng/mL and ECG showed no acute or evolving changes. Fasting plasma glucose was at 4.8 mmol/L (within normal range). Secondary dehydration was observed using the skin pinch test, so patient was started on intravenous normal saline drip (3 x 500 mL bag per 24 hours). Patient was found to be anaemic due to pre-existing chronic renal failure. Evening Patient reported mild chest pain and SOB. His troponin I levels were 0.15 ng/mL and other vitals were normal. His creatinine levels were 423 ÃŽÂ ¼mol/L. Day 2 Patient felt comfortable and his vitals were normal. His creatinine levels decreased to 345 ÃŽÂ ¼mol/L. Day 3 Patients condition was well, no chest pain was reported but he was still experiencing some SOB in the morning, which subsided in the afternoon. Patient was put on continuous peritoneal dialysis in the late morning. Patients vitals were normal, and he was taken off enoxaparin in the evening. Day 4 Patient complained of chest pain in the morning, with minimal SOB. His vitals were normal. Subcutaneous enoxaparin 60 mg was given and the IV saline was continued. Lab Findings Urine Biochemical Analysis (Day 1) Investigation values Normal values Protein ++100 mg/dL Glucose negative negative Blood negative Leucocytes +-10 WBC/ÃŽÂ ¼L Ketone negative negative Bile negative negative Urobillinogen normal Specific gravity 1.025 1.003 1.040 pH 5.5 4.6 8.0 Nitrite negative negative Table 2: Results of urine biochemical analysis on Day 1 Lipid Panel Fasting Serum Lipid Plasma total cholesterol / mmol/L 4.5 Desirable Borderline 5.17-6.19 High risk >6.20 Plasma triglyceride / mmol/L 1.27 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable Borderline 1.7-5.64 High risk >5.65 Plasma LDL-cholesterol / mmol/L 2.91 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable Borderline 3.36-4.12 High risk >4.13 Plasma HDL-cholesterol / mmol/L 1.01 à ¢Ã¢â‚¬  Ã¢â‚¬Å" Desirable >1.03 High risk Total cholesterol / HDL-cholesterol 4.5 Desirable Borderline 3.8-5.8 High risk >5.9 Table 3: Results of lipid panel (fasting serum lipid levels). Renal Profile Electrolytes Measured levels on Day 1-1.14am Measured levels on Day 1-12.54am Measured levels on Day 2-10.47am Normal range Urea / mmol/L 22.8 22.4 21.1 2.8-7.2 Sodium / mmol/L 129 128 129 136-146 Potassium / mmol/L 5.3 4.8 4.7 3.5-5.1 Chloride / mmol/L 98 94 101 98-107 Creatinine / ÃŽÂ ¼mol/L 423 398 345 58-96 Table 4: Renal profile of Mr. X showing levels of electrolytes and creatinine. Plasma troponin I 0.15 ng/mL Liver Function Test Measured level Normal range Plasma total protein 81 g/L 66-83 g/L Plasma albumin 34 g/L 35-52 g/L Plasma globulin 47g/L 25-44 g/L A/G ratio 0.7 0.9-1.8 Plasma alkaline phosphatase 119 u/L 30-120 u/L Plasma aspartate transaminase 19 u/L Plasma alanine transaminase 43 u/L à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ Plasma total bilirubin 6 ÃŽÂ ¼mol/L 5-21 ÃŽÂ ¼mol/L ESR 47mm/hour à ¢Ã¢â‚¬  Ã¢â‚¬Ëœ 0-20 mm/hour Table 5: Results of liver function test showing protein and liver enzyme levels in plasma. Full Blood Count (FBC) (Beckman Coulter) Cell type Measured level Normal range WBC 9.9109/L 4-10109/L RBC 3.341012/L 3.8-4.81012/L Haemoglobin 95g/L 120-150g/L Haematocrit 0.273L/L 0.36-0.46L/L Mean cell volume 81.8fl. 83-101fl. Mean cell haemoglobin 28.4pg. 27-32pg MCH concentration 347g/L 315-345g/L Platelets 353109/L 150-400109/L RDW 19.4% Neutrophils 3.3 2-7 x109/L Lymphocytes 1.74 1-3 x109/L Monocytes 0.55 0.2-1.0 x109/L Eosinophils 0.21 0.02-0.5 x109/L Basophils 0.03 0.02-0.1 x109/L Table 6: Full blood count of Mr. X. Vital Stats Chart Date Time Blood Pressure/ mmHg Temperature / oC Pulse Rate/ bpm SpO2/ % Blood Glucose levels/ mmol/L Day 0 11.05 pm 140/80 37 91 100 13.9 11.30 pm 137/84 37 80 100 Day 1 8.30 am 130/80 37 70 4.8 (fasting) 3.55 pm 130/70 37 90 10.30 pm 108/64 37 81 Day 2 8.20 am 119/69 37 78 4.50 pm 130/90 37 82 9.6 9.45 pm 140/90 37 80 6.7 Day 3 8.50 am 114/77 37 72 98 6.6 Table 7: Records of vital stats of Mr. X from Day 0 3. Disease Overview Pharmacological Basis of Drug Therapy Acute coronary syndrome (ACS) is a broad term used to classify a continuum of symptoms and events stemming from acute ischaemic episodes affecting the cardiac muscle.1 This includes unstable angina, non-ST segment elevation myocardial infarction (NTEMI), and ST segment elevation infarction. It is usually characterised by chest pain which increases in its severity at rest or with physical exertion. The ischaemic events usually arise from the development of unstable atheromatous plaques,2 which explains the fact that stable angina (due to a stable coronary atheromatous plaque) is not included under this umbrella term. Rupture, ulceration or fissures of the atherosclerotic plaque often leads to formation of a thrombus, causing occlusion of coronary arteries and inadequate blood flow and, subsequently, inadequate supply of oxygen and nutrients to the cardiac muscle. This can be precipitated by acute stress factors on the sclerotic cap usually consisting of fibrous material, which is caus ed by local blood flow disturbances or vasospasms3. Unstable angina usually occurs without cardiac muscle damage while myocardial infarction (MI) may occur with or without myocardium damage. The thrombus formed in unstable angina is labile and obstruction is transient, and not a full-on occlusion as would occur in MI.4 Unstable angina occurs at rest and is almost indistinguishable from a non-ST segment elevated myocardial infarction except in the severity of cardiac muscle ischaemia. Theoretical definitions of unstable angina would include changes in usual patterns of stable angina after a stable pain-free period, or severe acute anginal pain causing almost total incapacity5, though it is difficult to define it exactly as the term is often used by medical professionals to describe a range of different conditions intermediate between stable angina and MI. The primary clinical symptoms of unstable angina are: sudden occurrence of chest pain that persists for more than 20 minutes which may be felt in other areas such as the jaw, arm, shoulder, neck or back; without cause (as opposed to stable angina which stems from physical exercise); shortness of breath, rapid pulse rate, and sometimes a rapid drop in blood pressure. Patients suffering from an ACS have a high risk of MI and possible even death; immediate hospitalization is often required1 and treatment is of a more urgent nature compared to that of stable angina. It has been suggested by the National Health Service (NHS) Hospital Episode Statistics in 1998 that 1000 out of every million per population is affected with unstable angina, or 10 acute hospital admissions per week.6 On a more recent note, NHS has reported in 2009 that angina affects between 10-15% of women and 10-20% of men aged 65 and above in England.7 Due to the close relationship between unstable angina and coronary events, it is worth noting that the highest averaged rates of cardiovascular events were observed in Glasgow and Belfast (UK), North Karelia and Kuopio (Finland), Newcastle (Australia), and Warsaw (Poland).8 Diagnosis of an unstable angina episode, or any ACS in that matter, is based on several aspects9. Physical symptoms include anginal pain at rest that lasts for 20 minutes or more; new onset angina severely limiting ability of physical activity; or changes in existing angina intensity, frequency or length of attack. One or more of these symptoms are an urgent indication that the patient is suffering from an ACS attack. Upon admission to hospital, ECG and blood tests should be performed to confirm the type of ACS in order to initiate treatment. In unstable angina, the ST segment is not elevated and levels of cardiac enzymes are normal (especially troponin T and I). If the onset of symptoms is unclear as to indicate ACS, a measurement of serum troponin concentration should be carried out 12 hours from presentation to establish the diagnosis.10 Treatment of unstable angina and NSTEMI are similar in terms of pharmacological management; indeed they are at presentation indistinguishable exc ept in terms of the severity and extent of cardiac muscle ischaemia, in which the ischaemia is less severe in unstable angina and less troponin T and I are released into the bloodstream. Antiplatelet agents. Aspirin and clopidogrel are the immediate emergency drugs used in the ambulance, both being antiplatelet drugs. Aspirin is an irreversible inhibitor of arachidonate cyclooxygenase (COX) enzyme, in which covalent acetylation of the serine moiety in a hydrophobic channel in the enzyme11 reduces synthesis of thromboxane A2 in platelets and prostaglandins in the endothelium. This prevents platelet aggregation and further enlargement of the thrombus formed in the coronary artery. Clopidogrel is an inhibitor of the ADP-dependent activation of the GPIIb/IIIa receptor and prevents the formation of fibrinogen bridges between glycoprotein IIb/IIIa receptors on the surfaces of platelets11, subsequently preventing platelet activation. Glycoprotein IIB/IIIA receptor antagonists, eg, abxicimab, have the advantage of inhibiting all pathways in the platelet activation process by inhibiting the glycoprotein IIB/IIIA receptor. Anticoagulants. Unfractionated heparin is an activator of antithrombin III, which inhibits the action of thrombin and serine proteases. The heparin also binds to thrombin; the combined effect of this and the heparin-antithrombin complex formed inhibits thrombin, which decreases the conversion of fibrinogen to fibrin and reduces platelet aggregation. In contrast, low molecular weight heparins (LMWH) have molecular sizes that are too small to bind to thrombin but still bind to antithrombin III, which inactivates all serine proteases including Factors XIIa, IXa, and Xa11, preventing the coagulation process. Direct thrombin inhibitors such as hirudin and bivalirudin inhibit thrombin reversibly. These agents can bind to free and bound thrombin, thus have the ability to prevent and dissolve preformed clots. Synthetic pentasaccharides (fondaparinux) is a selective indirect inhibitor of Factor Xa. It binds to antithrombin III reversibly, catalyzing the inactivation of Factor Xa12 and inhibit ing the coagulation cascade. Beta blockers. All beta blockers bind to beta-adrenoceptors, competitively antagonizing the action of catecholamines. These drugs block the beta-1 adrenoceptors at the heart, achieving a decreased heart rate and force of cardiac contractions, as well as lowering blood pressure. Atenolol is relatively specific for cardiac beta-1 adrenoceptors and exerts fewer side effects associated with beta-2 adrenoceptor blockade, for example bronchospasm in asthmatics. Nitrates. Organic nitrates mimic the actions of endogenous nitric oxide to relax vascular smooth muscle by increasing the synthesis of cGMP, leading to the dephosphorylation of myosin light chains.11 Vasodilatation of coronary arteries causes increased coronary blood flow and coupled with its effects of decreasing arterial pressure and also cardiac output, the myocardial oxygen consumption is largely reduced. Statins. Also termed HMG-CoA reductase inhibitors, these medicines inhibit the rate-limiting enzyme in the synthesis of cholesterol, in which this enzyme converts HMG-CoA to mevalonic acid. ACE inhibitors are diuretics acting on the rennin-angiotensin system which inhibit the angiotensin-converting enzyme (ACE) and block the production of angiotensin II from angiotensin I. This reduces vascular resistance, increases tissue perfusion, and reduces cardiac afterload. Angiotensin II receptor inhibitors also act on the same system as the ACE inhibitors, except that they block the angiotensin II receptors directly instead of inhibiting their formation. The outcome is the same as above. Evidence for Treatment of the Condition Antiplatelet Agents The SIGN guidelines advocate that aspirin and clopidogrel be given to patients with ECG ischaemic changes or increased levels of cardiac markers; and aspirin is advocated for all patients suffering from ACS. A meta-analysis of 287 randomised trials proves the protective effect of aspirin on patients with unstable angina, halving the rate of cardiovascular events, including death, non-fatal MI and strokes, or also termed the first primary outcome; while in those with an acute MI, it reduces the rate of coronary events by almost a third13. Long-term use of aspirin for these patients was also shown to be a beneficial antiplatelet therapy. According to the same study, reduction of serious vascular events by clopidogrel was 10% compared to aspirin. The combined use of clopidogrel and aspirin as compared with a placebo and aspirin showed significantly higher success rates in reducing occurrences of first primary outcomes (9.3% compared to 11.4%, P On the flipside, although short term studies have shown that antiplatelet medications are effective for patients with renal failure in the prevention of serious vascular events13, the risks of bleeding is increased by renal disease15, posing a possible contraindication for antiplatelets to Mr. X. A clinical study found that treatment for NSTEMI ACS in patients with chronic renal disease (mild to moderate stages) was less aggressive than those with normal renal function, despite the risk that these patients with renal disease would experience greater adverse outcomes from insufficient treatment for ACS compared to the other patient group16. However the available information on adverse effects of antiplatelets on patients with varying degrees of renal disease is limited and it would appear that this would result in the reluctance of medical professionals in using this class of drugs for patients with chronic renal disease as well as ACS. It can be inferred that Mr. X would gain the maximum benefits if his medications were changed to aspirin 300 mg and clopidogrel 300 mg stat and aspirin 75 mg and clopidogrel 75 mg thereafter, in which the patient should be closely monitored for signs of bleeding. Heparins LMWHs A 2003 review of 7 studies involving 11,092 patients with non-ST elevation ACS found that low molecular weight heparins (LMWH) were more effective than unfractionated heparins in reducing MI events, requirement for revascularization procedures, and thrombocytopenia17. No difference in the mortality, recurrent angina, major and minor bleeds were observed in the two types of drugs. A meta-analysis of 12 randomised trials with 17,157 patients involved found that patients who have had a non-ST elevation ACS who were put on aspirin experienced no significant difference in benefits in efficacy (preventing MI or death) or safety (major and minor bleeding complications) when they were put on unfractionated heparin or LMWH17, implicating no difference in the thrombolytic effect in both classes of drugs. These results are partially similar to those of the first review. Another meta-analysis of 2 phase-3 trials comparing enoxaparin and unfractionated heparin, on the other hand, showed a signifi cant (20%) difference in reducing death or severe cardiac ischaemic events18. From an economic point of view, authors of yet another meta-analysis on the subject stated that the cost of LMWH is 3-5 times higher than unfractionated heparin19. From these data it can be concluded that LMWHs does indeed have additional positive treatment outcomes compared to unfractionated heparins22; it does not show significantly decreased side effects (bleeding). Enoxaparin has, though, an increased bleeding effect on patients with renal disease as reported by an investigation of 106 patients, in which total bleeding complications occurred in 22% of normal patients and 51% of patients with impaired renal function (p It is still the drug of choice for patients present with non-ST elevated ACS, and this is applicable to Mr. X with unstable angina. Beta-Blockers Beta-blockers were not prescribed for Mr. X. The SIGN guidelines states that beta-blockers should be the drug of choice for first line treatment of anginal pain in patients with non-ST elevated ACS. A meta-analysis of 5 trials consisting of 4700 patients in all showed a 13% reduction in anginal pain with the use of beta blockers (initially IV then oral for a week) in patients with non-ST elevated, MI-characterised chest pain23. It was stated in the clinical progress Mr. X had chest pain on Day 1 and 4, thus the addition of a beta blocker to his medications would be useful in alleviating his pain. Despite the popular belief that beta-blockers are contraindicated in patients with diabetes mellitus, it is possible to treat these patients using beta-blockers as long as good glycaemic control is achieved and the patient is monitored regularly24. This would further support its use in Mr. X; furthermore, several studies have shown that diabetic patients derive a significant benefit from the use of beta-blockers after an MI, in which diabetic patients had a significantly lower mortality 1 year post-discharge25, total mortality after 3 years, and deaths from cardiac events26. A multicentre randomized trial, the HINT trial, on patients with unstable angina found that metoprolol, a relatively cardioselective beta blocker, reduced occurrence of myocardial ischaemia or progress to MI within 48 hours, indicating that metoprolol has a short term beneficial effect on patients not already taking beta blockers prior to the unstable angina episode27. It has been suggested that beta-blockers be the first line treatment for unstable angina and if patients remain unstable, a calcium channel blocker should be added28. Statins The beneficial effects of statins in reducing mortality and cardiovascular events have been proven by a meta-analysis of large, randomized controlled trials (n=90,056) where coronary artery disease was present or absent29. The positive results were also proven spanning a large range of serum cholesterol levels. Investigations comparing the use of intensive versus moderate doses of statins in the early stages and post-ACS showed positive results: a meta-analysis of 4 large trials (n=27,548) shows a 16% reduction in cardiovascular deaths or MI, as well as a 16% reduction in cardiovascular deaths or coronary events30. This view is shared by another meta-analysis of the same subject of 13 randomised controlled trials which found a decrease in mortality and coronary events after 4 months of treatment31. These data support the use of statins by Mr. X. Nitrates Nitrates have been widely used in relieving pain from unstable angina, despite its lack of clinical evidence in supporting its role in improving survival and reducing the rate of MI and cardiovascular events32. ISIS-433 and GISSI-334 reports no significant difference of the use of glyceryl trinitrate post-MI in reducing the overall mortality; however this may be explained by the fact that more than 50% of patients in the controlled group are also on other forms of nitrate therapy, such as intravenous glyceryl trinitrate. Despite this, nitrates will still be of use for reducing the pain in post-MI patients and those with unstable angina. The BNF advises against the use of nitrates in patients with serious anaemia (Hb Glycaemic control Mr. Xs plasma glucose levels were elevated on the day he was admitted to hospital (13.9 mmol/L). Diabetes mellitus has been proven to be a strong independent risk marker for coronary heart disease: patients with poorly controlled diabetes at hospital admission have a worse outlook on prognosis and future development of cardiovascular events35. The DIGAMI investigation reports that the use of intensive insulin therapy increased long-term prognosis (P=0.011) of patients presenting with hyperglycemia (>11mmol/L) at admission compared with those on standard antidiabetic therapy36. These data support the use of insulin to control the blood glucose levels of Mr. X which were highly increased upon admission. This is also supported by the SIGN guidelines which advocate immediate control of blood glucose is carried out for MI patients with glucose levels of more than 11.0 mmol/L for at least 24 hours. ACE Inhibitors The SIGN guidelines recommend that patients with unstable angina should be given ACE inhibitors as long-term therapy. In patients at high risk of cardiovascular events, ACE inhibitors (ramipril was investigated in a report37) have been proven to reduce overall mortality, MI, and stroke, particularly in patients with diabetes mellitus. Perindopril was found to reduce cardiovascular risk (relative risk reduction =20%, P=0.0003) in a population with stable coronary heart disease in absence of heart failure38 in a double-blinded, randomized multicentre trial involving 13,655 patients. A meta-analysis of the 2 above trials and a third one (PEACE) showed a reduction in overall mortality, cardiovascular death, non-fatal myocardial infarction, stroke, heart failure, and coronary artery bypass surgery by ACE inhibitors39. This demonstrates the benefits of ACE inhibitors in patients with atherosclerosis: as patients who had an ACS event would have a higher rate of cardiovascular events, the po sitive outcomes of ACE inhibitors can perhaps be extrapolated to this population in order to decrease coronary events and improve prognosis. However, the BNF advises caution and close clinical monitoring if ACE inhibitors are to be used in patients with hyponatremia ( Oxygen therapy On admission, Mr. Xs SpO2 was 99% and remained high throughout his stay in the hospital. The use of oxygen therapy is significantly beneficial only in hypoxic patients (with SpO2 Anaemia and Unstable Angina Anaemia can disturb the balance between myocardial oxygen supply and demand: a decrease in the number of red blood cells can lead to a reduction in the supply of oxygen to the myocardium. Thus correction of the causative factor would be sensible in the treatment of unstable angina for the patient in context. Mr. X was given a combination of ferrous fumarate, vitamin B complex, and folic acid for treatment of his anaemia. From the data in Table 6, it can be seen that Mr. X has low haemoglobin concentrations (95 g/L) and a low mean cell volume (81.8 fl.). To confirm that Mr. X is indeed suffering from iron-deficiency anaemia (as suggested by his treatment medication), three parameters must be established namely the plasma iron, the plasma ferritin, and total iron binding capacity. However, as very few conditions can cause abnormalities in the mean cell volume, and a decreased value is due to iron-deficiency anaemia or thalassemia42, it is safe to assume that Mr. Xs anaemic condition is due to an insufficiency of iron. Iron supplements are given to correct the iron status of the patient, in which the ferrous form given orally is found to be cheap, safe and effective in the majority of patients with iron-deficiency anaemia2. Vitamin B complex and folic acid are only indicated in patients with the respective deficiencies2; there is little evidence that they would be of any significant benefit in patients with iron-deficiency anaemia. Summary Based on the evidence given, Mr. Xs aspirin dose should be changed to 300 mg stat and 75 mg thereafter, and clopidogrel should be added into his medication profile in the same doses. These changes ensure that Mr. X is obtaining sufficient antiplatelet effects from his medications to prevent another attack of unstable angina or even a myocardial infarction. Present drugs that were given for his condition that are suitable and supported by evidences include enoxaparin, lovastatin, insulin, and GTN: these can be safely continued without problems. A beta-blocker (metoprolol tablets) may be given additionally in doses of 50-100 mg as evidences described above have shown that they can be safely used in diabetic patients contrary to popular belief; an ACE inhibitor (perindopril as previously used by Mr. X) may be initiated coupled with regular electrolyte